Every finding on record at Los Altos Post-Acute

Based on interview and record review, the facility failed to provide quality of care for six of 18 residents (Residents 1, 2, 3, 4, 9, and 10) who have Diabetes Mellitus (DM, a chronic disease characterized by high levels of sugar in the blood) when:1. For Resident 1, the facility did not follow the physician's order to monitor blood glucose (BG, blood sugar) every 6 hours by glucometer (a device used to measure the amount of glucose in your blood) from 4/18/25 to 7/7/26 (a period of over 14 months); the facility did not conduct periodic laboratory tests to monitor Resident 1's blood glucose as in accordance with accepted professional standards of practice since 4/21/25 (or more than 14 months ago); the facility did not adequately monitor signs/symptoms (s/s) of hypoglycemia (a medical condition with blood glucose drops to dangerous low levels - s/s are such as increased sweating, weakness, shakiness, and confusion) and/or hyperglycemia (a medical condition with high blood glucose levels [s/s such as increased thirst, increased hunger, fatigue, blurred vision, and changes in metal status]) from 4/18/25 to 11/22/25 (a period of 7 months).These failures resulted in Resident 1 developing severe hyperglycemia. Resident 1 was transferred to a hospital's emergency department (ED) on 7/7/26, where blood glucose level of 921 milligram per deciliter (mg/dl, unit of measurement [normal range are 70 to 99 mg/dl while fasting, under 140 mg/dl after meals]) and eventually admitted to the ICU (Intensive Care Unit, a specialized hospital unit that provides care for patients with severe, life-threatening illnesses or injuries). Resident 1 was hospitalized for 20 days from 7/7/26 to 7/27/26.2. For Resident 2, the facility did not monitor BG while receiving medication for Diabetes Mellitus from 6/1/26 to 7/31/26 (a period of 2 months); the facility did not adequately monitor s/s of hypoglycemia and/or hyperglycemia from 6/1/26 to 8/17/26 (a period of over 2 months).3. For Resident 3, the facility did not follow the physician's order to check Hemoglobin A1C (Hgb A1C, a blood test that measures average blood sugar level over the past two to three months) and did not monitor BG while receiving a medication for DM from 11/25/25 to 8/20/26 (a period of over 8 months).4. For Resident 4, the facility did not monitor BG while receiving medication for DM from 2/19/26 to 8/20/26 (a period of 6 months).5. For Resident 9, the facility did not monitor BG while receiving medication for DM from 9/4/25 to 6/18/26 (a period of over 9 months).6. For Resident 10, the facility did not adequately monitor s/s of hypoglycemia and/or hyperglycemia from 5/17/26 to 8/24/26 (a period of over 2 months).These failures had the potential to compromise these residents' DM care and management and affect the quality of care for these residents. 1. A review of Resident 1's Face Sheet (summary of a Resident's basic information) indicated Resident 1 was admitted to the facility on [DATE] and had diagnoses including persistent vegetative state (a condition when a person is awake, but shows no signs of awareness), dementia (a progressive state of decline in mental abilities), Type 2 DM (a condition where the body cannot use insulin [a hormone produced by the pancreas that regulates blood glucose levels] properly, causing sugar to build up in the body), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/4/26, was reviewed. Section B0100 was coded Yes, which indicated Resident 1 was persistent vegetative state. Section GG0130 was coded 01, which indicated Resident 1 was dependent (means, Helper does all of the effort, resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) in eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene. A review of Resident 1's physician orders indicated, Resident 1 had an enteral feed (deliver liquid nutrition directly into the stomach) order of Glucerna (medical nutritional drinks to help manage blood sugar levels in people with diabetes or high blood glucose) 1.5 at 65 milliliter (ml, unit of dose measurement)/hour x 20 hours, order date 5/13/25. There was no medication order for DM management. A review of Resident 1's admission order from the acute hospital, dated 4/18/25, indicated Resident 1 was to continue receiving Glucose Monitoring Fingerstick [a quick medical method used to draw a tiny drop of blood from the finger] Orders: Blood Glucose (Glucometer) Every 6 hours. A review of Resident 1's Progress Notes by Physician Assistant (PA) C dated 4/18/25, 1/9/26, 1/12/26, 1/15/26, 1/23/26, 2/13/26, 2/23/26, and 2/27/26 indicated, Diet: on tube feeding [delivers liquid food, water, and medicines directly into the stomach through a soft plastic tube], Glucerna. We will continue checking blood sugar. A review of Resident 1's medical records indicated there was no documentation indicating the facility monitored Resident 1's BG every 6 hours by glucometer from 4/18/25 to 7/7/26 (a period of over 14 months). There was no documentation indicating the facility adequately monitored for s/s of hypoglycemia and/or hyperglycemia for Resident 1 from 4/18/25 to 11/22/25 (a period of 7 months). A review of Resident 1's laboratory results indicated Hemoglobin A1C 4.9 % (normal range is 4.0 to 6.0 %) on 4/21/25, and glucose 149 mg/dl (higher than normal range) on 1/24/26. There was no laboratory test including Hgb A1C and/or glucose after 1/24/26. A review of Resident 1's Progress Notes written by license nurse, dated 7/7/26, indicated, 12:10 a.m., during rounds, patient noticed with rapid breathing, lethargic [having very little energy, feeling slow, and being unable to do anything]. Temp [temperature] 100 'F [Fahrenheit, a scale of temperature at which water freezes at 32 degrees and boils at 212 degrees under standard conditions], PR [pulse rate] 145, RR [respiration rate] 27, BP [blood pressure] 101/41.1:25 a.m. Pt. was transported to ER [emergency room, ED]. A review of Resident 1's hospital ED Provider Notes, dated 7/7/26 at 1:44 a.m., indicated, Found on work up to have.Gap acidosis [a type of metabolic acidosis characterized by an excess of unmeasured acids in the blood] secondary to lactic acidosis (a serious medical condition where too much lactic acid [a chemical compound produced naturally by the body] builds up in the blood) vs [versus] DKA [diabetic ketoacidosis, a serious and life-threatening health condition that can happen as a result of diabetes]. The note further indicated his glucose level was 921 mg/dl (means a critical medical emergency that requires immediate treatment). A review of Resident 1's hospital Discharge Summary (DS), dated 7/27/26, indicated, He presented with septic shock (a life-threatening medical emergency where an infection causes dangerous low blood pressure and organ failure [a serious medical condition when vital organs stop working properly]), requiring intubation [a medical procedure where a doctor places a flexible plastic tube into a person's windpipe to keep an airway open during surgery or a severe illness], volume resuscitation [the emergency administration of intravenous fluids, blood to restore circulating blood volume]. He remained at high risk for acute decompensation [a sudden, severe worsening of a chronic medical condition] throughout the ICU stay.He presented with severe hyperglycemia [high blood glucose] and DKA/HHS [diabetic ketoacidosis/hyperosmolar hyperglycemic state, life-threatening health condition caused by severe lack of insulin, marked by high blood glucose] . The DS further indicated Resident 1's Hgb A1C was 9.1 % (very high, indicating average BG level is significantly elevated over the past two to three months). During an interview with the DON on 7/22/26 at 3:30 p.m., she confirmed Resident 1's latest Hgb A1C was checked on 4/21/25 (14 months ago). The DON stated Resident 1's Hgb A1C level on 4/21/25 was within normal range, and the facility monitored Resident 1 for s/s of hypoglycemia and/or hyperglycemia. The DON stated the facility should provide diabetic care according to the facility policy titled Nursing Care of the Older Adult with Diabetes Mellitus. During an interview with the RD on 7/28/26 at 11:28 a.m., she stated Glucerna was recommended for Resident 1 because the resident was diabetic. During an interview and record review with the DON on 7/28/26 at 12:10 p.m., she confirmed the physician order, dated 4/18/25, to monitor Resident 1's BG every 6 hours by glucometer was not carried out, and the facility did not monitor Resident 1's BG from 4/18/25 to 7/7/26 (a period of over 14 months). The DON acknowledged the physician order should have been followed as ordered. During an interview and record review with the AP on 7/28/26 at 12:50 p.m., she stated Resident 1's Hgb A1C was within normal range in 2025 and confirmed Resident 1's latest Hgb A1C was checked on 4/21/25 (14 months ago). The AP stated she thought the facility was monitoring Resident 1's BG as ordered, and she did not know why BG monitoring order was not carried out. During phone interview and record review with PA C on 7/29/26 at 10:50 a.m., she stated Resident 1's Hgb A1C was within normal range in 2025 and confirmed Resident 1's latest Hgb A1C was checked on 4/21/25 (14 months ago). PA C stated she assumed the facility was monitoring Resident 1's BG as ordered and did not ensure Resident 1's BG was monitored. During an interview with Licensed Vocational Nurse (LVN) D on 8/20/26 at 1:40 p.m., she stated she was not familiar with the facility policy about DM management but received the facility's training for DM management. LVN D stated the DM training included the facility should monitor the resident's BG once or twice a day for the resident with DM. A review of the facility's training titled Diabetic Management, dated 6/18/26, it indicated LVN D attended the training. During an interview with LVN E on 8/20/26 at 3:35 p.m., she stated she was not familiar with the facility policy about DM management but received the facility's training for DM management. LVN E stated the facility should monitor the resident's BG for the residents with DM. LVN E further stated she would contact the physician if there was no physician order to monitor the resident's BG for the resident with DM. A review of the facility's training titled Blood Glucose Monitoring, dated 4/15/26 and 5/28/26, it indicated LVN E attended both training. During an interview and record review with the DON on 8/24/26 at 10:05 a.m., she confirmed there was no documentation indicating the facility adequately monitored Resident 1 for s/s of hypoglycemia and/or hyperglycemia from 4/18/25 to 11/22/25 (a period of over 7 months). The DON acknowledged the facility should have monitored Resident 1 for s/s of hypoglycemia and hyperglycemia from 4/18/25 to 11/22/25. 2. A review of Resident 2's Face Sheet indicated Resident 2 was admitted to the facility on [DATE] and had diagnoses including Type 2 DM. A review of Resident 2's physician orders indicated Resident 2 had an order of Semaglutide (a medication used to treat type 2 DM) inject 0.25 mg (a unit of dose measurement) subcutaneously (giving a medication into the layer of fat below the skin) in the evening every Friday for type 2 DM, order date 6/10/26. A review of Resident 2's medical records indicated there was no documentation indicating the facility monitored Resident 2's BG by glucometer from 6/1/26 to 7/31/26 (a period of 2 months). There was no documentation indicating the facility adequately monitored Resident 2 for s/s of hypoglycemia and/or hyperglycemia from 6/1/26 to 8/17/26 (a period of over 2 months). During an interview and record review with the DON on 8/24/26 at 9:55 a.m., she confirmed there was no documentation indicating the facility adequately monitored Resident 2 for s/s of hypoglycemia and/or hyperglycemia from 6/1/26 to 8/17/26 (a period of over 2 months). The DON acknowledged the facility should have monitored Resident 2 for s/s of hypoglycemia and hyperglycemia from 6/1/26 to 8/17/26 (a period of over 2 months). 3. A review of Resident 3's Face Sheet indicated Resident 3 was admitted to the facility on [DATE] and had diagnoses including Type 2 DM. A review of Resident 3's physician orders indicated Resident 3 had an order of Metformin (a medication used to manage high blood glucose levels in people with type 2 DM) 500 mg 1 tablet by mouth two times a day for DM, order date 11/24/25. Also, Resident 3 had an order to check Hgb A1C every 6 months, order date 3/27/26. A review of Resident 3's medical records indicated there was no documentation indicating the facility monitored Resident 3's BG by glucometer from 11/25/25 to 8/20/26 (a period of over 8 months). There was no documentation indicating Resident 3's Hgb A1C was checked, or Resident 3 refused the Hgb A1C test. During an interview and record review with the DON on 8/20/26 at 8:55 a.m., she confirmed the physician order to check Resident 3's Hgb A1C every 6 months, dated 3/27/26, and Resident 3's Hgb A1C was not tested as ordered. The DON acknowledged the physician order to check Resident 3's Hgb A1C should have been followed as ordered, and nurse should have documented if Resident 3 refused the Hgb A1C test. 4. A review of Resident 4's Face Sheet indicated Resident 4 was admitted to the facility on [DATE] and had diagnoses including Type 2 DM. A review of Resident 4's physician orders indicated Resident 4 had an order of Metformin 500 mg 1 tablet by mouth two times a day for DM, order date 2/19/26. A review of Resident 4's medical records indicated there was no documentation indicating the facility monitored Resident 4's BG by glucometer from 2/19/26 to 8/20/26 (a period of 6 months). 5. A review of Resident 9's Face Sheet indicated Resident 9 was admitted to the facility on [DATE] and had diagnoses including Type 2 DM. A review of Resident 9's physician orders indicated Resident 9 had an order of Metformin 850 mg 1 tablet by mouth two times a day for DM, order date 9/4/25. A review of Resident 9's medical records indicated there was no documentation indicating the facility monitored Resident 9's BG by glucometer from 9/4/25 to 6/18/26 (a period of over 9 months). 6. A review of Resident 10's Face Sheet indicated Resident 10 was admitted to the facility on [DATE] and had diagnoses including Type 2 DM. A review of Resident 10's medical records, there was no documentation indicating the facility adequately monitored for s/s of hypoglycemia and/or hyperglycemia for Resident 10 from 5/17/26 to 8/24/26 (a period of over 3 months). During an interview and record review with the DON on 8/24/26 at 10:00 a.m., she confirmed there was no documentation indicating the facility adequately monitored Resident 10 for s/s of hypoglycemia and/or hyperglycemia from 5/17/26 to 8/24/26 (a period of over 3 months). The DON acknowledged the facility should have monitored Resident 10 for hypoglycemia and hyperglycemia from 5/17/26 to 8/24/26 (a period of over 3 months). A review of the facility P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, revised 4/2026, indicated, Symptoms Associated with Diabetes: 1. Hyperglycemia. 2. Diabetic ketoacidosis (DKA). Complications Associated with Diabetes: 2. Hypoglycemia . For the resident receiving oral medication(s) who is well controlled, monitor glucose levels at least twice weekly. For residents with confirmed diabetes, the nurse shall assess and document/report the following during the initial assessment: Resident's glucose history over 48 hours, Usual patterns of blood sugar over recent months. A review of the facility's undated P&P titled, Physician/Practitioner Orders Policy indicated, The facility shall ensure that orders issued by an authorized practitioner are accurately received, reviewed, and implemented. A review of the facility's job description for Physician indicated, Provide timely, comprehensive medical care to residents.Collaborate with the interdisciplinary team to promote quality outcomes, resident safety, regulatory compliance, and person-centered care. Develop, review, and update medical treatment plans. Issue, authenticate, and review medical orders. A review of an online publication by the American Diabetes Association (ADA), titled Glycemic Targets: Standards of Medical Care in Diabetes-2022, it indicated the following recommendations under Glycemic Assessment: Assess glycemic status (A1C or other glycemic measurement such as time in range or glucose management indicator) at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). Assess glycemic status at least quarterly and as needed in patients whose therapy has recently changed and/or who are not meeting glycemic goals. A review of an online publication, dated 5/15/24, by the Centers of Disease Control and Prevention (CDC) titled Your Diabetes Care Schedule, it indicated, Every day: Blood sugar checks. Check up to several times a day as directed by your doctor. Every 3 months: A1C test. If you're meeting your treatment and blood sugar goals, have this test every 6 months. A review of the facility's training course titled Diabetic Management, dated 6/18/26, it indicated, Managing Blood Glucose Levels: It's crucial for individuals with Type 2 diabetes to monitor and maintain healthy blood glucose levels. Close monitoring of the person's blood sugar level is one of the best ways to prevent long-term complications from the disease. Most people with diabetes need their blood sugar level tested at least once per day. A review of the facility's training course titled Blood Glucose Monitoring, dated 4/15/26 and 5/28/26, it indicated, Blood glucose monitoring is the process of measuring the amount of sugar (glucose) in the blood. It helps individuals with diabetes manage their condition and prevent complications.

Based on interview and record review, the facility failed to prevent the development and worsening of a pressure ulcer (PU, localized damage to the skin and/or underlying tissue usually over a bony prominence) for six of eight residents (Residents 1, 2, 5, 6, 7, and 8) who have a facility acquired PU when:1. For Resident 1, interdisciplinary team (IDT, a group of health care professionals from diverse fields who work toward a common goal for residents) did not accurately identify and assess the presence of a PU on the left buttock to provide necessary pressure ulcer treatments and nursing interventions to aid wound healing. Resident 1's IDT PU Assessment (the team meetings documentation when the team [DON, wound nurse, registered dietitian [RD], administrator [ADM] and infection preventionist [IP]) talked about resident's current PU, reviewed possible contributing factors, and interventions to implement) was not initiated and completed in a timely manner.These failures resulted in Resident 1 developing stage 4 PU (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) in the facility due to not receiving proper PU treatment and nursing interventions to aid in wound healing. Resident 1 was transferred to a hospital's emergency department (ED) on 7/7/26, where stage 4 PU with exposed bone on the sacrum (a triangular-shaped bone at the base of the spine that connects the backbone to the hips) area was identified upon initial wound assessment on 7/7/26 at 3:50 a.m. and eventually admitted to the ICU (Intensive Care Unit, a specialized hospital unit that provides care for patients with severe, life-threatening illnesses or injuries). Resident 1 was hospitalized for 20 days from 7/7/26 to 7/27/26.2. Resident 2 developed unstageable (UTS) deep tissue injury (DTI - a damage to muscle and soft tissue underneath the skin caused by long-lasting pressure or friction) to right (R) heel without licensed nurses' knowledge and documentation of its early detection to prevent it from getting worse and the IDT PU Assessment were not initiated and completed in a timely manner.These failures resulted in Resident 2's development of DTI on right heel and had potential to affect Resident 2's health and well-being.3. For Resident 5, licensed nurses did not follow physician's order and Resident 5's care plan for use of low air loss (LAL - a medical bed that helps prevent PU, and heal wounds) mattress, and the IDT PU Assessment were not initiated and completed in a timely manner.This failure had the potential to result in Resident 5's PU worsening and developing another PU.4. Resident 6 had developed a skin tear on coccyx (the small, triangle-shaped boned at the very bottom of the spine) on 8/9/2026, hospice nurse (a specialized nurse who provides end-of-life comfort care to patients with terminal [6 months or less to live] illnesses) was not notified, no treatment order until 8/12/2026 and the IDT PU Assessment was not initiated and completed in a timely manner.These failures resulted in Resident 6's skin tear on coccyx to worsened into UTS PU within three days.5. For Resident 7, the IDT PU Assessment was not initiated and completed in a timely manner.This failure resulted in Resident 7's PU worsening on right heel and had potential to affect Resident 7's health and well-being.6. For Resident 8, the IDT PU Assessment was not completed in a timely manner.This failure had the potential to result in Resident 8's PU worsening and had potential to affect Resident 8's health and well-being. 1a. A review of Resident 1's Face Sheet (summary of a Resident's basic information) indicated Resident 1 was admitted to the facility on [DATE] and had diagnoses including persistent vegetative state (a condition when a person is awake, but shows no signs of awareness), dementia (a progressive state of decline in mental abilities), Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) status. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/4/26, was reviewed. Section B0100 was coded Yes, which indicated Resident 1 was persistent vegetative state. Section GG0130 was coded 01, which indicated Resident 1 was dependent (means, Helper does all of the effort, resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity) in eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene. Section M0210 was coded No, which indicated Resident 1 did not have unhealed pressure ulcers/injuries. A review of Resident 1's SNF Wound Care notes dated 12/31/25, 3/11/26, 3/25/26, 5/20/26, 5/27/26, 6/3/26, 6/25/25 and 7/2/26, indicated Resident 1 had an abrasion (a minor skin scrape caused by friction against a rough surface) 3.0 x 1.5 x 0.1 cm (centimeters, unit of measurement) on the left buttock on 12/31/25. There were two abrasions (one addition) on the left buttock measured 4.0 x 4.2 x 0.1 cm on 3/11/26. The two abrasions on the left buttock extended to the midline crease (the central vertical line dividing the two buttocks) on 3/25/26. The left buttock abrasion extending to midline crease measured 1.0 x 1.0 cm, UTD (unable to determine) on 5/20/26; 2.5 x 2.0 cm, UTD on 5/27/26; 2.0 x 1.8 cm, UTD with undermining (the destruction of tissue or ulcer extending under the skin edges so that the wound is larger at its base than at the skin surface) of 1.0 cm on 6/3/26; 2.5 x 2.0 cm, UTD with undermining of 3.0 cm on 6/17/26; 2.5 x 2.7 cm, UTD with undermining of 5.1 cm on 6/25/26; 2.6 x 2.7 cm, UTD with undermining of 5.0 cm on 7/2/26. A review of Resident 1's Wound Assessment notes for abrasion on the left buttock extending to midline crease indicated, undermining 1 cm and 55 % slough (dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds) on 6/3/26; undermining 3 cm and 40 % slough on 6/17/26; tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) 5.1 cm and 20 % slough on 6/24/26; tunneling 5.0 cm, 20 % slough, and 30 % Eschar (dead tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like, usually firmly attached to the base, sides and/or edges of the wound and over time falls off). A review of Resident 1's Progress Notes written by license nurse, dated 7/7/26, indicated, 12:10 a.m., during rounds, patient noticed with rapid breathing, lethargic [having very little energy, feeling slow, and being unable to do anything]. Temp [temperature] 100 'F [Fahrenheit, a scale of temperature at which water freezes at 32 degrees and boils at 212 degrees under standard conditions], PR [pulse rate] 145, RR [respiration rate] 27, BP [blood pressure] 101/41.1:25 a.m. Pt. was transported to ER [emergency room, ED]. A review of Resident 1's hospital ED Provider Notes, dated 7/7/26 at 1:44 a.m., indicated, Found on work up to have pneumonia [a lung infection], UTI [urinary tract infection, an infection in the urinary system], and osteomyelitis [a painful infection and inflammation of the bone]. A review of Resident 1's hospital Wound Care Note, dated 7/8/26, indicated Resident 1 had stage 4 PU with exposed bone on the sacrum area, and the wound was first assessed on 7/7/26 at 3:50 a.m. Resident 1's stage 4 PU on the sacrum was measuring 5 x 5 x 3.8 cm with undermining 7.5 cm. A review of Resident 1's hospital Discharge Summary (DS), dated 7/27/26, indicated, He presented with septic shock (a life-threatening medical emergency where an infection causes dangerous low blood pressure and organ failure [a serious medical condition when vital organs stop working properly]), requiring intubation [a medical procedure where a doctor places a flexible plastic tube into a person's windpipe to keep an airway open during surgery or a severe illness], volume resuscitation [the emergency administration of intravenous fluids, blood to restore circulating blood volume]. He remained at high risk for acute decompensation [a sudden, severe worsening of a chronic medical condition] throughout the ICU stay.He has a large stage 4 sacral decubitus ulcer [known as bedsore or PU] with CT [computed tomography, a medical test that uses X-rays and a computer to make detailed pictures of the inside of the body] evidence of osteomyelitis. During an interview and record review with the facility Director of Nursing (DON) on 7/21/26 at 3:40 p.m., she reviewed Resident 1's SNF Wound Care note dated 6/25/26 and Wound assessment dated [DATE] for the left buttock wound, and the DON stated the wound seems unstageable (a severe PU where full-thickness skin and tissue loss is completely blocked from view by thick, dead tissue known as slough or eschar) because of slough and eschar, not abrasion. The DON stated the nurses followed their wound clinic note. The DON confirmed there was no IDT meeting to intervene in the left buttock wound when wound worsened prior to sending Resident 1 to the acute hospital on 7/7/26. The DON stated the IDT did not intervene with the left buttock wound because it was determined as an abrasion, not PU. The DON acknowledged the nurses should have accurately assessed and clarified Resident 1's left buttock wound. The DON acknowledged the IDT should have identified Resident 1's non - healing left buttock wound, assessed accurately, and discussed the cause of non-healing wound, updated the care plan with a measurable goal and interventions, and provided necessary and timely interventions to aid wound healing. During an interview and record review with Licensed Vocational Nurse (LVN) A on 7/22/26 at 10:25 a.m., she stated she was one of the treatment nurses and provided treatments for Resident 1 prior to sending Resident 1 to the hospital on 7/7/26. LVN A stated Resident 1's left buttock abrasion got worse and became stage 4 PU in her knowledge, but she documented it as abrasion because the previous DON instructed her to document as abrasion on the left buttock, same as the wound clinic documentation. LVN A stated she informed the previous DON about the progress of the left buttock wound during weekly wound meetings in May and June 2026. During an interview and record review with Registered Nurse (RN) B on 7/22/26 at 11:11 a.m., he stated he was one of the treatment nurses and provided treatments for Resident 1 prior to sending Resident 1 to the hospital on 7/7/26. RN B stated Resident 1's left buttock wound started as an abrasion and became unstageable PU with tunneling in May 2026 from his assessment. RN B stated he informed the previous DON about the left buttock wound concerns like wound staging and worsening during weekly wound meetings in May and June 2026. RN B stated the previous DON instructed him to continue documenting as abrasion on the left buttock, same as the wound clinic documentation. During an interview with the Registered Dietitian (RD) on 7/28/26 at 11:30 a.m., she stated Resident 1's left buttock wound was reported as an abrasion until July 2026. The RD stated she would recommend interventions to aid healing the wound if she was informed of the left buttock wound as PU. During an interview and record review with Resident 1's Attending Physician (AP, doctor assigned to the resident while the resident is in the facility) on 7/28/26 at 1:00 p.m., she stated she was depending on the wound clinic recommendation for her residents' wound care, and Resident 1's left buttock wound was reported as an abrasion to her. During phone interview with Resident 1's Physician Assistant (PA) C on 7/29/26 at 10:56 a.m., she stated Resident 1's left buttock wound was managed by the wound clinic, and she only managed Resident 1's medications. PA C acknowledged physician/PA are responsible for providing comprehensive medical care to the residents. A review of Resident 1's admission Assessment for his re-admission on [DATE], indicated stage 4 PU on sacrum, measuring 3 x 4.5 x 4.5 cm, was identified upon re-admission wound assessment. During phone interview with RN B on 8/4/26 at 2:02 p.m., he confirmed Resident 1 was re-admitted to the facility on [DATE], and Resident 1's stage 4 PU on the sacrum was same wound which the facility previously documented as abrasion on left buttock. During phone interview with the Wound Clinic Physician (WCP) on 8/4/26 at 3:40 p.m., he stated Resident 1's wound on the left buttock was documented as an abrasion because the wound was started as abrasion. The WCP stated the abrasion was classification of the wound and was meant that Resident 1's wound on the left buttock was started as abrasion. The WCP stated he did not revise the abrasion regarding the wound changes for possible legal concern. The WCP stated the wound clinic reported all description of the abrasion on the left buttock and recommended proper wound treatments according to the description. A review of the facility policy and procedure (P&P) titled, Interdisciplinary Team Meeting Policy, created 4/21/25, indicated, The facility shall conduct initial and ongoing interdisciplinary meetings to ensure resident care is coordinated, individualized, and responsive to changes in condition, needs, and preferences in accordance with federal and state regulations. This policy applies to all licensed staff, department heads, clinical leaders, and administrative personnel involved in resident assessment, care planning, and service delivery. The IDT may include representatives from nursing, social services, dietary, therapy, behavioral health, and/or a medical provider. IDT meetings shall occur: with significant change in condition, following incidents or care concerns that require interdisciplinary review. A review of the facility's undated P&P titled, Prevention of Pressure Injuries indicated, Significant changes will be communicated to the interdisciplinary team . A review of the facility's undated clinical protocol titled, Pressure Ulcers indicated, When a pressure injury or other skin breakdown is identified, the licensed nurse will assess and document relevant findings.The physician, nurse practitioner, physician assistant, wound clinician, or other appropriate clinician may assist with diagnosis, classification, or contributing factors. A review of the facility's job description for Physician indicated, Provide timely, comprehensive medical care to residents.Collaborate with the interdisciplinary team to promote quality outcomes, resident safety, regulatory compliance, and person-centered care. Develop, review, and update medical treatment plans. Issue, authenticate, and review medical orders. A review of the facility's job description for Director of Nursing indicated, Collaborates with members of the interdisciplinary team, physicians, consultants, and community agencies to identify and resolve issues and improve the quality of services. A review of the facility's undated P&P titled, Licensed Nurse Documentation and Assessment Policy indicated, Licensed nurses shall perform and document resident assessments in accordance with applicable federal and state regulation, accepted standards of nursing practice.Assessment documentation shall: Be accurate . 1b. A partial extended survey was conducted by the team of nurse surveyors on 8/18/2026. Review of Resident 1's list of IDT: Pressure Ulcer assessments, indicated the assessment dated [DATE] was created on 8/18/2026. Further review indicated the assessment dated [DATE] was created on 8/13/2026. During an interview with registered nurse D (RN D), a wound treatment nurse on 8/20/2026 at 10:30 a.m., RN D stated their DON created resident's IDT: Pressure Ulcer assessment during the meeting. During an interview with the medical record director (MRD) on 8/21/2026 at 10:05 a.m., the MRD stated Point Click Care (PCC -the facility's electronic health record) would allow their staff to create their assessment and backdate. The MRD further stated, But we don't typically condone to backdate their stuff. During a concurrent interview with MRD and record review of Resident 1's list of IDT: Pressure Ulcer assessment on 8/21/2026 at 10:13 a.m., the MRD confirmed the assessment dated [DATE] was created on 8/18/2026 and the assessment dated [DATE] was created on 8/13/2026. 2a. Review of Resident 2's face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including chronic venous hypertension (long -lasting high blood pressure in the leg veins) with ulcer (open sore on the skin) of bilateral lower extremity (both legs) and type 2 DM. Review of Resident 2's admission MDS assessment dated [DATE], indicated Resident 2's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review indicated Resident 2 required substantial/maximal assistance (helper does more than half the effort, lifts or hold trunk or limbs and provides more than half the effort) to roll left and right (ability to roll from lying on back to left and right side), and from sit to lying (the ability to move from sitting on side of bed to lying flat on the bed). Resident 2 was dependent (helper does all the effort) on chair/bed to chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). Review of Resident 2's clinical record titled, Braden Scale [a widely used clinical tool that predicts a patient's risk of developing pressure injuries or pressure ulcer] for Predicting Pressure Ulcer] dated 8/14/2026, indicated Resident 2's score was 15 (AT RISK - a score of 15-18). Review Resident 2's Pressure Ulcer assessment dated [DATE], indicated there was no pressure ulcer in Resident 2's right heel. Review of Resident 2's Pressure Ulcer assessment dated [DATE], indicated a DTI on Resident 2's right heel, with 65% eschar (a thick, dry, and hardened layer of dead skin tissue that forms over a severe wound, burn, or ulcer). Review of Resident 2's clinical record titled, COC: Change of Condition Assessment, dated 8/17/2026, indicated, New DTI on right heel.found new DTI on R heel. Was found yesterday [8/16/2026] by tx [treatment] nurse. During a concurrent interview with the infection preventionist (IP) and record review of Resident 2's Pressure Ulcer Assessment prior to 8/16/2026 assessment on 8/20/2026 at 12:09 p.m., IP stated she did not know how the DTI on Resident 2's right heel started. IP further stated that she could not find any documentation on how the right heel DTI started. During an interview with RN B on 8/21/2026 at 10:44 a.m., RN B stated he did not know how Resident 2's right heel DTI started. RN B further stated the nurses and certified nursing assistants (CNA) assessed resident's skin and if they found skin issues, they would report to treatment nurses. RN B stated, nurses should have caught something in her heel prior to becoming worse. During a review of Resident 2's care plan titled, Potential for Impaired Skin Integrity as evidenced by Braden Scale for Predicting Pressure Ulcer Risk, date initiated 6/2/2026, indicated in one of the interventions, Observe skin integrity during routine care. During a review of the facility's undated policy and procedure titled, Prevention of Pressure Injuries, indicated, Ongoing skin observation will occur during routine care and activities of daily living. 2b. Review of Resident 2's list of IDT: Pressure Ulcer assessments, indicated the following IDT related to PU's dated 7/16, 7/23, 7/30, 8/6, and 8/13/2026 were all created on 8/18/2026. During a concurrent interview with the MRD and record review of Resident 2's list of IDTs related to PU assessment on 8/21/2026 at 9:53 a.m., the MRD confirmed all IDT PU assessments dated 7/16, 7/23, 7/30, 8/6, and 8/13/2026 were all created on 8/18/2026. The MRD stated the date and time of an assessment should be created the same day it happened. 3a. Review of Resident 5's face sheet indicated Resident 5 was re-admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of right femur (a broken right thighbone in the upper hip area where the broken bone pieces moved out of their normal alignment) and tracheostomy status (a surgical opening made through the front of the neck into the windpipe to help a person breathe). Review of Resident 5's significant change in status MDS assessment dated [DATE], indicated Resident 5's BIMS score was 15. Further review indicated Resident 5 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to roll left and right, with sit to lying, and with chair/bed to chair transfer. Resident 5 was frequently incontinent with urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) and frequently incontinent with bowel movement (2 or more episodes of bowel incontinence, but at least one episode of continent bowel movement). Review of Resident 5's clinical record titled, Braden Scale for Predicting Pressure Ulcer dated 7/22/2026, indicated Resident 5's score was 17 (AT RISK - 15-18). Review of Resident 5's Order Summary Report, dated 8/19/2026, indicated an order dated 8/6/2026, Low Air Loss Mattress for wound care and management. Check placement and patency every shift. Review of Resident 5's care plan titled, LAL MATTRESS CARE PLAN, date initiated 8/6/2026, indicated, Resident is on LAL-Low Air Loss mattress for pressure re-distribution and support surface while in bed. The resident has potential/actual impairment to skin integrity thus the use of LAL mattress for skin/wound care management. During an observation on 8/20/2026 at 9:52 a.m., inside Resident 5's room, Resident 5 was lying on a regular mattress and there was no bed pump found at the end of the bed. During a concurrent observation and interview with minimum data set nurse (MDSN) on 8/20/2026 at 9:59 a.m., inside Resident 5's room, MDSN confirmed Resident 5 was not lying on a LAL mattress. During a concurrent interview with MDSN and record review of Resident 5's order summary report and list of care plans on 8/20/2026 at 10:04 a.m., MDSN stated there was an order for Resident 5 to use a LAL mattress since 8/6/2026 and it was still an active order. MDSN confirmed that the use of LAL mattress was care planned. MDSN stated Resident 5 should be in a LAL mattress. During an interview with RN D on 8/20/2026 at 10:30 a.m., RN D confirmed Resident 5 was seen and examined by their new wound doctor on 8/19/2026 and the plan was to continue with current order. RN D stated Resident 5 still needs the LAL mattress. During a review of the facility's undated policy and procedure titled, Physician/Practitioner Orders Policy, indicated, The facility shall ensure that orders issued by an authorized practitioner are accurately received, reviewed, and implemented in accordance with applicable federal and California regulations, accepted standards of nursing practice, and the resident's individualized plan of care.Practitioner orders shall be implemented. When implementation cannot occur as ordered due to resident refusal.or other barriers, the licensed nurse shall notify the ordering practitioner as appropriate and obtain additional direction prior to implementation whenever necessary. 3b. Review of Resident 5's list of IDT: Pressure Ulcer assessments, indicated the following IDT related to PU's dated 7/23 and 7/30/2026 were created on 8/4/2026 and the IDT dated 8/13/2026 was created on 8/18/2026. During a concurrent interview with the MRD and record review of Resident 5's list of IDT PU assessments on 8/21/2026 at 10:10 a.m., the MRD confirmed the IDT PU assessments dated 7/23 and 7/30/2026 were created on 8/4/2026 and the IDT PU assessment dated [DATE] was created on 8/18/2026. 4a. Review of Resident 6's face sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low), fracture (broken bone) of one rib, right side, and wedge fracture of first lumbar vertebra (a type of spinal compression fracture where the front part of the bone collapses and forms a wedge shape while the back of the bone stays normal). Review of Resident 6's Order Summary Report dated 8/19/2026, indicated an order dated 8/4/2026, admitted to.Hospice on 8/4/2026. Review of Resident 6's significant change in status MDS assessment dated [DATE] indicated Resident 6's BIMS score was 13 and she required substantial/maximal assistance with toileting hygiene, lower body dressing, lying to sitting on side of bed, sit to stand, and toilet transfer. Further review indicated Resident 5 was frequently incontinent with urine and bowel movement and under skin condition section, it indicated Resident 6 did not have any pressure ulcer. Review of Resident 6's clinical record titled, Braden Scale for Predicting Pressure Ulcer dated 7/22/2026, indicated Resident 6's score was 14 (MODERATE RISK - 13-14). Review of Resident 6's clinical record titled, COC: Change of Condition Assessment, dated 8/9/2026, indicated, CNA notified this writer of 5x5 cm (length [L] x width [W] centimeters - a small unit of length in the metric system) skin tear noted on coccyx. Surrounding skin is partially intact with blister [a small, raised bubble on the skin that contains clear liquid) noted on right side.Pt [patient] reports pain in the back only during repositioning. Further review indicated the physician and wound care nurse were notified. The COC did not indicate if the hospice nurse was notified and there was no wound treatment ordered except for a wound consult order. Review of Resident 6's Pressure Ulcer Assessment, dated 8/12/2026, indicated Resident 6 had unstageable (UTS - a deep skin wound covered by dead tissue that block doctors from seeing how far the damage goes) PU on sacral coccyx area which measured L: 11 cm x W: 13 cm x Depth: UTD (unable to determine), and the wound bed had 15% granulation tissue (the fresh, pink or red, bumpy tissue that grows to fill in an open wound during the healing process), 15% slough (a layer of soft, yellow, white, tan, or green dead tissue resting over the wound bed), 50% eschar and 20% epithelialization (the process where new skin cells grow and move across a wound to close it and rebuild a protective skin barrier). During a concurrent interview with RN D and photo review of Resident 6's wound on 8/20/20/2026 at 10:30 a.m., RN D confirmed Resident 6 had UTS PU on coccyx area and she was in hospice care. RN D stated the facility treatment nurses were responsible for Resident 6's wound treatment. RN D showed the picture of Resident 6's wound taken on 8/19/2026 to this writer, and the photo revealed the wound bed was covered with 90% black colored tissue and the remaining 10% was bright red in color. During a concurrent interview with the IP and record review of Resident 6's physician orders and nursing progress notes on 8/20/2026 at 12:17 p.m., IP stated she could not find any documentation if the hospice nurse was notified when the nurse found the new skin tear to coccyx area on 8/9/2026. IP confirmed there was no treatment ordered on 8/9/2026 for Resident 6's coccyx skin tear. During a concurrent interview with RN B and record review of Resident 6's physician orders and nursing progress notes on 8/21/2026 at 11:00 a.m., RN B confirmed there was no treatment ordered for Resident 6's skin tear on 8/9/2026. RN B stated the treatment order should have been obtained from the doctor and implemented at the time the wound was noted on 8/9/2026. RN B further stated that there was no documentation if hospice nurses were notified about the new skin issue. RN B stated a skin tear to coccyx could be from rubbing in bed or wheelchair which should be identified as PU. During a concurrent interview with the DON and record review of Resident 6's physician orders and nursing progress notes on 8/24/2026 at 10:45 a.m., the DON stated there was no treatment ordered for Resident 6's skin tear on 8/9/2026 until 8/12/2026, but the treatment ordered was for UTS PU on coccyx area. The DON stated 8/9/2026 was a Sunday, and the IDT talked about new COC the following day. The DON confirmed there was no documentation that the IDT was held on 8/10/2026 to discuss Resident 6's new wound. The DON stated the treatment order could have been in Resident 6's hospice binder. When asked, should the treatment order been entered to their electronic health record for treatment nurses to know and implement the order? The DON stated, yes. 4b. Review of Resident 6's list of IDT: Pressure Ulcer assessments, indicated IDT related to PU's dated 8/13/2026 was created on 8/18/2026. During an interview with the IP on 8/20/2026 at 12:22 p.m., the IP confirmed she attended the IDT PU meeting before. The IP stated the DON should create the assessment in PCC on the day they held the meeting since the team were available to present their recommendations. During a concurrent interview with the MRD and record review of Resident 6's list of IDT: Pressure Ulcer assessments on 8/21/2026 at 10:05 a.m., the MRD confirmed the IDT PU assessment dated [DATE] was created on 8/18/2026. During an interview with the chief of nursing (CNO) on 8/21/2026 at 11:58 a.m., the CNO stated the IDT team held the meeting and documented in their papers. When asked if the paper document was an official facility document, the CNO stated, the written notes in paper were not an official facility document. During an interview with the DON on 8/24/2026 at 10:13 a.m., the DON stated she started as a DON in training at the facility on 7/6/2026 and she sat on each IDT PU meeting with the previous DON since then. The DON further stated she started leading the IDT PU meeting after 7/26/2026. She confirmed that most of the IDT PU assessments were entered the day the partial extended survey was conducted on 8/18/2026. She stated she met with the wound nurses on 8/18/2026 to talk about their assessments and she created the assessment on the same day. The DON stated she did not know about the policy on creating an assessment, and further stated, but we can backdate once they remembered when to do it. The DON stated, it is acceptable to backdate because we discussed this. 5. A review of Resident 7's Face Sheet indicated Resident 7 was admitted to the facility on [DATE] and had diagnoses including disease of spinal cord (long, tube-shaped bundle of nerve tissue that runs from the base of the brain down the center of the back), unspecified and osteomyelitis, unspecified. During a review of Resident 7's SNF Wound Care notes indicated Resident 7 has 3 different wound sites and one of the wounds was on right heel abrasion, trauma as follows;-6/10/26 =3.0 x1.5 cm, UTD, no undermining or tunneling was noted-6/17/26 =4.0 x5.5 cm, UTD, no undermining or tunneling was noted-6/25/26 =5.5 x4.2cm, UTD, no undermining or tunneling was noted-7/2/26 = 2.5 x 3.5 cm, UTD, no undermining or tunneling was noted-7/16/26 =2.1 x 3.6 cm, (unstageable pressure wound) UTD, no undermining or tunneling was noted.-7/22/26 = 4.5 x 5.0 cm (merged with right heel medial [middle]), unstageable pressure wound, this is reclassified to stage 4 pressure wound.-7/29/26 = 4.5 x 6.0 cm (stage 4), UTD, no undermining or tunneling was noted-8/5/26 = 5.1 x 6.2 cm (stage 4), UTD, no undermining or tunneling was noted-8/12/26 = 7.0x 7.0 cm (stage 4), UTD, no undermining or tunneling was noted During a revi

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. One dirty basin with small amount of amber colored liquid and a dirty pullup on the floor inside Room A residents shared bathroom (four residents were inside Room A).2. Two of the air conditioning (AC) units were dusty with black and grey buildup.These failures had the potential to cause harm and spread infections to residents, staff, and visitors. Findings:1. During an observation on 7/1/26 at 12:14 p.m., inside Room A's resident shared bathroom, there was one dirty basin with small amount of amber colored liquid, next to the basin was one dirty pullup left on the floor.During a follow -up observation on 7/1/26 at 1:20 p.m., inside Room A's shared bathroom, the dirty basin and dirty pullup were still on the floor.During an interview and review of photos taken from state phone on 7/1/26 at 2:08 p.m., with the Infection Preventionist (IP), she stated dirty basin and pull up should be thrown away, nothing should be on the floor. The IP reviewed the photos taken from state phone dated 7/1/26 at 12:14 p.m., and 1:30 p.m., she confirmed the one dirty basin with small amount of amber colored liquid next to one dirty pullup inside Room A's bathroom, she stated it should not be there, it should be thrown away to trash, she stated the basin should be on the top of the sink and the brief/pull up should be in the trash.During a follow up interview on 7/1/26 at 2:16 p.m., with the IP, the IP stated Resident 4 has a behavior of putting things on the floor and the certified nursing assistant (CNA) will just pick it up. The IP was asked if Resident 4's behavior was on the care plan, the IP stated there was no care plan, she further stated they can do the care plan today.During a review of the facility's policy and procedures titled, Infection Prevention and Control Program, undated, indicated, An infection prevention and control (IPC) program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.2. During an observation on 7/1/26 at 12:15 p.m., inside Room A, the air conditioning (AC) unit there was a washcloth, dust with black and grey buildup inside the AC unit.During a concurrent observation and interview inside Room A on 7/1/26 at 2:00 p.m., with the Maintenance Director (MDR), the MDR checked the AC unit inside Room A, there was washcloth, dust with black and grey buildup inside the AC unit. The MDR opened the cover of the AC and removed the washcloth, he stated the AC unit shouldn't be like this, the MDR further stated the Housekeeping, and Maintenance cleans the AC unit every month.During an observation on 7/1/26 at 1:16 p.m., inside Room B the air conditioning (AC) unit was dusty with black and grey buildup inside the AC unit.During a concurrent observation and interview inside Room B on 7/1/26 at 1:53 p.m., with the Maintenance Director (MDR), the MDR checked the AC unit, he confirmed it was dusty with black and grey buildup inside the AC, the MDR tried to clean the dust and black buildup inside the AC unit with the paper towels and some of the dust and black buildup came off, he stated that AC unit shouldn't be like that.During a review of facility deep clean schedule for June 2026, it indicated, Room A was scheduled for June 4 (Thursday), and Room B was scheduled for June 17 (Wednesday).During an interview and review of photos of AC unit from state phone on 7/1/26 at 2:22 p.m., with Housekeeping Manager (HM), the HM stated the Housekeeping cleans the room for deep cleaning every month including floor, fan, windows bed frame, and mattress. The HM stated the Housekeeping and Maintenance work together. She further stated cleaning the AC unit, the Housekeeping will clean the surface or outside the AC unit and the Maintenance will clean the inside of the unit. She further stated and confirmed that the photos of AC unit inside Room A and B were not clean.During an interview on 7/1/26 at 2:46 p.m., with the Administrator (ADM), the ADM stated cleaning the AC unit is the responsibility of the Housekeeping and the Maintenance departments, cleaning inside the AC unit is the Maintenance.During a review of Maintenance Assistant Job description, indicated, The primary purpose of this position is to maintain the grounds, facility and equipment in a safe and efficient manner in accordance with current applicable federal, state and local standards, guidelines and regulations, established facility policies and procedures and as directed by your supervisor to ensure a successful maintenance program is always maintained. Equipment and Supply Functions.Ensure the facility and its equipment is properly maintained for resident comfort and staff convenience.During a review of the facility's policy and procedures titled, Infection Prevention and Control Program, undated, indicated, An infection prevention and control (IPC) program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.During a review of the facility's policy and procedures titled, Cleaning and Disinfecting Residents' Rooms, revision date 2/2026, indicated, Purpose. The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. General Guidelines. 1. Resident rooms are cleaned regularly and as needed by housekeeping/environmental service.

Based on interview and record review, the facility failed to ensure needed care and services were provided in accordance with the resident's goals of care and professional standards of practice for one resident (Resident 1), when Resident 1's blood pressure (BP, the force of the blood pushing against the walls of the arteries as the heart pumps it through the body) was not checked prior to administering BP medication on 4/5/26, 4/6/26, 4/8/26, 4/11/26 and 4/12/26 and Resident 1's BP was not rechecked on 4/4/26 and 4/7/26 after an episode of low BP reading (A low blood pressure [hypotension] range is defined as any reading below 90/60 mmHg [a unit of measurement]). These failures put Resident 1 at risk for clinical decline and delayed clinical response and support.A review of Resident 1's medical records indicated an admission date of 4/1/26 and discharge date of 4/13/26. Resident 1's diagnoses included but were not limited to unspecified atrial fibrillation (an irregular and often very rapid heart rhythm); depression, unspecified (a serious mood disorder that causes persistent sadness, hopelessness, and a loss of interest in activities once enjoyed); malignant neoplasm of colon, unspecified (an uncontrolled growth of abnormal cells forming in the inner lining of the large intestine); and presence of urogenital implants (medical devices or materials surgically placed in the body to help the urinary and reproductive systems work properly). A review of Resident 1's Physician Orders included, Metoprolol Succinate ER Oral Tablet Extended Release 24 hour 25 MG [milligram, a unit of measurement] Give 1 tablet by mouth two times a day for HTN [hypertension, high BP] Hold for SBP [systolic blood pressure, the top number in a blood pressure reading. It measures the maximum force the blood exerts against the artery walls when the heart beats and actively pumps blood out into the body] < [less than] 110 and HR [heart rate] < 60 started on 4/1/26. During an interview on 6/29/30 at 2:00 p.m. with Licensed Vocational Nurse (LVN) A, LVN A stated blood pressure must be checked prior to administering the medication Metoprolol. LVN A also stated the nurse must check if there were parameters set by the doctor. LVN A stated for BP in the range of 80/50 mmhg, the doctor must be made aware and the BP must be monitored every 15 to 30 minutes. During a concurrent interview and record review of Resident 1's MAR and recorded BP readings with the Director of Nursing (DON) on 6/29/26 at 2:16 p.m., the DON verified Metoprolol was scheduled to be given twice a day. The DON also verified Resident 1's blood pressure was only checked once on 4/5/26 at 3:31 p.m., 4/6/26 at 6:59 a.m., 4/8/26 at 6:59 a.m., and 4/11/26 at 4:21 p.m. The DON also verified Resident 1 had a low BP reading of 94/56 mmhg on 4/4/26 at 9:35 p.m. and the BP was rechecked the next day on 4/5/25 at 3:31 p.m. The DON verified another low BP reading of 80/54 mmhg on 4/7/26 at 4:09 pm and the next BP check was the following day on 4/8/26 at 6:59 a.m. with 98/68 mmhg. The DON also verified there was no BP check done on 4/12/26. The DON stated, the nurse should have rechecked and monitored the blood pressure more frequently if there was an episode of low BP. The DON also stated, blood pressure must be checked prior to administering the medication Metoprolol. A review of Resident 1's Medication Administration Record (MAR) for April 2026 indicated that Metoprolol was scheduled to be given at 9 a.m. and 4 p.m. Metoprolol was given twice on 4/5/26, 4/6/26. 4/11/26 and 4/12/26.A review of facility's job description for Licensed Practical Nurse revised August 2024 indicated, .Resident Care Functions.Obtain and document resident vital signs as needed.Duties and Responsibilities.Administer medications within the scope of practice and according to practitioner orders and report adverse consequences, side effects or any medication errors A review of facility's job description for Registered Nurse revised July 2024 indicated, .Duties and Responsibilities. Administer medications within the scope of practice and according to practitioner orders and report adverse consequences, side effects or any medication errors A review of facility's undated policies and procedures (P&P) entitled Vital Sign Policy indicated, .3. Vital signs will be obtained by the nurse or therapist, as indicated, when administering certain medications, or monitoring for effectiveness of medications or therapies. For example, a. Certain cardiac drugs are given only when a resident's pulse or blood pressure is within a certain range.

Based on observation, interview, and record review, the facility failed to provide services according to professional standards for one of one resident (Resident 1) when:1.Licensed nurses did not administer Resident 1's Vancomycin (a powerful prescription antibiotic used to treat serious bacterial infections) as ordered within 60 minutes prior to or after scheduled time and three doses were missed in May 2026;2.Resident 1 received only two doses of Mounjaro (brand named of tirzepatide, a prescription medication taken as a weekly injection to help control blood sugar with type 2 diabetes mellitus [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) since it was ordered on 5/4/2026;3.Licensed nurses did not follow physician's order to check Resident 1's finger-stick blood sugar (FSBS - a quick method of checking a person's sugar level using a small device called a glucometer) for five days; and4.Certified nursing assistant A (CNA A) did not provide Resident 1's lunch tray on 6/11/2026.These failures had the potential to affect Resident 1's care, health, and well-being.Findings:1a. Review of Resident 1's clinical record titled, admission Record, dated 6/11/2026, indicated Resident 1 was admitted at the facility on 5/4/2026 with diagnoses including cellulitis (a common, potentially serious bacterial infection of the deep layers of the skin and underlying tissues) of right lower limb (or lower extremity, consists of the hip, thigh, knee, leg, ankle and foot), type 2 DM with other skin complications, osteomyelitis (an infection and inflammation of the bone), right ankle and foot, and unspecified protein-calorie malnutrition (a potentially life-threatening condition caused by inadequate intake of protein, calories or both).Review of Resident 1's admission minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1 had a brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact).During a phone interview with Resident 1 on 6/11/2026 at 8:29 a.m., Resident 1 stated nurses were not giving his antibiotics (Vancomycin) on time and sometimes nurses were not giving it to him. Resident 1 stated his last day of antibiotics was on 6/4/2026.Review of Resident 1's order listing report, dated 5/4 - 6/30/2026, indicated an order of Vancomycin 1.25 grams (unit of weight and mass) intravenously (IV - inside a vein, a medical method used to give fluids, nutrients, or medications directly into a person's bloodstream using a needle or flexible tube) every 12 hours for bacteremia (presence of bacteria in the bloodstream) until 6/4/2026, order revised on 5/8/2026.Review of Resident 1's May 2026 medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), indicated the Vancomycin IV dose was scheduled at 9:00 a.m. and 9:00 p.m. daily. Further review indicated the date and time the Vancomycin was given late to Resident 1:5/15/2026, 9:00 a.m. dose was given at 12:37 p.m. and 9:00 p.m. dose was given on 5/16/2026 at 6:49 a.m.5/16/2026, 9:00 a.m. dose was given at 10:43 a.m.5/17/2026, 9:00 p.m. dose was given at 11:18 p.m.5/22/2026, 9:00 a.m. dose was given at 10:11 a.m.5/23/2026, 9:00 p.m. dose was given on 5/24/2026 at 1:45 a.m.5/27/2026, 9:00 a.m. dose was given at 1:33 p.m.Review of Resident 1's June 2026 MAR, indicated Resident 1 received the Vancomycin late on:6/1/2026, 9:00 p.m. dose was given at 10:23 p.m.6/3/2026, 9:00 p.m. dose was given at 10:15 p.m.During a concurrent interview with minimum data set nurse (MDSN) and record review of Resident 1's 5/2026 MAR on 6/11/2026 at 3:47 p.m., MDSN confirmed the above late administration of Resident 1's Vancomycin. 1b. During a concurrent interview with MDSN and record review of Resident 1's May 2026 physician's order, MAR, and nursing progress note on 6/11/2026 at 4:19 p.m., MDSN confirmed Vancomycin was not administered to Resident 1 on 5/24, 5/25 and 5/27/2026 for 9:00 p.m. dose. MDSN stated as indicated in the progress note, Vancomycin was not administered on 5/25/2026 due to registered nurse (RN) availability. MDSN further stated there was no RN available to administer the IV Vancomycin and that was not an excuse. MDSN stated, It should have been given. Further review, MDSN confirmed there was no documentation on why Vancomycin was missed on 5/24, and 5/27/2026. MDSN stated licensed nurses should document in resident's MAR after they administered the medication, when it was missed and the reason why it was missed.During an interview with licensed vocational nurse B (LVN B) on 6/11/2026 at 2:45 p.m., LVN B stated medications should be given one hour before or one hour after the scheduled time and should be documented in residents' MAR. LVN B further stated licensed nurses should notify the physician, resident or responsible party the reason when a certain medication was not given.During a concurrent phone interview with the director of nursing (DON) and record review of Resident 1's 5/2026 MAR and nursing progress notes on 6/18/2026 at 12:15 p.m., the DON confirmed the above late administration and missed doses of Vancomycin. The DON stated the medication should be administered an hour before and an hour after the dosing time and as ordered by the physician. The DON confirmed the order for Resident 1 was to administer the Vancomycin every 12 hours. The DON stated they had some RNs who worked on 5/25/2026, that the assigned nurse should have informed them to administer Resident 1's Vancomycin. She further stated that the assigned nurse should have called her if an RN was needed.During a review of the facility's policy and procedure titled, Administering Medications, date revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.Sign MAR after administered.2. During a phone interview with Resident 1 on 6/11/2026 at 8:29 a.m., Resident 1 stated he was supposed to get his injectable medication for diabetes (Mounjaro) once a week, but he never got it weekly. He stated he could only remember getting it once.Review of Resident 1's order listing report dated 5/4 - 6/30/2026, indicated an order of Mounjaro auto-injector 2.5 milligrams (mg - unit of measurement)/0.5 milliliter (ml - volume of measurement) to inject 2.5 mg subcutaneously (SQ - to inject under the skin) one time a day every Wednesday for DM.Review of Resident 1's 5/2026 and 6/2026 MAR indicated, Resident 1 did not receive the Mounjaro injection on 5/6, 5/13, 6/3, and 6/9/2026.During a concurrent interview with MDSN and record review of Resident 1's 5/2026 and 6/2026 MAR and progress notes on 6/11/2026 at 3:47 p.m., she confirmed Resident 1's missed dose of Mounjaro. MDSN stated they were missed due to pending insurance authorization.During a phone interview with the DON on 6/18/2026 at 11:44 a.m., when asked what the facility should have done to provide Mounjaro to Resident 1 as ordered by the physician, the DON stated they would notify the physician, asked if there were any alternative medication and they would follow the physician's order. When asked if those were documented, the DON stated, I have to review the documentation. The DON did not get back to this writer.During a review of the facility's undated policy and procedure titled, Diabetes - Clinical Protocol, indicated, Based on the preceding assessment, including causes and complications, the provider will order individualized interventions.Treatments will be consistent with applicable guidelines.3. Review of Resident 1's 5/2026 MAR indicated an order of FSBS every morning and at bedtime with start date on 5/15/2026 and scheduled every 7:00 a.m. and at 9:00 p.m. Further review indicated licensed nurses did not complete Resident 1's FSBS on 5/15/2026 at 9:00 p.m.; 5/16/2026 at 7:00 a.m. and 9:00 p.m.; 5/17/2026 at 7:00 a.m. and 9:00 p.m.; 5/18/2026 at 7:00 a.m. and 9:00 p.m.; 5/19/2026 at 7:00 a.m. and 9:00 p.m.; and 5/20/2026 at 7:00 a.m.During a concurrent phone interview with the DON and record review of Resident 1's 5/2026 MAR, the DON confirmed the above list of missed FSBS checked. The DON stated nurses should have documented the reason for the missed FSBS. The DON stated, I need to investigate.During a review of the facility's undated policy and procedure titled, Diabetes - Clinical Protocol, indicated, The provider will order desired glucose targets and monitoring regimens, as well as parameters for reporting information related to blood sugar management. The staff will incorporate orders and reporting parameters into the Medication Administration Record.4. During a phone interview with Resident 1 on 6/11/2026 at 8:29 a.m., Resident 1 stated there was a time when his breakfast would be delivered late or sometimes would not be provided to him.During a concurrent observation and interview with Resident 1 on 6/11/2026 at 1:32 p.m., inside Resident 1's room, Resident 1 was seated at the edge of his bed, waiting for his lunch tray to be delivered. Resident 1's roommate, Resident 2 had a lunch tray placed on his overbed table, and his lunch tray was already partly eaten. Resident 1 stated, . I still did not get lunch and look at the time. I guess they are retaliating since I complained.During an interview with Resident 1's assigned licensed nurse, LVN B on 6/11/2026 at 1:38 p.m., LVN B stated he did not know Resident 1 was not eating yet, and stated he would look for CNA A, who was assigned to Resident 1.During an observation at the hallway near Resident 1's room on 6/11/2026 at 1:41 p.m., LVN B was still looking for CNA A, other CNAs were already collecting finished lunch trays, and they stocked the used trays inside the parked meal cart at the hallway. LVN B found Resident 1's lunch tray still inside the parked meal cart and it was mixed with the used meal trays. LVN B stated he would order a new lunch tray for Resident 1 because the old lunch tray was already cold.During an interview with CNA A on 6/11/2026 at 1:54 p.m., CNA A confirmed he missed to deliver Resident 1's lunch tray today. CNA A stated he assisted Resident 1's roommate, Resident 2 with his lunch and he did not notice Resident 1 did not have his tray.During a phone interview with the DON on 6/18/2026 at 12:15 p.m., the DON stated the CNAs should let the nurses know if there was a problem with meal trays. The DON was unable to state the person responsible in checking to make sure all residents received their meal trays.During a review of the facility's policy and procedure titled, Frequency of Meals, date revised 7/2017, indicated, Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and the plan of care. The facility will serve at least three (3) meals or their equivalent daily at scheduled times.The following meal times have been established by out facility for residents: Breakfast - 7:00 am, Lunch - 11:30 am, Dinner - 5:00 pm.

Based on observation, interview, and record review, the facility failed to provide the necessary care to maintain a psychosocial well-being for one of one resident (Resident 1) when Resident 1 with diagnosis of post-traumatic stress syndrome (PTSD - a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or deeply stressful event) had to share a bathroom with male residents. This failure resulted in Resident 1's verbalization of feeling unsafe and had the potential to result in psychosocial distress (the emotional, mental, and social difficulties an individual experiences when overwhelming stress or painful events exceed their ability to cope).Findings:Review of Resident 1's clinical record titled, admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental illness that causes constant fear) and PTSD.Review of Resident 1's quarterly minimum data set (MDS - federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact).Review of Resident 1's clinical record titled, Progress Note, dated 5/19/2026, indicated Resident 1 called the police regarding a naked person entering her room. Further review indicated the police came to the facility and requested that the patient who entered her room be moved to another room to prevent further incidents.During a concurrent observation and interview with Resident 1 on 5/20/2026 at 10:04 a.m., inside Resident 1's room, Resident 1 was observed walking towards her bed and then she sat at the edge of her bed. Resident 1 stated on 5/19/2026 at around 4:00 a.m., she woke up and found a naked man standing in front of her bathroom door and he was facing her at the end of her bed. Resident 1 further stated she was terrified, unable to move when she saw the naked man, and she thought she would be killed. Resident 1 started crying during the interview and stated that she thought the residents whom she was sharing the bathroom in the other room were unable to use the bathroom independently. Resident 1 stated she was abducted by two men before and was sexually assaulted. She further stated, why are men always after me? Resident 1 stated she did not feel safe at the facility after the incident.During an observation on 5/20/2026 at 10:44 a.m., inside Resident 1's bathroom, there was a toilet and another door that led this writer inside Resident 2 and Resident 3's room.During a concurrent observation and interview with Resident 2 on 5/20/2026 at 10:55 a.m., inside Resident 2 and Resident 3's shared room, Resident 3's bed was empty, and Resident 2 was in bed watching TV. There was a sink located inside their room. Resident 2 confirmed they (with Resident 3) shared the bathroom with Resident 1. Resident 2 stated Resident 3 was confused the other night when he walked inside their bathroom naked, and he ended up inside Resident 1's room.During an interview with licensed vocational nurse A (LVN A) on 5/20/2026 at 11:08 a.m., LVN A stated she was not sure if Resident 1 should share the bathroom with male residents and she was not aware of Resident 1's diagnosis of PTSD. LVN A further stated the admission staff and social services (SS) oversaw assigning rooms to their residents.During an interview with SS on 5/20/2026 at 12:29 p.m., SS stated he spoke with Resident 1 on 5/19/2026 about the incident and Resident 1 told him that the incident was pretty distressing to her, that a man was inside her room. SS further stated Resident 1 was not happy it happened. SS stated, we don't want male and female sharing a bathroom, but it was a temporary room changed. SS further stated he was aware of Resident 1's diagnosis of PTSD and she was a victim of domestic violence.During an interview with the assistant director of nursing B (ADON B) on 5/20/2026 at 1:48 p.m., the ADON B stated she was aware about the incident on 5/19/2026 with Resident 1. When asked if Resident 1 was made aware of sharing the bathroom with Resident 3 who could use the bathroom himself, the ADON B stated she was not sure and that was missed.During an interview with licensed vocational nurse C (LVN C) on 6/16/2026 at 9:16 a.m., LVN C confirmed the 5/19/2026 incident when Resident 3 went inside Resident 1's room through the shared bathroom. LVN C stated Resident 3 was transferred to Resident 2's room on 5/18/2026 because he was throwing poop to his previous roommate and was going to other resident's room peeing all over the place. LVN C stated Resident 1 was not supposed to share the bathroom with male residents.During a review of the facility's policy and procedure titled, Quality of Life -Accommodation of Needs, date revised August 2009, indicated, The resident's individual needs and preferences shall be accommodated to the extent, except when the health and safety of the individual or other residents would be endangered.In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom.

Based on interview and record reviews, the facility failed to implement the discharge plan for one out of three residents (Resident 1) when the facility staff (Social Services and/or Case Manager) did not send a referral for home health services (HH, healthcare provided in the client's home) to a Home Health Agency (HHA). The failure had the potential to compromise the health and safety of Resident 1.A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including difficulty in walking, not elsewhere classified and muscle weakness. During a review of Resident 1's document titled, discharged summary/Post Discharge Plan of Care, effective date 11/10/25, indicated in IV. Rehab/Discharge Potential. B. rehab, B2. Comments: Pt (Patient) is independent in bed mobility and transfers. Pt (Patient) is supervision for ambulation with FWW (Front-wheeled walkers, are mobility aids with two front wheels and rear glides, designed to be pushed forward without lifting, making them ideal for users with limited strength or partial weight-bearing needs.), independent with w/c (wheelchair). Pt (Patient) to continue with home health services. During a review of Resident 1's physician assistant (PA) notes, dated 11/12/25, indicated, .35 minutes spent to discharge a patient and review medication and order PT/OT and needed equipment and ordering medication to outpatient pharmacy. During a review of facility discharged resident list, indicated Resident 1 was discharged to Private home/apt (apartment) with no home health services effective date 11/14/25. During a review of Resident 1's Case Manager (CM) notes, dated 11/12/25, indicated, Pt (Patient) will be discharging to home with HH/R/PT/OT [HH - Home Health, R- Rehab - PT -(Physical Therapy) and OT - (Occupational Therapy), are rehabilitation services designed to improve mobility, function, and quality of life after injury or illness]. During a phone interview on 11/26/25 at 2:01 p.m., with Family Member (FM), the FM stated Resident 1 was discharged home on [DATE], the FM stated when they're leaving, they were told they will be contacted about the home health service (HH, healthcare provided in the client's home). The FM stated there was no HH visit since Resident 1 was discharged from the facility. The FM further stated he tried calling the facility staff but no call back. During a concurrent interview and record review on 12/16/25 at 1:18 p.m., with the Social Services (SS), she reviewed Resident 1's discharged summary/Post Discharge Plan of Care, effective date 11/10/25, she stated Resident 1 was discharged from facility to home with the home health. SS was asked if she send a referral for HH, she stated she did not know about the HH referral, the Case Manager (CM) knows more about the referral for HH PT/OT. During a concurrent interview and record review on 12/16/25 at 1:45 p.m., with the CM, she reviewed Resident 1 discharge plan she stated, normally before the patient is discharge the HH is set up, they go with the rehab department recommendation if they need HH, they will fax or email the referral. The CM further stated she did not send a referral for HH, she further stated usually is the SS for HH referral. During a concurrent interview and record review on 12/16/25 at 12:39 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 1 clinical records, the ADON confirmed home health was marked on Resident 1's discharged summary/Post Discharge Plan of Care, effective date 11/10/25. ADON stated he thinks it should be set up for home health. The ADON further stated he did not see any documentation for HH referral. During a current interview and record review on 1/22/26 at 1:37 p.m., the DON stated Social Service and Case Manager are responsible for referral for HH, the DON reviewed and confirmed Resident 1's PA notes, dated 11/12/25, indicated, review medication and order PT/OT and needed equipment and ordering medication to outpatient pharmacy. During an interview on 1/14/25 at 12:45 p.m., with the Administrator (ADM), he stated the person responsible for HH referral is either the case manager or the social services. During a follow-up interview on 1/22/26 at 2:18 p.m., with the Director of Nursing (DON), the DON confirmed the facility discharged residents list, indicated Resident 1 was discharged Private home/apt (apartment) with no home health services, effective date 11/14/25. These interviews with the DON and ADM indicated vague and overlapping duties and responsibilities between the Social Services and Case Manager and created confusion which affected the discharge of Resident 1 who was not provided with a referral to a HHA by either the SS or the CM. Resident 1 ended up being discharged home without any home care services at all. During a review of SS job description titled, Director of Social Services indicated, Administrative Functions: Plan, develop, organize, implement, evaluate and direct the social service programs of the facility. Refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. Ensure social service progress notes are informative and descriptive of the services provided and of the resident's response to the service. Develop and maintain a community and social services referral file of agencies and organizations that assist residents. Participate in community planning related to the interests of the facility and the services and needs of the resident and family. During a review of CM job description, titled Case Manager indicated, Duties and Responsibilities .Identify post-discharge needs such as nursing and therapy services, medical equipment, home modification or activities of daily living (ADLs) assistance. According to the State Operations Manual, Appendix PP -Long Term Care Facilities, F627 - S483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.

Based on observation, interview and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for one resident (Resident 1) out of one sampled Resident. This failure resulted in Resident 1's elopement, minor injuries, and subsequent hospital visit.FINDINGS: A review of Resident 1's medical record indicated an admission date of 9/16/25. Resident 1's diagnoses included but were not limited to unsteadiness on feet, other abnormalities of gait and mobility, and cognitive communication deficit.A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 8 (a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact).A review of Resident 1's Progress Notes dated 11/4/25 at 10:39 am by Registered Nurse (RN) A indicated, Patient is at [hospital name].A review of a complaint filed with the Department on 11/4/25 12:04 p.m. regarding Resident 1 indicated, . English speaking pt (patient) who has been staying at [skilled nursing facility (SNF) name], length of stay unknown. Patient presented to [acute hospital name, hospital] ED (emergency department) and was BIB (brought in by) a good Samaritan near [hospital] due to patient reporting that he had a misstep, which lead to unwitnessed fall. He hit his head and had abrasion to left hand. Pt (patient) left [SNF name] and did not tell anyone because he, he had a feeling I was going to be killed. Currently, pt (patient) denies MH (mental health) symptoms [denied SI (suicidal Ideation)].per chart, pt (patient) has memory loss and his cognition is impaired .A review of After Visit Summary dated 11/4/25 from [hospital] indicated, Today's visit, Reason Visit: Fall; Diagnoses: Injury of head, initial encounter; Skin Abrasion. A Review of Resident 1's care plan indicated a care plan for Resident at risk for falls and/or injuries related to anemia, neutropenia, COPD, weakness, acute myeloblastic leukemia. Date Initiated 9/17/205 but interventions prior to 11/5/25 did not include monitoring for wandering and wanderguard (electronics security system used in senior living, hospitals and memory care facilities to prevent vulnerable residents, from wandering off and getting lost or into danger; by using wearable tags that trigger alarms or lock doors when they approach exit points) or a personalized care plan to include monitoring for safety for Resident 1 despite the diagnoses which included cognitive communication deficit.A review of Resident 1's clinical record indicated no elopement assessment and Elopement Care Plan prior to elopement incident on 11/4/25.A review of Resident 1's Progress Notes dated 11/4/25 at 4:31 pm by Licensed Vocational Nurse (LVN) B indicated, Resident arrived back to facility.able to make needs known verbally.Bruising and bandage noted to left hand/wrist area. Wanderguard [wearable tags and door sensors to alert staff and even lock doors if someone approaches an exit] placed.A review of Resident 1's Physician Order indicated, Monitor L [left] wrist Wanderguard placement and function q [every] shift, started 11/5/25 after the incident. During a concurrent observation and interview on 11/5/25 at 1:47 p.m.at the front entrance of the facility with the Director of Nursing (DON), the DON verified there was no CCTV (video surveillance system) at the entrance/exit doors of the facility. The DON also verified there were three residents on the porch without any staff supervision.During an interview on 11/5/25 at 2:34 p.m. with the Receptionist, she confirmed the facility has no receptionist from 8:00 p.m. to 8:00 a.m. During an interview on 11/5/25 at 2:45 p.m. with RN A, RN A stated he was the nurse in charge for Resident 1 in the morning of 11/4/25. RN A stated, Resident 1 was not in the facility when his shift started. RN A also stated that by 8 a.m. on 11/4/25 the staff checked outside the facility and started looking for Resident 1. RN A stated he should have asked the outgoing nurse to check the residents with him during shift report (meaning do the rounds to check if all residents are accounted for during shift change). A review of facility's policy and procedure (P&P) entitled Elopements, the P&P indicated, 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to Administrator and nursing staff. 2. If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the departure in a courteous manner;.A review of facility's policy and procedure (P&P) entitled Safety and Supervision of Residents , the P&P indicated, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities Individualized, Resident -Centered Approach to Safety: 1. Our individualized, resident -centered approach to safety addresses safety and accident hazards for individualized residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accidents hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.Systems Approach to Safety.2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment

Based on observation, interview and record review, the facility failed to ensure needed care and services were provided when call lights were not answered promptly and urgently. This failure had the potential to put residents at risk for physical, emotional and psychosocial distress. The census during the abbreviated survey was 134. Findings: During an observation on 6/12/25 at 3:26 p.m., call light was on for room [ROOM NUMBER]. Two licensed nurses were doing report by the medication cart along the hallway outside the room next to room [ROOM NUMBER]. During an interview on 6/12/25 at 3:32 p.m. with Registered Nurse (RN) A, RN A verified room [ROOM NUMBER]'s call light was on while she was getting report (change of shift endorsement) from another nurse. RN A stated nurses can answer call lights even during report. During a concurrent observation and interview on 6/12/25 at 3:39 p.m. with the Director of Nursing (DON), the DON verified call lights were on for several rooms and staff were in the hallway and nurse station. The DON stated call lights must always be answered by staff even during report. During an interview on 6/12/25 at 3:40 p.m. with Registered Nurse (RN) B, RN B stated staff must answer call lights and check on the residents. A review of facility's policy and procedure (P&P) entitled Call Lights: Accessibility and Timely Response dated October 2022, the P&P indicated, .10. To facilitate timely call light response, all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified .

Based on the interview and record review, the facility failed to ensure the half side rails were installed after obtaining the informed consent for one of three sampled residents (1) to help him reposition and stabilize in bed. This failure resulted in Resident 1's falling out of bed within six and half hours after being newly admitted to the facility on [DATE] and was transferred back to an acute hospital for further evaluation and management, and jeopardized Resident 1's health and safety during the short stay in the facility and caused Resident 1 to have a transfer to the acute hospital where he was diagnosed with intraparenchymal hemorrhage of brain (bleeding within the brain's functional tissue). FINDINGS: The clinical records of Resident 1 were reviewed. Resident 1's Face Sheet (document that summarizes a person's medical information) indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including non-specified sequelae (late effects) of nontraumatic intracerebral hemorrhage (ICH, also known as hemorrhagic stroke, condition where bleeding occurs within the brain tissue itself, caused by a ruptured blood vessel, causing damage and potentially life-threatening consequences). A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a communication tool) change of condition (COC) 911 Transfer notes, dated 2/5/25, indicated, he was admitted on [DATE] at 2:28 p.m. and the incident occurred on the same day at 9:00 p.m. for an unwitnessed fall with possible head strike and Resident 1 was found turning to his left side on the bedside floor. A review of Resident 1's acute hospital records dated 2/5/25 at 11:20 p.m. indicated, Note Type: ED NOTES indicated, PRE-HOSPITAL NOTIFICATION REPORT . Alert: Trauma: Blood Thinners? Yes? LOC? Unknown Mechanism Fall from bed. Medical/Chief Complaint: FROM SNF, unwitnessed fall from bed 2-3ft, on blood thinner, c/o head pain. Recent CVA with left side deficit. A review of acute hospital record dated 2/7/25 2:52 p.m. indicated: Clinical Summary: . He comes in after being found down on the floor of his SNF and was brought in as a trauma. CTH (computed tomography of the head, is a noninvasive diagnostic imaging procedure) shows mild expansion of his IPH (intraparenchymal hemorrhage), two other small foci of hyper density are also minimally increased in size. A review of Resident 1's acute hospital neurocritical care records, dated 2/6/25, indicated, . who presents from skilled nursing facility (SNF) status post (s/p) fall from bed. Systolic blood pressure (SBP, the pressure in your arteries when your heart beats)150 on arrival, computed tomography of the head (CTH, is a noninvasive diagnostic imaging procedure) with stable to slight interval increase in IPH (intraparenchymal hemorrhage). Further review of the history of present illness (HPI) indicated that he was discharged from the hospital yesterday afternoon 2/5/2025 to a skilled nursing facility (SNF), where he sustained an unwitnessed approximate 2-to-3-foot fall and was found to be in a prone position next to his bed. Per brother at bedside in the ED, the patient was placed in a bed without guardrails at the facility. The family requested guardrails and stayed with the patient until late evening but left prior to the patient's unwitnessed fall from bed. A review of Resident 1's interdisciplinary team (IDT, an approach to healthcare that integrates multiple disciplines through collaboration) facility notes, dated 2/6/25 indicated and documented, Resident found on floor by certified nursing assistant (CNA). Patient unable to verbalize how he fell . Patient impulsive and has poor safety awareness. Patient also has left side (L) weakness, status post (S/P, is a medical term for a previous treatment, diagnosis, or event) stroke and leans to the left. Patient was sent out to emergency room (ER) for further evaluation. Upon return IDT recommend to place wedge on L side to keep patient at midline. Continue strengthening and mobility with Therapy. During a review of Resident 1's facility physician assistant notes, dated 2/5/25, indicated, He was found on the floor to the left side of his body by the CNA. He had an unwitnessed fall. The patient states that he turned towards his left side and fell over. States that he did hit the top of his head on the ground. Bed was in the lowest setting. No observed injuries or broken skin to his head. No bumps or bruises. The patient's range of motion is at baseline, weaker at the left side secondary to his diagnosis. During a review of intake information to the State Department of Public Health, dated 2/7/25, indicated, . Patient reports he was placed in a bed without rails. Patient was reaching for the call light when he rolled off the bed. During a review of Resident 1's Bed Rails -Safety Assessment, dated 2/5/25, indicated he had Poor trunk control at risk of gravity effects for rolling, sliding, or slipping from bed. Per wife patient uses siderail with strong side to assist with bed repositioning. During a review of Resident 1's facility's verification of informed consent, dated 2/5/25, it indicated the half side rails to be used in bed was signed and obtained from Resident 1's wife who is the legal decision maker, upon admission. During a review of Resident 's facility physician's orders, dated 2/5/25, indicated, SIDE RAILS: 1/4 rails up as per doctor's order as needed to promote full or partial independence with turning and repositioning in bed, to provide support, stability, and personal comfort during transfers. Reposition frequently and as necessary to avoid injury. A further review indicated Resident 1 was also prescribed Enoxaparin Sodium Solution (is a blood thinner to prevent blood clots) 40 milligrams (MG, a unit of mass)/0.4 milliliters (ML, a unit of volume), inject 40 mg subcutaneously two times a day for preventing blood clotting. During a review of Resident 1's fall risk assessment dated [DATE], it indicated he was at moderate risk (Scoring ranges 0-24 mean at low risk, scoring 25-44 at moderate risk and scoring 45 and higher at high risk) for falling with score of 35. Further review of Resident 1's post fall assessment, dated 2/6/25, indicated Resident 1 was at high risk for falls with a score of 65. During a telephone interview on 2/19/25 10:29 a.m., with registered nurse A (RN A), RN A stated it was unfortunately too sudden when he turned himself in the bed and he fell out of the bed. RN A confirmed he did not install half side rails at that time because he was unaware side rail informed consent had been obtained already. During an interview on 2/19/25, at 2 p.m., with the assistant of director nursing (ADON), ADON confirmed staff should have installed the side rails after obtaining the side rail informed consent as soon as possible. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention and Response, dated 8/2023, the P&P indicated, Each Resident will be.assessed for fall risk factors and will receive care and services in accordance with individualized level of risk to minimize the likelihood of falls.

Based on record review, interview, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure a discharge Minimum Data Set (MDS) accurately reflected the location to which a resident was discharged for 1 (Resident #141) of 27 sampled residents for whom MDS assessments were reviewed. Findings included: A facility policy titled, MDS STANDARD OF PRACTICE, dated 01/2024 indicated, It is the practice of this facility to conduct accurate coding and delivery of services provided to capture accurate assessment of each resident's functional capacity and health status as per CMS RAI MDS 3.0 Manual guidelines. The CMS Long-Term Care Facility RAI 3.0 User's Manual, version 1.19.11, dated October 2024, revealed section A2105: Discharge Status specified, Item Rationale - This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. The manual further specified, Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Coding Instructions Select the two-digit code that corresponds to the resident's discharge status. - Code 01, Home/Community: if the resident was discharged to a private home, apartment, board, and care, assisted living facility, group home, transitional living, or adult foster care. A community residential setting is defined as any house, condominium, or apartment in the community, whether owned by the resident or another person; retirement communities; or independent housing for the elderly. An Admission Record indicated the facility admitted Resident #141 on 01/03/2025. According to the Admission Record, Resident #141 was discharged home on 01/14/2025. Resident #141's Progress Notes revealed a note dated 01/14/2025 at 12:01 PM that indicated the resident was discharged home. Resident #141's [facility name] Notice of Transfer or Discharge, dated 01/14/2025, indicated the resident was discharged home in accordance with their discharge plan. However, Resident #141's discharge, return not anticipated MDS, with an Assessment Reference Date (ARD) of 01/14/2025, revealed the MDS was coded to reflect that the resident was discharged to a short-term general hospital on 01/14/2025. During an interview on 02/27/2025 at 10:35 AM, MDS Coordinator #3 stated that Resident #141 was discharged home on 01/14/2025. MDS Coordinator #3 stated that Resident #141's discharge MDS, dated [DATE], was incorrectly coded and should have reflected the resident was discharged home, instead of reflecting the resident was discharged to a short-term hospital. During an interview on 02/27/2025 at 11:32 AM, the Director of Nursing (DON) stated she expected MDS assessments to be coded correctly. The DON said Resident #141's discharge MDS should have been coded to reflect that the resident was discharged home and not to a hospital. During an interview on 02/27/2025 at 11:37 AM, the Executive Director (ED) stated he expected MDS assessments to be coded correctly. 52066

Based on record review, interview, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of diagnosed mental illness for 1 (Resident #63) of 4 sampled residents reviewed for PASARR requirements. Findings included: A facility policy titled, Resident Assessment- Coordination with PASARR Program, reviewed/revised on 09/18/2024, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. An Admission Record revealed the facility admitted Resident #63 on 06/12/2021. According to the Admission Record, the resident had a medical history that included diagnoses of dementia (onset date of 06/12/2021) and major depressive disorder (onset date of 06/12/2021). Resident #63's Care Plan Report included a focus area, initiated 06/13/2021, that indicated the resident took antidepressant medications related to a diagnosis of depression. Resident #63's Level I PASARR, completed on 06/12/2021, revealed the screening type was an Initial Preadmission Screening (PAS). Section V- Mental Illness of the resident's Level I PASARR was completed in a manner to reflect that the resident did not have a diagnosed mental disorder such as Schizophrenia/Schizoaffective Disorder, Psychotic/Psychosis, Delusional, Depression, Mood Disorder, Bipolar, or Panic/Anxiety. The Level I PASARR was also completed in a manner to reflect the resident did not have a diagnosis or other evidence of a neurocognitive disorder, including dementia. Resident #63's diagnoses of dementia and major depressive disorder were not reflected. As a result, the resident's Level I PASARR was Negative, due to no mental illness, intellectual disability, developmental disorder, or dementia. During an interview on 02/27/2025 at 10:57 AM, MDS Coordinator #3 stated the importance of Level I PASARRs was to determine if residents required a Level II Evaluation. MDS Coordinator #3 reviewed Resident #63's diagnoses and Level I PASARR, dated 06/12/2021, and stated the resident had diagnoses of depression and dementia when they were admitted to the facility. MDS Coordinator #3 further stated, the resident's Level I PASARR should have been resubmitted because it was not accurate. During an interview on 02/27/2025 at 11:15 AM, the Director of Nursing (DON) confirmed Resident #63 was admitted to the facility with mental health diagnoses and stated the resident's Level I PASARR should have been resubmitted to reflect the presence of the diagnoses. During an interview on 02/27/2025 at 11:37 AM, the Executive Director (ED) stated Resident #63's Level I PASARR was not accurate and should have been resubmitted.

Based on observation, interview, and record review, the facility failed to implement infection control measures when: 1.Certified nursing assistant B (CNA B) and restorative nurse assistant C (RNA C) did not wear N95 (a mask or a respirator worn over the mouth and nose to protect the respiratory system by filtering out dangerous substances [such as dusts, fumes, or bacteria] from inhaled air) properly; and 2.Certified nursing assistant C (CNA D) did not follow the contact (set of steps to prevent the spread of infection from a patient to others) with bodily fluids precautions posted before the entrance in Resident 2's room, did not follow the proper sequence of putting on personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments), did not remove and discard the dirty gown and gloves prior to leaving Resident 3's room and did not perform hand hygiene before leaving the room. These failures had the potential to result in the transmission and spread of infection throughout the facility. Findings: 1.During the entrance conference with director of nursing (DON) on 1/14/2025 at 9:45 a.m., DON confirmed the facility had COVID-19 cases since December 2024. DON stated it started with one resident that was sent out to the hospital, then followed by a positive COVID-19 test of a certified nursing assistant (CNA) the following day. DON further stated, there were 38-42 patients affected by COVID-19 since December 2024 and their current census was 137. During a concurrent interview with infection preventionist (IP) and record review on 1/14/2025 at 10:15 a.m., IP reviewed the list of COVID-19 residents and staff. IP confirmed the outbreak of COVID-19 started on 12/24/2024 when Patient 1 was transferred out to the hospital due to nausea and vomiting (n /v). IP stated Patient 1 was tested for COVID-19 at the hospital and the result was positive for infection. IP further stated certified nursing assistant A (CNA A) tested positive for COVID-19 infection on 12/25/2024. IP confirmed they had 42 patients and 11 staff affected by COVID-19 infection. IP stated some residents were taken off isolation and other staff had reported to work already. IP confirmed she also tested positive for COVID-19 infection on 1/3/2025 and she just started working at the facility on 1/10/2025. During an observation on 1/14/2025 at 10:48 a.m., near the exit door towards the smoking area, CNA B was observed standing beside Resident 2 who was sitting on a wheelchair without a facemask, and beside Resident 2 was RNA C who was sitting. Both CNA B and RNA C were having a conversation with their face mask positioned down to their chin while Resident 2 was sitting in between them. Both CNA B and RNA C pulled up their face mask when they observed the evaluator nurse approaching. During an interview with CNA B on 1/14/2025 at 10:50 a.m., CNA B confirmed above observation. CNA B stated she should have covered her nose and mouth with the face mask while talking to RNA C. CNA B confirmed the facility was having COVID-19 outbreak. During an interview with RNA C on 1/14/2025 at 10:55 a.m., RNA C confirmed above observation. RNA C stated she pulled down her mask because she had asthma (a condition in which your airways narrow and swell. This can make breathing difficult and trigger coughing). RNA C stated she should have covered her mouth and nose with the face mask due to COVID-19 outbreak in their facility and Resident 2 was sitting in between them without a facemask in placed. During a phone interview with IP on 1/15/2025 at 9:43 a.m., IP stated staff should wear their N95 properly especially when they were with residents. During a review of the facility's policy and procedure titled, Coronavirus Disease (COVID-19) - Source Control, date revised May 2023, indicated, Source control measures are utilized as part of the core COVID-19 infection prevention and control measures. Source control refers to the use of well-fitting cloth masks, facemasks or respirators that covers the mouth and nose and prevents the spread of respiratory secretions when individuals are breathing, talking, sneezing, or coughing. 2.During an observation in Station AA on 1/14/2025 at 11:18 a.m., CNA D was observed standing in front of Resident 3's door, donning (put on) a new pair of gloves first, then CNA D pulled out the isolation cart's drawer, took a gown and wore it. CNA D entered Resident 3's room without eye coverings or face shield and started talking to Resident 3. Resident 3 was in bed wearing the facility's gown without face mask. CNA D closed the door to provide privacy. During an interview with licensed vocational nurse E (LVN E) on 1/14/2025 at 11:27 a.m., LVN E did not know Resident 3's precaution, but she was aware Resident 3 had human immunodeficiency virus (HIV, a virus that attacks the body's immune system). LVN E stated the sequence in donning Resident 3's PPE: mask first, then gown, face shield, and gloves. LVN E further stated gloves should be worn last. LVN E confirmed CNA D was cleaning up Resident 3. During a concurrent observation and interview with IP on 1/14/2025 at 11:32 a.m., in front of Resident 3's room, IP confirmed the signage on top of Resident 3's isolation cart indicated Resident 3 was on contact and bodily fluid precautions. IP stated all staff should enter Resident 3's room with full PPE (N95, gown, face shield, and gloves). IP checked the isolation cart for face shields, and she did not find one. IP stated, It's my fault because the isolation cart does not have face shield, but staff knew where to find the face shields. IP further stated, staff should wear face shield prior to entering Resident 3's room. During a follow up observation on 1/14/2025 at 11:43 a.m., CNA D stepped out of Resident 3's room still with PPE in placed. CNA D threw a plastic with garbage at the hallway's garbage container near Resident 3's isolation cart. CNA D started to remove the gown and gloves and threw them into the same hallway's garbage container. CNA D did not perform hand hygiene after, then walked to Station AA's hallway to get the Hoyer lift (a medical device that helps caregivers move patients from one place to another). During a concurrent observation and interview with CNA D on 1/14/2025 at 11:47 a.m., in front of Resident 3's room door, CNA D was pushing the Hoyer lift towards Resident 3's room. CNA D confirmed above observation, and stated he did not wear a face shield because he couldn't find one in the isolation cart. CNA D stated he did not wash or sanitized his hands because he needed to get the Hoyer lift for Resident 3. CNA D further stated, he should have worn a face shield prior to entering Resident 3's room, removed and threw his PPE prior to going out of the room and performed hand hygiene. Review of Resident 3's clinical record titled, Admission Record, indicated Resident 3 was admitted to the facility with diagnoses including paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), colostomy status (an opening into the colon from the outside of the body), bacteremia (a condition where bacteria are present in the blood), resistance to multiple antibiotics (when a microorganism, like bacteria, virus or parasite is resistant to more than one antimicrobial drugs), HIV, methicillin resistant staphylococcus aureus (MRSA, a type of bacteria that is resistant to mangy antimicrobial drugs), other specified bacterial agents as the cause of diseases classified elsewhere, and osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection). Review of Resident 3's clinical record titled, Order Summary Report, an order dated 5/31/2024, indicated Resident 3 was on contact isolation precaution due to Carbapenem-resistant Enterobacterales (CRE, bacteria that are resistant to some or all antibiotics in the carbapenem class. CRE infections can be serious and difficult to treat). Further review indicated, Resident 3 had suprapubic catheter (a flexible tube that drains urine from the bladder through a small cut in the lower abdomen). Review of Resident 3's clinical record titled, Infectious Diseases, dated 1/8/2025, indicated Resident 3 had chronic hip and penile wounds, HIV, left hip decubitus ulcer (a skin injury caused by prolonged pressure on an area of the body), and osteomyelitis. During a review of the facility's policy and procedure titled, Infection Prevention Manual for Long Term Care, Isolation Precautions: Standard Precautions, date revised May 2024, indicated, It is the policy of this facility to use Standard Precautions for resident care based on anticipated blood or body fluids (BBF) excretions and secretions exposure other than sweat which are considered potentially infectious .include a group of infection prevention practices that apply to all patients, regardless or suspected or confirmed infection status .These practices include hand hygiene; use of gloves, gown, mask, eye protection, or face shield . Further review indicated, Personal Protective Equipment (PPE) .Remove, discard PPE, and perform hand hygiene in room when activity is complete. PPE is provided to all employees. Each employee is responsible for knowing where the equipment is kept in the department. Review of Centers for Disease Control and Prevention's (CDC, national public health agency of the United States) Sequence for Putting on Personal Protective Equipment (PPE), indicated, 1. GOWN; 2. MASK OR RESPIRATOR; 3. GOGGLES OR FACE SHIELD 4. GLOVES.

Based on interview and record review, the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC, a form given by the facility to all Medicare beneficiaries before the end of a Medicare covered Part A stay or when all of Part B therapies are ending) was not given in a timely manner to one of two sample residents (Resident 1). This failure resulted in Resident 1 not being able to make an appeal. Findings: During an interview over the phone on 9/19/24 at 8:53 a.m. with Resident 1's relative (RR), it was stated that RR saw a voicemail from the facility on 9/11/24. RR also stated she wanted to make an appeal and called the facility on 9/11/24 regarding the NOMNC. RR stated that facility informed RR that they will call back with the information. RR stated that facility did not call back. A review of Resident 1's admission record indicated, Resident one was admitted on [DATE]. A review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool) dated 8/14/24 indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) score of 5 (a score of 13 to 15 suggests the resident is mentally intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). A review of facility provided document titled Notice of Medicare Non-Coverage for Resident 1, NOMNC indicated, The effective date coverage of your Skilled Nursing Services Will End: 9/10/24. NOMNC also indicated, Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above. A handwritten note under additional information indicated, Patient family member/Responsible Party did not answer. Voicemail left and copy left in pt room. NOMNC was signed by two Case Managers dated 9/9/24 at 6:33 p.m. During a concurrent interview and record review on 9/25/24 at 1:18 p.m. with Social Services Director (SSD), SSD confirmed NOMNC for Resident 1 was signed and dated by two case managers on 9/9/24 at 6:33 p.m. SSD stated Business Office sends the NOMNC to the case managers and we notify residents at least 72 hours. During a concurrent interview and record review on 9/25/24 at 2:47 p.m. with the Administrator (ADM), ADM confirmed NOMNC was dated given on 9/9/24 at 6:33 p.m. via voicemail. ADM also confirmed there was no indication on the NOMNC document that the information was understood and received by Resident 1's responsible party. ADM also stated, NOMC should have been given three days prior to end of Medicare coverage. During a concurrent interview and record review on 9/25/24 at 3:00 p.m. with the Director of Nursing (DON), DON stated I did not know what the NOMNC was. DON also confirmed the NOMNC was signed and dated 9/9/24 and timed 6:33 p.m. by two facility Case Managers. DON confirmed there was no signature from Resident 1 or a responsible party. A review of facility's policy and procedure (P&P) titled Transfer and Discharge (including AMA) revised 7/20/23, the P&P indicated, The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: .d. An explanation of the right to appeal the transfer or discharge to the State .f. Information on how to obtain an appeal form According to Title 42 of the Code of Federal Regulations, S 405.1200 Notifying beneficiaries of provider service terminations, Timing of notice. A provider must notify the beneficiary of the decision to terminate covered services no later than 2 days before the proposed end of the services.

Based on interview and record review, the facility failed to ensure that resident representative was notified prior to discharge for one (Resident 1) of two sampled residents. This failure had the potential to result in psychosocial distress for Resident 1 when Resident 1's relative (RR) was not able to communicate with Resident 1 before, during and right after Resident 1's discharge to another facility. Findings: During an interview over the phone on 9/19/24 at 8:53 a.m. with Resident 1's relative (RR), RR stated that facility did not communicate the discharge of Resident 1. RR stated she saw a voicemail on 9/10/24 from the facility regarding discharge and called the facility on 9/10/24 to make an appeal. RR stated she was told she will receive a call back with the information. RR stated that facility did not call back. RR also stated discharge date was not provided by the facility and there was no written notice of discharge given. RR also stated, she went to the facility on [DATE] and was informed that Resident 1 was already discharged . A review of Resident 1's medical record indicated, Resident one was admitted on [DATE] and was discharged on [DATE] at 11:59 a.m. A review of Resident 1's Minimum Data Set (MDS, a federally mandated assessment tool) dated 8/14/24 indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation and judgement status of the resident) score of 5 (a score of 13 to 15 suggests the resident is mentally intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). A review of Resident 1's Order Summary indicated, MD determines that Resident does NOT have the mental capacity to make healthcare decisions as per History and Physical with order date 8/9/24. A review of facility provided document titled Advance Health Care Directive, signed by Resident 1 and dated 1/14/16. The document indicated that RR was designated and appointed by Resident 1 as agent to make healthcare decisions . During an interview on 9/25/24 at 11:22 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that social services communicate with the residents' family about the discharge process. During a concurrent interview and record review on 9/25/24 at 1:18 p.m. with Social Services Director (SSD), SSD stated he did not call RR to notify about discharge. RR stated it was the Case Manager who must call the family to notify about the discharge. RR also stated case manager should have waited for the call back from RR before proceeding to discharge Resident 1. During a concurrent interview and record review on 9/25/24 at 2:47 p.m. with the Administrator (ADM), ADM confirmed Resident 1's Advance Directive indicated RR as agent to make health care decisions. The ADM stated we should have not discharged Resident 1 without speaking with RR. During a concurrent interview and record review on 9/25/24 at 3:00 p.m. with the Director of Nursing (DON), DON confirmed Resident 1's Advance Directive indicated RR as agent to make health care decisions. The DON stated we should not discharge the resident home without speaking with the responsible party. A review of facility's policy and procedure (P&P) titled Transfer and Discharge (including AMA) revised 7/20/23, the P&P indicated, The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: b. The effective date of transfer of discharge.

Based on observation, interviews, and record review, the facility failed to ensure two of two residents (Resident 1 and 2) received proper care and treatment services when: 1. For Resident 1, there was no physician order and care plan regarding the use of left-hand splint; and 2. For Resident 2's treatment for the nephrostomy sites (an opening in the skin of the back where the tube is inserted to drain urine from the kidney), was not initiated until 4 days after admission and it was not documented in some days. These failures could affect the residents' health and individualized care and services provided while in the facility. Findings: 1. Review of Resident 1's Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including sepsis (blood poisoning due to an infection), urinary tract infection (UTI, an infection caused by a bacterium (germs) that gets into the bladder or kidneys) and Alzheimer's disease (a progressive disease that destroys memory and mental functions). Review of Resident 1's physician progress note dated 6/18/2024, indicated Resident 1's son told the physician that his mother's left hand was painful at that time. Review of Resident 1's clinical record titled, SBAR [Situation, Background, Assessment and Recommendation, an assessment tool used to facilitate prompt and appropriate communication of a problem)], dated 6/19/2024, indicated Resident 1 was transferred out at the hospital for probable septic [a life-threatening medical condition that occurs when an infection causes a body-wide reaction that leads to dangerously low blood pressure and organ failure] and dehydration [a harmful reduction in the amount of water in the body]. Review of Resident 1's x-ray of left wrist dated 6/19/2024, indicated, Nondisplaced fracture (still broken bones, but the pieces weren't moved far enough during the break to be out of alignment) of the trapezium [a bone in the wrist below the base of the thumb]. Action required. Review of Resident 1's History and Physical by a physician dated 6/25/2024, indicated Resident 1 was readmitted back to the facility on [DATE]. Further review indicated, Also found to have a new left trapezium fracture for which she was seen by ortho [orthopedist, a medical specialist who focuses on injuries and disease affecting the bones, muscles, joints and soft tissues] and placed in a splint [an external device that stabilizes and holds a part of the body in place to protect it and support it after an injury or to treat certain health condition] with plans for outpatient follow-up. During an interview with registered nurse A (RN A) on 7/10/2024 at 12:05 p.m., RN A confirmed Resident 1 had a left wrist splint in place. RN A stated she did not know the indication of Resident 1's splint use. During an interview with the certified nursing assistant B (CNA B) on 7/10/2024 at 2:20 p.m., CNA B confirmed Resident 1 did not fall and CNA B was not sure why Resident 1 was wearing a splint to left wrist. During a concurrent observation and interview with Resident 1 on 7/10/2024 at 2:25 p.m., inside Resident 1's room, Resident 1 was in bed, oxygen was in used, and left hand was observed swollen, with splint in place. Resident 1 stated she was okay, and did not complain of pain. Resident 1 confirmed she did not know how she hurt her left wrist. During a concurrent interview with both director of nursing (DON) and case manager (CM) and record review on 7/10/2024 at 4:14 p.m., DON and CM reviewed Resident 1's physician's orders, transfer records, and list of care plans. Both DON and CM stated they were not aware about Resident 1's fracture of left wrist. DON confirmed there was no order and no care plan developed for Resident 1's splint use. DON stated there should be a physician's order and care plan developed for splint use on Resident 1's left wrist. During an interview with licensed vocational nurse C (LVN C) on 8/1/2024 at 1:11 p.m., LVN C stated the admitting nurse should have called Resident 1's doctor to obtain a doctor's order for the splint use if it was still needed. LVN C further stated, the use of splint should have been care planned. During a review of the facility's policy and procedure titled, Admission Orders, dated 11/28/23, indicated, The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission. The orders should provide information to maintain or improve the resident's functional abilities . During a review of the facility's policy and procedure titled, Care Plan, Comprehensive, dated Dec. 2017, indicated, Care Plans should be developed by the Interdisciplinary Team (IDT), which includes activities, dietary, nursing management, social services, and therapy and includes input from direct care staff including Licensed Nurses and Nursing Assistants .Care Plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs . 2. Review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including pyelonephritis (medical term for kidney infection), hydronephrosis (a condition that causes one or both kidneys to swell and stretch due to a buildup of urine), and encounter for attention to other artificial openings of urinary tract. During a phone interview with hospital's social work clinician (SWC) on 8/1/2024 at 8:49 a.m., SWC confirmed Resident 2 was admitted back at the hospital on 7/27/2024 with admitting diagnosis of UTI associated with nephrostomy catheter. During an interview with LVN C on 8/1/2024 at 1:21 p.m., LVN C stated, nurses should call the doctor if resident was admitted with nephrostomy tube to get a treatment order on its sites and other nephrostomy care. LVN C further stated, nurses should document after a treatment was completed. During an interview with registered nurse D (RN D) on 8/1/2024 at 1:40 p.m., RN D stated Resident 2 was alert and oriented to person, place, and time. RN D confirmed Resident 2 had a fever, and he was transferred to the hospital for further evaluation. RN D stated, admission nurses should call the doctor to obtain orders related to nephrostomy care. RN D further stated, nurses should document once they were done with the treatment as ordered. During a concurrent interview with nurse supervisor (NS) and record review on 8/1/2024 at 1:57 p.m., NS reviewed Resident 2's treatment administration record (TAR). NS confirmed Resident 2's treatment to nephrostomy sites just started on 5/21/2024, 4 days after his admission. NS confirmed the treatment to clean the nephrostomy sites, changed the dressings and to empty every shift were not documented as completed on: 7/6/2024, night shift; 7/17/2024, days shift; 7/18/2024, days shift; 7/24/2024, days shift; and 7/26/2024, evening shift. NS stated, treatment should be documented once it was done or completed. During an interview with DON on 8/1/2024 at 4:12 p.m., DON stated the admitting nurse should have called Resident 2's attending physician to obtain a treatment order for nephrostomy site and for nephrostomy care. DON further stated, nurses should document once the treatment is done. During an interview with assistant director of nursing (ADON) on 8/28/2024 at 10:18 a.m., ADON stated, if the treatment was not documented, it did not happen. During a review of the facility's policy and procedure titled, Wound Treatment Management, dated 4/1/2024, indicated, Wound treatments will be provided in accordance with physician's orders, including the cleansing method, type of dressing, and frequency of dressing change .Treatments will be documented on the Treatment Administration Record. Electronic Medical Record or in the electronic health record.

Based on interview and record review, the facility failed to ensure one of four allegations of abuse was reported within 24 hours per Federal and State law when one resident (Resident 1) left the facility AMA (against medical advice) for his safety after he telephoned the police to report an allegation of being touched inappropriately. This failure had the potential to compromise resident's safety and result in further abuse. Findings: During a review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of fusion of the spine (major surgery designed to stop motion to alleviate pain) in the lumbar region (series of small bones enclosing the spinal cord in the low back). Face Sheet further indicated Resident 1 was self-responsible. During a review of Resident 1's Release from Responsibility for Discharge, dated 10/14/23, the Release from Responsibility for Discharge indicated, Resident 1 was leaving against the advice of the attending physician. During a review of Resident 1's Notice of Transfer or Discharge, dated 10/17/23, the Notice of Transfer or Discharge indicated, a discharge date of [DATE] and Resident 1 left AMA. There was nothing documented why Resident 1 left AMA. During a telephone interview, on 5/2/24 at 1:25 p.m., with Resident 1, Resident 1 stated two certified nursing assistants (CNAs) ripped off my covers and pulled my sweatpants down and grabbed my genitals. Resident 1 stated he called 911 (three-digit emergency number for police, fire, or safety) and the police came out. Resident 1 stated he felt like he was the victim of sexual assault, and he left the facility for his safety. During an interview, on 5/3/24 at 11:47 a.m., with the Assistant Director of Staff Development (ADSD), the ADSD stated Resident 1 called the police and told them someone touched him inappropriately. ADON stated the Administrator is the Abuse Coordinator. During an interview, on 5/3/24 at 11:56 a.m., with the Administrator (ADM), the ADM stated he does not recall if it was reported to him. ADM stated it was his first few weeks of being on the job. During a subsequent interview, on 5/3/24 at 1:07 p.m., with the ADSD, the ADSD stated she reported it to the ADM and the ADM told her to go interview the resident. ADSD stated the resident left before she could interview him. ADSD acknowledged allegations of abuse should be reported and investigated per Federal and State law. ADSD stated we did not do that. During a subsequent interview, on 5/3/24, at 1:28 p.m., with the ADM, the ADM stated the ADSD talked to the police and the police reported there was nothing to investigate. ADM acknowledged any allegations of abuse should be reported and investigated per Federal and State law. Review of the facility's revised October 2022 policy Abuse or Suspected Abuse and Crime Reporting indicated, It is the responsibility of all employees to immediately report to the facility administrator, and to other officials in accordance with Federal and State law, any incident of suspected or alleged abuse .within the designated time frame by e-mail, fax or telephone .not later than 24 hours after the allegation is made . Reporting is made to the Administrator (Abuse Coordinator), State Survey Agency, Adult Protective Services and all other required agencies (e.g. law enforcement when applicable).

Based on interview and record review, the facility failed to investigate one of four allegations of abuse when Resident 1 reported being touched inappropriately. This failure had the potential to compromise resident's safety and result in further abuse. Findings: During a review of Resident 1's Face Sheet (document that contains a summary of personal and demographic information), the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] with a primary diagnosis of fusion of the spine (major surgery designed to stop motion to alleviate pain) in the lumbar region (series of small bones enclosing the spinal cord in the low back). Face Sheet further indicated Resident 1 was self-responsible. During a review of Resident 1's Release from Responsibility for Discharge, dated 10/14/23, the Release from Responsibility for Discharge indicated, Resident 1 was leaving against the advice of the attending physician. During a review of Resident 1's Notice of Transfer or Discharge, dated 10/17/23, the Notice of Transfer or Discharge indicated, a discharge date of [DATE] and Resident 1 left AMA. There was nothing documented why Resident 1 left AMA. During a telephone interview, on 5/2/24 at 1:25 p.m., with Resident 1, Resident 1 stated two certified nursing assistants (CNAs) ripped off my covers and pulled my sweatpants down and grabbed my genitals. Resident 1 stated he called 911 (three-digit emergency number for police, fire, or safety) and the police came out. Resident 1 stated he felt like he was the victim of sexual assault, and he left the facility for his safety. During an interview, on 5/3/24 at 11:47 a.m., with the Assistant Director of Staff Development (ADSD), the ADSD stated Resident 1 called the police and told them someone touched him inappropriately. ADSD stated the Administrator is the Abuse Coordinator. During an interview, on 5/3/24 at 11:56 a.m., with the Administrator (ADM), the ADM stated he does not recall if it was reported to him. ADM stated it was his first few weeks of being on the job. During a subsequent interview, on 5/3/24 at 1:07 p.m., with the ADSD, the ADSD stated she reported it to the ADM and the ADM told her to go interview the resident. ADSD stated the resident left before she could interview him. ADSD acknowledged allegations of abuse should be reported and investigated per Federal and State law. ADSD stated we did not do that. During a subsequent interview, on 5/3/24, at 1:28 p.m., with the ADM, the ADM stated the ADSD talked to the police and the police reported there was nothing to investigate. ADM acknowledged any allegations of abuse should be reported and investigated per Federal and State law. During a concurrent interview and record review, on 6/3/24, at 11:40 a.m., with the Director of Staff Development (DSD), the alleged perpetrators (CNAs) employee files were reviewed. The employee files indicated the CNAs had not been counseled or suspended pending the outcome of an investigation and the DSD stated both CNAs had voluntarily resigned for reasons not related to the alleged incident. Review of the facility's revised October 2022 policy Abuse or Suspected Abuse and Crime Reporting indicated, .suspected or alleged abuse .will be investigated with results reported to officials in accordance with state law, including State Licensing & Certification agency, within five days of incident . Facility policy further indicated To protect residents .from harm .the facility shall suspend staff member(s) believed to be involved, pending the outcome of an investigation.

Based on interview and record review, the facility failed to follow professional standards for two of three residents (Resident 1 and 2) when: 1. Resident 1 ' s eye drop medication was not discontinued after the resident ' s refusals and statement it caused eye irritation; 2. Medications were not provided timely for Residents 1 and 2. These failures had the potential to result in health complications. Findings: 1. Review of Resident 1 ' s clinical record indicated he was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular heart rhythm which can lead to blood clots and stroke) and glaucoma (damage to the nerve in the eye cause by fluid buildup or increased pressure). Review of Resident 1 ' s physician orders indicated he had a physician order for dorzolamide ophthalmic solution 2% (eye drops used to treat glaucoma) one drop in left eye two times a day, dated 10/29/23. Review of Resident 1 ' s MD progress notes, dated 10/30/23 indicated Resident 1 has glaucoma and was not able to tolerate dorzolamide due to eye irritation. Review of a nurse ' s note, dated 11/1/23 indicated Resident 1 refused dorzolamide eye drops and said it irritates his eyes . staff reported to the case manager and she said it is dc [discontinued]. Review of Resident 1 ' s Medication Administration Record (MAR, record of medications given) for November 2023 indicated nurses continued to offer dorzolamide from 11/1/23 to 11/6/23. Review of Resident 1 ' s physician orders indicated dorzolamide was discontinued on 11/6/23 per family and patient request and the MD was made aware. During an interview on 12/13/23 at 12:08 p.m., the case manager stated the medication should have been discontinued earlier. 2a. Further review of Resident 1 ' s physician orders indicated he had physician orders for the following medications: Dabigatran etexilate mesylate (blood thinning medication used to prevent blood clots and stroke) 150 milligrams (mg, unit of measurement) one capsule by mouth two times a day, dated 10/29/23. Ezetimibe (medication used to lower high cholesterol) 10 mg one tablet by mouth at bedtime, dated 10/29/23. Calendula external cream (moisturizing cream) apply to lower back topically two times a day, dated 11/8/23. Further review of Resident 1 ' s MAR for November 2023 indicated Resident 1 did not receive the following medications: Dabigatran etexilate mesylate 150 mg on 11/8/23 at 9 a.m. and 5 p.m. Calendula cream on 11/12/23 at 9 a.m. Ezetimibe 10 mg on 11/14/23 at 9 p.m. Review of Resident 1 ' s Orders - Administration Note, dated 11/8/23 indicated Dabigatran etexilate mesylate 150 mg will follow up with pharmacy. Review of Resident 1 ' s Orders - Administration Note, dated 11/8/23 indicated Dabigatran etexilate mesylate 150 mg med not available, reordered, will call pharmacy to check delivery. Review of Resident 1 ' s Orders - Administration Note, dated 11/12/23 indicated calendula cream was not available . will reorder. Review of Resident 1 ' s Orders - Administration Note, dated 11/14/23 indicated Ezetimibe 10 mg was not available. MD notified that [pharmacy] did not send dose. During an interview on 12/13/23 at 10:05 a.m., registered nurse A (RN A) stated he was looking for the cream and did an exhaustive search. RN A stated later on during the shift he was able to find the cream, but was not able to give it at the time it was due. 2b. Review of Resident 2 ' s clinical record indicated she was admitted to the facility with diagnoses including acute kidney failure and muscle weakness. Review of Resident 2 ' s physician orders indicated she had physician orders for the following medications: Florastor 250 mg (miligrams, a unit of measure) give 1 capsule by mouth two times a day for probiotic, start date 11/22/23 and Pantoprazole Sodium oral tablet delayed release 40 mg, give 1 tab by mouth two times a day for ulcer, start date 10/23/23. Review of Resident 2 ' s MAR for November 2023 indicated Resident 2 did not receive the following medications: Florastor 250 mg on 11/22/23 at 9 a.m. Florastor 250 mg on 11/23/23 at 9 a.m. Pantoprazole sodium 40 mg on 11/23/23 at 9 a.m. Review of Resident 2 ' s Orders - Administration Note, dated 11/22/23 indicated florastor 250 mg not given not available Review of Resident 2 ' s Orders - Administration Note, dated 11/23/23 indicated pantoprazole sodium 40 mg not available. Review of Resident 2 ' s Orders - Administration Note, dated 11/24/23 indicated florastor 250 mg not available. During an interview on 12/11/23 at 12:18 p.m., the director of nursing (DON) stated sometimes the pharmacy does not deliver meds due to insurance issues or because certain medications need approval. The DON stated the facility was in the process of switching to a different pharmacy. Review of the facility ' s policy, Medication Administration, dated 12/2012 indicated, Routine and emergency medications will be administered as ordered within the timeframes indicated per facility practice. The policy also indicated, Always check the resident ' s condition. Monitor for potential serious drug interactions, side effects, or adverse reactions . Document drug refusal, alert MD for continued refusals. Review of the facility ' s policy, Medication Shortages/Unavailable Medications, dated 4/2022 indicated, If the medication is unavailable from Pharmacy or a Third Party Pharmacy, and cannot be supplied from the manufacturer, Facility should obtain alternate Physician/Prescriber orders, as necessary.

Based on interview and record review, the facility failed to provide services according to professional standards for one of three sampled residents (Resident 1) when a licensed vocational nurses A (LVN A) did not follow the five rights of medications administration (safety check prior to medication administration: right patient, right drug, dosage, right route, right time) and administered the wrong medications to Resident 1. This resulted in Resident 1 getting administered incorrect medications. Findings: Review of Resident 1's electronic medication administration record (EMAR, electronic version of medications received by a resident), dated 9/19/23, indicated physician ordered medications for her. Review of an SBAR- Medication regimen report, dated 9/19/23, indicated Resident 1 received the following medications which were not ordered for her by a physician: Adderall xr, cellcept, escitalopram, Pepcid, Oxybutynin Chloride, Oyster shell Calcium/Vitamin D, presdniSONE Oral tablet, senna, D3. During a telephone interview with LVN A on 11/2/23 at 4:12p.m., LVN A stated she did not follow the 5 rights of medication administration and gave the wrong medications to the Resident 1. During an interview with Director of Nursing (DON) on 11/2/23 at 1:36 p.m., she stated LVN A administered medications to Resident 1 that were not prescribed for her. The DON verified that LVN A should have followed the five rights of medication administration. Review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 1/2023, indicated, Medication are administered . in accordance with professional standards of practice .

Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for two of 24 sampled residents (40 and 94) when: 1. Resident 40 was not properly assessed for Smoking Safety Screen. This failure resulted in Resident 40 sustaining [CONDITION(S)] to face, neck, and chest after smoking unsupervised while on oxygen on 7/31/21; 2. Resident 94 was not provided adequate supervision while smoking as indicated in his smoking care plan. This failure had the potential to result in serious injury to the residents in the facility. Findings: 1. Review of Resident 40's clinical record indicated Resident 40 was admitted on [DATE]. He was on hospice and had diagnoses of [CONDITION(S)] ([CONDITION(S)], a group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure (condition in which not enough oxygen passes from your lungs and into your blood), depressive disorder (mood disorder which interferes with daily life), anxiety disorder (persistent feeling of worry and apprehension), [CONDITION(S)] disorder (a combination of symptoms of [CONDITION(S)] and mood disorder), and tobacco use. Review of Resident 40's Minimum Data Set (MDS, an assessment tool) dated 7/28/21, indicated he had a brief interview of mental status (BIMS, a structured cognitive test) scoring 13 (cognitively intact). Review of Resident 40's Safe Smoking Safety Screen, dated 9/30/20, indicated and emphasized in red letterings 'Residents on Oxygen may not be independent smokers', but the form indicated with a check mark that 'Resident is a safe smoker and may smoke independently.' Resident 40's Smoking Safety Screen was completed and signed by licensed vocational nurse A (LVN A). The interdisciplinary team (IDT, a coordinated group of experts from several different fields who work together toward a common business goal) members who attended the meeting were not listed on the space provided on the form. Review of Resident 40's Physician order, dated 9/28/20, indicated decrease Oxygen to 2 L/M (liters per minute, oxygen flow rate) via NC (nasal cannula, a device used to deliver supplemental oxygen). Keep oxygen saturation (the percentage of oxygen in the blood) between 88/92 %. Review of Resident 40's SBAR (Situation, Background, Assessment, Recommendation) Physical Injury Report of Incident, effective date 7/31/21, indicated pt was smoking with nasal cannula oxygen on, burned himself on up chest. sent pt to valley medical. Review of Resident 40's emergency department provider notes, dated 7/31/21, indicated status post oxygen tank explosion. Reports smoking cigarette while on oxygen. [CONDITION(S)] to face and neck with singed nasal hairs, singed beard hair with soot around mouth, small singe [CONDITION(S)] to tip of tongue, charred spots on tongue, soot across both palms, superficial burn of left forearm. Review of systems could not be obtained due to: Critically ill. States that his [CONDITION(S)] are painful. [MEDICATION(S)] (a pain medication) injection 50 mcg (micrograms) Intravenous given 7/31/21 at 19:11. During an interview and observation with Resident 40 on 3/11/22 at 8:48 a.m., Resident 40 was in his room and on oxygen at four liters per minute via nasal cannula. Resident 40 stated he could not remember the date of the incident, but he can remember that he went out to smoke with oxygen on and burned his face, neck, and chest, During an interview with the director of nursing (DON) on 3/11/22 at 10:50 a.m., the DON stated Resident 40 was an independent smoker and no supervision was needed during the time of incident. During an interview and record review with the DON on 3/14/22 at 12:17 p.m., the DON confirmed Resident 40's Smoking Safety Screen, dated 9/30/2020, indicated and emphasized in red letterings 'Residents on Oxygen may not be independent smokers' but the form indicated with a check mark that 'Resident is a safe smoker and may smoke independently. The DON confirmed Resident 40 was on oxygen at two L/M continuously starting 9/30/20. The DON confirmed Resident 40 should not be independently smoking because Resident 40 was on oxygen. The DON confirmed Resident 40's Smoking Safety Screen, dated 9/30/20, had an incorrect assessment. During an interview and record review with the DON on 3/15/22 at 11:05 a.m., the DON confirmed the IDT members attending in the Resident 40's Smoking Safety Screen, dated 9/30/2020, was blank. The DON confirmed she could not find any supporting documents that IDT members attended. Review of facility's policy, Smoking revised 2/2018, indicated 'for those facilities that allow smoking, it is policy to monitor and evaluate residents for safety related to smoking. The IDT is responsible for evaluating safety risks and providing a safe designated smoking location. PROCEDURE, The IDT evaluates cognitive ability, judgement, mental dexterity and mobility, as well as the need for adaptive or safety equipment upon admission, with a significant change of condition/function, and annually for a resident expressing a desire to smoke. Staff will control the distribution of smoking material (cigarettes, cigars, tobacco, lighters). Resident assessed and deemed independent smokers may be provided a way to secure their own smoking materials in a locked drawer or container. Portable oxygen tanks and/or other O2 delivery systems are NEVER allowed in designated smoking areas, even if oxygen is turned off. 2. A review of Resident 94's clinical record indicated he was admitted to the facility with diagnoses related to [CONDITION(S)] (a mental health condition that affects everything from how you think, feel and behave), unspecified, [CONDITION(S)] disorder (a disorder associated with episodes of mood swings), psychotic disorder with delusions due to known physiological condition (a mental disorder characterized by disconnection from reality), and type 2 diabetes mellitus with diabetic chronic kidney disease (occurs when the body is unable to regulate glucose [sugar] in the blood and with complication to kidneys). A review of Resident 94's Smoking Safety Screen, dated 8/12/2021, indicated interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) review, Resident must be supervised, wear a protective non-flammable cover (smoking apron), and needs physical assistance when smoking. (Physical assistance includes but is not limited to lighting, holding, or extinguishing resident's smoking materials) A review of Resident 94's care plan, titled, High Risk for accidental injury, smoking related diseases and conditions related to: Resident was found smoking in his bed inside his room (8/27/21), date initiated 8/12/2021, indicated as one of the interventions, Supervised smoking only with smoking apron. During an observation on 3/9/2022 at 1:26 p.m., Resident 94 was sitting in his wheelchair smoking on the patio. Resident 94's left hand was observed shaking. Resident 94 was not wearing a smoking apron and there were no staff available for supervision while smoking. During a concurrent interview and record review on 3/10/2022 at 9:09 a.m., social services (SS) reviewed Resident 94's Smoking Safety Screen, dated 8/12/2021. The SS confirmed Resident 94 should be supervised when smoking. The SS further stated an independent resident can supervise Resident 94. During an interview on 3/11/2022 at 9:21 a.m., the DON confirmed Resident 94 was not supervised while smoking because he was deemed safe based on his psychiatric consultation. During a review of the facility's policy and procedure titled, SMOKING POLICY, dated February 2018, indicated, 3. For residents who have been determined unsafe when smoking and need supervised smoking, staff will provide appropriate supervision for: Use of adaptive equipment (smoking aprons, etc.); Disposal of cigarettes in appropriate receptacles; Prohibiting smoking in the presence of oxygen use.

Based on observation, interview, and record review, the facility failed to implement the activities of daily living (ADL's such as bed mobility, toileting, and transferring) self-care deficit care plan for one of eight sampled residents (Resident 104) when the intervention for two persons assist during bed mobility was not provided. This failure resulted in Resident 104 sustaining a fall from bed on 5/3/19, with contusion (any collection of blood outside of a blood vessel) of right upper extremity, contusion of left knee, and avulsion (losing a toenail) of left index toenail. Findings: Review of Resident 104's undated face sheet indicated he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 104's Minimum Data Set (MDS, an assessment tool) dated 2/13/19, indicated he had a brief interview of mental status (BIMS, a structured cognitive test) score of 3 (severe cognitive impairment). Under the ADL's, it indicated that a two persons on physical assist was required assistance for bed mobility, transfer, and toileting. Review of Resident 104's self-care deficit care plan initiated on 10/6/17 and revised 9/5/18, indicated the resident needs assistance with ADL's related to hypertension, impaired cognition, [MEDICAL CONDITION], diabetes, and left hand contracture. The intervention that was started 10/19/17 was two persons on physical assistance was required for bed mobility, transfer, and toileting. Review of Resident 104's fall risk assessment dated [DATE], indicated he had a score of 75 (a score of 45 and higher represented a high risk for fall). Review of Resident 104's Situation, Background, Assessment, Recommendation (SBAR, a technique that can be used to facilitate prompt and appropriate communication) dated 5/3/19, indicated the fall occurred on 5/3/19 at 7:30 p.m., when certified nurse assistant [NAME] (CNA E) provided ADL care to Resident 104, CNA [NAME] turned the resident away from her by herself and that resulted to Resident 104 falling on the floor. Resident 104 complained of pain on the back of his head and both arms. Resident 104 was transferred to acute hospital after the fall. Review of 104's acute hospital after visit summary dated 5/3/19, indicated Resident 104 had a fall, contusion of right upper extremity, contusion of left knee, and avulsion of the left index toenail. During an observation with Resident 104 on 11/18/19 at 9:15 a.m., he was observed lying on his bed, could not move both of his arms and both of his hands. During an interview with licensed vocational nurse F (LVN F) on 11/20/19 at 3:22 p.m., he was the assigned charged nurse for Resident 104 on 5/3/19 when the incident happened. LVN F stated CNA [NAME] was turning Resident 104 on the bed by herself and the resident fell on the floor. LVN F also stated Resident 104 needed two person assist for bed mobility and the fall could have prevented if CNA [NAME] waited for someone to help her. LVN F stated CNA [NAME] was no longer employed in the facility. During an interview and clinical review with the director of nursing (DON) on 11/21/19 at 2:59 p.m., she stated CNA [NAME] was providing ADL care when Resident 104 fell on the floor. The DON stated the self-care deficit care plan on ADL care, which indicated a two persons physical assistance was required on bed mobility was not implemented. The DON also stated Resident 104's fall could have been prevented if two person assist was provided during the ADL care. During an interview and clinical review with the director of staff development (DSD) on 11/22/19 at 8:54 a.m., she stated Resident 104 was a high risk for falls and should have two person assist during ADL care to prevent fall. The DSD also stated CNA [NAME] should have read the Kardex (a medical information system used by nursing staff as a way to communicate important information about their residents) when providing care. The Kardex indicated Resident 104 needed two persons assist during ADL care. Review of the facility's 8/2014 policy, Fall Management, indicated to evaluate the risk factor, and implement interventions to minimize risk, injury and occurrences of fall.

Based on interview and record review, the facility failed to implement the care plan intervention for needs assistance with activities of daily living (ADL) for one of three residents (1) when Resident 1 needed two-person physical assist for bed mobility but only one certified nursing assistant (CNA) turned her in bed. This failure resulted in Resident 1's falling off the bed and sustaining a comminuted fracture (a break of the bone into more than two fragments) of the proximal right humerus (the top of the right arm bone). Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 12/22/18, indicated Resident 1 needed extensive assistance with two-person physical assistance for bed mobility. Review of Resident 1's care plan for Self-Care Deficit as Evidenced by Needs Assistance with ADLs, dated 12/15/18, indicated Resident 1 required two-person physical assistance for bed mobility. Review of Resident 1's MDS Kardex Report (a medical information system used by nursing staff as a way to communicate important information on their patients) started on 12/15/18, indicated Resident 1 needed extensive assistance with two+ persons physical assist for bed mobility. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) Fall Report of Incident, dated 12/26/18, indicated Resident 1 fell off bed while being repositioned to change and was sent to acute care emergency department (ED) on the same day for complaint of shoulder pain. Review of Resident 1's Emergency Department Provider Notes, dated 12/26/18, indicated the emergency medical services (EMS) administered 8 milligrams (mg, a metric unit of mass) of [MEDICATION NAME] (a drug used to treat severe pain) to Resident 1 during the transportation to the ED for complaint of right shoulder pain, and ED X-ray result indicated Resident 1 sustained comminuted [MEDICAL CONDITION] right humerus. During an interview with CNA A on 1/25/19 at 11:30 a.m., she stated that morning, Resident 1 was in bed in her room. CNA A stated she looked at Resident 1's Kardex at the beginning of the shift but she forgot how many assistants Resident 1 needed. CNA A asked Resident 1 how many staff usually helped her. Since Resident 1 stated only one, CNA A changed Resident 1 by herself. CNA A stated she was on the right side of Resident 1 and pulled the sheet under Resident 1 toward herself to turn Resident 1 to the other side of the bed. Resident 1 turned to the other side of the bed. However, Resident 1's right leg was on top of her left leg which made Resident 1 fall off the bed to the floor.

Based on observation, interview and record review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 1) who was unable to carry out activities of daily living (ADL) in regards to foot care. Resident 1 had a problem behavior of refusing care. The licensed nurses and certified nurse assistants (CNAs) did not follow up on Resident 1's refusal of care, specifically removal of her socks. Resident 1 developed macerations (skin condition that occurs when fluid or moisture is in contact with the skin for extended periods of time, particularly when the skin is covered) and fungal infection to her feet. This failure compromised the resident's health and had the potential to cause pain and suffering. Findings: During an observation on 3/20/17 at 9:50 a.m., Resident 1 was seated on her bed and her feet were exposed to air on a mattress. Both of her feet and toes had macerated areas. Review of Resident 1's undated Admission Record form indicated she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].), and chronic pain. Resident 1 was self- responsible for making her own health care decisions. The Minimum Data Set (an assessment tool), dated 7/5/16, indicated Resident 1 did not have problems with daily decision-making skills, was dependent on staff for all ADLs such as eating, had functional limitation in range of motion (movement) to her upper and lower extremities, and was at risk for developing pressure ulcer (wound that occurs as a result of prolonged pressure on a specific area of the body, commonly known as bed sores). During an interview on 3/20/17 at 10:15 a.m., certified nurse assistant (CNA) A stated she had been taking care of Resident 1 the last couple of months and she had been refusing care. The resident wore the same pair of socks for many days, would not let anyone remove her socks or clean her feet and would get mad. During an interview on 3/20/17 at 12 noon, CNA B stated Resident 1 was given a bed bath on 3/1/17 because she refused to be showered. Resident 1 would cry a little, when she refused care, such as having her socks removed. When the resident was bathed she had her socks on and CNA B stated she did not see her feet. Resident 1's refusal of taking off her socks and not cleaning her feet was not reported to the charge nurse. In a follow-up interview on 3/20/17 at 12:10 p.m., CNA A stated she did not remember when she last saw Resident 1's feet and did not report the refusal because everyone knew about Resident 1's refusal for foot care. Review of Resident 1's Skin/Wound Note dated 5/25/16 at 2:10 p.m., indicated a wound specialist physician noted Resident 1's toe nails were long on both feet. The resident refused podiatry (specialized medical care and treatment of [REDACTED]. During an interview on 3/20/17 at 1:45 p.m., with the director of nurses (DON) who reviewed the record, she stated there was no documentation after 5/25/16 indicating Resident 1 was offered further podiatry services. Review of Resident 1's Altered behavior care plan started on 10/21/14 identified problems behaviors such as refusing help from staff but did not specify Resident 1's refusal for removing her socks and receiving foot care. During an interview on 3/20/17 at 2 p.m., with the DON, she stated the refusal of foot care should have been included in the care plan. Review of Resident 1's Nursing Weekly Summary Review (NWSR) form dated 3/1/17, indicated Resident 1 had rashes on her groin, abdominal folds and arms. Under the Body Check/Skin Inspection of the form there was a checkmark indicating Current skin concerns but there was no narration indicating what the concern was. During an interview on 3/20/17 at 3:10 p.m., the licensed vocational nurse (LVN) C who completed the 3/1/17 NWSR stated she did not document the condition of Resident 1's feet because the resident refused to have her socks removed. LVN C stated she should have documented the refusal. During an interview on 3/20/17 at 2 p.m., the DON stated when Resident 1 was transferred to an acute care hospital on [DATE] staff knew about her skin rash over her body but did not know about the condition of her feet. The DON recalled she was contacted by hospital case manager around 3/9/17 and was informed about the feet maceration. Review of the acute care hospital PODIATRY CONSULT NOTE, dated 3/7/17 at 8:44 p.m., indicated Resident 1 had Severely unmanaged feet bilateral (both). Multiple grossly elongated (unusually long) and thickened nails bilateral. Left hallux (great toe) partially avulsed (injury in which a body structure is forcibly detached from its normal point of insertion) with minimal proximal medial (situated nearer to the point of attachment) border attached which was removed. No purulence (pus) underneath. There are maceration and thick amounts of fungal (yeast) debris throughout her interspaces as well as peeling [MEDICATION NAME] tissue (sheet of cells that covers a body surface or lines a body cavity) throughout. There is more raw [MEDICATION NAME] layer overlaying the dorsal (back) left foot. Review of Resident 1's Skin Inspection Assessment (SIA) form under the Body Check/Skin Inspection section provided guidance to document the type, length, width, depth and stage of the skin. The SIA form dated 3/11/17, after Resident 1 was readmitted to the facility indicated she had scattered redness to both her feet and legs, scaly/dry skin to both legs, and scattered scabs to her left arm. There was no notation about the toe nails and no further description of the feet such as indicating location and size of maceration. During an interview on 3/20/17 at 3:10 p.m., registered nurse (RN) D who reviewed his 3/11/17 SIA note stated Resident 1's feet were red and dry and he did not remember how the toes looked. RN D stated his documentation of the resident's wounds to her feet should have been specific. Review of Resident 1's NWSR form dated 3/13/17, under the Body Check/Skin Inspection. During an interview on 3/20/17 at 3:20 p.m., RN E, who reviewed his NWSR note dated 3/13/17 described Resident 1's usual behavior of not letting staff touch her feet, taking off her pink socks and screaming at staff when she refused care. RN E acknowledged the 3/13/17 documentation lacked a description of Resident 1's skin condition. The Skin Integrity policy, dated December 2016, indicated all new admissions were to have a skin risk assessment and an initial head to toe skin assessment by a Licensed Nurse. Weekly head to toe assessment was to be completed for all residents by a licensed nurse. The JOB DESCRIPTION / PERFORMANCE EVALUATION of CNAs included a task to notify the charge nurse/supervisor of concerns promptly including safety concerns and resident health/status change. During an interview on 3/20/17 at 2 p.m., the DON stated when she found out about Resident 1's foot, she interviewed CNAs from the weekend of March 18th and 19th and learned about the resident's refusal of removing her socks and the CNAs not reporting to licensed nurses. The DON further stated when residents refused care, staff were supposed to continue to offer services, work with residents and document. They did not do this for Resident 1.

Based on interview, observation, record, and document review, the facility failed to ensure an environment that was free of accident hazards for one sampled resident (Resident 1), when a heating pad was placed on Resident 1 on 11/29/12, resulting in a 2nd degree burn of the left upper back, pain, and complex wound treatments. Findings: Resident 1 was admitted on [DATE] and readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. Resident 1's Brief Interview for Mental Status (BIMS) from the same MDS in item C0500, indicated a Summary Score of 15, meaning that Resident 1 was cognitively intact. Resident 1's Functional Status from the same MDS in item G0110, Activities of Daily Living Assistance, was indicated as extensive assistance for bed mobility in self-performance/support; total dependence/extensive assistance for transfers in self-performance/support; and extensive assistance/limited assistance for dressing in self performance/support. During an interview with Resident 1 in her room on 12/13/12 at 12:34 pm, she stated that she had used a heating pad for several years and that the facility staff knew she was using it. Resident 1 reported that she normally placed it on the front surface of her upper body and was not clear how the injury happened to the left side of her back, as she was unable to place the heating pad at that location. Resident 1 stated that while in bed during the night of 11/29/12, she had been repositioned by staff and fell asleep after being repositioned. She stated that the heating pad was kept in a pillowcase and had been relocated under her body. The Resident complained of pain at the site of injury. The Resident stated that CNA 1 noticed a, "skin discoloration" on her left back while providing morning care on 11/29/12 and CNA 1 reported to licensed nursing staff. During an observation on 12/13/12 at 12:34 pm, TN (Treatment Nurse) 1 changed Resident 1's left back dressing, medicated the wounds, and provided pain medication for the Resident. Along with TN 1, the surveyor observed multiple areas on Resident 1's left back that were irregularly shaped, reddish, and several with yellowish slough (dead tissue) near the center of each area. TN 1 and the surveyor also observed other areas of skin on the left side of the resident's back that were reddish colored. During an interview at 4:05 pm on 12/13/12, the Administrator acknowledged that facility staff knew the heating pad was used by Resident 1. The Administrator also acknowledged that Resident 1's skin was assessed as a "rash" instead of a 2nd degree burn by the licensed nursing staff. The Administrator reported that the heating pad did not have an auto shut-off feature, had been discarded after being removed from Resident 1's room, and acknowledged that there was no MD order for the use of a heating pad. Review of Resident 1's Physicians Orders for November 2012 reflected that there was no physician order for [REDACTED]. During an observation on 12/14/12 at 4 pm, the surveyor observed multiple areas on Resident 1's left back that were irregularly shaped, reddish, and several with yellowish slough (dead tissue) near the center of each area and also observed other areas of skin on the left side of the resident's back that were reddish colored. During this observation, TN 2 measured Resident 1's left back area of injury and reported a length of 24 centimeters (cm is abbreviation for centimeters, 24 cm equals 9.45 inches) and a width of 13.5 cm (5.31 inches). There was no depth measured, but TN 2 estimated the depth at approximately 0.2 cm (0.08 inches). TN 2 stated the entire area of 24 cm by 13.5 cm was red before treatments began and that wound measurements had been taken of the entire reddened area, not of the several, separated reddened areas with yellowish slough at the time of the 12/14/12 observation. During an interview with Resident 1 on 12/14/12 at 4 pm, she stated that her use of the heating pad began in 2005. The Resident reported that a second heating pad had been mailed to her by her daughter "about 3-4 weeks ago" when the first one stopped working. Review of four separate facility Interview/Investigative Records, all dated 12/03/12 and untimed, reflected the following: 1. "CNA (CNA 1) discover (sic) the rash and reported to the Charge Nurse.... She never request (sic) to be assisted with the heating pad been connected (sic). CNA usually place (sic) it on the side of the bed. always has (sic) been cover (sic) with a pillow case. Last time he saw her using it was 3 months." 2. "CNA (CNA 2) worked on the 26th, 28th, 29th. has (sic) been working with her for 3 months... He used to see the heating pad on the left side of her bed... on occasion saw resident using it on her left shoulder. she does not ask x (for) assistance. He changed resident 2 x (times a) night on those days (sic) he did not see the heating pad on her back." 3. CNA 3, "Worked with resident on the 29th... of November... at PM shift. Has been working with resident for 3 to 4 years (sic) Has the heating pad x (for) one year always keeps it under the pillow. Resident does not ask for assistance with it. Saw her using at times on left shoulder always in cover with a pillow case. Saw the rash on the 29th but it was reported by the CNA who works in the morning." 4. CNA 5, "Has worked with the resident for 3 1/2 months. He saw the heating pad the (unintelligible word) time he worked with her. He never put it on her but has given her the 'switch'. He is not sure how long the resident wears it but she puts it on when she goes to bed." Review of "Heating Devices: How to Avoid Burns" by Joan Ferlo Todd RN, BSN Nurse-Consultant, Food and Drug Administration, was found online at http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm 6.htm on 03/20/13, and noted, "Therapeutic heating devices, such as heating pads... DON'T (sic) use the device on someone who's sleeping... ".