Every finding on record at Laguna Hills Health and Rehabilitation Center

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of seven sampled residents (Resident 1). * The facility failed to ensure Resident 1's elevated temperature reading was reported to the physician. In addition, the facility failed to ensure Resident 1's abnormal lab results were reported to the physician. These failures had the potential for the resident to not receive the necessary care and interventions and negatively affect the resident's well-being. Findings: Medical record review for Resident 1 was initiated on 7/8/26. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 6/26/26, showed Resident 1 had capacity to make needs known. a. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical and/or mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical, emotional, and/or mental condition. Further review of the P&P showed a significant change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff by implementing standard disease related clinical interventions;b. impacts more than one area of the resident's health status;c. requires interdisciplinary review and/or revision to the care plan; andd. ultimately is based on the judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. Review of Resident 1's Weights and Vitals Summary dated 7/3/26, showed Resident 1 had a temperature of 101.8 degrees Fahrenheit. Review of Resident 1's medical records failed to show documented evidence Resident 1's physician was notified and made aware of Resident 1's elevated temperature. Review of Resident 1's Progress Notes dated 6/18/26 and 7/7/26, showed Resident 1 was admitted to acute care hospital with the diagnosis of sepsis. On 7/9/26 at 1125 hours, an interview and medical record review for Resident 1 was conducted with LVN 3. LVN 3 verified Resident 1 had an elevated temperature of 101.8 degrees Fahrenheit on 7/3/26. LVN 3 stated a normal temperature was around 98.6 degrees Fahrenheit. LVN 3 stated Resident 1's temperature of 101.8 degrees Fahrenheit was considered a COC and should have been reported to the physician to ensure Resident 1 did not develop sepsis. On 7/9/26 at 1354 hours, a telephone interview was conducted with RN 2. RN 2 stated an elevated temperature of 101.8 degrees Fahrenheit was considered a COC. RN 2 stated a resident with elevated temperatures should be assessed and the resident's physician should be notified of the resident's condition. b. Review of the facility's P&P titled Lab and Diagnostic Test Results - Clinical Protocol revised 11/2018 showed a nurse will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition. Review of Resident 1's Lab Results Report dated 7/1/26, showed Resident 1's WBC level was 11.78 10*3/ul and potassium level was 2.88 mEq/L. Further review of the laboratory results showed the reference ranges for WBC was 4.0 -11.0 10*3/ul and potassium was 3.5 - 5.5 mEq/L. Further review of Resident 1's medical records failed to show documented evidence Resident 1's physician was notified of the abnormal lab results report dated 7/1/26. On 7/9/26 at 1605 hours, an interview and medical record review for Resident 1 was conducted with the DON. The DON verified the above findings. The DON stated she reviewed Resident 1's laboratory results dated [DATE], and verified there was no documented evidence the physician was notified of Resident 1's abnormal laboratory results. The DON stated she expected the nurses to contact the physicians for abnormal laboratory results. On 7/9/16 at 1610 hours, an interview was conducted with the Administrator, DON, and Administrator Resource. The Administrator, DON, and Administrator Resource were made aware and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to inform the residents' responsible parties of a change of condition for two of nine sampled residents (Residents 5 and 6). * The facility failed to notify Resident 5 and 6's responsible parties when the residents had fall incidents. These failures resulted in the responsible parties not being informed timely of the residents' change of condition.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). In addition, the P&P showed the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. a. Closed medical record review for Resident 5 was initiated on 7/2/26. Resident 5 was admitted to the facility on [DATE], and was discharged on 6/17/26. Review of Resident 5's Advance Health Care Directive dated 10/14/24, showed Family Member 1 was the designated individual of Resident 5 as her agent to make health care decisions. Review of Resident 5's H&P examination dated 6/6/26, showed the resident had no capacity to understand and make decisions. Review of Resident 5's eInteract Change in Condition Evaluation - V 5.1 dated 6/7/26 at 0000 hours, showed the resident was on the floor lying on a thick comforter. The document further showed under the Resident Representative Notification, Resident 5 was notified of the incident on 6/7/26 at 0010 hours. Review of Resident 5's Multidisciplinary Care Conference V2 dated 6/9/26 at 1430 hours, showed a care conference was conducted. There was no documented evidence to show Family Member 1 was notified of the fall incident during the care conference 6/7/26. On 7/3/26 at 1018 hours, an interview and concurrent closed medical record review for Resident 5 was conducted with the SSD. The SSD stated part of the admission process was to verify if there was a responsible party for the resident. The SSD verified Resident 5's facesheet showed the resident was self-responsible. On 7/3/26 at 1046 hours, an interview was conducted with the SSD. The SSD stated Resident 5's daughter attended the care conference on 6/9/26, with the resident. The daughter who attended care conference was Family Member 1. The SSD stated Family Member 1 provided a copy of the Advance Health Care Directive. On 7/3/26 at 1059 hours, a follow-up interview was conducted with the SSD. The SSD verified Resident 5's fall incident on 6/7/26, was not discussed with Family Member 1, after Family Member 1 provided a copy of the Advance Health Care Directive which showed she was the resident's responsible party. b. Medical record review for Resident 6 was initiated on 7/3/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's admission Record (undated) showed his daughter was listed as his responsible party. Review of Resident 6's eInteract COC - V 5.1 dated 7/1/26 at 0130 hours, showed Resident 6 had a fall. Resident 6 was sitting next to his bed after trying to sit into his wheelchair to go to the bathroom. Resident 6's call light was within reach but was not initiated by the resident. The document further showed under the Resident Representative Notification, Resident 6 was self-responsible. Review of Resident 6's eInteract COC - V 5.1 dated 7/1/26 at 1500 hours, showed Resident 6 had a fall when he was found lying on the floor on the left side next to bed. Resident 6 stated he was trying to transfer himself back into bed without calling for help. The document further showed under the Resident Representative Notification, Resident 6 was self-responsible. On 7/3/26 at 1317 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 1. RN 1 verified Resident 6's daughter was listed as his responsible party, and stated the resident's daughter should have been notified of the fall incidents. On 7/3/26 at 1515 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were notified and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to one of nine sampled residents (Resident 8). * The facility failed to ensure a root cause analysis for Resident 8's right humeral fracture was completed. Additionally, there was no documented evidence to show how to provide care for Resident 8's fracture. This failure posed the risk of staff not providing appropriate care for Resident 8.Findings: Medical record review for Resident 8 was initiated on 7/3/26. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's Progress Note H&P examination dated 2/1/26, showed Resident 8 was initially admitted to the facility with generalized weakness, and fall with right knee tibial plateau fracture. Review of Resident 8's eInteract Change in Condition Evaluation dated 4/24/26, showed Resident 8 complained of right shoulder pain which started on 4/3/26. Further review of the document showed the physician recommended a right shoulder x-ray. Review of Resident 8's eInteract Change in Condition Evaluation dated 4/25/26, showed Resident 8 was found with right humeral fracture with the physician recommendation to be sent out to the acute care hospital. Review of Resident 8's After Visit Summary from the acute care hospital dated 4/25/26, showed the resident was diagnosed with an upper arm bone humerus fracture, and to use splint or immobilizer. However, further review of Resident 8's medical record failed to show documented evidence of a root cause analysis to address how Resident 8 sustained the right humeral fracture. Additionally, there was no documented evidence to show how staff could provide care for Resident 8's right humeral fracture. On 7/3/16 at 1130 hours, an interview and concurrent medical record review for Resident 8 was conducted with LVN 4. LVN 4 stated he did not know how Resident 8 sustained a right humeral fracture. LVN 4 stated they manage Resident 8's right humeral fracture by providing pain medication when she asks for it. LVN 4 was unsure if Resident 8 used a sling or immobilizer. On 7/3/26 at 1330, an interview and concurrent medical record review for Resident 8 was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure three of three nursing staff (CNAs 2 and 3, and LVN 4) interviewed demonstrated the competencies and skill sets needed to provide safe nursing care to the residents who were on anticoagulant medication. * CNAs 2 and 3 failed to explain failed to explain how to handle and care for residents that are on anticoagulant medication. * LVN 4 failed to explain what the main side effects to monitor for when the residents were on an anticoagulant medication. These failures had the potential for the residents to receive inadequate care and posed the residents at risk for adverse consequences.Findings: Review of the facility's document titled Certified Nurse Assistant (undated) showed the essential duties and responsibilities include:- making residents comfortable (putting them in bed, bringing them water, etc.);- helping residents with their daily grooming, shower or sponge bath;- proper lifting and transitioning residents from wheelchair to bed, bed to chair, etc.;- helping residents sit, stand and walk;- transporting residents to dining area (for meals and activities) and returning them to their room; and- timely report of change in residents condition to the nurse supervisor. Review of the facility's P&P titled Anticoagulation-Clinical Protocol revised 11/2018 showed the staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems.If any individual in anticoagulation therapy shows signs of excessive bruising, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. Medical record review for Resident 1 was initiated on 5/21/26. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Admission/readmission Data Tool effective date 4/29/26, showed Resident 1 had scattered discoloration to the upper extremities, abdominal area, and the right lower extremity. Review of Resident 1's Order Summary Report showed a discontinued physician's order dated 4/29/26, to monitor for ecchymosis (bruising, abnormal bleeding, bloody stool, coffee ground emesis, vomitus, nosebleed, and skin tears. Report to physician promptly every shift (anticoagulant use). Review of Resident 1's Order Summary Report dated 5/13/26, showed Pradaxa (blood thinner medication used to prevent and treat blood clots) oral capsule 110 mg, give one capsule by mouth every 12 hours for atrial fibrillation. Review of Resident 1's MAR for 2026, showed Resident 1 was administered with Pradaxa medication on the following dates and times:- dated 5/14/26 at 1700 hours;- dated 5/15/26 at 1700 hours;- dated 5/16/26 at 0900 hours;- dated 5/17/26 at 0900 hours, and 2100 hours;- dated 5/18/26 at 0900 hours, and 2100 hours;- dated 5/19/26 at 0900 hours, and 2100 hours;- dated 5/20/26 at 0900 hours, and 2100 hours;- dated 5/21/26 at 0900 hours, and 2100 hours; and- dated 5/22/26 at 0900 hours. a. Review of the facility document titled Nursing Staffing Assignment and Sign in sheet dated 5/2/26 at 2200-0700 hours, showed CNA 3 was assigned to Resident 1. On 5/21/26 at 1517 hours, an interview was conducted with CNA 3. When asked how residents who were at risk for bruising and bleeding easily cared for, CNA 3 apologized and could not answer the question. When asked if Resident 1 was observed with any bruising, CNA 3 stated he could not remember. When asked if CNA 3 knew what bruising was, CNA 3 stated he did not. After explaining what bruising was, CNA 3 was asked what the process was if he noticed any bruising on the resident, CNA 3 stated he would provide pericare, apply zinc cream, and if there's an infection to inform the charge nurse. b. Review of the facility document titled Nursing Staffing Assignment and Sign in sheet dated 5/3/26 at 0700-1500 hours, showed CNA 2 was assigned to Resident 1. On 5/21/26 at 1435 hours, an interview was conducted with CNA 2. CNA 2 verified she was assigned to Resident 1 on 5/3/26. When asked how residents were handled during care when the residents were taking blood thinners and have the risk of bleeding and bruising easily. CNA 2 stated to wear a gown and gloves. When asked how residents were handled during bladder and bowel care, showering and repositioning if they bruise and bleed easily, CNA 2 stated, ask for help. c. On 5/22/26 at 1510 hours, an interview was conducted with LVN 4. When asked if he had worked with Resident 1, LVN 4 stated he has since her recent admission. When asked what the process was if a resident was on anticoagulant medication, LVN 4 stated they were high risk for bleeding, and they were monitored for bleeding. When asked if they were only monitored for bleeding, LVN 4 stated that I know of. When asked where the monitoring was documented, the LVN stated in the MAR. When asked how and what to monitor on the residents who were on anticoagulant medications, LVN 4 stated he would have to check, and that he was aware they are at high risk for bleeding. On 5/21/26 at 1601 hours, an interview was conducted with the DSD. The DSD stated her role as the DSD was to provide onboard training, staffing education, and help with staffing. When asked if CNAs were educated on what it means to be on a blood thinning medication, the DSD stated they knew to report any changes of conditions. The DSD verified there were no in-service training provided to the staff on how to care for the residents on anticoagulant medications. On 5/22/26 at 0913 hours, an observation was made of CNA 1 providing bladder and bowel care and changing the residents gown. CNA 1 called for LVN 3 to join to assess Resident 1's skin. Resident 1 was observed to have bruising on her left and right arm, and discoloration under her left breast. On 5/26/26 at 1121 hours, an interview was conducted with the DON. The DON was made aware about the staff interviews and acknowledged the findings. Cross reference to F757.

Based on observation, interview, medical record review, and the facility P&P, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of the pressure ulcer for one of three sampled residents (Resident 1). * The facility failed to provide the necessary skin treatment when Resident 1 was admitted to the facility with MASD to the perineum and the buttocks on 4/29/26, and when Resident 1 was readmitted with pressure injury. In addition, the facility failed to assess Resident 1's pressure injury, obtain an order for the pressure injury, and ensure Resident 1's low air loss mattress setting was correct. These failures had the potential for the resident's existing pressure injury to worsen and developed additional wounds.Findings: Review of the facility's P&P titled admission Assessment and Follow Up: Role of the Nurse revised 9/2012 showed the purpose of this procedure is to gather information about the residents physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing the required assessment instruments, including the MDS. Review of the facility's P&P titled Resident Examination and Assessment revised 2/2014 showed the purpose of this procedure is to examine and assess the resident for any abnormalities in health status which provides a basis for the care plan. The preparation included the following: 1. Review the resident's admission assessment and/or preliminary care plan to assess for any special situations regarding their residents care;2. Assemble equipment and supplies as needed Review of the facility's P&P titled Prevention of Pressure Injuries revised 4/2020 showed the following:Skin Assessment: 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment as indicated according to the residents risk factors, and prior to discharge2. During the skin assessment, inspect:a) presence of erythema;b) Temperature of skin and soft tissue: and;c) Edema3. Inspect the skin on a daily basis when performing or assisting with personal care or ADL's.a) Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency;b) Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.)c) Wash the skin after any episodes of incontinence, using pH balanced skin cleanser;d) Moisturize dry skin daily, and;e) Reposition resident as indicated on the care plan.Monitoring:1. Evaluate, report and document potential changes in the skin; and2. Review the interventions and strategies for effectiveness on an ongoing basis; Medical record review for Resident 1 was initiated on 5/21/26. Resident 1 was admitted to the facility on [DATE], transferred to the acute care hospital on 5/3/26, and readmitted on [DATE]. Review of Resident 1's H&P examination dated 5/14/26, showed Resident 1 had the capacity to make decisions. a. Review of Resident 1's Admission/readmission Data Tool effective date 4/29/26, showed Resident 1 had MASD in the perineum and buttocks. Review of Resident 1's Care Plan Report dated 4/30/26, showed a care plan problem addressing the resident is at risk for pressure sore or the potential for pressure ulcer development related to disease process. Review of Resident 1's medical records failed show the wound care orders for Resident 1's MASD and if the skin was monitored for MASD. On 5/26/26 at 1121 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. When asked what wounds Resident 1 was admitted with on 4/29/26, the DON stated Resident 1 had MASD on the peri area and buttocks. When asked what interventions were implemented, the DON verified there were no treatment orders or any treatments rendered for Resident 1 prior to her discharge to the acute hospital on 5/13/25. b. Review of Resident 1's Wound Care RN Assessment and Recommendation from the acute care hospital dated 5/8/26, showed Wound 5/3/26 Pressure Injury Coccyx. The note showed the date and time it was first assessed was 5/3/26 at 2200 hours. The section for Present on Original Admission, indicated yes. The note further showed Resident 1 had coccyx Stage 2 pressure injury. Review of Resident 1's Admission/readmission Data Tool dated 5/13/26 showed, Resident 1 had healing Stage 3 pressure injury on the coccyx, bruise on back to abdomen, and a dressing on the upper back. Review of Resident 1's Progress Notes dated 5/14/26 at 0834 hours, showed Resident 1 had scattered discolorations throughout BUE/BLE/trunk/back, dark purple in color with intact skin.no further skin issues noted. Review of Resident 1's document titled SNF admission Note dated 5/14/26, with the physician's progress notes showed the following active problems:- Deep tissue pressure injury of sacrum. There is a community acquired pressure-related deep tissue injury in the sacrum which was discovered during admission on [DATE]. Wound care consult.- Pressure ulcer of sacrum Stage 3. Diagnosis present and considered in the overall care of this resident. Review of Resident 1's medical records failed to show the wound care orders or monitoring for Resident 1's pressure injury. On 5/21/26 at 1630 hours, a telephone interview was conducted with LVN 1. LVN 1 stated the process for admissions would include reviewing medications, ensuring medications were correct, and performing an assessment which includes a skin assessment. LVN 1 stated the major skin assessment would occur the following morning. On 5/22/26 at 0850 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 2. LVN 2 stated the process for admissions would be for the treatment nurse to assess the resident's skin the following day of admissions. When asked of Resident 1's skin was reassessed by a treatment nurse after 4/29/26, LVN 2 verified there were no other skin assessments after 4/29/26. When asked if Resident 1's skin was assessed upon transfer to the acute care facility on 5/3/26, LVN 2 verified the skin assessment were left blank, since the resident was transferred out as an emergency transfer. On 5/22/26 at 0913 hours, an observation was conducted of CNA 1 providing bladder and bowel care and changing Resident 1's gown. CNA 1 called for LVN 3 to join to assess Resident 1's skin. Resident 1 was observed to be wearing adult briefs and lying on a LAL (low air loss) mattress. When CNA 1 removed the adult briefs, it was observed Resident 1 had bright pink/redness in her perineal area with spots or broken skin, redness in the bilateral groin, and redness on her sacrum with an open spot. LVN 3 stated she would do a change of condition and wait for the physician's orders before providing any treatment. On 5/22/26 at 1038 hours, a wound care observation for Resident 1and concurrent interview was conducted with LVN 3. LVN 3 was observed providing Resident 1's wound care treatment. LVN 3 stated she received the new physician's orders for Resident 1's Stage 1 pressure injury to the sacrococcyx, and perineal MASD. Review of Resident 1's TAR for May 2026 showed a physician's order dated 5/22/26, for perineal MASD; cleanse with NS (normal saline), pat dry, apply zinc oxide (wound treatment) ointment with antifungal ointment (Miconazole 2%) to the affected area and leave open to air daily and as needed for 30 days, and sacrococcyx pressure injury (Stage 1), cleanse with NS, pat dry, apply zinc oxide ointment (Miconazole 2%) to the affected area and cover with foam dressing daily and as needed for 30 days then reassess. On 5/22/26 at 1129 hours, a follow up interview and concurrent medical record review for Resident 1 was conducted with LVN 2. LVN 2 stated on 5/14/26, Resident 1's skin assessment showed she had a healing Stage 3 pressure injury. When asked if there were any treatments rendered for her healing Stage 3 pressure injury, LVN 2 stated she did not see anything until 5/22/26. c. On 5/22/26 at 0930 hours, an observation of Resident 1's low air loss mattress setting and concurrent interview was conducted with LVN 3. Resident 1's LAL mattress setting was beyond the 320 pounds indicator. When asked how to set the LAL mattress setting, LVN 3 stated the setting was according to the resident's weight. When asked if Resident 1 weighed more than 300 pounds, LVN 3 stated no. LVN 3 was observed turning the LAL mattress setting down to the 160 pounds indicator. On 5/22/26 at 1129 hours, a follow up interview and concurrent medical record review for Resident 1 was conducted with LVN 2. When asked how the LAL mattresses were set, LVN 2 stated based on the resident's weight and comfort. When asked how to identify if the resident was comfortable, LVN 2 stated ask the resident. When asked if Resident 1 was over 300 lbs., LVN 2 stated no. LVN 2 verified Resident 1 only weighed 113 lbs. LVN 2 was made aware of the observation when the LAL setting was at 230 and 160 lbs. LVN 2 acknowledge the LAL mattress settings were inaccurate.

Based on observation, interview, medical record review, and the facility P&P review, the facility failed to provide the necessary care and service for one of three sampled residents (Resident 1) who was on anticoagulant medication. * The facility failed to ensure Resident 1 was monitored for the side effects of anticoagulant medication use. This failure had the potential delay in the identification of the side effects due to anticoagulant medication use and for the resident to receive necessary care and interventions.Findings: Review of the facility's P&P (Policies and Procedures) titled Anticoagulation-Clinical Protocol revised 11/2018 showed the staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems If any individual in anticoagulation therapy shows signs of excessive bruising, hematuria (presence of blood in urine), hemoptysis (coughing or exportation of blood or blood -tinged mucus), or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. Medical record review for Resident 1 was initiated on 5/21/26. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed a discontinued physician's order dated 4/29/26, to monitor for ecchymosis (bruising, abnormal bleeding, bloody stool, coffee ground emesis, vomitus, nosebleed, and skin tears. Report to physician promptly (anticoagulant use) every shift. Further review of the physician's order failed to show the monitoring for anticoagulant use was not ordered when Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Admission/readmission Data Tool dated 5/13/26, showed healing Stage 3 on the coccyx, bruise on back to abdomen, and a dressing on upper back.Review of Resident 1's Order Summary Report dated 5/13/26, showed Pradaxa (blood thinner medication used to prevent and treat blood clots) oral capsule 110 mg (milligrams), give one capsule by mouth every 12 hours for atrial fibrillation (an irregular and often very rapid heart rhythm). Review of Resident 1's MAR (Medication Administration Summary) for dated May 2026 showed Resident 1 was administered Pradaxa medication on the following dated and times:- dated 5/14/26 at 1700 hours;- dated 5/15/26 at 1700 hours;- dated 5/16/26 at 0900 hours;- dated 5/17/26 at 0900 hours, and 2100 hours;- dated 5/18/26 at 0900 hours, and 2100 hours;- dated 5/19/26 at 0900 hours, and 2100 hours;- dated 5/20/26 at 0900 hours, and 2100 hours;- dated 5/21/26 at 0900 hours, and 2100 hours; and- dated 5/22/26 at 0900 hours. On 5/22/26 at 0913 hours, an observation was conducted for Resident 1. Resident 1 was observed lying in bed with bruising on her left upper arm. On 5/22/26 at 1129 hours, an interview and concurrent medical record review was conducted with LVN 2. When asked if Resident 1 was taking any anticoagulant medications, LVN 2 stated, yes Pradaxa. When asked what were the side effects of taking an anticoagulant medication, LVN 2 stated skin discoloration, bleeding, ecchymosis and bleeding gums. LVN 2 verified Resident 1 was not monitored for side effects while taking an anticoagulant medication. On 5/26/26 at 1121 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified Resident 1 had scattered discoloration to upper and lower extremities, and skin discoloration to the abdomen. When asked what would be the process for the residents that were taking anticoagulants, the DON stated to monitor for bruising, bleeding, and discoloration. The DON verified Resident 1 was not monitored for anticoagulant side effects. Cross reference F726.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were stored in a safe manner for two of two nonsampled residents (Residents 5 and 6). * The facility failed to ensure the medications for Residents 5 and 6 were not left unattended on top of Medication Cart A. This failure had the potential for the medication to be accessed by an unauthorized individuals.Findings: Review of the facility's P&P titled Medication Labeling and Storage dated 2/2023 showed the facility stores all the medications and biologicals in locked compartments under proper temperature, humidity and light controls. Further review of the P&P showed to not leave medications unattended. On 4/15/26 at 1212 hours, an observation in the facility hallway and concurrent interview was conducted with RN 1. Two medication bubble packs were observed left unattended on top of Medication Cart A by room [ROOM NUMBER]. Medication Cart A was parked in the hallway where the staff, residents, and visitors would pass through. The following were on top of Medication Cart A:- a bubble pack of doxazosin mesylate (blood pressure medication) one mg tablet, to give one tablet by mouth one time a day for hypertension (high blood pressure) for Resident 5. The bubble pack contained nine white tablets; and - a bubble pack of Xarelto (blood thinner) 10 mg tablet, to give one tablet by mouth one time a day for DVT prophylaxis for Resident 6. The bubble pack contained four red tablets. RN 1 was called and verified the findings. RN 1stated the medications should not be left unattended to ensure protection of the residents' safety and privacy. a. Medical record review for Resident 5 was initiated on 4/15/26. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's Order Summary Report showed a physician's order dated 3/24/26, for doxazosin mesylate one mg tablet, to give one tablet by mouth one time a day for hypertension and to hold if the SBP was less than 110 mmHg. b. Medical record review for Resident 6 was initiated on 4/15/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Order Summary Report showed a physician's order dated 2/19/26, for Xarelto 10 mg tablet, to give one tablet by mouth one time a day for DVT prophylaxis On 4/16/26 at 1715 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged above findings.

Based on interview, closed record review, and facility P&P review, the facility failed to ensure the discharge information and assessments were completed for one of seven sampled residents (Resident 1). * The facility failed to ensure the information in Resident 1's Discharge Instruction Form/Recapitulation of Stay was complete. In addition, the facility failed to provide documentation to show Resident 1 was given the instructions and medications upon discharge. These failures had the potential for Resident 1 to not receive a complete discharge information, instructions, and medications which could potentially affect the resident's health. Findings: Review of the facility's P&P titled Discharging the Resident revised 12/2016 showed the following:- If the resident is being discharged home, ensure the resident and/or responsible party receive teaching and discharge instructions; and- Assess and document resident's condition at discharge, including skin assessment, if medical condition allows. Closed medical record review for Resident 1 was initiated on 3/24/26. Review of Resident 1's Facesheet dated 3/25/26, showed Resident 1 was readmitted to the facility on [DATE], and discharged on 3/20/26. The document also showed Resident 1 had a history of compression fracture (occurs when a spinal bone collapses, typically causing sudden, sharp back pain) of T7-T8 (seventh and eighth vertebra located in mid-back), and hypertension (high blood pressure) and muscle weakness. Review of Resident 1's H&P examination dated 3/12/26, showed Resident 1 had the capacity to make medical decision. Review of Resident 1's Physician's Order Summary showed the following physician's order:- dated 3/5/26, alendronate sodium (a medication used to treat/prevent osteoporosis - bone disease characterized by decreased bone mass and density, making bones fragile and prone to fracture) oral tablet 70 mg, in the morning every Saturday;- dated 3/5/26, amlodipine besylate (blood pressure medication) oral tablet 5 mg, one tablet one time a day for hypertension (high blood pressure);- dated 3/5/26, calcium citrate plus 315-5 mg-mcg (calcium citrate-vitamin D - supplement) two tablets two times a day;- dated 3/5/26, apixaban (blood thinner) oral tablet 5 mg, give one tablet by mouth every 12 hours for atrial fibrillation (rapid heart beat);- dated 3/5/26, for the back surgical incision, to keep a dry gauze bandage over the sutures/staples for two weeks post operation (surgery date 3/2/26). If the gauze/ bandage becomes soiled or falls off, replace until two weeks post op, every shift until 3/16/26; - dated 3/6/26, physical therapy QD, five times per week for 60 days with therEx, therAct, gait training, neuro re-ed, group therapy and occupational therapy QD, five times per week for 60 days with therEx, therAct, neuro re-ed, group therapy, and self-care management due to muscle weakness. Further review of Resident 1's physician's order dated 3/17/26, showed the last covered day of the the resident in the facility was on 3/16/26, and to discharge on [DATE] back to prior living arrangements/hotel, home health registered nurse for medical management, and home health physical therapy for safety evaluation. Review of Resident 1's Discharge Instruction Form/Recapitulation of Stay dated 3/20/26, showed blank entries on the following sections:- Therapy services received while in SNF (Skilled Nursing Facility);- Medication Education - medication reconciliation of medications, provided current list of reconciled medications list to the subsequent/next provider, and the name of the next provider;- Social Services & Activities - dental condition, vision, hearing, speech, cognition and activities;- Emergency - contact information for urgent problems of if your symptoms get worse;- Current Medical Diagnoses - relevant medical condition;- Functional Status;- Discharge Day Status - skin assessed and condition on discharge, lung sounds, and the abdomen, bowel and urinary status. Further review of Resident 1's discharge instruction form showed a check mark to indicate a Discharge Information/Recap of Stay and Pharmacy Discharge Medication Summary were sent with Resident 1. However, the facility failed to show the documentation or the copy of form which contained the current medication list and what medications Resident 1 was discharged with, considering Resident 1 was on high blood pressure and blood thinner medications. On 4/2/26 at 1513 hours, an interview and concurrent closed record review for Resident 1 was conducted with the DON. The DON verified Resident 1's discharge instruction form information and assessments were incomplete and verified there was no documentation to show the current medication list and what medications Resident 1 was discharged with.

Based on interview, closed medical record review, and the facility P&P review, the facility failed to provide the necessary services to maintain the resident's highest practicable well-being for one of seven sampled residents (Resident 3). * The facility failed to initiate a change of condition assessment and notify the physician when Resident 3 had a second fall on 3/29/26. In addition, the facility failed to update Resident 3's care plan with the interventions to prevent injury and further fall. These failures had the potential for Resident 3 to not receive the appropriate care and interventions which could negatively affect the resident's health and well-being.Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status dated 2/2021 showed the nurse will notify the resident's attending physician or physician on a call when there has been a (an): (a) accident or incident involving the resident.(i) specific instruction to notify of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that:a. will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting);b. impacts more than one area of the resident's health status;c. requires interdisciplinary review and/or revision to the care plan. The P&P further showed prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Review of the facility's P&P titled Falls - Clinical Protocol revised 3/2018 showed the following:- The physician will help identify individuals with a history of falls and risk factors for falling. (a) Staff will ask the resident and the caregiver or family about a history of falling. (b) The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). (c) While many falls are isolated individual incidents a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause.- The staff will evaluate and document falls that occur while the individual is in the facility; for example when and where they happen, any observations of the events, etc. The Fall P&P's Cause Identification showed for an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall and under the section for Monitoring and Follow-up showed the following:- The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls.b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented;- If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. Medical record review for Resident 3 was initiated on 4/1/26. Review of Resident 3's Facesheet dated 4/6/26, showed Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's eINTERACT Change in Condition Evaluation form dated 3/29/26 at 0635 hours, showed Resident 3 had a fall on 3/29/26. The form further showed during routine morning medication pass at 0635 hours, Resident 3 was found in her room next to her bed laying down on the floor. Review of Resident 3's Progress Note Dated 3/29/26 showed the following:- at 1900 hours, showed Resident 3 was noted laying on the floor on her left side with her head laying on the pillow, no complaints of pain or discomfort;- at 2314 hours, the LVN spoke to Resident 3's family member. On 4/1/26 at 1158 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 3 had fallen on the previous night. On 4/3/26 at 1518 hours, an interview was conducted with LVN 1. LVN 1 stated she received a report Resident 3 had sustained a fall. When asked how many falls Resident 3 had, LVN 1 stated two or three. Further review of Resident 3's medical record failed to show a post fall assessment was completed or the physician was notified when Resident 3 had another fall incident. Review of resident 3's Care Plan Report dated 3/30/26, showed a care plan problem showing during routine morning medication passed at 0635 hours patient was found in her room next to her bed laying down on the floor. Further review of the care plan failed to show for revised interventions to help prevent injuries and recurrence of fall. On 4/7/26 at 1511 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 verified Resident 3 had two falls on the same day on 3/29/26 at 0635 hours and 1900 hours. When asked if a COC was initiated for the second fall, RN 1 stated I don't see one. When asked if a second fall process would include a COC, RN 1 stated that's my understanding. RN 1 verified there was no documentation to show if the physician was notified of the second fall. When asked if the physician should have been notified, RN 1 stated of course, yes. On 4/7/26 at 1702 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide an adequate and written notice of the room change for one of five sampled residents (Resident 1). * The facility failed to communicate the room change to Resident 1 in her primary language. In addition, the facility failed to provide Responsible Party 1 a written notice of Resident 1's room change. These failures had the potential for resident's rights to be violated.Findings: Review of the facility's P&P titled Room Change/Roommate Assignment revised 3/2021 showed the following:- Resident room or roommate assignment may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered; and- Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives) are given at least a 1 hour advance written notice of such change. Advance written notice of a roommate change includes why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate. On 3/19/26 at 1632 hours, a telephone interview was conducted with Responsible Party 1. Responsible Party 1 stated the SSD left a voicemail for her stating they were moving Resident 1 from a private room to a shared room. Responsible Party 1 stated she rushed to the facility and was verbally told the facility needed Resident 1's private room for an incoming resident who would require an isolation room. Responsible Party 1 stated she was not given any documentation or notice in writing of the room change. Responsible Party 1 stated she asked for additional time to pack and move Resident 1's belongings as she had been in the same room for five years and that request was denied. Responsible Party 1 further stated the staff began to move Resident 1's belongings to the new room and it was very upsetting for Resident 1. Medical record review for Resident 1 was initiated on 3/25/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS assessment dated [DATE], under Cognitive Patterns showed a BIMS summary score of 9 which indicated moderate cognitive impairment. Review of Resident 1's Facesheet showed Resident 1's primary language was other. On 3/25/26 at 1315 hours, an interview was conducted with Resident 1 with Responsible Party 1 present. Resident 1 stated the room change was very distressing for her as she had to pack all of her belongings so quickly and felt the facility should not have done that to her because she had been in her previous room for a long time. On 3/25/26 at 1328 hours, an interview and concurrent facility document review was conducted with the SSD. The SSD stated the room change process would include filling out a Notification of Room Change form. The SSD stated the purpose of the Notification of Room Change form was to notify all parties of the room change and to inform them of their rights to appeal the room change. Review of Resident 1's Notification of Room Change form showed the form was not complete. The form was missing the date of notification of both Resident 1 and Responsible Party 1, whether they approved of the change, and the signature of Resident/Resident Representative and date. The SSD stated if they attempt to reach the resident's representative and they were unable to speak to them, they will not do the room change. The SSD stated a call was placed to Responsible Party 1 and a voicemail was left, but they did not wait for Responsible Party 1 to respond before beginning the room change. The SSD stated she had a conversation with Resident 1; however, she spoke to Resident 1 in English and did not use a translator to explain the situation to Resident 1 in her native language of Farsi. The SSD acknowledged she should have used a translator to communicate the situation to Resident 1. On 3/25/26 at 1405 hours, an interview and concurrent facility document review was conducted with the Admissions Director. The Admissions Director stated the process for a room change would include filling out the Notification of Room Change and notifying the resident and responsible party if necessary and if the resident does not speak English, we had a translator line we can use, or we will use a staff member to translate. The Admissions Director also verified the Notification of Room Change form for Resident 1 was incomplete. On 3/25/26 at 1616 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator verified Resident 1's Notification of Room Change form was incomplete and not provided to Resident 1 or Responsible Party 1. The Administrator also verified Resident 1 speaks very little English.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from abuse. * CNA 5 borrowed $500 from Resident 1, which caused Resident 1 to feel worried and emotional when the money was not returned on time. CNA 5 then asked Resident 1 to lie and say the money was payment for work CNA 5 had done for the resident. This failure negatively affected Resident 1's emotional wellbeing.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation Prevention Program revised 4/2021 showed the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation Review of the facility's SOC 341 dated 12/29/25, showed Resident 1 loaned CNA 5 $500, and the money had not been fully returned. Medical record review for Resident 1 was initiated on 1/29/26. Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 7/14/25, showed Resident 1 had the capacity to understand and make medical decisions. The H&P further showed the resident 1 had diagnoses including generalized anxiety disorder. Review of Resident 1's SBAR Communication Form dated 12/29/25, showed there was a change in condition regarding the resident lending money to a staff member. Review of Resident 1's care plan dated 12/29/25, showed the resident was at risk for emotional distress and anxiety related to a recent incident when the resident voluntarily lent money to CNA 5 out of pity. Review of Resident 1's Progress Note dated 12/29/25, showed the ADON met with Resident 1 to discuss the matters of a CNA, who Resident 1 had stated borrowed $500 dollars. Further review of the Progress Note showed Resident 1 informed the ADON CNA 5 had expressed to Resident 1 she had financial struggles which caused Resident 1 to feel bad, so she loaned CNA 5 $500. Resident 1 further stated to the ADON CNA 5 paid Resident 1 $250 a week ago, but Resident 1 was worried because she had not received the rest of the money. Review of Resident 1's MDS assessment dated [DATE], showed the resident was cognitively intact. On 1/29/26 at 1315 hours, an interview was conducted with Resident 1. Resident 1 stated CNA 5 was one of the best CNAs she ever had. Resident 1 stated CNA 5 told her about the personal and financial hardships she was facing, and had offered CNA 5 $500 to help with the financial hardships. Resident 1 stated CNA 5 informed her she would pay her back in two weeks. Resident 1 stated CNA 5 paid her $250 a week later. Resident 1 stated CNA 5 then blocked her phone and stopped communicating. Resident 1 stated it was getting close to Christmas time and she was getting worried. Resident 1 stated she did not want to report it but one of the nurse supervisors overheard her talking about it on the phone with her sister. Resident 1 stated CNA 5 then contacted her and asked her to lie and say she had done work for her. Resident 1 stated it made her feel emotional. On 2/2/26 at 0949 hours, an interview was conducted with the SSA. The SSA stated Resident 1 informed them CNA 5 spoke to Resident 1 about CNA 5's struggles outside of work. The SSA stated Resident 1 felt sad about CNA 5's situation and did not want CNA 5 to get in trouble, but she just wanted the rest of the money back. On 2/2/26 at 1010 hours, an interview, medical record review and concurrent facility document review was conducted with the ADON. Review of the Employee handbook dated June 2024 showed under the section of giving and receiving gifts showed, staff cannot solicit or accept tips, gifts, loans, gratuities, bequests, or any item of value from any resident, family member, or visitor or any other person conducting business with the facility. Employees were also not allowed to purchase items or borrow money from residents. Any violation of the facility's gifts and gratuities policy could result in disciplinary action. The ADON stated every new employee receives a copy of the employee handbook upon hire. The ADON stated it was also included in the abuse training. On 2/4/26 at 1730 hours, an interview was conducted with the DON and the Administrator. The Administrator stated CNA 5 should not have taken the money from the resident. Cross Reference to 684

Based on interview and medical record review, the facility failed to conduct the status post change of condition assessments for one of nine sampled residents (Resident 1). * The facility failed to conduct any follow up nursing assessments on Resident 1 who had a change of condition involving an incident where a CNA borrowed money from Resident 1. This failure posed the risk for changes in Resident 1's psychosocial well-being not identified and potentially delayed the necessary care and treatment for the resident.Findings: Medical record review for Resident 1 was initiated on 1/29/26. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 1's H&P examination dated 7/14/25, showed Resident 1 had the capacity to understand and make medical decisions. Resident 1 had diagnoses including generalized anxiety disorder. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was cognitively intact. Review of Resident 1's SBAR Communication Form dated 12/29/25, showed there was a change in condition regarding Resident 1 lending money to a staff member. Review of Resident 1's Care Plan Report initiated on 12/29/25, showed a care plan problem to address Resident 1's risk for emotional distress/anxiety related to recent incident of voluntarily lending money to CNA out of pity. Review of Resident 1's Progress Notes dated 12/29/25, showed the ADON met with Resident 1 to discuss the matters of a CNA who Resident 1 had stated borrowed $500 dollars from her. Further review of the progress notes showed Resident 1 stated to the ADON CNA 5 had expressed to Resident 1 she had financial struggles which caused Resident 1 to feel bad, so Resident 1 loaned CNA 5 the money. Additional review of the progress notes showed Resident 1 stated CNA 5 had paid Resident 1 back the $250 a week ago; however, Resident 1 was worried because she had not received the rest of the money. On 2/2/26 at 1450 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON stated following a change in condition, nurses are required to conduct nursing assessments related to the change in condition every shift for 72 hours. The ADON stated the purpose of the post event nursing assessments was to address any potential complications from the specific change in condition. Review of Resident 1's progress notes did not show any post event nursing assessments and monitoring related to the change of condition incident. The ADON verified the nursing assessments were not done. Cross Reference to F602.

Based on interview, medical record review, and facility P&P review, the facility failed to implement their P&P to ensure timely reporting of a reasonable suspicion of a crime related to injuries of unknown source in accordance with Section 1150B of the Act for one of six sampled residents (Resident 4). * The facility failed to report timely to the CDPH, L&C Program, Long-Term Care Ombudsman office, and local law enforcement agency when Resident 4 was discovered with a discoloration to her right eyebrow region. This failure had the potential to compromise or impede the protection of Resident 4 and the other residents at the facility.Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Report and Investigating revised 9/2022 showed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations). If a resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Review of the SOC 341 - Report of Suspected Dependent/Elder Abuse dated 9/10/25, showed the facility had reported an allegation of abuse to the CDPH, L&C Program on 9/10/25 at 1357 hours, regarding the discoloration around the eye of Resident 4. The document showed Resident 4 was visited by Family Member 1 on 9/10/25, and Family Member 1 reported to the Administrator that he would like an investigation done. Medical record review for Resident 4 was initiated on 9/11/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had severely impaired cognition and was dependent on the facility staff for mobility. Review of Resident 4's Change in Condition Evaluation dated 9/8/25 at 2245 hours, written by LVN 2, showed Resident 4 was found with a coin-sized skin discoloration to the right eyebrow region. Resident 4's provider and resident representative were notified. Review of Resident 4's Skin/Wound Note dated 9/9/25 at 1153 hours, showed a skin assessment was done for Resident 4. The licensed nurse noted a purple discoloration around the right eye area measuring 5 cm x 1.5 cm and the skin was intact. The documentation showed Resident 4 had no complaints of pain, nor discomfort during the skin assessment and no other skin issues were noted. On 9/11/25 at 0940 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 4 required total assistance from the facility staff for activities of daily living and mobility. Family Member 1 stated he was notified about a discoloration to Resident 4's right eye on 9/8/25 between 2230 to 2300 hours. Family Member 1 stated he visited Resident 4 on 9/10/25, noticed she was bruised around her right eye, and had spoken with the Administrator to tell him he thought the bruising was caused by abuse to Resident 4. On 9/11/25 at 1528 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated CNA 2 had reported Resident 4 had a skin discoloration to her right eyebrow on 9/8/25 around 2100 to 2200 hours. LVN 2 stated he went to assess Resident 4 and Resident 4 had a coin-sized dark red in color discoloration to her right eyebrow. LVN 2 stated he was not sure where the discoloration came from and stated he and CNA 2 did not witness when Resident 4 developed the discoloration. LVN 2 further stated he attempted to ask Resident 4 what had happened; however, Resident 4 did not answer any questions at that time. On 9/11/25 at 1607 hours, an interview and medical record review was conducted with the DON. The DON was informed and acknowledged the findings. The DON stated Family Member 1 was notified at the time the discoloration was discovered, had visited Resident 4 on 9/10/25. The DON added Family Member 1 wanted the facility to investigate Resident 4's skin discoloration. The DON stated the facility did not know how Resident 4 got the skin discoloration and verified Resident 4 was unable to verbalize how she had gotten the skin discoloration. The DON stated the facility did not know the source of the injury until after the facility had conducted their investigation. On 9/15/25 at 1305 hours, an interview was conducted with the Administrator. The Administrator verified he was the facility's abuse coordinator and stated when someone reported an abuse, he would send the SOC 341 to the CDPH, L&C Program, ombudsman, and law enforcement if he was available. The Administrator stated he reported Resident 4's skin discoloration to her right eye because Family Member 1 wanted the facility to investigate. The Administrator stated Resident 4 did not remember how the skin discoloration happened and there were no witnesses. The Administrator stated it was unknown how Resident 4 got the skin discoloration and it would be reportable under normal circumstances. The Administrator stated Resident 4 was prone to accidents and reporting would be a gray area from his standpoint. On 9/15/25 at 1343 hours, an interview was conducted with the Administrator. The Administrator acknowledged the above findings.

Based on interview and closed medical record review, the facility failed to provide one of six sampled residents (Resident 1) sufficient preparation and orientation to ensure a safe discharge from the facility. * The facility failed to inform Resident 1 her insurance would not cover the cost of her physician ordered DME (a hospital bed and wheelchair), prior to her discharge from the facility. This failure had the potential to compromise Resident 1's ability to make an informed decision regarding her discharge plan of care, potentially leading to financial hardship, physical and psychosocial distress. Findings: On 9/10/25 at 0919 hours, a telephone interview was conducted with Resident 1. Resident 1 stated she was supposed to receive a hospital bed upon her discharge to home from the facility, however, she did not receive it. Resident 1 stated she was using her recliner chair, was unable to care for herself, had a lot of issues with her mobility, and only had a walker to assist with ambulation. Closed medical record review for Resident 1 was initiated on 9/10/25. Resident 1 was admitted to the facility on [DATE], with diagnoses including cellulitis (infection of the skin) of the right and left lower limbs, and lymphedema (chronic swelling in the soft tissues, most frequently in the arms or legs). Resident 1 was discharged from the facility on 8/27/25. Review of Resident 1's H&P examination dated 6/30/25, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 9/11/25, showed the following physician's orders:- dated 8/26/25, to discharge home on 8/27/25, per the resident's request with home health RN for safety, PT, OT, bath aide, and wound care; and- dated 8/27/25, for DME: hospital bed and ultralight wheelchair for safety and bed mobility. Review of Resident 1's Discharge Instruction Form/Recapitulation of Stay dated 8/27/25, showed Resident 1 had medical equipment arrangements upon discharge, however, the discharge instructions did not state the information about what DME was arranged, the company to contact, or when the DME would be provided. Further review of Resident 1's medical record failed to show documented evidence Resident 1's DME arrangements were set up by the facility prior to the resident's discharge. On 9/10/25 at 1505 hours, an interview and concurrent closed medical record review was conducted with the SS Staff. The SS Staff stated she assisted with arranging the home health, caregiver resources, transportation, and DME upon discharge of a resident. The SS Staff stated she would obtain the order for the DME from the physician and contact the DME company before the resident discharged , if the resident was able to receive the DME. The SS Staff stated if the resident requested to leave the day before the discharge, she sometimes would not receive a response from the DME company right away but would contact the resident the day after the discharge. The SS Staff stated Resident 1 discharged to her home on 8/27/25, and had physician's orders to discharge with a hospital bed and wheelchair. The SS Staff stated she was made aware Resident 1 was not eligible for her insurance to cover the DME on 8/27/25, and communicated this information to the SSD at around 1100 hours. The SS Staff stated she was not working on 8/27/25, and was not sure if the SSD communicated this information to Resident 1. The SS Staff verified she did not inform Resident 1 regarding her ineligibility for the DME prior to her discharge. On 9/10/25 at 1615 hours, an interview and concurrent closed medical record review was conducted with the SSD. The SSD stated if there was a physician's order for the DME, she expected her staff to inform the resident if their insurance or DME company could not provide the DME and a progress note to document the conversation had occurred with the resident. The SSD stated the SS Staff had made the referral for Resident 1's DME and knew Resident 1 would discharge on [DATE]. The SSD stated if the facility staff knew it was not possible to have the DME in place prior to the resident's discharge, she expected her staff to educate the resident about the timeframe for the services to be set-up. The SSD stated she did not communicate to Resident 1 the information regarding Resident 1's ineligibility for the DME. The SSD verified there was no documented evidence Resident 1 was notified regarding her DME services prior to or after her discharge from the facility. On 9/15/25 at 1343 hours, an interview was conducted with the Administrator. The Administrator acknowledged the above findings.

Based on interview, closed medical record review, and facility P&P review, the facility failed to ensure a notice of transfer/discharge was provided to the resident or the resident's responsible party for one of six sampled residents (Resident 2) prior to the resident's discharge from the facility. * The facility failed to provide the written notice pf transfer/discharge to Resident 2 or the resident's responsible party prior to the resident's discharge from the facility. In addition, the facility failed to ensure a copy of Resident 2's notice of transfer/discharge was provided to the State Long-Term Care Ombudsman prior to the planned discharge date . This failure had the potential to violate Resident 1's rights to appeal their discharge. Findings: Review of the facility's P&P titled Transfer or Discharge, Facility-Initiated dated 10/2022 showed under the section notice of transfer or discharge (planned), showed the resident and his or her representative are given a thirty day advance written notice of an impending transfer or discharge from this facility. A copy of this notice is sent to the office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Under the section notice of transfer or discharge (emergent or therapeutic leave), showed under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge if the resident's health improves sufficiently to allow a more immediate transfer or discharge. Closed medical record review for Resident 2 was initiated on 9/10/25. Resident 2 was readmitted to the facility on [DATE], and discharged on 8/27/25. Review of Resident 2's medical record failed to show a notice of transfer/discharge was provided to Resident 2, Resident 2's representative, or to the LTC Ombudsman on or prior to his discharge on [DATE]. On 9/10/25 at 1505 hours, an interview and concurrent closed medical record review was conducted with the SS Staff. The SS staff stated she would provide the notice of transfer/discharge two days prior to the resident's discharge date or when the resident stated they wanted to go home. The SS staff stated Resident 2 was discharged on 8/27/25, per his wife's request. The SS Staff verified there was no documented evidence a notice of transfer/discharge was provided to Resident 2 or Resident 2's representative. On 9/11/25 at 1341 hours, an interview and concurrent closed medical record review was conducted with the SSD. The SSD stated the social services department was responsible for providing the notice of transfer/discharge. The SSD stated if the resident had requested to be discharged , the facility would provide the notice on the date the resident requested to be discharged . The SSD stated Resident 2's wife had requested Resident 2 to be discharged , and the discharge order was placed on 8/26/25, for him to discharge on [DATE]. The SSD verified there was no documented evidence a notice of transfer/discharge was provided to Resident 2, Resident 2's representative, or to the LTC ombudsman prior to his discharge from the facility.

Based on observation, interview, and facility P&P review, the facility failed to ensure the environment remained free from accident hazards for one of four final sampled residents (Resident 42) and two nonsampled residents (Residents 26 and 166) reviewed for accidents. * The facility failed to post signage on Resident 42's room to indicate the oxygen was in use. * The facility failed to ensure the resident rooms contained secured closet/storage cabinets for 103 of 103 resident rooms. * A pair of long scissors was observed on Resident 166's overbed table. These failures posed the risk for injuries to the residents, staff, and visitors.Findings: 1. On 8/19/25 at 1010 hours, an observation was conducted of Resident Room E. Resident 26 resided in Room E. A closet/storage cabinet was observed adjacent to Resident 26’s wall and bed. The closet/storage cabinet was unsecured. On 8/19/25 at 1029 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified Resident 26’s room (Room E) contained an unsecured closet/storage cabinet. The Maintenance Director was asked how many resident rooms were within the facility. The Maintenance Director stated the facility consisted of 103 resident rooms. The Maintenance Director was then asked how many resident rooms contained unsecured closet/storage cabinets. The Maintenance Director stated all the 103 resident rooms contained unsecured closet/storage cabinets. The Maintenance Director stated the resident closet/storage cabinets were unsecured as the resident rooms were in the process of being refurbished. The Maintenance Director stated the facility ordered new resident closet/storage cabinets for all the resident rooms throughout the facility (103 rooms). The Maintenance Director stated all of the residents closet/storage cabinets would be secured, to prevent the possibility of tipping over during an earthquake, which could result in injuries to the residents. 2. Review of the facility’s P&P titled Personal Property revised August 2022 showed the residents are permitted to retain and use personal possessions as space permits, unless doing so would infringe on the right or health and safety of other residents. Medical record review was initiated on Resident 166 on 8/20/25. Resident 166 was admitted to the facility on [DATE]. Review of Resident 166’s MDS assessment dated [DATE], showed Resident 166 had a BIMS score of 10, indicating moderate cognitive impairment. Review of Resident 166’s plan of care showed a care plan problem dated 7/2/25, addressing Resident 166' risk for impaired cognitive function or impaired thought process related to the disease process and medications side effects. On 8/19/25 at 1018 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with LVN 2 and CNA 4 for Resident 166. Resident 166 was observed with a pair of scissors on top of the resident's overbed table. LVN 2 was asked if Resident 166 was allowed to have the pair of scissors at bedside. LVN 2 stated no and that he would it remove it right away. CNA 4 was observed giving the scissors to LVN 2. CNA 4 was asked if Resident 166 could have the pair of scissors at the bedside. CNA 4 stated Resident 166 was not allowed to have the pair of scissors at the bedside and was unsure on how the resident got it. CNA 4 further stated Resident 166 was independent and walked around the facility. On 8/19/25 at 1329 hours, an interview was conducted with RN 1. RN 1 was informed of the above findings and verified the pair of scissors was removed from Resident 166's bedside. RN 1 stated Resident 166 was not allowed to have the pair of scissors because I know how this resident is.” RN 1 further stated no residents in the facility were supposed to have scissors at the bedside. On 8/20/25 at 1013 hours, an interview and concurrent medical review was conducted with the ADON. The ADON was informed and verified the above findings. The ADON stated an immediate in service/training would be provided to the nursing staff regarding the safety hazard (scissors) observed at Resident 166's bedside. However, the ADON verified there was no in service/training provided to address the safety hazard observed at Resident 166's bedside on 8/19/25. On 8/24/25 at 1245 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and verified the above findings. 3. Review of facility's P&P titled Oxygen Administration dated 02/24 showed for portable oxygen cylinder should be strapped to the stand. When providing an oxygen therapy to the residents in the room who needed an oxygen, the licensed nurse should place a no smoking sign on the outside of the room entrance door and a Oxygen in Use sign should be placed over the resident's bed. On 8/18/25 at 1012 hours, Resident 42 was observed in bed. A portable oxygen cylinder tank with a holder was observed inside Resident 42's room. There was no posted signage observed for the use or presence of oxygen in Resident 42's room. Medical record review for Resident 42 was initiated on 8/19/25. Resident 42 was admitted to the facility on [DATE]. Review of Resident 42's Order Summary Report dated 8/19/25, showed a physician's order dated 8/12/25, to administer oxygen at two liters per minute via nasal cannula as needed for shortness of breath. On 8/18/25 at 1252 hours, an observation, interview and concurrent medical record review for Resident 42 was conducted with RN 5. RN 5 was summoned to Resident 42's room. RN 5 verified and acknowledged the presence of the portable oxygen tank with a holder in Resident 42's room. RN 5 was asked if there were any posted signage for the use of oxygen in the room doorway or inside the room. RN 5 verified and acknowledged there was no posted signage in the room for the use of oxygen. On 8/25/2025 at 1304 hours, an interview and concurrent medical record review for Resident 42 was conducted with the DON. The DON was informed and verified the findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure Station A ice machine drainpipe maintained an air gap (space between the water outlet and the flood level of the drain that prevents backflow of waste water from the drain) at the floor sink drain. This failure had the potential to result in waterborne illnesses in a highly susceptible resident population. * The facility failed to ensure proper storage of refrigerated food in the kitchen. * The facility failed to ensure the kitchen equipment was clean and in good condition. * The facility failed to ensure the broom and dustpan were stored in a sanitary manner. * The facility failed to ensure proper covering, labeling, and dating of foods in the refrigerator used for the residents' food brought in by visitors and failed to ensure the expired foods were discarded. * The facility failed to ensure the freezer used for the residents' food brought in by the visitors had a thermometer and was monitored for temperature. * The facility failed to ensure the ice machine in the kitchen had an airgap. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.Findings: Review of the facility’s document titled Cambridge Laguna Hills Diet Roster Rollup (undated) showed 166 of 168 residents residing in the facility received food prepared in the kitchen 1. Review of the facility’s P&P titled Food Receiving and Storage revised 11/2022 showed foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer are covered, labeled and dated. During the initial tour of the kitchen with the DSS on 8/18/25 at 0813 hours, there were two uncovered sheet pans filled with cake in the walk-in refrigerator. The DSS verified the findings. 2. Review of the facility’s P&P titled Sanitization revised 11/2022 showed all utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. According to the USDA Food Code 2022 Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022 Section 4-101.11 Multiuse, Characteristics, materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food under normal use conditions shall be safe, durable, corrosion-resistance and nonabsorbent, sufficient in weight an thickness to withstand repeated ware washing, resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. During the initial tour of the kitchen with the DSS on 8/18/25 at 0813 hours, the following was observed: - one stand mixer with a chipped, rusted, and corroded base; - one can opener with dried yellow food residue on the blade; - two drawers containing utensils with dried yellow food residues and crumbs inside of the drawer. - one whisk with a corroded handle; - one whisk with dried brown food residues; - one pot and one pan with corroded rubber handles; and - one pancake dropper with built-up black and gray dust. The DSS verified the above findings. 3. According to the USDA Food Code 2022 Section 6-501.113 Storing Maintenance Tools, Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be stored so they do not contaminate food, equipment, utensils, linens, and single-service and single-use articles; and stored in an orderly manner that facilitates cleaning the area used for storing the maintenance tools. During the initial tour of the kitchen with the DSS on 8/18/25 at 0813 hours, there was one broom and one dustpan stored on the floor in the area leading to the facility’s dining room. On 8/25/25 at 1014 hours, the DSS, DON, and Administrator acknowledged the above findings. 4. Review of the facility’s P&P titled Food Receiving and Storage revised 11/2022 showed foods shall be received and stored in a manner that complies with safe food handling practices. All foods belonging to residents are labeled with the resident’s name, the item and the “use by” date. Other opened containers are dated and sealed or covered during storage. Review of the facility’s P&P titled Foods Brought by Family/Visitors revised 8/2024 showed food brought by family/visitors is labeled, dated and stored in a manner that is clearly distinguishable from facility prepared food. The nursing staff and/or designee will discard perishable foods weekly on or before the “use/best by” date. The nursing and/or food service staff will discard any foods prepared for the residents that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). During an observation of the residents’ refrigerator inside Medication Room A with RN 1 on 8/18/25 at 0850 hours, the following was observed: - two bottles of immunity drink labeled with “good”, not labeled with a name, room number, or date; - one bottle of protein drink, unlabeled; - one opened bag of tamales, unsealed, exposing the tamales; - one sealed package of Klondike bars and three individual bars, unlabeled; - two bottles of sealed Sprite, unlabeled; - one container of cottage cheese with no expiration date; - one container of cut fruits, labeled with two dates, 8/15/25 and 8/17/25; - one opened carton of milk, unlabeled; and - one bag containing an In-N-Out burger and fries, not fully sealed, dated 8/16/25. RN 1 stated they labeled the residents’ food with name, room number, and the date they received the food item. RN 1 stated they threw the perishable food items away after 24 hours. RN 1 verified the above findings. 5. Review of the facility’s P&P titled Food Receiving and Storage revised 11/2022 showed foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines. Review of the facility’s P&P titled Refrigerators and Freezers revised 11/2022 showed this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. During an observation of the residents’ refrigerator inside Medication Room A with RN 1 on 8/18/25 at 0850 hours, the freezer portion of the residents’ refrigerator had residents’ food items inside. There was no freezer temperature log and no thermometer in the freezer. RN 1 verified the findings. RN 1 stated the evening and night shift charge nurse or supervisor was responsible for checking the refrigerator temperatures. On 8/18/25 at 1014 hours, the DSS, DON, and Administrator acknowledged the above findings. The DON stated the perishable foods should not be kept for longer than 24 hours. The DON stated they labeled the residents’ food with the name and date it was brought in. 6. a. According to the USDA Food Code 2022 Section 5-202.13, Backflow Prevention, Air Gap, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment stall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (one inch). Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. During the initial tour of the kitchen with the DSS on 8/18/25 at 0813 hours, the kitchen ice machine’s drainpipe was on the floor and touching the drainage inlet, surrounded by a puddle of water. The DSS stated the drainpipe was knocked over and proceeded to fix the drainpipe. On 8/19/25 at 1340 hours, a concurrent observation and interview was conducted with the DSS. The kitchen ice machine’s drainage pipe was observed touching the drainage inlet. The DSS verified the findings and proceeded to fix the drainpipe. b. On 8/21/25 at 1307 hours, an observation and concurrent interview was conducted with the Maintenance Director. Station A resident ice machine had a pipe draining water from the ice storage compartment of the ice machine into a floor sink drain. The air gap between the pipe outlet and the flood level of the floor sink drain was not maintained, as evidenced by the pipe outlet extending into the floor sink drain. The Maintenance Director verified the findings and stated an air gap needed to be maintained, to ensure no backflow of contaminated drain water entered the ice machine. The Maintenance Director stated he had ordered a new pipe.

Based on observation, interview, and facility P&P review, the facility failed to ensure one of 169 residents (nonsampled Resident 17) was provided care in a manner that promoted dignity and respect. * The facility failed to provide Resident 17 with privacy during bedside toileting. This failure had the potential for the resident to experience a decline in her psychosocial well-being. Findings: Review of the facility's P&P titled Dignity revised February 2021 showed the staff will maintain and protect resident privacy during personal cares. Medical record review for Resident 17 was initiated on 8/18/25. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed a physician's order dated 2/4/21, for the resident to use a bedside commode. On 8/21/25 at 0928 hours, Resident 17 was observed being transferred to a bedside commode by CNA 1. Resident 17's privacy curtain was pulled closed but the basin, which was under the resident's commode and approximately six inches above the commode, was observed from the hallway due to the gap between the privacy curtain and the floor. CNA 1 was heard asking the resident if she wanted her room door closed, and the resident declined. On 8/21/25 at 0947 hours, Resident 17 was still observed sitting on the commode. The commode basin was still observed on the floor, where contents going into the commode could potentially be observed from the hallway. On 8/21/25 at 1004 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 17 just had a bowel movement while on the commode. On 8/21/25 at 1007 hours, an interview was conducted with Resident 17, who was now sitting in her wheelchair. Resident 17 stated she was not aware her commode basin was visible from the hallway, even with the privacy curtain pulled closed. The resident stated she just assumed the privacy curtain hid everything, and preferred her commode basin not be visible from the hallway during use. On 8/21/25 at 1048 hours, a follow-up interview was conducted with CNA 1. CNA 1 stated Resident 17's bedside commode was an over-the-toilet commode, and did not have place to attach a basin. CNA 1 stated she realized the resident's commode basin was viewable from the hallway under the privacy curtain, when the resident wanted her door to remain open. When asked if there was anything to block the view of the resident's commode basin during use, the CNA stated she did not think so. When asked about the trash receptacle located in the room, the CNA tested it by moving a trash receptacle next to the privacy curtain. CNA 1 verified the trash receptacle extended above the bottom of the privacy curtain and could have obstructed the view of the commode basin from the hallway.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered to two of 33 final sampled residents (Residents 158 and 174). * Resident 158 had a bottle of Total Beets (dietary supplement) 650 mg chewable at the bedside. Resident 158 did not have a physician's order to self-administer the Total Beets 650 mg or to keep any medication at the bedside. * Resident 174 had the bottle of Instaflex Advanced (dietary supplement) at the bedside. Resident 174 had no physician's order to keep any medication at the bedside. These failures had the potential to negatively impact Resident 158 and 174's physiological well-being and the potential for the residents to administer the medications inaccurately. Findings: Review of the facility's P&P titled Administering Medications revised 4/2023 showed the medications are administered in a safe and timely manner, and as prescribed. The residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. 1. On 8/18/25 at 0919 hours, an observation and concurrent interview was conducted with Resident 158. A bottle labeled Total Beets (supplement) 650 mg was observed on Resident 158's bedside table. The label on the bottle showed the supplement contained 10 mg of Niacin (vitamin B3), 2 mg of vitamin B6, and 25 mcg of vitamin B12 per serving. Resident 158 stated he took the Total Beets every day. Medical record review for Resident 158 was initiated on 8/18/25. Resident 158 was admitted to the facility on [DATE]. Review of Resident 158's MDS assessment dated [DATE], showed Resident 158 was cognitively intact. Review of Resident 158s Order Summary Report dated 8/26/25, failed to show a physician's order for the self-administration of the Total Beets 650 mg medication. Review of Resident 158's plan of care failed to show a care plan problem was initiated or developed to address the resident's self-administration of the Total Beets 650 mg medications. On 8/19/25 at 1027 hours, Resident 158 was observed in bed. The bottle of Total Beets 650 mg medication was observed on Resident 158's bedside table. On 8/20/25 at 1107 hours, an interview and concurrent medical record review for Resident 158 was conducted with LVN 1. LVN 1 stated for the self- administration of the medications, the IDT determined if the resident could safely self-administer the medication. LVN 1 stated there should be a physician's order specific to the medication the resident would self-administer and a care plan developed for the self-administration of the medication. LVN 1 further stated the medication would be kept in the medication carts and for the independent residents, the medication could be kept in the resident's room, however it should be locked so the other residents could not get access to the medication. LVN 1 reviewed Resident 158's medical record and verified Resident 158 had no physician's order or a care plan for the self-administration of the Total Beets 650 mg medication. LVN 1 stated the medication should not be left at the bedside. On 8/20/25 at 1130 hours, a follow-up interview was conducted with LVN 1. LVN 1 stated she went to Resident 158's room and verified the above findings. 2. On 8/18/25 at 1126 hours, an observation and concurrent interview was conducted with Resident 174. A bottle labeled Instaflex Advanced medication was observed at Resident 174's bedside. When asked about the medication, Resident 174 stated the medication was for her stomach and she self-administered the medication. Resident 174 further stated the medication inside the bottle was not what was on the bottle label. Medical record review for Resident 174 was initiated on 8/18/25. Resident 174 was admitted to the facility on [DATE]. Review of Resident 174's medical record failed to show a Self-Administration of Medication Assessment was done for Resident 174. Review of Resident 174's Order Summary Report dated 8/21/25, failed to show the physician's order for the self-administration of medications. Review of Resident 174's plan of care failed to show a care plan problem was initiated or developed to address the resident's self-administration of the medications. On 8/20/25 at 1032 hours, an interview and concurrent medical record review for Resident 174 was conducted with RN 5. RN 5 stated for the self- administration of medications by the residents, the resident needed to be assessed by the physician, as well as an assessment by the IDT, to ensure the resident could safely administer the medications. RN 5 stated there should be a physician's order for the self-administration of medications and the medication should be kept in a locked drawer. RN 5 reviewed Resident 174's medical record and verified the resident had no physician's order to self- administer medications and a self-administration of medication assessment was not done. When asked about the bottle labeled Instaflex Advanced medication at Resident 174's bedside, RN 5 stated the bottle was found by the CNA yesterday and was removed. On 8/25/25 at 1025 hours, an interview was conducted with the DON. The DON stated for the self-administration of medications, the resident should have an assessment for the self-administration of medications to determine if the resident was alert and capable of administering the medications. The DON stated if the resident had the capacity and was able to self-administer the medication, there should be a physician's order for the self-administration of the medication and a care plan would be developed to address the resident's self-administration of the medication. The DON further stated the medication kept at the resident's bedside should be locked and the facility staff entering the room should observe for any medications at the bedside to prevent other residents from having access to the medications. On 8/25/25 at 1044 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs of two of two final sampled residents (Resident 8 and 49) reviewed for communication needs. * The facility failed to ensure the appropriate communication devices were used by staff to meet Residents 8 and 49's daily needs. This failure had the potential to negatively impact the resident's psychosocial well-being and result in delayed provision of care.Findings: Review of the facility's P&P titled Accommodation of Needs Communication revised 3/2021 showed the following: - In order to accommodate the individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents’ wishes including interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity. Review of the facility's P&P titled Translation and/or Interpretation of Facility Services revised on 11/2020 showed the following: - The facility’s language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility; - When encountering LEP individuals, staff members will conduct the initial language assessment (e.g. “I Speak Cards”) and notify the staff person in charge of the language access program; - It is understood that providing meaningful access to services provided by this facility requires also that the LEP residents’ needs and questions are accurately communicated to the staff. Oral interpretation services therefore including interpretation from the LEP resident’s primary language back to English; and - Staff shall be trained upon hire and at least annually on how to provide language access services to LEP residents. 1. During an observation on 8/18/25 at 1225 hours, Resident 49 was lying in bed awake, alert, and verbally responsive. Resident 49 was greeted in English; however, Resident 49 did not speak and understand English. There were communication cards in the Chinese language available and posted on Resident 49’s wall. On 8/18/25 at 1240 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 spoke to Resident 49 in English while providing care. CNA 4 did not use the communication cards in Chinese language or request a Chinese speaking staff to communicate with the resident. CNA 4 stated she used gestures to communicate with Resident 49 and verified she did not speak any Chinese. CNA 4 further stated Resident 49 speaks and understands the Chinese language. Medical record review for Resident 49 was initiated on 8/20/25. Resident 49 was admitted to the facility on [DATE]. Review of Resident 49’s care plan for communication dated 7/4/25, showed the following: - Resident 49 cannot communicate easily with staff; - Resident 49 wanted or needed an interpreter to communicate with a doctor or health care staff; and - Resident 49’s primary language is Chinese. Review of Resident 49's H&P examination dated 7/5/25, showed Resident 49 had the capacity to understand and make decisions. Review of Resident 49’s MDS assessment dated [DATE], showed Resident 49’s Brief Interview for Mental Status (BIMS) score was 8, indicating moderate cognitive impairment. On 8/19/25 at 1350 hours, an interview was conducted with CNA 5. CNA 5 stated Resident 49 spoke Chinese and could not understand English. On 8/19/25 at 1504 hours, an interview was conducted with the ADON. The ADON stated a non-English speaking residents must have communication cards in their preferred language available in each resident’s room provided by the Activities Department for any staff to use. The ADON further stated staff could call the language translation line if needed. In addition, the ADON stated the staff not using the appropriate communication devices would prevent the resident's needs to be met. On 8/25/25 at 1054 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. On 8/18/25 at 1231 hours, an observation of Resident 8 and concurrent interview was conducted with CNA 8. Resident 8 was lying on bed with head of the bed slightly elevated. CNA 8 communicated with Resident 8 in English using hand gestures, however there were communication card boards posted on Resident 8's wall. CNA 8 stated she thought Resident 8 spoke Japanese and she communicated with the resident by using hand gestures. CNA 8 further stated the staff additionally rely on the resident’s wife for translation. CNA 8 stated she only made herself understood by using hand gestures and added Resident 8's wife was usually present. On 8/20/25 at 1150 hours, an observation of Resident 8 and concurrent interview was conducted with CNA 10. Resident 8 was seated on his wheelchair and CNA 10 communicated with Resident 8 in English using hand gestures. CNA 10 asked Resident 8 about his dialysis appointment, however the resident did not answer. CNA 10 stated she uses only the hand gestures to communicate with Resident 8 and Resident 8's wife was usually available for translation. Medical record review for Resident 8 was initiated on 8/18/25. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 8's MDS assessment dated [DATE], showed Resident 8’s BIMS score was 10, indicating moderate cognitive impairment. Review of Resident 8's H&P examination dated 5/21/25, showed Resident 8 could make needs known. On 8/20/25 at 1252 hours, an interview was conducted with the ADON. The ADON stated Resident 8 spoke Korean, and the resident’s wife was always available at the bedside to translate. The ADON was informed two CNAs communicated with Resident 8 by using hand gestures. Resident 8’s wife was not at the bedside. The ADON verified the CNAs should have used the communication card boards posted on the wall and should have reached out to the charge nurses for oral interpretation services for clear interpretation and understanding when providing care to Resident 8. On 8/22/25 at 1443 hours, the DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the worsening of pressure injuries and promote the healing of existing pressure injuries for two of four sampled residents (Residents 1 and 3). * Resident 3 had a Stage 2 pressure injury on the back upon admission to the facility on [DATE]. The facility failed to assess, measure, notify the physician to obtain a wound treatment order andimplement the necessary interventions to prevent further skin breakdown of Resident 3's Stage 2 pressure injury on the back. This failure resulted in Resident 3's Stage 2 pressure injury on the back deteriorating and developing into an unstageable pressure injury. Resident 3 was transferred to the acute care hospital for further evaluation of the pressure injuries on 7/29/23. * The facility failed to ensure the LAL mattress setting was consistent with Resident 1's weight. This posed the risk for Resident 1 to not benefit from the therapy provided by the LAL mattress. Findings: Review of the National Pressure Injury Advisory Panel's (NPIAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers/Injuries dated 2019 defined the pressure injury stages as follows: - Stage 1: intact skin with a localized area of non-blanchable erythema (superficial reddening of the skin), which may appear differently in darkly pigmented skin. - Stage 2: partial thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) tissue is not visible and deeper tissues are not visible. - Unstageable: full-thickness skin loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead tissue). Review of the facility's P&P titled Pressure Injury Risk Assessment revised 3/2020 showed to develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown revised 4/2018 showed the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 1. On 8/8/23 at 0823 hours, an interview was conducted with Family Member 1. Family member 1 stated Resident 3 had two pressure injuries on his upper and lower back areas upon admission to the facility on [DATE]. Family Member 1 stated she requested the facility to transfer Resident 3 to the acute care hospital because she was concerned Resident 3's wounds were getting worse. Family Member 1 stated Resident 3's wounds on his back areas were increasing in size and appeared more reddened in color. Family Member 1 stated Resident 3 was in pain because of the wounds on his back. Closed medical record review for Resident 3 was initiated on 8/8/23. Resident 3 was admitted to the facility on [DATE], and discharged on [DATE]. Review of the acute care hospital's medical record titled SNF Placement Request Report dated 7/10/23, showed Resident 3 had the Stage 2 pressure injuries to the sacrum and back. The Stage 2 back pressure injury had pink wound base and partial thickness skin loss. The pressure injury did not have drainage or odor, and the surrounding skin did not have erythema. Review of the acute care hospital's medical record titled Patient Care Transfer Summary dated 7/11/23, showed Resident 3 had the Stage 2 pressure injuries to the sacrum and upper back. Review of Resident 3's Admission/Readmission Data Tool dated 7/11/23, completed by facility staff showed Resident 3 had two partial thickness skin loss (shallow open ulcer with red, pink wound bed) areas on the back and sacrum. Resident 3's Weekly Wound Evaluation dated 7/12/23, showed Resident 3 had the right and left heels Stage 1 pressure injuries and sacro coccyx Stage 2 pressure injury. The document did not include the resident's back pressure injury. Review of Resident 3's Progress Notes showed a Skin/Wound Note entry dated 7/12/23 at 2010 hours, showed the following skin alterations: - Sacro coccyx Stage 2 pressure injury measuring 3.5 cm (length) x 3.0 cm (width) x 0.1 cm (depth) and wound bed with 100% granulation, light drainage and peri wound macerated (wet, white tissue); - BUE (bilateral upper extremity) with scattered purplish skin discoloration; - Right heel Stage 1 pressure injury, wound bed with non-blanchable redness; and - Left heel Stage 1 pressure injury, wound bed with non-blanchable redness. * However, the progress note did not include the Stage 2 pressure injury on the resident's back as shown on the facility's Admission/Readmission Data Tool dated 7/11/23. Review of Resdient 3's plan of care showed the care plan problems addressing the pressure injuries to the resident's sacro coccyx and right and left heels. There was no documented evidence a care plan problem was developed to address the resident's Stage 2 back pressure injury until it had deteriorated to an unstageable pressure injury identified on 7/14/23. Further review of Resident 3's medical record showed no documented evidence of wound treatment provided to the resident's Stage 2 back pressure injury. There was no documented evidence the resident's back pressure injury had healed. Review of Resident 3's IDT Wound Management assessment dated [DATE], showed Resident 3 had the pressure injuries with the wound origin documented as admitted wound, including the unstageable mid spine pressure injury, measuring 14 cm x 6 cm x UTD (unable to determine) with 100% slough. Review of Resident 3's MDS dated [DATE], showed Resident 3 was cognitively intact and required extensive assistance from two or more staff members for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned her body while in bed) and extensive assistance from one staff member for toilet use (including how the resident was cleaned after elimination and pad changes). Review of Resident 3's Treatment Administration Record for July 2023 showed a physician's order dated 7/14/23 at 0859 hours, to cleanse the unstageable mid spine pressure injury with normal saline, pat dry, apply Medihoney (healing gel used to speed up the healing of burns and wounds), and cover with a foam dressing. Review of Resident 3's plan of care showed a care plan problem dated 7/14/23, addressing the unstageable mid spine pressure injury. The interventions included to provide the treatment as ordered, assess the wound weekly, reposition the resident every two hours, assess the resident's pain and intervene accordingly, provide skin care during ADL care, and observe/report signs and symptoms of infections. Review of Resident 3's Skin & Wound Evaluation dated 7/20/23, showed Resident 3's unstageable spine pressure injury with 50% granulation (the appearance of the red, bumpy tissue in the wound bed as the wound heals), and 50% slough, measuring 5.4 cm x 1.4 cm and depth measurement not applicable. The surrounding tissue had erythema and was macerated. Resident 3 complained of a pain level of 9 on a 0 to 10 pain scale (with o = no pain and 10 = worst pain) during treatment. Review of Resident 3's Skin & Wound Evaluation dated 7/27/23, showed Resident 3's unstageable mid spine pressure injury with 100% granulation and 50% slough, measuring 7.8 cm x 1.6 cm, and depth measurement not applicable. The assessment showed the pressure injury had evidence of infection: redness/inflammation and the wound was deteriorating. The surrounding tissue was denuded (loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate, or friction), macerated and had erythema. Resident 3 complained of pain level 6 during treatment. Review of Resident 3's Physician Order dated 7/29/23, showed an order to transport the resident to an acute care hospital for further evaluation of pressure injuries. On 8/9/23 at 1002 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON acknowledged the above findings and verified Resident 3 had a Stage 2 upper back pressure injury upon admission to the facility on [DATE]. The DON verified the Weekly Wound Evaluation on 7/12/23, did not show Resident 3's Stage 2 upper back pressure injury. The DON verified the initial wound treatment for the upper back pressure injury was started on 7/14/23, after the pressure injury was classified as an unstageable pressure injury. The DON verified Resident 3 did not have a physician's order for wound care consult and Resident 3 was not evaluated by the wound care specialist prior to discharging on 7/29/23. On 8/9/23 at 1025 hours, an interview and concurrent closed medical record review was conducted with LVN 3. LVN 3 stated the initial skin assessment was completed upon admission on 7/11/23, which showed Resident 3 having partial thickness skin loss to the back. LVN 3 stated LVN 4 completed the skin reassessment on 7/12/23. LVN 3 stated she reassessed Resident 3's wounds on 7/14/23, and observed Resident 3 with an unstageable mid spine pressure injury. LVN 3 verified she initiated the wound treatment for Resident 3's unstageable mid spine pressure injury on 7/14/23. LVN 3 stated Resident 3 was referred to a wound care specialist; however, LVN 3 verified Resident 3 did not have a physician's order for a wound care consult and Resident 3 was not evaluated by the wound specialist prior to his transfer to the acute care hospital. LVN 3 verified Resident 3's medical record did not show the facility addressed, provided wound treatment, or implemented the necessary interventions to prevent further skin breakdown of Resident 3's pressure injury on the back prior to 7/14/23. 2. Review of the Med-Aire 8 , 14027 System Manual for the LAL mattress showed the system is a high-quality powered air support surface that is specifically designed for the prevention and treatment of pressure injuries while optimizing patient comfort. The manual showed effective pressure redistribution therapy, wound management and device selection should be based on the patient's specific clinical condition and complete assessment of needs. The user can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting. A concurrent observation and interview with Resident 1 was conducted in Resident 1's room on 8/8/23 at 0859 hours. Resident 1 was observed lying on a LAL mattress and positioned on her back. The LAL mattress was on and set between 300 and 350 pounds. Resident 1 stated the mattress was firm and she felt uncomfortable at times when positioned on her back. Medical record review for Resident 1 was initiated on 8/8/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 had an unstageable pressure injury and required extensive assistance from two or more staff members for bed mobility. On 8/8/23 at 1423 hours, Resident 1 was observed lying on a LAL mattress. The LAL mattress was on and set between 300 and 350 pounds. On 8/8/23 at 1425 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the LAL mattress was on and set at 325 pounds. LVN 2 stated the treatment nurses wereresponsible for monitoring the use and settings for the LAL mattresses. On 8/8/23 at 1443 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 was asked what the purpose of the LAL mattress was and whether Resident 1's LAL mattress was on the correct setting. LVN 1 stated the purpose of the LAL mattress was to prevent putting too much pressure on the resident's wound causing the wound to get worse. LVN 1 verified the LAL mattress was on and set between 300 and 350 pounds. LVN 1 stated the LAL mattress should be set at 100 pounds because Resident 1 weighed 93 pounds. LVN 1 stated the LAL mattress setting should be based on the resident's weight. On 8/8/23 at 1451 hours, an interview was conducted with the DON. The DON stated the treatment nurses and licensed nurses should be checking for the correct settings on the LAL mattress every shift. The DON stated the LAL mattress should be set at 100 pounds because Resident 1 weighed 93 pounds.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for one of two sampled residents (Resident 2) and six of six nonsampled residents (Residents B, C, D, E, F, and G). * The facility failed to ensure safe smoking practices were followed for seven residents (Residents 2, B, C, D, E, F, and G). The facility failed to thoroughly assess each resident to determine if they required supervision. The residents who were assessed as needing supervision were not supervised. The individualized care plan problems were not followed and did not address interventions for residents who were non-compliant with facility smoking practices. This posed the risk for serious injury to the residents. On 5/20/19 at 1145 hours, the Administrator, DON, and ADON were informed an IJ was identified regarding the following deficient practices: * The facility failed to follow their Smoking P&P by failing to thoroughly assess the residents for the ability to smoke with or without supervision. The assessments did not determine if the resident was independent with smoking practices. * The facility failed to implement the outcome of the smoking assessment and care plan problems which addressed smoking interventions. * The facility failed to ensure the smoking materials were securely stored. * The facility failed to supervise the residents who had been assessed to require supervision. * The residents who were assessed to need a smoking apron were not provided a smoking apron. * The designated smoking area had cigarette butts in combustible trash liners and multiple cigarette butts on the ground and planters. On 5/22/19 at 1430 hours, the IJ was abated. The facility had implemented the following plan of corrective actions: * The facility would ensure each resident who had expressed the desire to smoke would be thoroughly assessed and update the care plan to address the outcome of the smoking assessment. * The facility would ensure all smoking materials were safely stored in the medication room for all residents who smoked. * The facility would implement a smoking schedule and provide supervision for all residents who smoked. * The designated smoking area would be cleaned five times daily. The facility provided documented evidence which showed residents who smoked were reassessed for smoking and their needs identified, smoking care plans were developed, supervised scheduled smoking times were established with assigned staff, smoking materials were secured, and cleaning of the smoking area was assigned at scheduled times. Findings: Review of the facility's P&P title Smoking Policy - Residents dated (MONTH) (YEAR) showed the resident will be evaluated on admission for the ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). The resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive), and as determined by staff. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. 1. Medical record review for Resident 2 was initiated on 5/16/19. Review of Resident 2's Progress Notes dated 5/13/19 at 1142 hours, showed Resident 2 had been found smoking in his room and was told to put out his cigarette. Resident 2 was told he could not smoke in his room and was taken out to the smoking patio. Review of Resident 2's plan of care showed a care plan problem dated 4/7/17, and revised on 4/12/17, to address the resident's non-compliance regarding facility safe smoking policy. The interventions included the need for frequent visual checks and inform the resident of the risk of continued non-compliance. Review of Resident 2's MDS dated [DATE], showed the resident had moderate cognitive impairment. The MDS did not show if Resident 2 smoked or not. Review of Resident 2's history and physical examination [REDACTED]. Review of Resident 2's Quarterly Risk Assessment (smoking assessment) dated 3/25/19, showed the resident did not have cognitive loss and smoked one to two times a day. The assessment did not show if Resident 2 was independent in smoking or required supervision, or where the smoking supplies were to be kept. On 5/16/19 at 1105 hours, an interview was conducted with Resident 2. Resident 2 stated he kept his smoking supplies in his room, and went out to the patio every day to smoke. On 5/16/19 at 1150 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON confirmed Resident 2 was non-compliant regarding the facility's safe smoking policy and she was aware the resident had been found smoking in his room. The ADON stated the following morning, she reminded Resident 2 he could not smoke in his room and the resident told her he would never do it again. The ADON stated the only interventions they implemented for Resident 2 were to conduct visual checks and remind him. On 5/20/19 at 0810 hours, an interview was conducted with LVN 1 and CNA 2. LVN 1 stated Resident 2 kept his smoking supplies in his room in the top drawer of his small dresser. CNA 2 stated Resident 2 usually kept his smoking supplies in a small bag he hung on his wheelchair. CNA 2 stated the CNAs would drop off the residents at the smoking courtyard and ask the residents when they should return to pick them up. On 5/20/19 at 0832 hours, an interview was conducted with LVN 3. LVN 3 stated the residents went out to the smoking patio whenever they wanted and there was no set smoking schedule. LVN 3 stated the residents' smoking materials were kept with the residents as it was part of their personal belongings. On 5/20/19 at 1030 hours, a follow-up interview was conducted with CNA 2. CNA 2 was asked if the staff stayed with the residents when they smoked. The CNA stated the staff just passed by the smoking patio door now and then and looked at the residents out there, but no one stayed with them. CNA 2 stated more than once he had seen Resident 2 falling asleep while holding a cigarette in his hand. CNA 2 stated Resident 2 never wore a smoking apron. On 5/20/19 at 1100 hours, an interview was conducted with the ADON. The ADON stated an investigation had not been completed after Resident 2 was found smoking in his room on 5/13/19, nor had the resident been re-assessed for smoking. On 5/20/19, the facility provided a list of five residents who currently smoked, Residents 2, B, C, D, and E. On 5/21/19, the facility provided an updated list of the residents who smoked, which included two additional residents, Residents F and G. 2. Medical record review was initiated for Resident D on 5/20/19. Resident D was admitted to the facility on [DATE]. Review of Resident D's Smoking assessment dated [DATE], showed Resident D had no cognitive impairment or dexterity problems. The safety section of the assessment showed Resident D could light her own cigarette, required a smoking apron, and did not require the facility to store her cigarettes or lighter. On 5/20/19 at 0830 hours, an interview was conducted with Resident D. Resident D stated she was allowed to smoke anytime without staff supervision. Resident D was asked where she was allowed to smoke and Resident D pointed at the window to the outside smoking patio. Resident D stated she was allowed to keep her smoking materials in her room. Resident D was observed to have a tissue box on her bed, and inside the tissue box was a pack of cigarettes and a disposable lighter. LVN 4 verified Resident D had the smoking materials on her bed. Review of Resident D's plan of care showed a care plan problem dated 6/6/18, which addressed the resident was non-compliant regarding the facility's safe smoking policy. The interventions included to inform the resident of procedures and purpose of using safety equipment (apron) as the resident refused to wear the smoking apron. The resident did not want the facility to safely store her smoking materials and wants to smoke without notifying anyone for assistance. However, there were no interventions to identify if Resident D was safe to smoke independently. On 5/20/19 at 1005 hours, an observation of the designated smoking patio was conducted. Residents C and D were observed sitting in their wheelchairs and smoking. Immediately next Residents C and D was a trash receptacle lined with a plastic bag. There was no one supervising Residents C and D did not have a smoking apron on. Resident D was holding a stuffed toy on her lap, a small cloth pillow next to the arm of her wheelchair, and her tissue box which held her cigarettes and lighter next to the other arm of the wheelchair. 3. On 5/20/19 at 0855 hours, an interview was conducted with Resident C. Resident C stated she was aware of the designated smoking area and would go by herself to smoke. Resident C stated no staff supervised the smoking area, but they were very close by. Resident C was asked if the facility had scheduled times to smoke. Resident C stated the residents could smoke anytime between 1000 hours and 2100 hours. Resident C stated she did not wear a protective smoking apron. Medical record review was initiated for Resident C on 5/20/19. Resident C was readmitted to the facility on [DATE]. Review of Resident C's Smoking assessment dated [DATE], showed Resident C was assessed to have no cognitive impairment or dexterity problems. The safety section of the assessment showed Resident C could light her own cigarette, required supervision, and did not require the facility to store her cigarettes or lighter. Review of Resident C's plan of care showed a care plan problem dated 5/6/19, to address the resident's risk for accidentally burning of self/property related to smoking. The interventions included to encourage the resident to smoke in the designated smoking area and to provide visual check or supervise resident on a regular basis when smoking. 4. Medical record review for Resident B was initiated on 5/20/19. Review of Resident B's Smoking assessment dated [DATE], showed she smoked one to two times a day. The assessment did not show if she required supervision while smoking or if she was independent. The previous smoking assessment dated [DATE], showed Resident B needed to wear a smoking apron and required the facility was to store her cigarettes and lighter. Review of Resident B's plan of care showed a care plan problem dated 5/10/19, addressing the resident's non-compliance with the safe smoking policy. The interventions showed Resident B required frequent visual checks and her fingers and clothes were to be checked for any cigarette burns. On 5/20/19 at 0835 hours, an interview was conducted with LVN 4. LVN 4 stated she did not know if Resident B had her smoking materials with her or not. LVN 4 stated she did not have them in her medication cart and did not know where they were kept. LVN 4 stated she had seen Resident B smoking in the courtyard about a week ago. On 5/20/19 at 1020 hours, an interview was conducted with Resident B. Resident B stated she did not have cigarettes in her room and she got the cigarettes from other residents. 5. On 5/20/19 at 0815 hours, an interview was conducted with LVN 7. LVN 7 stated Resident [NAME] smoked. LVN 7 stated he had not seen Resident [NAME] smoke. LVN 7 was asked if the residents who smoked were allowed to keep their own cigarettes. LVN 7 stated yes, and there was a form on the resident's record to indicate if the resident had the mental capacity or not. On 5/20/19 at 0820 hours, an interview was conducted with Resident E, and LVN 7 was present during the interview. Resident [NAME] was asked if she had cigarettes, she replied no. LVN 7 asked Resident [NAME] if we could look in her bedside table, Resident [NAME] said, yes. A pack of cigarettes and a disposable lighter were observed in the top drawer of Resident E's bedside table. Medical record review was initiated for Resident [NAME] on 5/20/19. Resident [NAME] was admitted to the facility on [DATE], and had a Smoking Safety Evaluation completed on 4/27/19. The assessment showed Resident [NAME] smoked. However, there was nothing to identify if the resident was independent with smoking or required supervision. There was no care plan problem developed to address Resident E's smoking needs. On 5/20/19/ at 0922 hours, an interview and concurrent record was conducted with the ADON. The ADON verified the above findings. 6. Medical record review was initiated for Resident F on 5/21/19. Resident F was admitted to the facility on [DATE]. Review of Resident F's Smoking assessment dated [DATE], showed the resident did not smoke. Review of Resident F's Smoking assessment dated [DATE], showed Resident F did smoke. However, the assessment did not show if the resident required supervision during smoking or not and did not show if the facility needed to store his smoking materials. Review of Resident F's Smoking assessment dated [DATE], showed he smoked three to five times a day. The assessment showed he had a dexterity problem requiring supervision. The assessment identified Resident [NAME] did not need the facility to store his cigarettes and lighter. Review of Resident F's plan of care showed the plan for smoking was initiated on 5/21/19. 7. Medical record review was initiated for Resident G on 5/21/19. Resident G was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident G's Smoking assessment dated [DATE], showed the resident did not smoke. Review of Resident G's Smoking assessment dated [DATE] at 1203 hours, showed the resident smoked one to two times a day in the morning. The assessment showed the facility did not need to store his cigarettes or lighter. Review of Resident G's Progress Notes dated 5/21/19 at 2138 hours, showed the writer was unable to complete his smoking assessment because the resident did not smoke during the evening shift. On 5/21/19 at 1420 hours, an interview was conducted with the Administrator. The Administrator confirmed he could not complete a smoking assessment for Resident G on 5/21/19, as he could not observe Resident G actually smoking. The resident did not go out to smoke in the evenings. On 5/20/19 at 0805 hours, an interview was conducted with LVN 6. LVN 6 was asked if she was aware of any residents on her assigned nursing station who smoked. LVN 6 stated she was unsure. LVN 6 was asked if she was aware of the facility smoking policy. LVN 6 stated the residents' smoking materials were to be kept in the medication cart and currently there were no smoking materials in the medication cart. LVN 6 stated the residents were not to keep lighters at the bedside, and the designated smoking area was the patio on Nursing Station 3. On 5/20/19 at 0825 hours, an interview was conducted with LVN 8. LVN 8 stated the residents were permitted to keep their own cigarette materials. LVN 8 stated the residents were assessed for the ability to keep the smoking materials. If the resident was not able to keep the smoking materials, then the staff would keep their smoking material and a CNA would supervise the resident when smoking. LVN 8 was asked if the facility had a smoking schedule. LVN 8 replied no, each resident is different. On 5/20/19 at 0845 hours, an observation of the designated smoking patio was conducted. There was a large trash receptacle lined with a combustible plastic bag. This trash can was observed to contained cigarette butts. The area was observed to have multiple cigarette butts scattered throughout the planting grounds, which contained dead eucalyptus leaves. There were 12 cigarette butts on the ground, approximately four feet from the trash receptacle, five cigarette butts under a bench, two in the raised planters, three near the roots of the eucalyptus tree, three under another bench, and one cigarette butt in the crack of the sidewalk. On 5/20/19 at 0920 hours, an interview was conducted with RN 1. RN 1 stated the facility's policy was to keep all resident's smoking materials. RN 1 stated if the residents refused to have the facility maintain their smoking materials, then the nurses should know as the residents could cause a fire. RN 1 stated she had seen the residents' smoking materials kept in the drawer of the residents' bedside table. She stated there was no scheduled time for smoking and no staff was assigned to watch the residents who smoked. RN 1 stated if the residents' plans of care should identify if they smoked and if they needed supervision or not. On 5/20/19 at 0935 hours, an interview was conducted with LVN 5. LVN 5 stated the facility's policy for the residents who smoked was for the facility to keep the residents' smoking materials, have the residents wear a smoking apron, and provide supervision. On 5/20/19 at 1025 hours, an interview was conducted with LVN 2. LVN 2 stated there were no schedule for resident to smoke and she had never seen the residents wearing a smoking apron when they smoked. On 5/20/19 at 1100 hours, an interview was conducted with the ADON. The ADON stated the smoking evaluations did not show if a resident could smoke independently or not. When asked how the facility determined if a resident could smoke independently or required supervision, the ADON was unable to answer. The ADON stated supervision was visual and staff did not stay with the residents on the patio while they smoked. The ADON confirmed the smoking courtyard patio was surrounded by resident rooms and the staff could only see the residents smoking from a window in the hallway leading out to the courtyard. The ADON stated the residents' smoking materials were to be kept in the nurses' medication cart. On 5/20/19 at 1145 hours, during an interview was conducted with the Administrator, DON, and ADON. The Administrator, DON, and ADON were informed an IJ was identified regarding the risk for serious injury to the residents who smoked in the facility. On 5/20/19 at 1415 hours, observation of the designated smoking patio was conducted. Residents C and D were observed smoking. There was no staff supervision and no smoking aprons in use. The ADON was immediately informed and verified this observation. The ADON then assigned a staff member to supervise the residents. On 5/20/19 at 1422 hours, the Administrator was informed Residents C and D were smoking without supervision and smoking aprons. The Administrator stated it was okay. The Administrator was informed according to Resident C's smoking assessment, she should have supervision and Resident D required a smoking apron. On 5/21/19 at 1235 hours, an observation of the smoking patio was conducted. The trash receptacle was observed with a plastic liner, and contained paper and cigarette butts. There were also three cigarette butts on the ground next to the eucalyptus tree roots and two cigarette butts next to a bench. On 5/21/19 at 1240 hours, Housekeeper 3 entered the smoking patio and removed the plastic trash liner and replaced it with a clean plastic trash liner and did not look anywhere else in the patio. Housekeeper 3 stated the smoking patio area was cleaned every hour. On 5/21/19 at 1244 hours, an interview was conducted with LVN 4. LVN 4 stated a lock box was kept in the medication room for some of the residents smoking materials. The lock box contained cigarettes for Residents 2 and F, and a list of residents who smoked. The list of residents included Residents 2, B, C, D, and G; however, Residents [NAME] and F were not included. The list indicated Resident 2 required supervision and Residents C, D, and G were independent with smoking. The list did not show if Resident B required supervision or was independent. When LVN 4 was asked who provided supervision for the residents, LVN 4 stated someone had to supervise and ultimately it was the nurses who were responsible. On 5/21/19 at 1250 hours, an interview was conducted with the ADON. The ADON stated Resident [NAME] was cognitively impaired and currently not able to smoke. The ADON stated Resident E's family member had taken her cigarettes home, and Resident [NAME] was no longer on the smoking list. On 5/21/19 at 1250 hours, an interview was conducted with the Administrator. The Administrator stated the staff who completed the smoking assessment had been instructed to document why the resident was independent or needed supervision in the note section of the Smoking Assessment form. The Administrator stated if a resident was non-compliant and was cognitively impaired, then they would require supervision when they smoked. The Administrator stated he had purchased several individual locked boxes for independent smoking residents to store their smoking materials in in their room. He stated he anticipated the locked boxes should arrive today. The Administrator stated the facility was working on inservicing staff on the new smoking policy. On 5/21/19 at 1400 hours, an observation of the smoking patio was conducted. The trash receptacle had been removed. Resident D was observed sitting in her wheelchair with two visitors. Resident C was observed sitting next to an ashtray. On 5/21/19 at 1410 hours, an observation and interview was conducted with Resident C. Resident C was observed to have her cigarettes in her purse on her lap. Resident C was observed to light a cigarette from another cigarette and tossed the lit cigarette butt in the dirt planter area. When asked why Resident C tossed the cigarette in the planter verse the ashtray, Resident C replied, They clean it every morning. When asked if the staff had informed her of the facility smoking policy, she stated no. When asked if she had signed an acknowledgement of the smoking policy. Resident C stated, no, oh maybe, I don't remember, I have short term memory loss. On 5/21/19 at 1420 hours, an interview was conducted with the Administrator and was informed of the smoking patio observation. The Administrator observed and verified the above findings. The Administrator stated he was aware Resident C tossed her cigarette butts on the grounds on the smoking patio. The Administrator stated the staff was now going from resident to resident to determine who smoked. The Administrator stated the interdisciplinary team was in the process of meeting to discuss each smoking resident's assessment and develop an individualized care plan for them. On 5/22/19 at 1415 hours, an interview was conducted with the Administrator. The Administrator stated the smoking policy now identified all residents' smoking materials were maintained by the facility and all residents would be supervised during scheduled smoking times. Also, the smoking patio was assigned to be cleaned five times a day.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) received the appropriate services to meet their nutritional needs and maintain desirable weight. The facility failed to accurately and consistently assess Resident 1's nutritional status to address the weight loss with approaches in a timely manner to prevent further weight loss. The facility failed to identify, implement, monitor, and modify the interventions specific to Resident 1's needs. These failures had contributed to a severe weight loss of 33 pounds in 26 days for Resident 1. Findings: According to the facility's P&P titled Weight Assessment and Intervention revised 1/12/18, the nursing staff will measure resident weights on admission, the morning after admission and weekly for three weeks thereafter (a total of four weeks). The threshold for significant unplanned and undesired weight change will be based on the following criteria: one week = 3% weight change is significant; one month = greater than 5% is severe. An individualized care plan shall address the following - The identified causes of weight change; - Goals and benchmarks for improvement; and - Time frames and parameters for monitoring and reassessment. The dietitian will discuss weight change with the resident and/or family. Closed medical record review for Resident 1 was initiated on 2/7/18. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Nutrition assessment dated [DATE] showed Resident 1 was 72 inches in height (6 feet tall) and his usual body weight was 190 pounds. Staff documented the resident's desired weight was 183 +/- 5 pounds. His most recent weight was 183 pounds. The goal was for the resident to consume 70% or more of each meal. Documentation showed Resident 1 had +1 [MEDICAL CONDITION] (swelling, the degree of indentation when an [MEDICAL CONDITION] area is pressed) to his lower extremities. Review of the initial MDS dated [DATE], showed Resident 1 was cognitively intact. Review of the Weight Summary failed to show Resident 1's weights were obtained on the day of admission (12/9/17) and the morning after admission (12/10/17). Review of the Weight Summary for Resident 1 showed the following: * On 12/11/17 = 183 pounds (initial weight taken two days after admission). * On 12/17/17 = 174 pounds (9 pounds, a 4.91% weight loss in six days). * On 12/24/17 = 172 pounds (11 pounds, a 6% weight loss in 15 days since admitted ). * Third weekly weight was due on 12/31/17; however, documentation failed to show a weight was obtained on this date. * On 1/4/18 = 150 pounds (33 pounds, a 18% weight loss in 26 days since admitted ). There were no further weights recorded after 1/4/18. Review of laboratory results dated [DATE] showed the following: - BUN was 16 mg/dL (normal range 7-21 mg/dL; blood urea and nitrogen, a test on kidney and liver function); - Creatinine was 0.9 mg/dL (normal range 0.5 - 1.4 mg/dL; a test on kidney function); - [MEDICATION NAME] was 2.2 g/dL (normal range was 3.5 - 5.0 g/dL; low [MEDICATION NAME] levels can also be seen in malnutrition and conditions where the body did not properly absorb and digest protein or in which large volumes of protein). Review of Resident 1's acute care hospital emergency department History and Physical record dated 1/12/18, showed the following laboratory values: - BUN = 72 mg/dl - Creatinine 1.6 mg/dl - [MEDICATION NAME] = 1.6% g/dl Review of Resident 1's plan of care showed a care plan problem to address nutrition initiated on 12/14/17. The care plan failed to address Resident 1's target weight range nor his dietary preferences. On 12/19/17, an IDT Weight Management Assessment showed Resident 1's weight was 174 pounds, a 9 pound loss in one week. The RD documented the resident was receiving a regular diet, his oral meal intake was variable, would provide house shakes twice a day between meals, recommended 1:1 feeding assistance with meals, and would continue to monitor. There was no documentation the resident's physician was notified of the weight loss. There was no documentation of the RD discussing the weight loss with Resident 1 and/or his family or documentation of Resident 1's [MEDICAL CONDITION]. Further review of the medical record failed to show any documentation regarding Resident 1's [MEDICAL CONDITION]. Review of the nurses' progress notes showed Resident 1 was transferred to the acute care hospital on [DATE] at 1430 hours, for episode of confusion, and returned to the facility on the same day (12/19/17) at 2000 hours. Review of the Discharge Instructions from the acute care hospital dated 12/19/17, showed Resident 1 did not have [MEDICAL CONDITION]. Review of Resident Specific Dietitian Recommendations dated 12/19/17, showed the RD recommended 1:1 feeding assistance with meals and house shakes 120 ml two times a day in between meals. Review of the nutrition care plan failed to show the new interventions recommended by the RD. Review of the physician's orders [REDACTED]. Review of Resident Specific Dietitian Recommendations dated 12/20/17, showed the RD recommended Resident 1 to be placed in RNA feeding program for all meals. Review of Resident 1's plan of care failed to show a care plan problem was created to address Resident 1's participation in the RNA feeding program for all meals. Review of the Order Summary Report dated 12/29/17, showed a physician's orders [REDACTED]. However, the facility failed to show any documented evidence Resident 1 was placed on the RNA feeding program. On 12/27/17, an IDT Weight Management Assessment showed Resident 1 weighed 172 pounds, a loss of 2 pounds in a week. The resident's oral meal intake was mostly 75 to 100% and was receiving house shakes twice a day. The RD documented Resident 1 continued to lose weight despite supplements and relatively good oral intake, would recommend RNA feeding program and fortified diet, and complete the entries for meal and intake supplement percentages. There was no documentation to show the weight loss as an 11 pounds or 6% weight loss in 15 days had been discussed with the physician or family. Review of the CNA - ADL Tracking Form for the month of (MONTH) (YEAR) showed the following entries for meal intake: Breakfast Lunch Dinner - 12/20/17 = 0-25% 26-50% 76-100% - 12/21/17 = 0-25% 0-25% 26-50% - 12/22/17 = 76-100% 76-100% 76-100% - 12/23/17 = 26-50% 26-50% 76-100% - 12/24/17 = 76-100% 0-25% 26-50% - 12/25/17 = 76-100% 76-100% 51-75% - 12/26/17 = 0-25% 0-25% 76-100% Further medical record failed to show documentation of Resident 1's intake of the house shakes. Review of the nutrition care plan failed to show new interventions nor approaches to address Resident 1's severe weight loss. On 1/8/18, an IDT Weight Management Assessment showed Resident 1 weighed 150 pounds a loss of 18% (33 pounds) in one month. Resident's oral intake was variable. Resident 1 continued to have weight loss despite dietary interventions of house shakes three times a day, Prostate twice a day and fortified meals. The plan was for Resident 1 to be transferred to another facility. Present in the IDT meeting were the RD, ADON and SSA. The note stated the plan was for Resident 1 to be transferred to another facility and to continue with the current plan of care. The entries of recent labs, meal and intake supplement percentages. There was no documentation to show the physician was made aware of the 18% weight loss. Review of the nutrition care plan failed to show new interventions nor approaches to address Resident 1's severe weight loss. Review of the ADL flowsheet from 12/9/17 to 1/12/18, showed inconsistencies in the support or assistance with provided for eating. On 2/7/18 at 1132 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 1 could feed himself at time. CNA 2 stated he would only feed Resident 1 whenever he left his food untouched. On 2/7/18 at 1343 hours, an interview and concurrent closed medical record review was conducted with the RD and DSS. The RD stated she did not observe Resident 1 eat when she did the Nutrition Assessment on 12/14/17. The RD stated Resident 1's weight losses were undesirable. The RD verified the plan of care was not revised to address Resident 1's weight loss. When asked how she identified if the interventions were suitable for Resident 1. The RD stated she did not know whether her recommendations of house shakes were carried out or not. When asked if she had discussed the weight loss with Resident 1 and/or his family regarding his severe weight loss identified on 12/27/17. The RD stated no, the charge nurses usually called the resident's family members. The RD stated she wrote Resident 1's intake as 75-100% during the IDT Weight Management Update on 12/27/17, based on the CNA's ADL flowsheet. When the CNA flowsheet was reviewed, the entries showed Resident 1's intake were mostly 0-25% and 26-50%. The RD stated she must have looked at the wrong resident's meal intake. The RD stated she did not have new interventions or recommendations when the severe weight loss of 6% was identified on 12/27/17, because she thought Resident 1 was eating well. When asked if she had recommended any laboratory tests to be done, the RD stated no. On 2/7/18 at 1602 hours and on 2/27/18 at 1500 hours, an interview was conducted with the ADON. The ADON verified Resident 1's weights were not obtained timely per the facility's P&P. The ADON verified the dietary recommendations for house shakes two times a day (dated 12/19/17) were not carried out. The ADON could not find documentation to show Resident 1 was placed on the RNA feeding program for all meals as per the RD recommendations on 12/20/17. The ADON stated Resident 1 was not appropriate for the RNA feeding program; the RNA feeding program was designed for the residents who could feed themselves and only needed assistance and cuing. She could not explain why this was not addressed in the IDT meetings.

Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure adequate assistance was in place to prevent a fall for one of two sampled residents (Resident 1). Resident 1 had been assessed as needing two persons for bed mobility. CNA 1 had not cared for Resident 1 before and was not aware Resident 1 needed to have two staff in attendance during bed mobility. Resident 1 fell off the bed onto the floor while CNA 1 was providing incontinence care with no other staff in assistance. As a result, Resident 1 sustained lacerations to the upper lip, right forehead, and right knee, requiring a transfer to the acute care hospital ED by 911 and sutures. Findings: On 10/11/17 at 1210 hours, Resident 1 was observed lying on an air-filled mattress. Resident 1 had yellowish discoloration under her eyes and light purple discoloration on the right side of her forehead. Medical record review for Resident 1 was initiated on 10/11/17. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the SBAR Communication Form and Progress Note dated 9/22/17 at 2015 hours, showed Resident 1 sustained a fall from bed onto the floor while being receiving incontinent care. Resident 1 was transferred to the acute care hospital ED by 911. Review of the acute care hospital Physical Exam and Procedures report dated 9/22/17, showed Resident 1 arrived at the ED at 2116 hours. Resident 1 was assessed to have the following injuries: a laceration to the anterior of her right knee and swelling to the left elbow, a full thickness laceration to her right forehead (measuring 3 cm) and a full thickness laceration to the upper lip (measuring 2 cm), both requiring sutures. On 10/11/17 at 0912 hours, an interview was conducted with Resident 1's responsible party. Resident 1's responsible party stated Resident 1 was totally bed bound and could not understand how she could have fallen. The responsible party stated the night nurse had informed her she made sure Resident 1 always had two staff assisting to change Resident 1, which clearly did not happen at the time the resident fell . Review of the MDSs dated 6/8 and 9/5/17, showed Resident 1 had severe cognitive impairment and required extensive assistance of two persons for bed mobility and total assistance of two persons for transfers. Review of Resident 1's plan of care showed a care plan problem dated 8/14/17, to address Resident 1's claim she had fallen out of bed. One of the interventions dated 8/15/17, showed two persons' assistance with bed mobility and transfers. On 10/11/17 at 1420 hours and again on 10/12/17 at 1445 hours, the interviews were conducted with LVN 1. LVN 1 stated he considered Resident 1 to need one person's assistance for bed mobility before the fall on 9/22/17. LVN 1 stated he was not aware of any documentation showing Resident 1 needed two persons to assist with bed mobility. On 1/12/17 at 1503 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 was a one person assist before the fall on 9/22/17. On 10/12/17 at 1130 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified the MDS dated [DATE], identified Resident 1 as needing two persons for bed mobility and the care plan problem was updated on 8/15/17, to reflect the need of two persons's assistance with bed mobility and transfers. The MDS Coordinator verified the Documentation Survey Report form for the task of bed mobility from June through September 2017 showed inconsistencies in the number of staff required to provide bed mobility assistance for Resident 1. On 10/12/17 at 1340 hours, an interview was conducted with the DSD. The DSD stated when a CNA from a nursing registry (business which provides CNAs as needed) was working, it was up to the licensed nurse to inform them of their assignments and give them the reports on the residents they were assigned to care for. On 10/20/17 at 1500 hours, a telephone interview was conducted with CNA 1. CNA 1 was assigned to care for Resident 1 on 9/22/17, when the fall occurred. CNA 1 verified she was employed by a nursing registry agency. CNA 1 stated she never received any report regarding Resident 1's care needs and was never informed Resident 1 needed two persons' assistance for bed mobility and transfers. CNA 1 stated she was cleaning and changing Resident 1 at the time of the accident. CNA 1 stated Resident 1 was trying to help by turning to her side, but she accidentally rolled too far and fell off the bed onto the floor. On 11/13/17 at 1420 hours, an interview was conducted with LVN 1. LVN 1 was the licensed nurse assigned to Resident 1 on 9/22/17, when the fall occurred. LVN 1 stated he did not give a report regarding Resident 1 to CNA 1. LVN 1 stated he told the other CNAs to answer whatever questions CNA 1 might have.

Based on interview and closed clinical record review, the facility failed to assess resident skin integrity, identify pressure ulcers in accordance with the facility's P&P, and implement measures to prevent the development and/or deterioration of pressure ulcers for two of two sampled residents (Residents 1 and 2). * Resident 1 was assessed with [REDACTED]. The following day (4/5/15), Resident 1 was identified to have redness to his coccyx (tailbone) area. Twelve days later, on 4/17/15, Resident 1's reddened coccyx area had deteriorated from a Stage I to a Stage III pressure ulcer. * Resident 2 was assessed to have redness to her coccyx area on 2/12/15. On 3/16/15, Resident 2 developed a DTI to her coccyx area. There were no preventative measures implemented when the Stage I pressure ulcer was identified to prevent further deterioration of the resident's skin. Findings: According to the 2009 National Pressure Ulcer Advisory Panel (NPUAP), pressure ulcers have been defined as localized tissue injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure (due to staying in one position for too long without shifting weight). Review of the facility's P&P titled Pressure Ulcer Risk Assessment revised 2/2014 showed staff will perform routine skin inspections (with daily care) and licensed nurses will conduct skin assessments at least weekly to identify changes. The licensed nurses are to be notified of any skin changes and inspect the skin. Residents at risk for skin breakdown need interventions implemented promptly in an attempt to prevent further skin breakdown; a pressure ulcer can develop within two to six hours. 1. Closed clinical record review was initiated for Resident 1 on 4/30/15. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's discharge H&P from the acute care hospital dated 4/3/15, showed Resident 1 had a decreased oral intake and was to receive oral supplements three times a day at the skilled nursing facility. However, review of the physician's admitting orders to the facility did not include oral supplements. Review of the Nursing Admission and Assessment form dated 4/4/15, and Physician Admitting Order form dated 4/4/15, showed Resident 1 had no skin break down. Review of the Braden Scale form dated 4/4/15, showed Resident 1's score was 19 (a score of 12 or less represents high risk of developing pressure ulcers). Review of the updated Nursing Admission and Assessment form dated 4/5/15, showed Resident 1 had redness to his coccyx area. Review of Resident 1's plan of care identified a short-term care plan problem dated 4/5/15, to address Resident 1's reddened peri-area (area between her legs). The interventions included to cleanse with water and apply zinc oxide cream (skin protectant), monitor for signs of infection, and notify the physician if the treatment was ineffective. However, there were no interventions to address turning, repositioning, and/or devices to relieve the pressure to Resident 1's reddened coccyx area. Review of Resident 1's plan of care identified a care plan problem dated 4/5/15, to address the risk for development of pressure ulcers manifested by impaired mobility had no interventions regarding a turning or repositioning program or the use of pressure-relieving devices. Review of the Nutritional Screening and Data Collection form dated 4/6/15, showed the dietary technician documented no nourishment or supplements were indicated. Review of the MDS dated [DATE], showed Resident 1 required one staff member's assistance for bed mobility and all ADL care. The MDS also identified Resident 1 was at high risk of developing pressure ulcers upon admission. Review of the facility's shower schedule showed Resident 1 was scheduled to be showered every Tuesday and Friday. With each shower, staff were to complete a Shower Skin Check form. There were no shower skin checks documented for Resident 1 on Tuesday (4/7/15), Thursday (4/10/15), or Tuesday (4/14/15). Review of a blank Shower Skin Check form showed a diagram of a body. The instructions on the form showed staff were to document any bruises, rashes, redness, skin tears, and pressure ulcers since the last shower. Review of Resident 1's SBAR form dated 4/16/15, showed a Resident 1 had a new pressure ulcer. Staff documented, The pressure ulcer was discovered during the assessment of the coccyx area. The pressure ulcer measured 1.5 cm (length) x 1.0 cm (width) x 1.0 (depth), with 80 percent slough. Resident was not aware of this condition, stated that feels pain in the area. Review of the Wound Evaluation Flow Sheet form initiated on 4/16/15, showed Resident 1 had a Stage III pressure to his coccyx and the physician was notified. Review of the physician's orders [REDACTED]. Review of the licensed nurses' progress notes dated 4/16/15 at 1320 hours, showed Resident 1 was evaluated by a wound care physician. Staff documented the physician pre-medicated the resident and applied [MEDICATION NAME] ointment (to numb the area). He then performed sharp curette debridement (removal of dead tissue) to the resident's coccyx Stage III pressure ulcer. A care plan problem dated 4/16/15, titled Pressure Ulcer Coccyx Stage III was developed. However, there were no interventions identified to address how to treat and promote the healing of the Stage III pressure ulcer on the coccyx area. Review of the IDT Wound Management form initiated on 4/16/15, showed Resident 1 developed a Stage III pressure ulcer after admission to the facility. On 4/24/15, the IDT documented the wound care physician had assessed the resident's wound and performed mechanical debridement (removal of dead tissue) and the resident had a LAL mattress in place. Review of the Physician's Progress Notes dated 4/17/15, showed Resident 1 had a Stage III pressure ulcer to his lower back (coccyx area). On 4/30/15 at 1415 hours, an interview was conducted with LVN 1. LVN 1 stated staff were to check a resident's skin during their scheduled showers. LVN 1 stated the CNAs were to report any skin changes to the treatment nurses or licensed nurses. LVN 1 stated when there was a change of condition, the licensed nurses would be required to write a report, notify the physician, obtain any new orders, and notify the resident's responsible party. On 4/30/15 at 1430 hours, an interview and concurrent closed clinical record review was conducted with the RD. The RD stated the licensed nurses were to notify her when there were any changes of condition and she then documented any necessary recommendations. The RD verified there was no documented evidenced the licensed nurses had notification her of Resident 1's development of the pressure ulcer. Review of Resident 1's CNA - ADL Tracking form for the month of April 2015 showed between 4/5/15 and 4/20/15, Resident 1 required one staff member's assistance for transfers and two staff members' assistance for bed mobility and personal hygiene care. On 4/30/15 at 1500 hours, an interview and concurrent closed clinical record review was conducted with CNA 2. CNA 2 stated when there were any changes of condition in a resident's skin, the CNAs were to document it on the back of the CNA - ADL Tracking form. CNA 2 verified Resident 1's CNA - ADL Tracking forms had no information pertaining to Resident 1's skin. On 4/30/15 at 1530 hours, an interview and concurrent closed clinical record review was conducted with LVN 2. LVN 2 stated Resident 1 had a Stage I pressure ulcer to his coccyx which had deteriorated to a Stage III pressure ulcer. When asked if Resident 1's Stage III pressure ulcer could have been prevented, LVN 2 stated if appropriate measures and interventions were provided, the pressure ulcer might not have deteriorated to a Stage III pressure ulcer. LVN 2 confirmed there was no documented evidence any preventative measures were in place when Resident 1's Stage I pressure ulcer was identified on 4/5/15. During an interview and concurrent closed clinical record review with the ADON on 4/30/15 at 1640 hours, the ADON confirmed there was no documented evidence staff had documented the shower checks for Resident 1 for 4/7, 4/10, and 4/14/15. 2. Closed clinical record review was initiated for Resident 2 on 4/30/15. Resident 2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Nursing Admission and Assessment form dated 2/12/15, showed Resident 2 had redness to her coccyx area. Review of the physician's admitting orders dated 2/12/15, showed a treatment order to cleanse Resident 2's reddened coccyx area with normal saline, pat dry, and apply zinc oxide cream every eight hours for 14 days. Review of Resident 2's treatment administration record from 2/12/15 to 2/26/15, failed to show the treatments to the reddened coccyx area were performed as ordered to prevent deterioration for 14 days. There was no documentation to show why the treatments were not done or that the physician's orders [REDACTED]. Continued review of Resident 2's closed clinical record found no documentation to show a care plan problem was developed to address the resident's development of skin redness on the coccyx area, treatment, or interventions to prevent further skin breakdown. Review of Resident 2's MDS dated [DATE], showed the resident required total assistance by one staff member for all her ADL care and was incontinent of both B&B. Review of the physician's progress notes dated 2/17/15 and 3/11/15, showed Resident 2 continued to have diarrhea. Review of Resident 2's SBAR dated 3/16/15, showed Resident 2 was identified with a DTI to her sacrococcyx area, measuring 2 cm (length) x 1.5 cm (width) x UTD. Staff identified the resident's surrounding skin as dark plum red discoloration at the wound base. Review of the physician's orders [REDACTED]. Further review of Resident 2's treatment record showed only one treatment was performed on 3/17/15, not two as ordered. There was no documentation as to why one more treatment on this day was not performed as ordered. Review of the physician's progress note dated 3/18/15, showed Resident 2 now had a Stage II pressure ulcer. On 5/20/15 at 1705 hours, an interview and concurrent closed clinical record review was conducted with LVN 2. LVN 2 reviewed Resident 2's treatment record and confirmed Resident 2's coccyx treatment was not documented as done as ordered from 2/12/15 to 2/26/15. He stated Resident 2's skin was being monitored and preventative measures should have been implemented. When asked if Resident 2's DTI could have been prevented. LVN 2 stated if appropriate measures and interventions were provided Resident 2's pressure ulcer might not have deteriorated. When asked to locate any documented preventative interventions implemented for Resident 2, LVN 2 was unable to do so.

Based on interviews, closed clinical record review, and facility documentation, the facility failed to accurately administer and monitor Resident 2's [MEDICATION NAME] (a narcotic/opioid [MEDICATION NAME], strong pain medication) via a Computerized Ambulatory Drug Delivery (CADD) pump. The physician ordered Resident 2 to receive [MEDICATION NAME] at 0.5 mg/hr via a CADD pump. However, the CADD pump was set to administer 30 mg/hr; resulting in Resident 2 receiving approximately 60 times the ordered dose. Resident 2 died within a few hours after [MEDICATION NAME] was administered. In addition, the facility failed to ensure RN 2 and RN 3, who were assigned to care for Resident 2, were knowledgeable in how to use a CADD pump. RN 2's repeated requests for assistance in setting up the CADD pump were ignored. Resident 2 was receiving hospice care (end of life). The facility failed to coordinate care between the facility and the hospice agency in relation to the delivery of the CADD pump and administration of [MEDICATION NAME]. Findings. Review of the facility's contracted pharmacy (Pharmacy 1) P&P titled "Narcotic Infusion" dated ,[DATE], showed the facility must ensure all nurses responsible for the care and management of residents receiving narcotic infusions are knowledgeable and competent in the administration. The electronic device is initially programmed by the pharmacy and must be double checked by two licensed nurses to verify agreement with the physician's orders [REDACTED]. Lexi-Comp Online (Web-Base resource for health professionals) shows the continuous infusion rate for [MEDICATION NAME] is 0.5 - 3 mg/hr. The peak time for a continuous infusion is 10 - 20 minutes. Under Warnings and Precautions: life-threatening respiratory depression may occur. Closed clinical record review for Resident 2 was initiated on [DATE]. Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of a hand-written document dated [DATE], showed it was signed by RN 1 and RN 2, and identified Resident 2's CADD pump was infusing at a continuous rate of 30 mg/hr. A Licensed Personnel Weekly Progress Note dated [DATE] at 1530 hours, showed the CADD pump was started. Documentation at 1605 hours, showed Resident 2 was having respiratory distress and her skin was clammy. At 1805 hours, Resident 2 had no blood pressure or pulse. Review of the facility's Inservice Meeting Minutes dated [DATE], showed the inservice topic was related to a CADD pump. Documentation showed RN 1's and RN 2's signatures to indicate they had attended the inservice. However, RN 3's signature was not on the sign-in sheet. On [DATE] at 1215 hours, a telephone interview was conducted with the RN Pharmacy Consultant. She confirmed she is the educator for Pharmacy 1 and had given an inservice to facility staff on [DATE], on how to use a CADD pump. She stated, during the inservice, she had informed the licensed nurses to always have two nurses verify the physician's orders [REDACTED]. On [DATE] at 1517 hours, a follow-up telephone interview was conducted with the RN Pharmacy Consultant. She stated during the inservice she provided to facility staff on [DATE], she did tell the nurses the CADD pump would be delivered pre-programmed to match the physician's orders [REDACTED]. On [DATE] at 1330 hours, an interview was conducted with the hospice agency's Clinical Supervisor. She confirmed Resident 2 was receiving hospice care and the resident's medications, including [MEDICATION NAME], were supplied by the hospice's pharmacy (Pharmacy 2). She stated the CADD pump would have been ordered by the hospice agency, but delivered to the facility by a separate company. The hospice Clinical Supervisor stated she had scheduled a licensed hospice nurse to go the facility to set-up the CADD pump when the medications and pump arrived. However, she was not informed when the facility had received it, and therefore, no hospice nurse was sent to set-up the CADD pump. She stated, on [DATE], when the licensed hospice nurse conducted her routine check on Resident 2, the nurse found the CADD pump medication bag empty; and the CADD pump screen showed the administration of [MEDICATION NAME] was at 30 mg/hr, not at 0.5 mg/hr, as ordered. During an interview on [DATE] at 0825 hours, RN 1 stated RN 2 came to his office on [DATE] at around 1430 hours, and told him she was not 100% sure how to use a CADD pump and could he help her. RN 1 told her, he was busy and could she ask the DON, ADON or RN Supervisor for help. He stated approximately fifteen minutes later, at around 1445 hours, RN 2 returned to his office "panicking" and told him nobody would help her. She said she did not know how to prime the machine. RN 1 explained he did not go into the resident's room to assist her, but told her to just push the prime button. At 1510 hours, RN 2 came back to RN 1 and said the CADD pump is beeping. RN 1 told her to go ask a supervisor for help. At 1520 hours, RN 2 told RN 1 the CADD pump screen showed the cassette was unlocked. At this time, RN 1 went to Resident 2's room and locked the pump. On [DATE] at 0955 hours, an interview was conducted with the DON. The DON stated RN 2 did come to her office on [DATE], asking for assistance with Resident 2's CADD pump. The DON stated she was having a meeting and told RN 2 "you know what to do; you had an inservice last week." The DON stated, she received a telephone call, on [DATE] at approximately 1930 hours, from Resident 2's physician. The physician told her Resident 2's CADD pump was beeping and the medication bag was empty. The physician also informed her the CADD pump screen showed the medication was programmed to administer [MEDICATION NAME] at 30 mg/hr, but his order was for 0.5 mg/hr. The DON stated, Resident 2's medication was delivered by Pharmacy 2 and the CADD pump machine was delivered separately from a different company. The DON stated she should have checked Resident 2's CADD pump to ensure it was at the appropriate setting and working properly. The DON stated, the licensed nurses were inserviced on the use of a CADD pump on [DATE]. The inservice was provided by Pharmacy 1. She confirmed RN 3 did not receive this inservice. During an interview on [DATE] at 1115 hours, the ADON stated RN 2 came to the DON's office on [DATE] between 1400 and 1500 hours, and told the DON she had a CADD pump and she needed somebody to help her set it up. The ADON stated the DON told RN 2 she had just been inserviced on how to use a CADD pump; and to just follow exactly what she was told during the inservice. The ADON said, she told RN 2 that if she felt uncomfortable with the CADD pump, to call the pharmacy to assist her in setting the pump up. When the ADON was asked who is responsible to ensure the staff is knowledgeable prior to accepting care of a resident, she stated the DON is responsible. On [DATE] at 1140 hours, an interview was conducted with the DSD. He stated about two and a half weeks ago, the DON asked him to do an inservice on the use of a CADD pump. He stated, he contacted the RN Consultant from Pharmacy 1. When the DSD was asked if the inservice on the CADD pump was mandatory, he stated, no, the inservice was only mandatory for the RN staff who was working on that day. The DSD confirmed RN 3 did not attend the CADD pump inservice. During a telephone interview conducted on [DATE] at 1345 hours, the Manager for Pharmacy 2's Home Infusion department. The Manager stated a 250 militer bag containing [MEDICATION NAME] was sent to the facility for Resident 2 with an order to use the CADD pump. He stated the bag was labeled with the medication concentration, the lock out times, and the maximum dose per hour to be administrated. The Manager stated there was no form for the nurses to use to track the medication sent with the medication. The Manager stated the CADD pump belonged to and was delivered by a different company. On [DATE] at 1355 hours, a telephone interview was conducted with RN 2. She stated Resident 2's [MEDICATION NAME] medication arrived at around 1400 hours, and the CADD pump arrived at around 1415 hours on [DATE]. She started the administration of the [MEDICATION NAME] was sometime between 1430 hours and 1445 hours. RN 2 stated she asked RN 1 the ADON and the DON for help prior to setting up the CADD pump. She stated RN 1 told her, he was too busy, and the ADON said to call the pharmacy. RN 2 stated the DON told her she had just been given an inservice and to try it first, then come back if she needed help. RN 2 stated, she went back to RN 1 and told him both the ADON and DON were not to going help her set-up Resident 2's CADD pump. She stated RN 1 turned on the pump and primed the tubing. RN 2 stated it was close to the change of shift, she went back to Resident 2's room and gave RN 3 report on the resident. She stated, she and RN 3 read the CADD pump screen and wrote down the readings on a piece of paper. RN 2 stated she still did not feel like the CADD pump was functioning properly and again asked RN 1 for help. RN 1 went to Resident 2's room, locked the cassette and said the CADD pump was working. RN 2 stated RN 3 told her he was not familiar with the CADD pump. RN 2 informed him of the recent inservice (on [DATE]) and how they were taught the CADD pump arrives from the pharmacy already programmed to match the physician's orders [REDACTED]." A telephone interview was conducted on [DATE] at 1530 hours, with RN 3. RN 3 stated he was not inserviced on the use of a CADD pump machine prior to being assigned to Resident 2. He stated he had never worked with a CADD pump before [DATE]. When RN 3 was asked if he had notified the DON, ADON, DSD or any other staff member prior to accepting care of Resident 2 on [DATE], he stated, no, he only told RN 2.

Based on observation, interview and clinical record review, the facility failed to address risk factors for developing pressure ulcers, and failed to promote prevention of pressure ulcer development by not implementing interventions that are consistent with the residents' needs for three of 27 sampled residents (Residents 3, 11 and 22). Resident 3 was admitted to the facility with no skin breakdown. The repositioning schedule was not implemented, and the heels were not elevated at all times, as ordered by the physician. Resident 3 developed new pressure ulcers to his left and right heels while in the facility. The right heel pressure ulcer deteriorated to a Stage III (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Some slough (dead tissue) may be present). Resident 11 had an order for [REDACTED]. Observation and interview showed heel protectors were not being worn to prevent pressure and shearing of skin. This places the residents at risk for experiencing pain, infection and decreased functional ability. The facility failed to provide a low air loss mattress for Resident 22 as ordered. This poses the potential for development of pressure ulcers, or worsening of Resident 22's skin condition. Findings: According to the 2009 National Pressure Ulcer Advisory Panel (NPUAP), pressure ulcers have been defined as localized tissue injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure (due to staying in one position for too long without shifting weight), or pressure with shear (occurs when layers of skin rub against each other or when the skin remains stationary and underlying tissue moves and tears, causing tissue damage). Review of the facility's P&P titled Pressure Ulcer and Wound Management revised date 9/20/10, shows, based on the assessment and identification of risk factors through the assessment process, the following interventions may be considered: assist with or turn and reposition, apply pillows/heel protectors/foot cradle or other lower extremity devices as indicated. 1. Initial tour round observations were conducted with LVN 3 on 2/21/12 beginning at 0630 hours. At 0655 hours, Resident 3 was visited. The LVN stated Resident 3 developed two pressure ulcers that were identified as blisters two weeks ago. LVN 3 stated the resident developed two Stage II (Partial thickness loss of skin presenting as a shallow open ulcer with a red pink wound bed, without slough) pressure ulcers to the left and right heels while in the facility. Resident 3 was awake and was observed to be positioned on his back, with the head of the bed elevated. Resident 3 had cotton fabric heel protectors on; however, his heels were resting directly on the mattress. Clinical record review for Resident 3 was initiated on 2/12/12. Resident 3 was readmitted to the facility on [DATE]. Review of the Nursing Admission assessment dated [DATE], showed Resident 3 was able to follow simple commands, was incontinent of bowel and bladder, his skin was intact, and the heels were not spongy. Review of the MDS dated [DATE], showed Resident 3 has severe cognitive impairment, and is completely dependent on staff for all care needs; he requires extensive assistance for turning/repositioning in bed with the assistance of one person. On 2/21/12 at 0800 hours, an interview was conducted with LVN 3. The LVN stated it is the facility's policy to assess if the residents are at risk for the development of pressure ulcers during their admission and to develop a specific care plan if necessary. On 2/21/12 at 1130 hours, an interview was conducted with Resident 3's family member. The family member stated Resident 3 was sent to an acute hospital on [DATE], due to [MEDICAL CONDITION]. Since he came back, he seems to have more difficulty to arouse; he sleeps most of the time. The family member stated Resident 3 is lethargic; he used to be more independent. On 2/21/12 at 0900, 1130 and at 1400 hours, Resident 3 was observed in bed, laying on his back. A flat pillow was under his legs; however, his right and left heels were laying on the mattress, without support to prevent pressure. On 2/21/12 at 1205 hours, the family member was observed feeding Resident 3 while he was in bed. The family member had to awaken the resident multiple times while feeding him. On 2/22/12 at 0830 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 3 is unable to turn, reposition or sit up by himself. She stated, two weeks ago, he was able to ambulate with a walker, and had no skin breakdown. Recently, he declined in ADLs, and is lying in bed most of the time. There was no documentation in Resident 3's clinical record to show staff members assessed the resident's risk for skin breakdown due to bedrest and inability to reposition self. On 2/22/12 at 0900, 1300 hours, and on 2/23/12 at 0750 and 1200 hours, Resident 3 was observed lying in his bed, sleeping, positioned on his back. There were two flat pillows placed under the resident's lower legs; however, both of the resident's heels were resting on the mattress, and were not offloaded (floating). Review of the Licensed Personnel Weekly Progress Notes from 1/18/12 through 2/21/12, showed the licensed nurses were documenting "pressure off in all areas." However, an entry dated 2/21/12 at 1730 hours, showed the only documentation indicating the resident was being turned every two hours. Review of a Change in Condition assessment dated [DATE], showed the reason for the assessment was a dry, right heel blister measuring 1.8 cm by 1 cm, and a dry, left heel blister measuring 2 cm by 2 cm. Review of a physician's orders [REDACTED]. Review of the care plan showed a care problem dated 8/5/11, to address the high risk for skin breakdown due to decreased activity and mobility, incontinency, and fragile skin. The approaches showed, assist to reposition every two hours and as needed, pressure reducing mattress, and heel pads. A short term care plan problem dated 2/2/12, to address the right and left dry blisters showed approaches for the treatment nurse to evaluate, treatment as ordered, assess for pain, heel protectors, and monitor if treatment is not effective. There was no intervention to offload the resident's heels. Review of the physician's orders [REDACTED]. Monitor dressing placement every shift, and change as needed if soiled/dislodged. On 2/21/12 at 1030 hours, LVN 2 identified himself as one of the two treatment nurses. LVN 2 was observed changing the dressings to Resident 3's pressure ulcers located on his left and right heels. LVN 2 removed the dressings from the left and right heels prior to the observation. When asked if the resident's pressure ulcers developed in the facility, the LVN stated, yes, he got them here; they started as blisters. The LVN stated the resident has heel protectors and a foot cradle (an arch shaped metal bar to keep the bed linens off the feet) to prevent pressure to his toes, because the resident doesn't move by himself; he requires total assistance. The LVN stated the last time the dressings were changed was on 2/19/12. During the treatment the following was observed: a. During the pressure ulcer treatment of [REDACTED]. b. During the pressure ulcer treatment of [REDACTED]." At this time, when the treatment nurse proceeded to remove the dressing from the resident's right heel, the old dressing was noted with serosanguineous drainage (thin bloody draining fluid). The treatment nurse then cleansed the wound with normal saline. Resident 3 started moaning, grimacing and pointing to his foot. Resident 3 appeared to be experiencing pain. No pain assessment was done prior to the pressure ulcer treatment. During observation of the treatment to the right heel, the treatment nurse stated the pressure ulcer measured 1.8 cm by 1.2 cm with 0.2 cm depth, with 75% slough (a mass of dead tissue), 25% reddened, it had increased in size, with minimal pain during treatment. The treatment nurse stated "I need to call the physician to reclassify, and change the treatment of [REDACTED]." Review of a physician's orders [REDACTED]. On 2/21/12 at 1200 hours, an interview was conducted with LVN 3. When asked why the heel pads were discontinued by the physician, she stated because we don't need heel protectors if we are offloading the resident's heels. On 2/22/12 at 1130 hours, an interview was conducted with the RD. The RD stated the resident's weight is stable, he is eating almost 80% of his diet, and the labs are normal. She stated, if she would have known about the deterioration of the pressure ulcers, she would have increased his protein intake, and recommended vitamin C and zinc sulfate to meet the needs for the healing process. Review of a physician's orders [REDACTED]. Review of the Physical Therapy Wound Care Evaluation dated 2/22/12, showed the wound appeared as a dry blister on 2/2/12. Has been followed by nursing. On 2/21/12, was opened and was identified as a Stage III decubitus (pressure ulcer). During an interview with the DON on 2/23/12 at 1330 hours, the concern regarding Resident 3's skin integrity problems, lack of specific care plan interventions for the pressure ulcers, not repositioning, and not consistently elevating Resident 3's heels was discussed. The DON was unable to give an explanation as to why the staff members are not taking steps to prevent deterioration of Resident 3's pressure ulcers. 2. Clinical record review for Resident 11 was initiated 2/21/12 at 1530 hours. Review of the physician's orders [REDACTED]. Review of the care plan problems for Resident 11 showed no care plan problem to address the use of heel protectors. Review of Resident 11's care plan problem to address high risk for skin breakdown dated 3/14/11, and last evaluated 12/11, showed a problem of decreased activity and mobility and fragile skin. Interventions included to handle gently during care, monitor for signs and symptoms of skin problems routinely, use pressure reducing devices and protective measures. An interview with RN 1 was initiated on 12/22/12 at 0930 hours. RN 1 was asked to show if Resident 11 had heel protectors on his feet. RN 1 confirmed Resident 11 had no heel protectors. Observation showed Resident 11 had a skin tear on his left lateral ankle. RN 1 stated the skin tear measured approximately 1.5 centimeter by 1 centimeter. The skin tear was slightly red and had a scab on it. RN 1 was asked if heel protectors would have covered the area with the skin tear, and possibly prevented the skin tear. RN stated the heel protector would have covered the area with the skin tear, and possibly prevented the skin tear. 3. Review of Resident 22's clinical record was initiated on 2/22/12. The resident was admitted to the facility on 1/27/12. The MDS (an assessment tool) dated 2/3/12, showed the resident is at risk of developing pressure ulcers. Review of the physician's orders [REDACTED]. Review of the care plan showed a care plan problem dated 1/27/12, to address the high risk for skin breakdown. The approaches included to provide pressure reducing devices: low air loss mattress. During an observation, interview, and clinical record review with LVN 5 on 2/22/12 at 1600 hours, LVN 5 confirmed Resident 22 was on a maxifloat mattress, not a low air loss mattress. She stated the resident needed low air loss mattress.