Every finding on record at La Jolla Post-Acute

Based on observations, interview, and record reviews, the facility failed to revise and implement Resident 3's comprehensive care plan following an altercation incident to address the identified risk factor and interventions necessary to prevent a recurrence. This failure resulted in Resident 3 not having an individualized plan of care addressing the identified risk for further altercations and the interventions necessary to promote residents' safety. Findings: A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis that included hemiplegia and hemiparesis (loss of physical function on one side of the body due to brain or spinal cord injury). On 8/3/26 at 7:30 A.M., Resident 2 and Resident 3 were sitting at a table together in a common area in Station two. Resident 2 was reaching for Resident 3's cup on the table, and Resident 3 hit Resident 2 on the left arm. Resident 2 and Resident 3 were separated and assessed for injuries. On 8/13/26 at 11:30 A.M., an observation was conducted in the common area in Station two. Resident 3 was sitting in his wheelchair at a table, reading a newspaper. Newspapers and small packets of butter and jelly were scattered on the table near Resident 3. On 8/13/26 at 2:06 P.M., an interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 3 did have behaviors of hoarding food items in his room, such as creamers, sugars packets, and cups, and would bring those items to the common area. The DON stated a care plan should have been developed for Resident 3 to address the hoarded items in the common area and try to prevent further incidents. A review of facility's policy titled Care Plan, Comprehensive Person Centered, revised December 2016, indicated .10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident

Based on observation, interview, and record review, the facility failed to ensure resident rooms were maintained at a comfortable temperatures for five out of ten sampled residents.This failure had the potential to affect the comfort and well-being of the residents in the affected rooms.Findings:A review of Resident 1's undated admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included anemia (define) and generalized muscle weakness.A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), dated 7/6/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, or thinking skills) of 9 which indicated moderate cognitive impairment.A review of Resident 2's undated admission Record indicated Resident 2 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (a condition caused by damage to the lungs, which makes it difficult to breathe).A review of Resident 2's MDS dated [DATE] indicated Resident 2 had a BIMS of 14, which indicated Resident 2's cognition was intact.A review of Resident 3's undated admission Record indicated Resident 3 was admitted on [DATE] with diagnoses which included migraine (define) and generalized muscle weakness.A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had a BIMS of 12, which indicated Resident 3's cognition was intact.A review of Resident 4's undated admission Record indicated Resident 4 was admitted on [DATE] with diagnoses which included chronic respiratory failure and generalized anxiety disorder.A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had a BIMS of 15 which indicated intact cognition.A review of Resident 5's undated admission Record indicated Resident 5 was admitted on [DATE] with diagnoses which included congestive heart failure (a condition where the heart does not pump blood well enough to meet the body's needs).A review of Resident 5's MDS dated [DATE] indicated Resident 5 had a BIMS of 14 which indicated intact cognition.An interview with the Maintenance Director (MS) was conducted on 7/16/26 at 12:02 P.M. The MS stated the Air Conditioning Unit that serviced the entire building was not functional. The MS stated, there's not enough BTU's [energy used by a cooling unit to remove heat] to cool the building.they need work done. The MS stated the facility's temperature should be between 71 and 81 degrees Fahrenheit (a scale for measuring heat and cold).During an observation in Resident 1's bedroom with the MS on 7/16/16 at 12:24 P.M., the MS measured the temperature using an infrared temperature gauge (a hand-held tool that measures room temperature). The temperature gauge indicated Resident 1's bedroom measured 84.4 degrees. During an interview with Resident 1on 7/16/16 at 12:25 P.M., Resident 1's stated, It's too hot in here. Its not comfortable.During a concurrent observation and interview in Resident 2's bedroom on 7/16/16 at 12:32 P.M., the temperature gauge indicated Resident 1's bedroom measured 84 degrees. Resident 2 was observed laying in bed with a fan at the foot of her bed. The fan was blowing air directly into Resident 2's face. Resident 2 stated, It's too warm in here.I'd like it to be cooler.During a concurrent observation and interview on 7/24/26 at 9:35 A.M., Resident 3 was observed in a bedroom with two other roommates. There was a fan on the high setting by the foot of Resident 3's bed. Resident 3 stated, It's still early but its already too warm in here. We only have one fan for three people.During a concurrent observation and interview on 7/24/24 at 9:42 A.M., Resident 4 was observed in her bedroom, with a fan on high setting. Resident 3 stated, It's hotter than Hades in here! Resident 4 stated she felt it was too hot in her bedroom, especially since her bed was next to the patio. Resident 3 stated it got warmer in the afternoon when the sun would shine through the patio.During a concurrent observation and interview on 7/24/24 at 10:04 A.M., Resident 5 stated he felt it was too warm in his bedroom. Resident 5 stated, the air conditioning doesn't work in this building.I'm very uncomfortable.During an interview with the Director of Nursing (DON) on 8/5/26 at 10:10 A.M., the DON stated it was important to maintain a comfortable temperature in the facility to ensure residents remained comfortable. The DON stated, This is their home, we need to ensure they are not too warm to promote their overall well-being, reduce stress, and prevent changes in condition. The DON stated, its important to maintain a comfortable environment.During a review of the facility's policy titled Homelike Environment, revised February 2021, the policy stated, Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect.a homelike setting. These characteristics include.comfortable and safe temperatures (71 F - 81 F).

Based on observation, interview, and facility policy review, the facility failed to ensure the dumpster area was clean and the dumpster lid was closed. This had the potential to affect all 140 residents who resided in the facility. Findings included: A facility policy titled, Environmental Maintenance - Grounds Maintenance effective 08/2014, indicated Purpose To define the procedure for inspecting the grounds and performing corrective maintenance as needed. The policy specified, 5. Visually inspect dumpster areas for any unsafe or unsanitary conditions. 6. Visually inspect for trash, debris, pests or rodents. During an observation of the dumpster on 04/21/2025 at 8:51 AM, the surveyor noted the dumpster was opened and there were disposable gloves, aluminum foil, and food packaging on the ground. During an observation of the dumpster on 04/22/2025 at 8:52 AM, the surveyor noted the dumpster was full, the dumpster lid was opened and could not close due to overflowing bags, and empty boxes were on the ground around the dumpster. During a concurrent interview and observation of the dumpster on 04/22/2025 at 9:00 AM, the surveyor noted the dumpster was full, the lid was opened and could not close due to overflowing bags, and empty boxes were on the ground around the dumpster. The Dietary Manager (DM) stated the dumpsters were full. During an interview on 04/23/2025 at 10:47 AM, the Director of Environmental Services (DES) stated he and the janitors were responsible for keeping the dumpster area clean. The DES stated there should be no papers or trash on the ground around the dumpsters and the dumpster lid should be closed. During a follow-up interview on 04/23/2025 at 1:01 PM, the DM stated maintenance made sure that everything was cleaned around the dumpster and the lids were closed. During an interview on 04/23/2025 at 1:05 PM, the Registered Dietician stated the dumpster area should be clean and the lids should be closed. During an interview on 04/24/2025 at 10:27 AM, the Executive Director stated he expected the dumpster area to be clean and there should be nothing on the ground around the dumpster. During an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated the expectation was that the dumpster lid should be closed and all debris should be picked up around the dumpster.

Based on interview, record review, document review, and facility policy review, the facility failed to complete a quarterly Minimum Data Set (MDS) for 10 (Residents #7, #21, #24, #27, #44, #55, #83, #94, #102, and #130) of 11 sampled residents reviewed for resident assessment. Findings included: A facility policy titled, MDS Standard of Practice, dated 01/2024, revealed, MDSs are transmitted within the timeframe's set forth in the CMS [Centers for Medicare & Medicaid] RAI [Resident Assessment Instrument] MDS 3.0 Manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. The manual specified, The MDS completion date must be no later than 14 days after the ARD [Assessment Reference Date]. 1. An Admission Record revealed the facility admitted Resident #21 on 12/09/2018. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and atherosclerotic heart disease. Resident #21's quarterly MDS, with an ARD of 03/15/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 2. An Admission Record revealed the facility admitted Resident #44 on 06/08/2024. According to the Admission Record, the resident had a medical history that included diagnoses of heart failure and acute respiratory failure. Resident #44's quarterly MDS, with an ARD of 03/08/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 3. An Admission Record revealed the facility admitted Resident #102 on 03/01/2023. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and emphysema. Resident #102's quarterly MDS, with an ARD of 03/08/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 52355 4. An Admission Record revealed the facility admitted Resident #7 on 11/07/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Resident #7's quarterly MDS, with an ARD of 02/28/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 5. An Admission Record revealed the facility admitted Resident #130 on 08/29/2024. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus with foot ulcer and essential hypertension. Resident #130's quarterly MDS, with an ARD of 02/25/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 45849 6. An Admission Record indicated the facility admitted Resident #24 on 11/25/2020. According to the Admission Record, the resident had a medical history that included diagnoses of age-related osteoporosis and atherosclerotic heart disease. Resident #24's quarterly MDS, with an ARD of 03/04/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 7. An Admission Record indicated the facility admitted Resident #27 on 12/06/2022. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and type 2 diabetes mellitus. Resident #27's quarterly MDS, with an ARD of 03/03/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 8. An Admission Record indicated the facility admitted Resident #55 on 12/14/2023. According to the Admission Record, the resident had a medical history that included diagnoses of congestive heart failure and chronic kidney disease. Resident #55's quarterly MDS, with an ARD of 03/09/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 9. An Admission Record indicated the facility admitted Resident #83 on 04/19/2022. According to the Admission Record, the resident had a medical history that included diagnoses of hypertensive chronic kidney disease and anemia. Resident #83's quarterly MDS, with an ARD of 03/09/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. 10. An Admission Record indicated the facility admitted Resident #94 on 09/01/2022. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and hypothyroidism. Resident #94'sA quarterly MDS, with an ARD of 03/04/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. During an interview with MDS Coordinator #1 and MDS Coordinator #2 o on 04/24/2025 at 8:59 AM, it was reported there were some MDSs that had not been submitted. They both reported the MDS should be signed as being completed 14 days after the ARD and from day 15 forward the MDS was considered late. It was reported the expectation was that all assessments are submitted on time. MDS Coordinator #1 stated the quarterly MDS for Residents #7, #21, #24, #27, #44, #55, #83, #94, #102, and #130 had not been submitted and was late. During an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated it was her expectation that MDS assessments were completed and submitted within the required timeframe. During an interview on 04/24/2025 at 10:58 AM, the Executive Director (ED) stated the facility had deadlines to complete, submit, and transmit MDS assessments. The ED stated it was his expectation that all MDS assessments were completed and submitted within the required timeframe.

Based on interview, record review, document review, and facility policy review, the facility failed to complete an annual Minimum Data Set (MDS) for 1 (Resident #33) of 11 sampled residents reviewed for resident assessment. Findings included: A facility policy titled, MDS Standard of Practice, dated 01/2024, revealed, MDSs are transmitted within the timeframes set forth in the CMS [Centers for Medicare & Medicaid] RAI [Resident Assessment Instrument] MDS 3.0 Manual. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA [Significant Change in Status Assessment] or an SCPA [Significant Correction to Prior Comprehensive Assessment] has been completed since the most recent comprehensive assessment was completed. Its completion dates depend on the most recent comprehensive and past assessments' ARDs [Assessment Reference Date] and completion dates. * The ARD must be set within 366 days after the ARD of the previous OBRA [Omnibus Budget Reconciliation Act] comprehensive assessment. * The MDS completion date must be no later than 14 days after the ARD. An Admission Record revealed the facility admitted Resident #33 on 03/09/2022. According to the Admission Record, the resident had a medical history that included diagnoses of type 2 diabetes and chronic kidney disease. An annual MDS, with an ARD of 03/05/2025, revealed the MDS was not signed or dated to indicate the assessment was complete. During an interview with MDS Coordinator #1 and MDS Coordinator #2 o on 04/24/2025 at 8:59 AM, it was reported there were some MDSs that had not been submitted. They both reported the MDS should be signed as being completed 14 days after the ARD and from day 15 forward the MDS was considered late. It was reported the expectation was that all assessments are submitted on time. MDS Coordinator #1 stated Resident #33's annual MDS with an ARD of 03/05/2025 had not been submitted and was late. During an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated it was her expectation that MDS assessments were completed and submitted within the required timeframe. During an interview on 04/24/2025 at 10:58 AM, the Executive Director (ED) stated the facility had deadlines to complete, submit, and transmit MDS assessments. The ED stated it was his expectation that all MDS assessments were completed and submitted within the required timeframe.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 2 residents (Resident #55 and Resident #71) of 27 sampled residents. Findings included: A facility policy titled, MDS Standard of Practice, dated 01/2024, revealed, It is the practice of this facility to conduct accurate coding and delivery of services provided to capture accurate assessment of each resident's functional capacity and health status as per CMS [Centers for Medicare & Medicaid] RAI [Resident Assessment Instrument] MDS 3.0 Manual guidelines. 1. An Admission Record indicated the facility admitted Resident #55 on 12/14/2023. According to the Admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder and anxiety disorder. An annual MDS, with an Assessment Reference Date (ARD) of 12/07/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #55 was not currently considered by the state level II preadmission screening and resident review (PASARR) process to have a serious mental illness or related condition. The MDS indicated Resident #55 had active diagnoses that included anxiety disorder and schizophrenia. During an interview with MDS Coordinator #1 and MDS Coordinator #2 on 04/24/2025 at 8:59 AM, it was reported that Resident #55 had a positive level II PASARR and it should have reflected on their annual MDS with an ARD of 12/07/2024. 2. An Admission Record indicated the facility admitted Resident #107 on 02/17/2024. According to the Admission Record, the resident had a medical history that included diagnoses of end stage renal disease, dependence on renal dialysis, dysphagia, and attention to gastrostomy. and. A quarterly MDS, with an Assessment Reference Date (ARD) of 01/12/2025, revealed Resident #107 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #107 did not have a feeding tube or receive dialysis while they were a resident of the facility. Resident #107's Care Plan Report included a focus area initiated 05/09/2024, that indicated the resident required hemodialysis related to a diagnosis of end stage renal failure. The Care Plan Report included a focus area initiated 02/19/2024, that indicated the resident required tube feeing related to a diagnosis of dysphagia. During an interview with MDS Coordinator #1 and MDS Coordinator #2 on 04/24/2025 at 8:59 AM, it was reported that Resident #107 was a dialysis and it should have been reflected on the resident's quarterly MDS with an ARD of 01/12/2025. They also stated the resident's MDS should have indicated the resident received a tube feeding. Resident #107's Order Summary Report, with active orders as of 01/12/2025, revealed an order dated 12/31/2024, for enteral feeding every eight hours and an order dated 01/02/2025, for dialysis treatment every Tuesday, Thursday, and Saturday. In an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated she expected a resident's MDS to be accurate and confirmed tube feeding and dialysis should have been coded on Resident #107's quarterly MDS. In an interview on 04/24/2025 at 10:59 AM, the Executive Director stated he expected a resident's MDS to be accurate.

Based on interview, record review, and facility policy review, the facility failed to ensure a Level I preadmission screening and resident review (PASRR) was timely resubmitted after a resident remained in the facility longer than 30 days for 2 (Resident #120) of 6 sampled residents reviewed for PASRR. The facility further failed to ensure the accuracy of the Level I PASRR for 1 (Resident #108) of 6 sampled residents reviewed for PASRR. Findings included: A facility policy titled, Admission, Transfer, Discharge and Bed-Holds dated 12/2016, revealed, The facility, in compliance with the Omnibus Budget Reconciliation Act of 1987, requires individuals diagnosed with major mental illness, mental retardation, or developmental disabilities to be screened prior to admission and throughout stay in accordance with PASRR requirements. 1. An Admission Record revealed the facility admitted Resident #120 on 02/04/2025. According to the Admission Record, the resident had a medical history that included diagnoses of bipolar disorder, schizoaffective disorder, anxiety disorder, major depressive disorder, and post-traumatic stress disorder. A letter from the California Department of Health Care Services dated 01/30/2025, revealed If the individual [Resident #120] remains in the NF [nursing facility] longer than 30 days, the facility must resubmit a new Level I Screening as a Resident Review on the 31st day. Resident #120's Care Plan Report included a focus area initiated 02/10/2025, that indicated the resident was a long-term stay in the facility for rehabilitation. Resident #120's medical record revealed no evidence to indicate a new Level I Screening was submitted when the resident remained in the facility after 30 days. During an interview with MDS Coordinator #1 and MDS Coordinator #2 on 04/23/2025 at 10:49 AM, both stated they were unable to articulate the process for residents admitted to the facility under a hospital discharge exemption for a PASRR. MDS Coordinator #2 stated he would investigate to see if another Level I was resubmitted. During an interview on 04/23/2025 at 12:01 PM, MDS Coordinator #2 stated the facility overlooked the resubmission of Resident #120's Level I when the resident remained in the facility. MDS Coordinator #2 confirmed the new Level I was not completed or submitted within the specified timeframe. During an interview on 04/24/2025 at 10:36 AM, the Director of Nursing stated it was her expectation that the Level 1 be submitted within the required timeframe. During an interview on 04/24/2025 at 10:58 AM, the Executive Director stated he expected a resident's Level I should be resubmitted within 30 days for any resident who remained in the facility longer than the anticipated 30 days. 52355 2. An Admission Record revealed the facility admitted Resident #108 on 09/26/2023. According to the Admission Record, Resident #108 had a medical history that included diagnosis of depression and schizophrenia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2025, revealed Resident #108 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident had active diagnoses to include depression and schizophrenia. Resident #108's Care Plan Report included a focus area initiated 02/10/2025, that indicated the resident had depression. The Care Plan Report included a focus area initiated 02/10/2025 and revised 04/24/2025, that indicated the resident had a psychosocial wellbeing problem related to a diagnosis of schizophrenia. Resident #108's Preadmission Screening and Resident Review Level 1 Screening dated 09/26/2023, revealed the resident did not have a serious diagnoses mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disorder. During an interview on 04/23/2025 at 2:29 PM, MDS Coordinator #2 stated Resident #108's Level I Screening was inaccurate and he should have reviewed it for accuracy. During an interview on 04/24/2025 at 10:52 AM, the Director of Nursing stated it was her expectation that a Level I Screening be resubmitted if it was not correct. During an interview on 04/24/2025 at 11:00 AM, the Executive Director stated his expectation was for the Level I Screening be accurate.

Based on observation, interview, record review, and facility policy review, the facility failed to properly dispose of medication for 1 (Resident #71) of 27 sampled residents. Findings included: A facility policy titled, Disposal of Medications and Medication-Related Supplies, updated 08/2019, indicated, Discontinued medications and medications left in the facility after a resident's discharge are destroyed. Destruction methods comply with federal and state laws and regulations, including the Office of National Drug Control Policy (ONDCP) guidelines for medication destruction. An Admission Record indicated the facility admitted Resident #71 on 04/07/2021. According to the Admission Record, the resident had a medical history that included a diagnosis of overactive bladder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #71's Order Summary Report that contained active orders as of 04/22/2025, revealed an order dated 04/07/2021, for desmopressin acetate tablet 0.1 milligram, give one table by mouth two times a day for overactive bladder. During an observation of the dumpster on 04/21/2025 at 8:51 AM, the surveyor noted a bubble pack card of desmopressin tablets on the ground with Resident #71's name on it that contained four tablets. During a concurrent interview and observation of the dumpster on 04/22/2025 at 9:00 AM, the surveyor noted a bubble pack card of desmopressin tablets on the ground with Resident #71's name on it that contained four tablets. The Dietary Manager (DM) stated she would have to ask nursing about the medication on the ground, as it was not her department. During an interview on 04/22/2025 at 9:10 AM, Registered Nurse (RN) #3 stated the facility disposed on medications in a bucket in the medication room. RN #3 stated the facility did not throw medication outside by the dumpster because it could be a danger to anyone as they could access the medication. According to RN #3, when medications are disposed of, the resident's name was removed and shredded and any remaining pills/tablets were popped out and placed in the destruction bucket for destruction/disposal. During an interview on 04/22/2025 at 9:30 AM, the Director of Nursing stated medications should be disposed of by placing the medication in the destruction receptable. During an interview on 04/23/2025 at 11:31 AM, RN #4 stated medications are placed in a discard bin for destruction/disposal. During an interview on 04/24/2025 at 10:27 AM, the Executive Director stated staff should follow the facility protocol for medication destruction and not place medications in the dumpster.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were not left at the bedside of 2 (Resident #55 and Resident #71) of 27 sampled residents Findings included: A facility policy titled, Medication Storage in the Facility, updated 08/2019, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. 1. An Admission Record indicated the facility admitted Resident #71 on 04/07/2021. According to the Admission Record, the resident had a medical history that included diagnoses protein-calorie malnutrition and disorders of bone density and structure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #71's Care Plan Report with an admitted [DATE], revealed no care plan to indicate the resident could self-administer their medications. Resident #71's Order Summary Report that contained active orders as of 04/22/2025, revealed an order dated 04/07/2021, for albuterol sulfate hydrofluoroalkane (HFA) aerosol solution, inhale two puffs orally every four hours as needed for wheezing and shortness of breath and calcium carbonate tablet chewable, give two tablets by mouth one time a day for supplement. There was also an order dated 08/23/2024, for calcium citrate-vitamin D oral tablet, give two tablets by mouth one time a day for supplement. There was no order to indicate the resident could self-administer their medications. During an observation on 04/21/2025 at 10:14 AM, the surveyor noted an albuterol inhaler, Coricidin D (an over-the-counter oral cough suppressant medication), and calcium supplement at the bedside of Resident #71. In an interview on 04/22/2025 at 9:10 AM, Registered Nurse (RN) #3 stated Resident #71 did not self-administer their medications and the resident's albuterol inhaler should be stored in the medication cart. In an interview on 04/23/2025 at 11:31 AM, RN #4 stated staff should not leave medications at a resident's bedside. 2. An Admission Record indicated the facility admitted Resident #55 on 12/14/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of congestive heart failure. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/07/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #55's Care Plan Report with an admitted [DATE], revealed no care plan to indicate the resident could self-administer their medications. Resident #55's Order Summary Report that contained active orders as of 04/22/2025, revealed no physician's order for Coricidin high blood pressure (HBP), an over-the-counter oral cough suppressant medication. During a concurrent interview and observation on 04/21/2025 at 2:24 PM, the surveyor noted Coricidin HBP on Resident #55's overbed table. Resident #55 stated they was waiting to get the physician's approval for the Coricidin HBP. During an interview on 04/23/2025 at 11:31 AM, Registered Nurse #4 stated staff should not leave medications at a resident's bedside. In an interview on 04/23/2025 at 2:06 PM, the Director of Staff Development stated medications should not be left at the resident's bedside unless it was care planned and in a locked container. During an interview on 04/24/2025 at 10:27 AM, the Executive Director stated medications were only allowed to be stored at a resident's bedside when there was a physician's order to do so. During an interview on 04/24/2025 at 10:50 AM, the Director of Nursing stated medications could only be left at a resident's bedside when a resident had been assessed to self-administer their medications and there was a physician's order to do so.

Based on interview and record review, the facility failed to ensure POLST (Physician Orders for Life-Sustaining Treatment- a medical order that outlines a patient's preferences for end-of-life care) was correctly documented into Resident 1's medical record. As a result, Resident 1's POLST signed by the physician to a full code status was changed to a Do Not Resuscitate (DNR) status. This failure had the potential for Resident 1 to not receive the full medical treatment in the event of a medical emergency. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included multiple fractures of the pelvis (break of the ring of bones that connect your spine to the hips), per the facility's Admission Record Form. On [DATE], an unannounced visit to the facility was conducted related to an alleged complaint that the facility changed the order of the resident's wishes listed in the POLST form from a full resuscitation to do not resuscitate , in case of medical emergency. A review of Resident 1's POLST form indicated, the POLST form was signed by the resident's wife on [DATE], and the physician signed the POLST on [DATE]. The POLST indicated, Resident 1 wished to be resuscitated if the resident had no pulse or was not breathing and full treatment if resident was found to have pulse and/or was breathing. A review of Resident 1's IDT Admission Assessment documentation, dated [DATE] indicated, under the Advanced Directive Resident 1 was a Full Code, Full Treatment. A review of Resident 1's Order Summary Report dated [DATE], indicated an order for Full Cardiopulmonary Resuscitation (CPR). A new order was changed to Do Not Resuscitate (DNR) dated [DATE]. During a concurrent record review and interview on [DATE] at 1:16 P.M., with the Licensed Nurse (LN) 1, LN 1 stated Resident 1's Full Code status was ordered on [DATE] according to Resident 1's POLST form. LN 1 further stated the physician signed the POLST form on [DATE]. LN1 acknowledged that the order for [DATE] for DNR was incorrect. During an interview on [DATE] at 3:31 P.M., with LN 3, LN 3 stated Resident 1's DNR code status was entered incorrectly during the audit process. LN 3 acknowledged that she entered Resident 1's code status incorrectly. LN 3 further stated that Resident 1's code status should be Full Code and not DNR. During an interview on [DATE] at 3:45 P.M., with the Administrator (ADM) and the Director of Nursing (DON), the ADM stated it's important for the staff to enter the code status correctly to ensure residents' wishes were honored. A review of the facility's policy and procedure, titled, Promoting the Right of Self-Determination for Healthcare Decisions and Advanced Healthcare Directives, dated [DATE], indicated . Each resident will receive the necessary care and services to attain or maintain the highest practice physical, mental, and psychosocial wellbeing, in accordance with comprehensive assessments and plan of care. Each resident and/or legal healthcare decision maker will be provided a mechanism for reaching decisions concerning preferred intensity of care, including the right to forego or withdraw life sustaining treatment.

Based on observation, interview, and record review, the facility failed to ensure three of six residents' (Resident 1, 2, and 3) medications were stored securely when: -Resident 1's medications were observed at the resident's bedside. -Resident 2 and 3 reported their medications were left at their bedsides. These failures had the potential for residents to receive the wrong medication and/or incorrect dosage which may cause clinically significant adverse consequences. Findings: A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]. A review of Resident 2's Admission Record indicated the resident was readmitted to the facility on [DATE]. A review of Resident 3's Admission Record indicated the resident was admitted to the facility on [DATE]. On 4/16/24 at 3:26 P.M., a telephone interview was conducted with Resident 3. Resident 3 stated her morning thyroid medication was often left at her bedside around 5 A.M., to take later when she woke up. On 4/17/24 at 10:27 A.M., an observation and interview was conducted with Resident 1 while inside the resident's room. There were four pills in a medicine cup on Resident 1's bedside table. Resident 1 stated the licensed nurse (LN) left the medications at his bedside this morning because he takes the pills slowly. On 4/17/24 at 11:09 A.M., an interview was conducted with Resident 2. Resident 2 stated there were times when her morning medications were left on her bedside table for her to take when she woke up. On 4/17/24 at 11:42 A.M., a joint observation in Resident 1's room and interview was conducted with LN 5. LN 5 observed the medications left at Resident 1's bedside. There were three pills inside Resident 1's medication cup: one round white pill, one oblong white pill marked ATV 40, and one yellow capsule marked 138 138. LN 5 stated the pills looked like vitamin C, atorvastatin (cholesterol lowering medication), and gabapentin (medication for pain). LN 5 stated atorvastatin was a medication given at night. LN 5 stated medications should not have been unsecured and left at the resident's bedside. LN5 further stated Resident 1 could have double dosed or missed a dose of medication. A review of Resident 1's April 2024 medication administration record (MAR) indicated the resident's atorvastatin 40 mg was scheduled to be given at 9 P.M. The same MAR indicated Resident 1's atorvastatin had been administered on 4/1/24 and 4/8/24 and coded as refused 4/2/24 through 4/7/24 and 4/9/24 through 4/16/24. On 4/17/24 at 3:30 P.M., an interview was conducted with the director of nursing (DON). The DON stated medications should not have been left unattended at the residents' bedsides. The DON stated residents could have experienced adverse medication reactions, taken too much medication, not enough medication, or incorrectly administered the medication to themselves. A review of the facility's policy titled Medication Storage in the Facility updated August 2019, indicated, Medications and biologicals are stored safely, securely, and properly

Based on interview and record review, the facility failed to ensure one of four residents' (Resident 3) routine medication was available to be administered to the resident. As a result, Resident 3 was not consistently administered her daily thyroid medication. Findings: A review of Resident 3's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hypothyroidism (low thyroid hormones). A review of Resident 3's physician order dated 10/2/23, indicated the resident was to receive levothyroxine (thyroid medication) 125 micrograms, two tablets daily, that was scheduled to be given at 6:30 A.M. On 4/16/24 at 3:26 P.M., a telephone interview was conducted with Resident 3. Resident 3 stated, The pharmacy here's not good, refills and deliveries don't get done. Resident 3 stated during the first week of April (2024) there were four days she did not receive her levothyroxine. Resident 3 stated when she asked about the availability of her levothyroxine, the licensed nurse (LN) told her there was none. On 4/17/24 at 2:25 P.M., a joint interview and record review was conducted with LN 5. LN 5 stated he worked on 4/8/24 and went to administer Resident 3's levothyroxine at 6:30 A.M., and the medication had been unavailable. LN 5 stated he informed Resident 3 that her medication was unavailable, and the resident told him that she had not received her levothyroxine for four days. LN 5 reviewed Resident 3's medication administration record (MAR) and stated he documented by mistake that Resident 3's levothyroxine had been administered on 4/8/24. LN 5 stated Resident 3's medication had not been available to administer to the resident and the pharmacy had not delivered it yet. LN 5 stated Resident 3 should have received her levothyroxine as ordered. A review of the pharmacy receipts titled Consolidated Delivery Sheets indicated Resident 3's levothyroxine refill (a 30-day supply) had been delivered to the facility on [DATE]. Resident 3's previous levothyroxine refill (30-day supply) had been delivered on 2/27/24. On 4/17/24 at 3:30 P.M., an interview was conducted with the director of nursing (DON). The DON stated Resident 3's levothyroxine should have been available and administered to the resident as ordered. A review of the facility's policy titled Medication Orders updated August 2019, did not provide guidance related to availability of medications and administration as ordered.

Based on observation, interview, and record review, the facility failed to supply a physician prescribed condom catheter (an external apparatus that fits on the outside of the penis and drains urine into an external bag) for one of one resident (Resident 1). As a result, the facility placed an indwelling catheter (sterile flexible tube placed inside the penis, to drain urine from the bladder into an external bag). When the indwelling urinary catheter was removed, Resident 1 experienced pain, bleeding, and verbalized fear of possible future indwelling urinary catheter placements. Findings: An unannounced visit was made to the facility on [DATE], in response to a complaint which involved an indwelling urinary catheter. Resident 1 was admitted to the facility on [DATE], with diagnoses of quadriplegia (inability to move arms/legs with paralysis from the neck down, per the facility ' s Admission Record. On [DATE] an interview was conducted with Resident 1, in his room. Resident 1 stated he no longer had anyone to care for him at home and was admitted to the hospital for long-term care placement. Resident 1 stated he has been a quadriplegic since 2007, following a motor vehicle accident. Resident 1 stated since 2007, he had been using condom catheters due to urinary incontinence (inability to control bladder). Resident 1 continued, stating when he arrived at the skilled nursing facility, he was told the facility ' s current supply of condom catheters were expired and a new box would need to be ordered. Since the condom catheters were unavailable, Licensed Nurse 1 (LN 1) placed Resident 1 in disposable underwear, designed to absorb urine referred to as incontinence briefs. Resident 1 stated he began to develop redness and skin irritation to his buttocks and the staff wanted him to have an indwelling urinary catheter, to give his skin a chance to heal until the condom catheters arrived. Resident 1 stated he was initially resistant, but eventually agreed to have the indwelling urinary catheter inserted. Resident 1 stated LN 1 inserted the urinary catheter. Resident 1 stated the following day, he realized he was having minimal urine output, so he requested LN 1 to remove the catheter. Once the catheter was removed, Resident 1 saw lots of bright red blood coming from his penis and he got scared. Resident 1 stated LN 1 was trying to stop the bleeding by applying paper towels to his penis, then she left to get the charge nurse for help. Resident 1 stated the charge nurse decided to send him to the hospital for evaluation. Resident 1 stated the emergency room physician said the catheter most likely had not been placed properly, which caused the bleeding. Resident 1 stated the emergency room staff placed a condom catheter on him and he was sent back to the long-term care facility with extra condom catheters. Resident 1 was told he needed to see a urologist for urethral scoping (allows a physician to see the inside of the urethra and bladder by using a small scope-like camera), in a week to see if there was any long-term damage inside his urethral. Resident 1 stated he was so worried the facility might run out of condom catheters again, and they would try to put another internal urinary catheter in him. Resident 1 stated the internal catheter really, freaked me out, and he never wanted to go through that again. On [DATE], Resident 1 ' s clinical record was reviewed. The admission Minimal Data Set (MDS-a clinical assessment tool), dated [DATE], listed a cognitive score of 12, indicting cognition was intact. The functional abilities indicated Resident 1 was dependent with transferring from bed to chair, showers, toiletry, but he could assist staff with rolling from side to side. The bladder and bowel section indicated Resident 1 was always incontinence of bowel and bladder. According to the facility ' s document, titled Skin & Wound Evaluation, dated [DATE], Moisture Associated Skin Damage (MASD) . right gluteal fold (right buttocks) . edge appears flush with wound bed or a sloping edge . Per the physician ' s order, dated [DATE], Right buttock, MASD: wash with soap and water, apply barrier cream at brief changes every day and evening shift for skin maintenance and, Patient agrees to have foley (brand name) catheter. There was no documented evidence of a physician ' s order for discontinuing the urinary catheter. Per the care plan, undated, titled Resident is incontinent (unable to control bowel and bladder discharge) related to quadriplegia, listed interventions such as: Check and change during personal care, house barrier ointment/cream, clean with each incontinence episode. There was no documented evidence a care plan was developed for indwelling or condom catheter. On [DATE] at 12:05 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated she started on [DATE], and could not find any documented evidence urinary catheters care in-services were provided to LNs or certified nursing assistants (CNAs) since she started. LN 1 ' s employee record was reviewed. LN 1 started working at the facility on [DATE]. Included, LN 1 ' s employee file was a 5-page document, titled Job Description/Performance Evaluation, both dated and signed by LN 1 on [DATE]. The first page, titled IV. Key/Essential Duties listed 32 job functions and at the end of each job functions were columns listed as: Great Performance (GP), Good Performance (G), Must Improve (MI). All the columns were blank with no checks or comments from an evaluator or supervisor. There was no documented evidence a supervisor or evaluator observed, documented, or reviewed LN 1 ' s knowledge or skills, and no other signatures except LN 1 ' s were present on the document. The DSD stated she had not conducted any annual competence skills evaluation with LNs since she took over the position. The DSD stated ideally nurses should have their skills and performances evaluated upon hire and annually to identify each staff members strengths and weakness. On [DATE] at 12:36 P.M., an interview was conducted with LN 1. LN 1 stated she had not performed any skills or performance checks when hired. LN 1 stated she had not received any in-services related to urinary catheter insertion or care while at this facility. LN 1 stated she graduated from nursing school in 2021 and received some urinary catheter training while in school. LN 1 stated she has inserted ,d+[DATE] catheters since nursing school and has never had any problems except for this last time, involving Resident 1. LN 1 continued, stating the facility had condom catheters size #25, but they were expired. More condom catheters were ordered, but central supply (Person who orders supplies for the facility) stated it would take about a week to receive more. LN 1 stated Resident 1 was placed in incontinence briefs until the condom catheters arrived. LN 1 stated on [DATE], she noticed moisture skin damage on Resident 1 ' s buttocks and suggested a urinary catheter. LN 1 stated Resident 1 was very resistant, but finally agreed to let her insert one. LN 1 stated while she was inserting the catheter, Resident 1 yelled that it hurt and asked her to stop. LN 1 stated she got a flash of urine in the tube, so she assumed the tip of the catheter was in the bladder. LN 1 stated she started to inflate the 10 cubic centimeter (cc) balloon with saline (a clear sterile solution to inflate the balloon, so it stays in place in the bladder), but she was getting a lot of resistance and was only able to insert ,d+[DATE] cc in the balloon. LN 1 stated the balloon usually holds 10 cc of saline, but she was getting lots of resistance at ,d+[DATE] cc. LN 1 denied gently pulling or pushing on the catheter after the balloon was inflated. LN 1 stated the resistance was strange, and she never experienced anything like that before and could not figure out what was going on. LN 1 continued, stating the next day Resident 1 told her he wanted the urinary catheter removed, because he felt something was wrong and he was not putting out as much urine as he usually did. Resident 1 stated he wanted to go back to the incontinent briefs until the condom catheters arrived. LN 1 agreed to remove the catheter. LN 1 stated she deflated the balloon and began to pull out the catheter, when she noticed Lots of red blood coming from his penis. LN 1 stated she ran to get some paper towels to apply pressure, but the resident continued bleeding. LN 1 stated she left Residents 1 ' s room to inform her charge nurse and to get an ice pack to apply to Resident 1 ' s groin area. LN 1 stated this had never happened to her before and she was not sure what was going on. LN 1 stated the physician was informed and Resident 1 was sent to the hospital for an evaluation. LN 1 could not estimate the blood amount that was lost. LN 1 continued, stating she returned to work the following day and Resident 1 informed her the physician said the urinary catheter was not placed in the bladder, as it should have been and was inflated in the urethra (a stricture that allows urine to drain from the bladder out the penis). LN 1 stated she was so upset, and she does not want to ever insert a urinary catheter again. On [DATE] at 12:51 P.M., an interview was conducted with the Charge Licensed Nurse (C-LN) on duty [DATE]. C-LN stated LN 1 said she was removing a urinary catheter from Resident 1, when he suddenly started to bleed from the penis. C-LN stated he went into the resident ' s room and noticed bright red blood on several paper towels, covering the residents groin area. C-LN stated he asked LN 1 how long the catheter had been in, and she replied one day. C-LN stated he instructed LN 1 to call the physician, while he completed a Change of Condition form. C-LN stated Resident 1 continued to bleed bright red blood slowly from the penis, so he was sent to the hospital for evaluation. C-LN stated he informed the Director of Nursing that Resident 1 was being sent out, but did not know what the cause of the bleeding was from. On [DATE] at 1:06 P.M., an interview was conducted with LN 2. LN 2 stated when inserting a urinary catheter, you will see a flash of urine in the clear flexible tubing. LN 2 stated before inflating the balloon, the LN should insert the tubing ,d+[DATE] inches more, to ensure the catheter was in the bladder. LN 2 stated if you got resistance with the balloon inflation, you probably were still in the urethra and should delated the balloon immediately, and insert the tubing further in. LN 2 stated if a nurse inflates the balloon in the urethra and not the bladder, you could cause damage to the urethral tissue and pain to the patient. On [DATE], the Director of Nursing (DON) was unavailable. On [DATE] at 1:20 P.M. an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she expected all LNs to have competency reviews upon hire and annual, to ensure they had the skills required to perform each nursing task. On [DATE], the hospital medical record were reviewed. According to the emergency room record, Resident 1 arrived in the emergency roiagnom on [DATE] at 3:58 P.M., with bleeding controlled. Resident 1 was seen by a urologist (a doctor who specializes in the urinary tract system) and cleared to return to the facility on [DATE], with condom catheters supplied. Resident 1 was to follow up the urologist in one week. On [DATE] at 3:16 p.m., an interview was conducted with the Urologist Nurse Practitioner (U-NP). The U-NP stated Resident 1 was seen on [DATE] for a follow-up of hematuria (blood in the urine). The U-NP stated Resident 1 had on a condom catheter, was urinating clear urine and had no pain, so a ureteroscopy (looking in the urethra via a scope) was not required or performed. The C-NP stated Resident 1 was told to return if there were any problems or concerns in the future. The U-NP stated she could not say what the bleeding was caused from, because she was not there when the urinary catheter was inserted or removed. On [DATE] at 1:41 P.M., an interview was conducted with the facility ' s central supply staff (CS 1). The CS 1 stated when Resident 1 was admitted ([DATE]) they had condom catheters, but not his size, which was #25. The CS 1 stated they had sizes that were larger and smaller, but not the #25 size. The CS 1 stated if you put on a larger size, it would just fall off, and a smaller size would not be comfortable. The CS 1 stated she ordered more and expected them to be delivered the following Monday ([DATE]). The CS 1 stated she informed staff and they said Resident 1 would be alright and could wait until they arrived. The CS 1 stated if something was urgent, she could have gotten additional condom catheters from one of their two sister facilities. The CS 1 also stated if they needed them stat (urgently) she could have ordered them over night on Amazon (an on-line delivery service), after getting the Administrator ' s permission, but the staff told her it was okay to wait and have them delivered. On [DATE] at 2:16 P.M., a follow-up interview was conducted with Resident 1. Resident 1 stated he has had a total of four urinary catheters placed since his 2007 accident. The first was immediately after the accident and he was in a coma. The second was a straight in and out catheter. The third was while he was recovering in a skilled nursing facility, and he was later told the catheter caused scar tissue damage to his urethra. Since the 3rd catheterization, he had a tissue prolapse (tissue coming out of the penis) which doctors refer to now as a skin tag. Resident 1 stated this last catheterization with the blood, freaked him out. He said he is better now and will never consent to a urinary catheter again, if he is given the choice. According to the facility ' s policy, titled Catheter (Indwelling) Insertion and Removal (Female and Male), undated, .11. DO NOT FORCE WATER INTO THE BALLOON. IF RESISTANCE IS ENCOUNTERED OR THE RESIDENT COMPLAINS OF PAIN, DEFLATE BALLOON, ADVANCE FARTHER INTO THE BLADDER AND INFLATE. 12. Tug gently on catheter until you feel resistance .

Based on interview and record review, the facility failed to ensure staff were competent upon hire for Licensed Nursing (LN) skills, such as the insertion of a urinary catheter for one of one staff reviewed (LN 1) for nursing competency. As a result, an indwelling urinary catheter (a sterile flexible tube placed inside the penis, to drain urine from the bladder into an external bag), was improperly inserted into Resident 1, resulting in bleeding when the catheter was removed the following day. (Cross reference F-684 Findings: An unannounced visit was made to the facility on [DATE], in response to a complaint received by California Department of Public Health involving the insertion of an indwelling urinary catheter. On 3/14/24 at 12:05 P.M., an interview and record review was conducted with the Director of Staff Development (DSD). The DSD stated she started working at the facility on 3/31/22. The DSD reviewed all the past in-services and stated she could not find any documented evidence urinary catheters care training was provided to LNs, reviewing in-service documents back to 2021. On 3/14/24, LN 1 ' s employee record was reviewed. LN 1 started working at the facility on 8/15/22. Inside LN 1 ' s employee file was a 5-page document, titled Job Description/Performance Evaluation, both dated and signed by LN 1 on 8/15/22. The first page, titled IV. Key/Essential Duties listed 32 job functions and at the end of each job functions were column boxes listed as: Great Performance (GP), Good Performance (G), Must Improve (MI). All the columns were blank with no checks or comments from an evaluator or supervisor. The remaining pages had sections uncompleted with titles such as Performance Accountabilities, Annual Review of Key Leadership Actions, Professional Growth, Documentation for Areas of Must Approve, and Performance Evaluation Acknowledgement. There was no documented evidence a supervisor or evaluator observed, documented, or reviewed LN 1 ' s knowledge or skills and no other signatures or dates were written on the document. The DSD stated she had not conducted any annual competence skills evaluation with LNs since she took over the position and believed the document titled, Job Description/Performance Evaluation was providing the LNs with their job description. The DSD stated ideally nurses should have their skills and performances evaluated upon hire and annually to identify each staff members strengths and weakness. The DSD stated LN 1 did not have any skill evaluations performed by an evaluator, so the facility was unaware of any additional training that should have been provided to improve her skills. On 3/14/24 at 12:36 P.M., an interview was conducted with LN 1. LN 1 stated she had not performed any skills or performance checks when hired. LN 1 stated she had not received any in-services related to urinary catheter insertion or care while at this facility. LN 1 stated she graduated from nursing school in 2021 and received some urinary catheter training while in school. LN 1 stated she had inserted 6-7 catheters since nursing school and has never had any problems before, except for this last time involving Resident 1. On 3/14/24, the Director of Nurses (DON) was unavailable for an interview. On 3/14/24 at 1:20 P.M., an interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated competency assessments should be perform on all staff upon hire. The ADON stated competency assessments were important to know the employees ' strengths and weaknesses, and to identify areas where additional training was required. The ADON stated without competency assessments, there would be no baseline to know how the employees grow and enrich their skills. The ADON stated annually competencies were also expected to be evaluated in order to refresh staff with the current standards of nursing practices. According to the facility ' s policy, titled Competency Evaluations, dated October 2022, .3. Initial competency is evaluated during the orientation process. An employee remains on orientation until all the competencies are verified. 4. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations .6. Checklist are used to document training and competency evaluations. 7. Only designated individuals may verify competency: a. Staff Development Coordinator, b. Orientation preceptor, c. Department head/Administrator, d. Higher level employee/professional who has demonstrated competency, e. Consultant expert, f. Physician .

Based on observation, interview, and record review the facility failed to follow infection control standards of practices when: 1. The Treatment nurse 1 (Tx LN 1) did not disinfect hands after removing gloves three out of six times while providing wound care for Resident 6. 2. Tx LN 1 did not disinfect scissors for two of two wound dressing changes for Resident 6. 3. One of three common resident shower rooms (shower between Station 1 and Station 2) was not cleaned after use. 4. Oxygen tubing was undated and was in contact with the floor for one of one resident (Resident 7). 5. A breathing treatment mouthpiece was exposed to the environment while lying on a tabletop for one of one resident (Resident 7). As a result, there was the potential for cross contamination and the spread of infection. Findings: 1. Resident 6 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the digestive system, per the facility ' s admission Record. On 12/29/23 at 10:42 A.M., an observation was conducted of Tx LN 1, while performing two abdominal wound dressing changes in Resident 6 ' s room. Tx LN 1 removed the old mid-abdominal dressing and used alcohol-based hand rub (ABHR), before applying new gloves. Tx LN 1 cleaned the wound with normal saline (NS), removed his gloves and put on a new pair of gloves without using ABHR or washing hands. TX LN 1 placed a new dressing, removed his gloves and placed on a new pair of gloves, without using ABHR or washing hands. On 12/29/23 at 10:45 A.M., Tx LN 1 continued by removing the second dressing located near the left groin area of Resident 6. Tx LN 1 removed his gloves and used alcohol-based hand rub (ABHR), before applying new gloves. Tx LN 1 cleaned the groin wound with NS, removed his gloves and put on a new pair of gloves without using ABHR or washing hands. TX LN 1 placed a new dressing, removed his gloves and placed on a new pair of gloves, without using ABHR or washing hands. 2. On 12/29/23 at 10:42 A.M., an observation was conducted of Tx LN 1, while performing two abdominal wound dressing changes in Resident 6 ' s room. While preparing the new dressing for the mid-abdominal wound, Tx LN 1 used scissors removed from the treatment cart to cut the Xerofoam (a medicated, non-adhesive dressing) package to obtain a smaller dressing to apply to the wound. Tx LN 1 was not seen disinfecting the scissors before removed from the treatment cart or after use cutting the Xeroform package. On 12/29/23 at 10:45 A.M., Tx LN 1 used the same scissors, previously removed from the treatment cart and used to cut the mid-abdominal wound to cut a second package of Xerofoam dressing. The interior Xeroform dressing was applied the smaller wound in the left groin area. Tx LN 1 was not seen disinfecting the scissors before or after use. On 12/29/23 at 10:50 A.M., Tx LN 1 returned the scissors to a drawer in the treatment cart without disinfecting the scissors. On 12/29/23 at 10:52 A.M., an interview was conducted with Tx LN 1. Tx LN 1 stated he was unaware he was supposed to use ABHR or wash hands between all glove changes, and thought he only needed to disinfect his hands when he touched something dirty. Tx LN 1 stated he never thought about disinfecting the scissors between use, but it made sense, since the scissors were touching the contaminated outside packaging and then touching the sterile dressing inside. Tx LN 1 stated by not using ABHR with all glove changes and not disinfecting the scissors between use, he could have caused cross contamination from one wound to the other. On 12/29/23 at 11:29 A.M., an interview was conducted with Tx LN 2. Tx LN 2 stated ABHR or hand washing needed to be completed each time gloves were removed. Tx LN 2 stated it was important to keep the wounds as clean as possible and by using ABHR, you minimized the risk of cross contamination. Tx LN 2 continued, stating if scissors were used during wound treatments such as customizing the new dressings, the scissors needed to be disinfected before and after each use, to ensure they were clean and to prevent cross contamination. 3. At 12/29/23 at 11:11 A.M., an observation was conducted of a common shower room, located between Station 1 and Station 2. The shower room was unlocked and had a foul smell when entered. The room contained three shower stalls on the right side. The first stall appeared recently used and had water droplets on the floor. The second stall contained a shower chair, with a brown substance on the shower floor. The second shower stall was dry and a used dry towel was hanging from the curtain rod. On 12/29/23 at 11:15 A.M. an observation and interview was conducted with certified nursing assistant (CNA 1), of the shower room located between Station 1 and Station 2. CNA 1 observed shower stall #2 and stated, It looks like poop, and it should have been cleaned up. CNA 1 stated the feces on the floor was an infection control issue and should have been cleaned up with disinfectant wipes, which were kept in the shower room for cleaning purposes. CNA stated it appeared the towel hanging on the curtain rod appeared dirty and it also should have been removed after the shower was used. CNA 1 stated the CAN ' s were responsible for cleaning and disinfecting the shower stalls after each resident. On 12/29/23 at 11:18 A.M., an observation and interview was conducted with licensed nurse (LN 3), of the shower room located between Station 1 and Station 2. LN 3 observed the feces on the floor inside shower stall 2 and the soiled towel hanging on the curtain rod. LN 3 stated the shower stall was dirty and should have been cleaned immediately after use. LN 3 stated the shower stall was an infection control issues and could cause cross contamination to others. LN 3 stated the housekeepers were responsible for checking and cleaning the showers. 4. Resident 7 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-a progressive and irreversible lung disease) with acute exacerbation (sudden worsening), per the facility ' s admission Record. On 12/29/23 at 11:05 A.M., an observation was made of Resident 7, while she sat up in bed. Resident 7 was wearing an oxygen cannula (a two-prong plastic tube, that delivers oxygen to the nose). The oxygen tubing was connected to an oxygen condenser (a machine that delivers oxygen), that was next to the right side of the bed. The oxygen tubing was undated, and it was in contact with the floor between the oxygen condenser and Resident 7. 5. On 12/29/23 at 11:05 A.M., an observation was conducted inside Resident 7 ' s room. On the bedside table to the left was an aerosol machine (a small machine that helps deliver a fine mist of medication to the respiratory system to assist in opening the airways). The undated oxygen tubing was connected to the machine and to a mouthpiece (attached to the mouthpiece was a container where the breathing medication was placed). The mouthpiece was resting on the end of the table, exposed to the environment and was not covered or inside its original package of a clear plastic bag. On 12/29/23 at 11:09 A.M., an interview was conducted with LN 2 in the hallway outside Resident 7 ' s room. LN 2 stated oxygen tubing was changed and dated every 7 days, to ensure condensation and bacteria was not gathering within the tubing. LN 2 stated oxygen tubing should never be in contact with the floor, because bacteria could travel from the floor to the lungs and cause an infection. LN 2 stated mouthpieces for breathing treatments should always be placed back in their plastic bags to protect them from being exposed to contaminates. On 12/29/23 at 11:20 A.M., an observation and interview was conducted with LN 3 inside Resident 7 ' s room. LN 3 observed the oxygen tubing on the floor and stating the tubing should never be in contact with the floor because it could lead to cross contamination. LN 3 stated the oxygen tubing was not dated and since Resident 7 was admitted yesterday, her oxygen tubing should have been changed and dated upon admission, since they had no idea how long the hospital placed tubing had been in used. LN 3 observed the mouthpiece and the resident ' s breathing machine on a table top to the left of the bed. LN 3 stated the mouthpiece was exposed to the environment and was not placed back in the plastic bag, so it should be considered contaminated and should not be used again. LN 3 stated he needed to throw the mouthpiece away and get a new one, so the resident ' s airway was protected against cross contamination. On 12/29/23 The Infection Control Nurse (ICN) and the Director of Staff Development (DSD) were unavailable for interviews. On 12/29/23 at 11:35 A.M., an interview was conducted with the DSD assistant (DSD-A). The DSD-A stated handwashing or hand disinfectant should be performed right after any gloves were removed to prevent cross contamination. The DSD-A stated the CNAs were expected to clean and disinfect the shower room after each use. The DSD-A stated oxygen tubing should never be on the floor and the tubing needed to be changed and dated every seven-days, per the facility ' s policy. The DSD-A stated any breathing device needed to be secured in a container between use, because it could become infected, and the bacteria or infection could travel to the residents ' lungs. On 12/29/23 at 12:20 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated she expected all staff, especially treatment nurses to disinfect their hands between glove changes. The DON stated all scissors and other equipment repeatedly used needed to be disinfected between use, to prevent germs and cross-contamination. The DON stated CNAs were expected to clean and disinfect showers after each use. The DON stated feces and dirty towels in the shower rooms was an infection control issue and did not present a homelike environment. The DON stated oxygen tubing should never be in contact with the floor and any breathing mouth pieces had the potential to gather bacteria, so they should always be contained and secured for protection. On 1/8/23 at 1:06 P.M., an interview was conducted with the ICN. The ICN stated she expected all staff to use ABHR or perform handwashing anytime gloves were removed or put on. The ICN stated showers should always be clean and ready for use and oxygen tubing should never touch the floor. The ICN stated all the infection control issues identified had the potential for cross-contamination and residents could have been infected, causing harm. According to the facility ' s policy, titled Infection Prevention and Control Program, copyright 2023, .4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. B. Hand hygiene shall be performed in accordance with our facility ' s established hand hygiene procedure. e. Environmental cleaning and disinfection shall be performed according to the facility policy. All staff have the responsibilities related to the cleanliness of the facility .10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection or sterilization shall be cleaned in accordance with our current procedure . According to the facility ' s policy, titled Routine Cleaning and Disinfection, copyright 2023, .Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas . According to the facility ' s policy, titled Oxygen Administration, copyright 2023, .5. Staff shall perform hand hygiene and don (to put on) gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .7. Cleaning and care of equipment shall be in accordance with t facility ' s policies for such equipment .

Based on observation, interview and record review, the facility failed to consistently monitor and document a low air loss (LAL-a mattress designed to prevent and treat skin issues) mattress, for prevention of skin injuries as ordered by the physician and listed as an intervention in the care plans for three of three residents (Resident 1, 2, and 3), reviewed for plan of care in order to maintain skin integrity. As a result, Residents 1, 2, and 3 had the potential for worsening skin injuries. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (a low, progressive circulation disorder), and diabetes (abnormal blood sugar levels), per the facility's Admission Record. On 9/12/23 at 10:18 A.M., an observation and interview was conducted with Resident 1. Resident 1 was lying in bed on a LAL mattress with green padded-protection boots on both feet and both ankles were propped up on a pillow. Resident 1 stated she was not doing well today and had necrotic feet (dying tissue in her feet). On 9/12/23, Resident 1's clinical record was reviewed. According to the Minimum Data Set, (MDS-a clinical assessment tool), dated 8/31/23, a cognitive score of 13 was listed, indicating cognition was intact. The functional status indicated Resident 1 was bedridden and did not get out of bed. According to the Physician's Order, dated 6/19/23, .Check LAL Mattress . (maintain skin integrity) Check functionality & mode/setting every shift . According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, the LAL mattress settings were checked 105 times out of 123 opportunities. According to the facility's Care Plan, titled Diabetic ulcers, undated, listed an intervention of low air loss mattress. 2. Resident 2 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure) and diabetes, per the facility's Admission Record. On 9/12/23 at 11:53 A.M., an observation and interview was conducted with Resident 2. Resident 2 was lying in a bariatric bed (a bed wider than a standard hospital bed which is reinforced to support a higher weight capacity), with a LAL mattress. Resident 2 stated she fell at home and could get up, resulting in a Stage 4 pressure ulcer (a break in the skin from prolonged pressure which extends down to the muscle and bone). On 9/12/23, Resident 2's clinical record was reviewed. According to the MDS, dated [DATE], a cognitive score of 15 was listed, indicating cognition was intact. The functional status indicated Resident 2 was bedridden and did not get out of bed. According to the Physician's Order, dated 6/19/23, .Check LAL Mattress . (maintain skin integrity) Check functionality & mode/setting every shift . According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, the LAL mattress settings were checked 106 times out of 123 opportunities. According to the facility's Care Plan, titled Actual Pressure Ulcer left lateral thigh (Stage 4), undated, listed an intervention of low air loss mattress. 3. Resident 3 was admitted to the facility on [DATE], with diagnoses which included cerebral palsy (a disease that affect a person's ability to move independently), and diabetes, per the facility's Admission Records. On 9/12/23 at 11:12 A.M., Resident 3 was observed in bed, lying on a LAL mattress. On 9/12/23, Resident 3's clinical record was reviewed. According to the MDS, dated [DATE], a cognitive score of 15 was listed, indicating cognition was intact. The functional status indicated Resident 3 required 2 persona staff assist for transfers and bed mobility. According to the Physician's Order, dated 6/19/23, .Check LAL Mattress . (maintain skin integrity) Check functionality & mode/setting every shift . According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, the LAL mattress settings were checked 102 times out of 123 opportunities. According to the facility's Care Plan, titled Actual Pressure Ulcer, coccyx (bottom of the spine), dated 7/22/23, listed an intervention of low air loss mattress. On 9/12/23 at 12:55 P.M., an interview was conducted with Licensed Nurse 1 (LN 1). LN 1 stated if LAL mattresses were not routinely checked for proper settings, the mattress could be too firm, which would add pressure to the wound. If under inflated the mattresses would not properly support the wound. LN 1 stated with over or under mattress inflation, the wound could worsen and become larger. On 9/12/23 at 12:59 P.M., an interview was conducted with the treatment nurse (Tx LN). The Tx LN stated LAL mattresses needed to be checked regularly to ensure they were operational and programed at the proper settings. The Tx LN stated if the LAL monitoring was not documented on the TAR, then it was not done. The Tx LN stated mattress settings were very important for wound healing and to prevent the wound from worsening. On 9/12/23 at 1:14 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated LAL mattresses were set according to the resident's weight and needed to be monitored by staff to ensure the correct settings applied. The DON stated if LAL mattresses were not checked as ordered and documented, resident wounds could worsen and become infected. According to the facility's policy, titled Pressure Ulcer, Prevention of, dated 2006, .7. Use appropriate support surface in the resident's bed or chair. 8. Use pressure reducing or relieving devices as necessary .Documentation Guidelines: Date, time, approached to prevent pressure ulcer development, preventative equipment used . According to the facility's policy, title Use of Support Services, undated, .3. Support surfaces will be chosen by matching the potential therapeutic benefit with the resident's specific situation. Considerations for utilizing specialized support surfaces: a. Medical condition, b. Size and weight. c. Mobility and activity levels .e. Presence of pressure injuries, including severity and location . A schedule for inspection and replacement will be established accordingly .

Based on observation, interview, and record review, the facility failed to consistently provide wound treatments as ordered by the physician for two of three residents (Resident 1 and Resident 3) reviewed for Quality of Care. As a result, Residents 1 and 3 had the potential for delayed healing and worsening of wounds. Findings: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (a low, progressive circulation disorder), and diabetes (abnormal blood sugar levels), per the facility's Admission Record. On 9/12/23 at 10:18 A.M., an observation and interview was conducted with Resident 1. Resident 1 was lying in bed on a LAL mattress (low air loss-a mattress designed to prevent skin injuries), with green padded-protection boots on both feet and both ankles. Resident 1's legs were propped up on a pillow. Resident 1 stated she was not doing well today and had, necrotic feet (dying tissue in her feet). On 9/12/23, Resident 1's clinical record was reviewed. According to the Minimum Data Set, (MDS-a clinical assessment tool), dated 8/31/23, a cognitive score of 13 was listed, which indicated cognition was intact. The functional status indicated Resident 1 was bedridden and did not get out of bed. The skin condition listed venous and arterial ulcers. According to the Physician's Order, dated 4/17/23, .Treatment: bilateral buttocks, sacrum (lower spine) and coccyx (bottom of spine): Cleanse with normal saline, pat dry, apply barrier cream .every shift . According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, of the bilateral buttocks, sacrum, and coccyx, the treatments were completed 105 times out of 123 opportunities. According to the facility's Care Plan, titled Diabetic ulcers; Requires assistance with turning and repositioning: listed interventions of Low Air Loss mattress and Treatment as Ordered. 2. Resident 3 was admitted to the facility on [DATE], with diagnoses which included cerebral palsy (a disease that affect a person's ability to move independently), and diabetes, per the facility's Admission Records. On 9/12/23 at 11:12 A.M., Resident 3 was observed in bed, lying on a LAL mattress. On 9/12/23, Resident 3's clinical record was reviewed. According to the MDS, dated [DATE], a cognitive score of 15 was listed, indicating cognition was intact. The functional status indicated Resident 3 required 2 person staff assist for transfers and bed mobility. According to the Physician's Order, dated 4/26/23, .Treatment: Bilateral groin and abdominal folds: Cleanse with normal saline, apply barrier cream .every shift . According to the Treatment Administration Record (TAR) for 8/1/23 through 9/10/23, for the bilateral groin and abdominal folds, the treatments were conducted 106 times out of 123 opportunities. According to the facility's Care Plan, titled Actual Pressure Ulcer, coccyx (bottom of the spine), Requires turning and repositioning, dated 7/22/23, listed interventions of Low Air Loss mattress and Treatment as Ordered. On 9/12/23 at 12:55 P.M., an interview was conducted with Licensed Nurse 1 (LN 1). LN 1 stated skin and wound treatments needed to be done as instructed by the physician. LN 1 stated if the treatments were not completed, the skin or wounds could worsen. On 9/12/23 at 12:59 P.M., an interview was conducted with the treatment nurse (Tx LN). The Tx LN stated wound treatments needed to be performed consistent, so the skin could heal faster. The TX LN stated if wound treatments were not documented, then they were not done. The Tx LN stated if treatments were missed, residents were at risk of having the treatment areas worsen and possible infection. On 9/12/23 at 1:14 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated if wound treatments were not documented, then they were not done. The DON stated she expected all treatments to be performed according to the physician's order, or else wounds could worsen and become infected. According to the facility's policy, title Wound Treatment Management, dated October 2022, .1. Wound treatments will be provided in accordance with physician orders, including the cleansing. method, type of dressing, and frequency of dressing change . 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record .

Based on observation, interview, and record review, the facility failed to ensure a licensed nurse (LN 3) notified the physician immediately after the resident's family member (FM) reported redness in resident's right stump (the extremity of a limb left after a surgical procedure) for one of three sampled residents (Resident 1) and a gauze left in Resident 1's contracted (stiffening of joints) right hand. This deficient practice resulted in a delay of receiving treatment to prevent the onset of infection and placed Resident 1's health at risk. Findings: On 2/17/23, the Department received a complaint related to a delay of notifying the physician related to a redness in a resident's stump. On 2/23/23, an unannounced visit to the facility was conducted. Resident 1 was readmitted to the facility on [DATE], with diagnoses which included high blood sugar and right above the knee amputation (surgical removal of a limb), per the facility's Admission Record. A review of Resident 1's minimum data set (MDS - an assessment tool), dated 12/23/22, indicated Resident 1 had a brief interview for mental status (BIMS - an interview to determine the resident's mental status) score of 3/15 which meant Resident 1 had impaired cognition. a. On 2/23/23 at 3:39 P.M., a joint observation of Resident 1 and an interview of Resident 1's family member (FM) 1 was conducted. Resident 1 was sitting in a wheelchair by the activity area with a blanket on his lap, and a bandage on his right stump. Resident 1 just looked at the writer when asked and did not respond to questions. FM 1 stated on 2/11/23 (Saturday), she came to the facility and visited Resident 1. FM 1 stated she reported the soreness and redness on Resident 1's right stump to LN 3. FM 1 stated on 2/13/23, another FM (FM 2) came to visit the resident. Per FM 1, FM 2 checked the resident's right stump and noted some pus (a whitish-yellow, yellow, or brown- yellow protein-rich fluid that accumulates at the site of an infection) in it and requested to talk to the doctor. Per FM 1, the doctor was not notified about the redness in Resident 1's stump and a blister (an area of skin covered by a raised, fluid-filled bubble). FM 1 stated no one addressed the issue to the doctor. FM 1 stated because of the infection, Resident 1 will have to undergo another surgery of his right stump. FM 1 stated Resident 1 had some discomfort when his stump was touched. On 2/23/23 at 5:04 P.M., a joint review of Resident 1's clinical record and an interview was conducted with LN 2. LN 2 stated she worked on 2/13/23 (Monday) and was notified that Resident 1 had some redness and soreness on his right stump. LN 2 stated she noted a pus discharge and redness on the resident's right stump. LN 2 stated it could be an indication of infection. LN 2 stated she informed the attending physician on 2/13/23 and the physician ordered oral antibiotic treatment for Resident 1. LN 2 stated Resident 1's attending physician was surprised because of not being informed about it Resident 1's condition. LN 2 stated there was a delay in Resident 1's treatment due to his allergy to the initial oral antibiotics ordered by the the physician. LN 2 stated the new order was started on 2/20/23. LN 2 stated LN 3 was working on 2/11/23 and should have notified the attending physician right away because a delay of treatment could lead to an infection. On 3/13/23 at 2:01 P.M., a telephone interview was conducted with LN 3. LN 3 stated he was the nurse supervisor on 2/11/23 (Saturday). LN 3 stated Resident 1's FM reported that Resident 1 had some redness on his right stump. LN 3 stated an ointment and dressing was applied on Resident 1's right stump but forgot to notify the physician about the redness on Resident 1's right stump. LN 3 stated he should have notified the physician immediately to prevent the delay of treatment. On 4/3/23 at 1:17 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated the LN should have notified Resident 1's physician as soon as it was reported to him so treatment could have been initiated promptly, to prevent possible skin infection on resident's stump. A review of the facility's policy titled Notification of Changes, revised 10/16/22, indicated, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority . when there is a change requiring notification .Circumstances requiring notification include . 2. Significant change in the resident's physical .condition such as .Clinical complications. b. On 2/23/23 at 3:39 P.M., a joint observation of Resident 1 and an interview of Resident 1's FM (1) was conducted. Resident 1 was sitting in a wheelchair by the activity area with curled right hand inward. FM 1 stated on 2/13/23, FM 2 came to the facility and visited the resident. LN 2 checked Resident 1's right hand and took a black shaded colored gauze out from Resident 1's contracted hand. FM 1 stated, It was gross. We don't know how long it had been there. FM 1 stated Resident 1 was taken to his to his primary care physician (PCP) and an x-ray and a swab was done on his contracted right hand. On 2/23/23 at 5:04 P.M., a joint review of Resident 1's clinical record and an interview was conducted with LN 2. LN 2 stated she worked on 2/13/23 (Monday) and was notified by FM 2 about the black shaded colored gauze taken out from Resident 1's contracted hand. LN 2 stated she did not know how long the gauze was left on Resident 1's contracted hand. LN 2 stated there was a foul smell and discharges coming out of Resident 1's contracted hand. LN 2 stated when staff did exercises to Resident 1, nursing staff should have placed a small towel, not a gauze. LN 2 stated the staff should have checked the right hand and removed the gauze to prevent moisture build up, bacteria growth, and infection. On 4/3/23 at 1:17 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated staff should have inspected Resident 1's contracted hand daily, cleaned it, and ensure there was no gauze to prevent skin breakdown and possible infection. A review of the facility's policy titled, Skin Assessment, revised 2/23/22, indicated, .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment .

Based on observation, interviews, and record reviews, the facility failed to develop a care plan (detailed plan with information about a patient's treatment, goal, and interventions) for one of three sampled residents (Resident 1) with a skin breakdown on the contracted (stiffening of joints) right hand. As a result, Resident 1 developed infection on the contracted right hand and delay in receiving treatment. Findings: On 2/23/23, an unannounced visit to the facility was conducted. Resident 1 was readmitted to the facility on [DATE], per the facility's Admission Record. A review of Resident 1's minimum data set (MDS - an assessment tool) dated, 12/23/22 indicated, Resident 1 had a brief interview for mental status (BIMS - an interview to determine the resident's mental status) score of 3/15 which meant Resident 1 had impaired cognition. On 2/23/23 at 3:39 P.M., a joint observation of Resident 1 and an interview of Resident 1's family member (FM 1) was conducted. Resident 1 was sitting in a wheelchair by the activity area with a stiff/curled right hand inward. Resident 1 just looked at the writer when asked and did not respond to questions. FM 1 stated on 2/11/23 (Saturday), she came to the facility and visited Resident 1, and noticed Resident 1's contracted right hand. FM 1 stated on 2/13/23, another FM (FM 2) came to visit Resident 1. Per FM 1, FM 2 checked Resident 1's right hand together with the treatment nurse/Licensed Nurse (LN 2). Per FM 1, FM 2 and LN 2 took a black shaded colored gauze from Resident 1's contracted hand. FM 1 stated, It was gross. We don't know how long it had been there. FM 1 stated she took Resident 1 to his primary care physician (PCP) and an x-ray and a swab was done on Resident 1's contracted right hand. On 2/23/23 at 5:04 P.M., a joint review of Resident 1's clinical record and an interview was conducted with LN 2. LN 2 stated she worked on 2/13/23 (Monday) and was notified by FM 2 about the gauze on Resident 1's contracted right hand. LN 2 stated she took out the black shaded colored gauze from Resident 1's contracted hand. LN 2 stated she did not know how long the gauze had been there in Resident 1's contracted hand. LN 2 stated there was a foul smell and discharges coming out of the skin of Resident 1. LN stated there was no care plan developed for Resident 1's skin breakdown and contracted right hand. LN 2 stated a care plan should have been developed so staff could monitor the contracted right hand and skin, and document Resident 1's progress. On 4/3/23 at 1:17 P.M., a telephone interview with the Director of Nursing (DON) was conducted. The DON stated a care plan should have been developed to address Resident 1's contracted hand and skin impairment because the care plan provided Resident 1's assessments, interventions, and goal of treatment so staff could monitor the contracted hand and to be free from foul smell and possible infection. A review of the facility's policy titled, Baseline Care Plan, revised 5/20/22, indicated, .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .1. The baseline care plan will . b. Interventions shall be initiated that address the resident's current needs including: 1. Any health and safety concerns to prevent decline or injury .

Based on interview and record review, the facility failed to consistently provide skin care as ordered by the physician for one of three residents, (Resident 1), reviewed for Quality of Care. As a result, there was the potential for Resident 1's skin integrity to worsen and for new skin injuries to occur. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included wedge compression fracture of the fourth lumbar (fracture of the spine in the lower back) and multiple sclerosis (a progressive, debilitating disease of the central nervous system), per the facility's Admission Record. On 3/8/23, Resident 1's clinical record was reviewed. Resident 1 was sent to the hospital on 2/27/23 for a change of condition and returned to the facility on [DATE]. According to the quarterly Minimum Data Assessment (MDS-a clinical assessment tool), dated 12/19/22, Resident 1 had a cognitive score of 11, indicating cognition was moderately impaired. The functional status indicated Resident 1 required two staff for assistance with bed mobility, personal hygiene, toileting, and dressing. Section H, titled Bladder and Bowel, indicated Resident 1 was always incontinent of urine and bowel According to the physician's order, dated 1/15/23, Nystatin External Powder 100000 unit/gram nystatin Topical (medication to prevention fungal or yeast infection and applied to the outer skin for absorption). Apply to rash topically every day and evening and discontinue 2/22/23. According to the treatment administration record (TAR), dated 2/1/23 through 2/21/23, Resident 1 received the treatment 37 times out of 42 opportunities. According to the physician's order, dated 1/16/23, Skin Folds-cleanse skin gently, apply miconazole (used to treat fungal or yeast infection) powder to skin folds every shift and discontinue on 2/22/23. According to the TAR, dated 2/1/23 through 2/21/23, Resident 1 received the treatment 48 times out of 63 opportunities. According to the physician's order dated. 1/16/23, MASD (moisture associated skin damage), Buttocks and Thigh-cleanse gently, apply miconazole powder to buttocks and thigh, apply triad skin paste to areas exposed to urine and stool every shift and discontinue on 2/22/23. According to the TAR, dated 2/1/23 through 2/21/22, Resident 1 received the treatment 48 times out of 63 opportunities. According to the care plan, titled Actual impairment of skin integrity to 1. Sacrum, coccyx (lower spine), inner thighs, buttocks MASD/incontinence dermatitis (infection of the skin) 2. Left great toes abrasion, 3. Bilateral under breast redness, 4. All skin folds including axilla (arm pits) redness, initiated 1/4/17 and revised 3/8/23, listed interventions of good peri-care every shift, treatment as ordered. According to the care plan, titled Self-Care deficit: Needs assistance with activities of daily living, dated 7/19/19, list interventions of Bed Mobility, Transfers-Two-person physical assistance required. On 3/8/23 at 1:58 P.M., an interview was conducted with the treatment nurse (LN 2). LN 2 stated she worked Mondays through Saturdays and was the only full-time treatment nurse. The LN 2 stated if she was off or called in sick, the medication nurses were required to do the treatments and to document them. LN 2 stated she has come in on some Mondays and realized the wound treatments were not done while she was off. LN 2 stated if treatments were not completed as ordered, the residents were at risk for a worsening injury, prolonged recovery, and possibly an infection. On 3/8/23 at 2:10 P.M., an interview was conducted with License Nurse 1 (LN 1). LN 1 stated wound treatments were important for skin integrity and to check the wound site routinely to ensure it was healing properly. LN 1 stated if the physician ordered a treatment, it should always be carried out as ordered. LN 1 stated by not consistently providing skin care, the skin issues could worsen, or infection could occur. On 3/8/23 at 2:17 P.M., an interview was conducted with the Interim Director of Nursing (I-DON). The I-DON stated they were working on getting another full-time Treatment Nurse. The I-DON stated the treatments needed to be completed as ordered by the physician. The I-DON stated if the treatments were not being performed consistently, the resident's skin issues could worsen or other complications could occur, such as infection. The facility's job description for Treatment Nurse, undated, list duties and responsibilities as, Identifies, manages and treats specific skin conditions .Provide .care on assigned residents, in accordance with the physician orders . According to then policy, titled Wound Treatment Management, dated October 2022, .1. treatments will be provided in accordance with physician orders .7. Treatments will be documented on the Treatment Administration Record .8. The effectiveness of treatments will be monitored through ongoing assessments of the wound .

Based on interview and record review, the facility failed to: 1. Have an effective system in place to notify staff members of COVID-19 (an infectious virus, spread by airborne particles) test results when 1 of 19 staff members (HSKP 1), tested positive for COVID-19 on (12/9/20) and was never notified by the facility of the test results. HSKP 1 became aware of the, Positive result when notified on 12/16/20, by the local Public Health Department of the quarantine period ending. The infected employee continued working in one of three units (Unit One), the designated yellow zone, (non-affective COVID-19 residents and staff). HSKP 1 worked a total of seven days in the non-COVID-19 unit, unknowingly aware of the previous positive COVID-19 test. This failure had the potential to expose 24 non-infected residents and 19 staff members to the COVID-19 virus. In addition, the facility failed to; 2. Ensure and implement safe infection control practices when multiple staff congregated in one of three employee breakrooms (Unit 3) during an outbreak of COVID-19 (an infectious virus, spread by airborne particles) within Unit Three with all residents testing positive. Healthcare Providers were not limited to their assigned breakrooms, in specific units and two of three employee breakrooms did not have cleaning products to disinfect between use. These failures had the potential for staff to expose one another to the COVID-19 virus, and to spread infections to others. Findings: 1. On 12/18/20 at 12:15 P.M., an unannounced visit was conducted in response to a complaint, related to Infection Control. The facility had a census of 94, with nine residents in Unit One (the non-COVID unit) and 85 residents in Unit's Two and Three (all positive for the COVID-19 virus). On 12/18/20 at 12:20 P.M., the Administrator (ADM) stated the Director of Nursing (DON) had COVID-19 symptoms on 12/7/20, and went home. The DON reported she tested COVID-19 positive and was still out sick. On 12/18/20 at 12:52 P.M., Housekeeper 1 (HSKP 1) approached with a Spanish/English Translator, Certified Nursing Assistant (CNA 5), in the courtyard, outside Unit 3. HSKP 1 stated she received a call from the local County Public Health Department on 12/16/20, while at work. HSKP 1 stated the County representative informed her she had finished her quarantine and was cleared to return to work. HSKP 1 stated she was confused, and the County representative informed her she had tested positive for COVID-19. HSKP 1 stated she was tested for COVID-19 at the facility on 12/7/20, and the results of the test were reported to the facility and the County Health Department on 12/9/20. During the same interview, HSKP 1 stated she had no idea she tested positive for COVID-19, because she had no symptoms and no one had informed her. HSKP 1 stated she continued working after being tested , because she received no test results and she believed she was negative. HSKP 1 stated the facility's practice was to inform staff of positive tests only, not negative tests. During the same interview HSKP 1 stated she contacted the ADM on 12/16/20 and asked why she was never notified. HSKP 1 stated she was very upset because her husband had chronic medical conditions and her daughter recently tested positive. HSKP 1 stated the ADM told her he was not responsible for the notification of the COVID-19 test results to the staff, and the Director of Nursing (DON) who was responsible, should have contacted her. On 12/18/20 at 2:01 P.M., an interview and record review were conducted with the Director of Medical Records (DMR). The DMR stated COVID laboratory results were sent to him via a lab portal, which he signed into via email. If any laboratory results returned positive, the DMR was responsible for informing the ADM and DON via a Tiger text (an instant text message). The DMR stated the ADM and DON were responsible for notifying staff of their positive COVID test results. The DMR verified he reported all positive test results via Tiger text to the ADM and DON on 12/9/20 and 12/10/20. HSKP 1's positive COVID test results were included in the Tiger text on 12/9/20. On 12/18/20, HSKP 1's laboratory test result, sample ID # 279 were reviewed. A nasopharyngeal (a clinical test of nasal secretion from the back of the nose and throat) swab, lab test was conducted on 12/7/20, with results received and reported to the facility on [DATE]. The laboratory test indicated, Positive: [DIAGNOSES REDACTED]-CoV-2, RT-PCR (the name of a new virus in humans causing contagious respiratory illness). On 12/18/20 at 2:25 P.M., an interview and record review were conducted with the Director of Maintenance (DM). The DM stated he was responsible for supervising the housekeeping staff. The DM stated all HSPKs were assigned to specific units and always worked in their specified units. The DM stated he had never been informed of HSKP 1's COVID positive test results. The DM stated he learned of HSKP 1's test results on 12/16/20, by HSKP 1 who was very upset. The DM stated if he had known, he would have sent HSKP 1 home immediately, to quarantine. On 12/18/20 at 2:30 P.M., the DM reviewed the staffing schedule and stated HSKP 1 worked in Unit One, from 6:30 A.M. to 2:30 P.M. on the following days; 12/7/20, 12/10/20, 12/11/20, 12/12/20, 12/13/20, 12/15/20, and 12/16/20 (Seven days, in the non-COVID unit). On 12/18/20 at 3:34 P.M. an interview was conducted with the DMR. DMR stated on 12/10/20, the facility identified residents with both positive and negative COVID test results in all three units. The DMR stated in Unit One, where HSKP 1 worked, nine residents were positive for COVID-19. The DMR stated the ADM made the decision to cohort (to group individuals) all positive residents in Unit's Two and Three, and convert Unit One to the non-COVID unit after rooms were deep cleaned (disinfecting everything within the room, from top to bottom). During the same interview, the DMR provided a daily census for Unit One on the days HSKP 1 worked, after positive residents were moved out and non-COVID-19 residents moved in: 12/10/20 through 12/12/20- census 24 12/13/20 and 12/15/20-census 22 12/16/20- census 9 After review of the resident census, the DMR stated no additional residents or staff in Unit One, tested positive for COVID-19 during the weekly COVID-19 testing conducted on 12/14/20 through 12/15/20, with exception of three staff members, which lab results were still pending. On 12/18/20 at 4:50 P.M., an interview was conducted with the ADM. The ADM stated the DMR and the DON both had access to the laboratory portal to obtain staff and resident lab results. The ADM stated the DON was responsible for notifying staff of positive COVID test, and she just missed it referring to HSKP 1's positive result. The ADM stated the DON was working from home and no other persons were assigned as a back-up for notifications of positive COVID-19 test results. During the same interview, the ADM stated they did not notify staff of negative results, because they do not have the, manpower to notify everyone via phone, as they did with positive results. The ADM stated he did not notify the local County Public Health Department or the California of Department Public Health (CDPH) of their failure to inform the staff member of the positive result and allowing HSKP 1 to continue to work. The ADM acknowledged by not informing the employee, other residents, and staff were at risk of being infected with the COVID-19 virus. On 12/18/20, the staffing schedule for Unit One was reviewed. On 12/7/20, 12/10/20, 12/11/20, 12/12/20, 12/13/20, 12/15/20 and 12/16/20, a total of 19 staff members worked in Unit One during the time HSKP 1 was working. The staff consisted of licensed nurses (LN) and certified nursing assistants (CNA). The shifts reviewed were the night (11:00 P.M. - 7:30 A.M.) shift and the day shift (7:00 A.M. - 3:30 P.M.). On 2/18/20, at 5:09 P.M. and at 6:03 P.M., attempts to interview the DON were unsuccessful. The facility's Mitigation Plan, dated 9/16/20, and approved on 10/2/20, was reviewed. Per the Mitigation Plan, . Reporting Test Results: The facility understands that conducting tests under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver subjects them to regulations that require the reporting of data for all testing completed, for each individual tested . According to the Mitigation Plan, . Healthcare Personnel Monitoring and Return to Work: Asymptomatic positive HCP (Healthcare Providers) may not care for residents who have not tested COVID-19 positive until at least 10-days from the date of their positive test . On 12/18/20 at 6:15 P.M., the ADM was informed of Immediate Jeopardy related to the facility's failure to ensure safe and consistent Infection Control practices related to the COVID-19 virus. The facility began to develop a plan to remove the immediacy. On 12/18/20 at 6:20 P.M., a subsequent interview was conducted with the ADM. The ADM stated on 12/16/20, he learned from HSKP 1, the local County Public Health Department had contacted her. The ADM stated he immediately notified the DON to determine what happened and to start an internal investigation. On 12/18/20 at 6:40 P.M., the ADM was notified the immediate jeopardy was still in affect and a return visit was scheduled for the following day, 12/19/20 at 9 A.M., to review the facility's Plan of Action. On 12/19/20 at 9 A.M., the facility's Plan of Action was reviewed. The Plan of Action included: . 1. Staff with recent COVID-19 test results from 12/7/20 through 12/18/20 were attempted to be contacted. Lab portal results listed were used to communicate and track COVID test results notifications communicated to all individuals tested , both positive and negative. Any staff member that could not be contacted will have their lab results printed and made available in a sealed envelope. Completed 12/18/20. 2. Positive Employee contract tracing: All patients exposed to the positive employee were notified that they were potentially exposed to COVID-19 by nurse supervisor. Confirmation of notification was documented in the patients EHR (electronic health record). All 9 residents currently in Station One received a COVID-19 test as part of the weekly testing. All resulted negative. Completed 12/18/20. 3. Positive employee contact tracing: Staff were notified of potentially being exposed to COVID-19 via payroll system SMS text message as well as posting at the entrance where the positive employee worked. Staff working Station One received a COVID-19 test as part of the weekly testing. Eleven have resulted negative, 3 labs results are still pending. Completed 12/19/20. 4. New COVID-19 test result notification procedure: Lab portal will be checked daily. Email alerts have been set up with the lab to notify DON and HIM (Health Information Manager) when new lab results were available. When alerted, DON and/or HIM will check lab portal. New positive cases will be messaged to the IP (Infection Preventions), ED (Employee Department), Payroll and Staffing Coordinator. Members of the notification will confirm who is responsible for notifying positive individuals of their positive lab results. Staff testing positive will be informed and removed from duty according to the mitigation plan return to work policy. The Health information management team will make phone calls daily to inform staff of negative lab results and offer copy of results. Communication will be tracked on a contact log and reconciled to lab portal. We have reached out to the lab to see if they are capable of notifying staff when their test results become available and what their test result is. Completed 12/19/20. 5. County Public Health was called on 12/19/20 and notified a positive employee worked several days past the date of their COVID (+) test result. Completed 12/19/20. 6. The employee (HSKP 1) had passed her quarantine period, deemed recovered and returned to work. On 12/19/20 at 12:31 P.M., the Immediate Jeopardy was removed, and the ADM was notified after verifying the facility's Plan of Correction, while on-site. 2. On 12/18/20, at 12:15 P.M., an unannounced visit was conducted in response to a complaint, involving infection control. The facility had a census of 94, with nine residents in Unit One (the non-COVID unit, designated the yellow zone) and 85 residents in Unit's Two and Three (all positive for the COVID-19 virus, designated as the red zone). On 12/18/20 at 12:43 P.M., an observation was made of the employees' breakroom on Unit 3. On the door outside the breakroom was a sign, which instructed staff to stagger (fixed times) breaks with a limit of three people allowed in the break room. Unit 3's break room was estimated to be 10 x 20 feet in size. The room consisted of three tables, 3 x 3 feet in size, with one chair at each table, and two large vending machines. There was an additional glass door, which lead to an outdoor patio, which contained multiple chairs and a few tables. Inside the break room were five employees, eating pizza. One employee was sitting at each of the three tables and two employees were standing on the opposite end of the two tables. No facial coverings were being worn. The employee's sitting and standing were maintaining a distance, less than 6 feet apart from each other. No cleaning products were visible in the breakroom. On 12/18/20 at 12:47 P.M., CNA 5 was interviewed inside Unit 3's breakroom. CNA 5 was standing at table #3, closest to the outside patio door. CNA 5 stated staff were supposed to stagger their breaks and they were instructed to limit the staff members to the breakroom. CNA 5 stated there were currently too many people in the break room and they were not following the recommendations. On 12/18/20 at 1:44 P.M., an interview was conducted with the Director of Maintenance (DM), while inspecting Unit 2 and Unit 3's employee breakroom. The DM stated he supplied spray bottles with 10% bleach in each breakroom. On 12/18/20 at 1:54 P.M., an inspection of Unit 2's breakroom was conducted with the DM. The DM pointed to an empty bottle holder mounted on the wall, next to the employee bathroom. The DM stated the bottle was supposed to be hanging in clear view and staff were instructed to call him when the bottles needed to be replaced. An empty labeled bleach bottle was located under a table. On 12/18/20 at 1:59 P.M., Unit 3's breakroom was inspected with the DM. The spray bottle holder was empty and no disinfectant could be located. Inside Unit 3's breakroom were five employees, two of the employees were wearing masks, and the remaining three employees were seated at each table. The DM stated he does not routinely inspect the breakrooms for supplies, and he expected the employee to notify him when supplies needed to be replaced. The DM stated all five employees inside the Unit 3's breakroom were housekeepers and they should not be taking their breaks all at the same time. On 12/18/20 at 5:30 P.M., an interview was conducted with Licensed Nurse 3 (LN 3). LN 3 stated she does not take any of her breaks in Unit 3's break room because it was always too crowded. LN 3 stated the housekeeping staff like to gather there on their breaks or at the end of the day. LN 3 stated only three employees should be in the break room at any one time, and not all staff follow those guidelines. On 12/18/20 at 6:12 P.M., an interview was conducted with the Administrator (ADM) The ADM stated signs were posted at the entrance to all employee break rooms indicating only three employees should be in the room at a time, and breaks should be staggered. The ADM stated he expected each Unit to organize and manage the staggering of employee breaks. The ADM stated they had no management staff available to monitor the break rooms, due to the staffing shortage. On 12/19/20 at 9:23 A.M., an observation was conducted of Unit 3's breakroom. Six employees were in the room, five without facial coverings. Three employees identified themselves as housekeepers. HSKP 1 was assigned to Unit 1, the non-COVID unit, and the remaining housekeepers were assigned to Unit 2 and Unit 3, the positive COVID unit. Three CNA's stated they were from Unit 3. HSKP 1 stated she was never informed she should remain in her designated unit (Unit 1) and be utilizing Unit 1's breakroom. The CNA's all nodded they heads, yes, they were aware only three staff should be in the room at a time and they were supposed to stagger their breaks. The Infection Control Nurse (ICN) was not available for an interview on 12/18/20 or 12/19/20. According to the facility's Mitigation Plan, dated 9/16/20, and accepted by the California Department of Public Health . 5. DESIGNATION OF SPACE: The facility has practices in place for designated spaces within the facility to facilitate the separation of COVID infected residents and for eliminating movement of HCP (healthcare providers) among units .Housekeeping staff .HCP will be assigned separate break rooms and restrooms if possible .