Every finding on record at Maywood Acres Healthcare

Based on observation, interview and record review, the facility failed to implement their policy and procedure related to grievance and complaints for one of two sampled residents (Resident 1) when there was no documentation of Resident 1's concerns and the action/resolution taken by the facility.This failure had the potential to overlook Resident 1's concerns that could result in the violation of resident rights. During a record review of Resident 1's clinical records, the admission record indicated Resident 1 was admitted on [DATE] with diagnoses that included weakness and vascular dementia (reduced blood flow to the brain and often affects person's ability to plan, organize or make decisions). Cognitive assessment indicated intact cognition, however, there are behavioral symptoms manifested by verbal aggression directed at others, refusing care that occur one to three days. Functional ability assessment indicated Resident 1 needs maximal assistance on toileting and dependent on showering. During a concurrent observation and interview on 4/13/26 at 1:30 p.m. with Resident 1, Resident 1 was seen lying in bed on her left side, alert and oriented, calm and cooperative; and stated she requested the supervisor of the facility not to assign her certified nurse assistants (CNA2 and CNA3) because they do not know their jobs and also mentioning her concerns with CNA1. During the interview on 4/13/26 at 1:45 p.m., certified nurse assistant (CNA) 1 stated that Resident 1 dislikes a particular staff member and that she verbally notified the charge nurse and the Director of Staff Development (DSD) about the concern.During the interview on 4/13/26 at 2:15 p.m., the Director of Staff Development (DSD) stated that the DSD office received and tried to resolve Resident 1's staffing concerns but did not initiate any written grievance form.During the interview on 4/13/26 at 2:30 p.m., the Social Services Director (SSD) stated their office keeps track of the facility's grievances, however, SSD confirmed not receiving any complaints from Resident 1 or from any staff member.During the interview on 4/13/26 at 2:45 p.m., the Director of Nursing (DON) stated Resident 1's concerns were in their QAPI (quality assurance) discussions but there was no grievance form in writing initiated for her complaints.During the interview on 4/13/26 at 3:00 p.m. with the administrator (ADM), ADM stated being aware of Resident 1's issues and acknowledged the grievance process was important to document concerns being mitigated by the facility.During a review of facility's policy and procedure (P&P), titled Grievance and Complaints, dated 5/20/2025, the P&P indicated, A team member will initiate and complete grievance form.plan of resolution will be made by the appropriate department.and Social Service department keeps track and trend of grievances.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care-screening tool) accurately reflected the dialysis (medical procedure where the blood is circulated directly through a dialysis machine that uses special filters to remove waste products and excess fluid from the blood) status of one of 24 sampled residents (Resident 1). This failure had the potential for Resident 1 to not received needed services. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included, end stage renal disease (a condition where the kidneys have permanently lost most of their function and can no longer adequately filter waste products and excess fluid from the blood) and dependence on renal dialysis. During a review of Resident 1's Order Summary Report (OSR), dated 8/28/25, the OSR indicated, Hemodialysis every Monday, Wednesday, and Friday with an order date of 6/27/25. During a concurrent interview and record review on 8/28/25 at 9:40 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS dated [DATE] was reviewed. Section O indicated the box under dialysis and hemodialysis was blank, indicating Resident 1 was not receiving dialysis. MDSC acknowledged Resident 1's MDS Assessments was not accurate, and the treatment of dialysis should have been marked. MDSC stated, It was overlooked . During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Accuracy, dated 5/2016, the P&P indicated, The facility conducts a comprehensive assessment to identify patient's needs per the guidelines set by RAI(Resident Assessment Instrument) Manual. the Resident Assessment Coordinator and MDS nurse completes a validation check for information entered in the RAI for each patient. During a review of CMS's RAI (Resident Assessment Instrument) Manual, Version 3.0, dated October 2024, section O (Special Treatments, Procedures, and Programs). The MDS Section O0110J1 for dialysis indicated, Code. renal dialysis which occurs at the nursing home or at another facility and Section O0110J2 for hemodialysis indicated, Check when the dialysis was hemodialysis.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure when a care plan was not created for 1 of 24 sampled residents (Resident 61) with Dementia (a general term describing a group of conditions that cause a progressive decline in cognitive abilities).This failure had the potential for resident to not receive appropriate care and treatment to attain highest practicable psychosocial well-being. During a concurrent observation and interview on 8/26/25 at 2:45 p.m. with Resident 61, Resident 61 was unable to state the current year, month, or date. Resident 61 was observed in bed and stated he was waiting for a certified nursing assistant (CNA) to shave him, pointing to his face and chin. During a review of Resident 61's admission Record (AR), the AR indicated, Resident 61 was admitted to the facility on [DATE] with diagnoses including, Alzheimer's disease (a type of dementia, a condition that causes a progressive decline in cognitive abilities, such as memory, thinking, and reasoning). During a review of Resident 61's History and Physical (H&P), dated 7/10/25, the H&P indicated, Resident 61 does not have the capacity to understand and make decisions and to monitor for behavior. During a concurrent interview and record review on on 8/27/25 at 10:45 a.m. with Director of Nursing (DON), the DON was unable to find a diagnosis-specific care plan for Dementia in either the hard copy of Resident 61's chart or the electronic health records. DON stated, We don't have a care plan for that. During a review of facility's policy and procedure (P&P) titled, Care Plans, undated, the P&P indicated 1) Assess the resident upon admission and initiate a plan of care for key problems or possible problems identified. The care plan will be completed within seven days. 6) After the resident Assessment Protocol is completed, the care plan will be updated to include any additional information gained within seven days of completion. 7) Any changes in resident's status will be put on the care plan as they occur.

Based on observation and interview, the facility failed to write the open date on the pharmacy sticker for Resident 61's respiratory solution vials located in Medication Cart #3.This failure resulted in the potential for Resident 61 to receive a medication that had been expired or no longer effective, placing Resident 61 at risk for decreased therapeutic benefit and potential adverse health outcome. Findings: During an observation on [DATE] at 12:07 p.m. of Medication Cart #3, an open medication box labeled 'Ipratropium Bromide 0.5 milligrams (mg)/Albuterol Sulfate 3mg' (an inhaled combination medication that contains two different bronchodilators to open the airways and make breathing easier) was noted in the bottom right-hand drawer of Medication Cart #3. Inside the box was an open foil package containing three (3) respiratory solution vials. Neither the foil package nor the box displayed a documented date of opening. During a record review of the pharmacy's expiration instructions located on the medication box indicated, Expires: 7 days if open. Additional review of the manufacture's open foil pouch located inside the medication box, instructions indicated, Once removed from foil pouch, the individual vials should be used within one week. During an interview on [DATE] at 12:11 p.m. with the Infectious Disease Nurse (IDN) stated, Staff who opened this medication did not document the date of opening and should have. During a review of the facility's policy and procedure (P&P) titled, Storage of Medication, dated 2019, the P&P indicated, Medications and biologicals are stored properly, following manufacture's recommendations or those of the supplier to maintain their integrity and to support safe administration

Based on observation, interview and record review, the facility failed to implement infection prevention and control practices when: 1. A nasal canula (NC) was found on the floor for one of nine residents (Resident 38). This failure had the potential for Resident 38 to acquire an infection from an unclean NC.2. Staff did not perform appropriate hand hygiene practices in the dining room during meal tray service. This failure had the potential to expose residents to cross infection contaminations.Findings: 1.During an observation on 8/27/25 at 2:39 p.m. inside Resident 38's room, a nasal canula (NC) was noted draped over the bed rail and touching the floor. The tubing was dated 8/24/25. During a concurrent observation and interview on 8/28/25 at 8:23 a.m. with Licensed Nurse (LN 5) in Resident 38's room, Resident 38 was observed with ongoing oxygen via nasal cannula. The nasal cannula tubing was dated 8/24/25. The nasal cannula was the same as noted on the floor on 8/27/25. LN 5 confirmed the oxygen tubing Resident 38 was using was the same NC observed on 8/27/25 touching the floor. During a review of the facility's policy and procedures (P&P) titled, Infection Control, dated 8/13/20, the P&P indicated, the facility must Maintain a safe, sanitary and comfortable environment . staff must be trained on infection control policies and procedures . the administrator adopts policies and procedures . for preventing transmission of infections. During an interview on 8/28/25 at 9:36 a.m. with Certified Nursing Assistant (CNA 6) regarding infection control policies on proper storage of a nasal cannula after use. CNA 6 stated a NC when removed is placed in the bag attached to concentrator. During an interview on 08/28/2025 at 10:17 a.m. with Director of Staff Development, (DSD). DSD stated, Training for the care of nasal cannulas or oxygen is on an as needed schedule and annually. DSD was unable to produce the last education for storage of a nasal cannula after use. During an interview on 08/28/2025 at 10:26 a.m. with the Director of Nursing (DON), DON stated a NC should not be on the floor. It should be in the bag on the concentrator when not in use. 2. During an observation on 8/26/25 at 11:17 a.m. in the large dining room, CNAs 3 and 4 were observed not performing hand hygiene between the following activities that included adjusting a resident's wheelchair at the table, touching the residents table, removing plastic wraps and lids off of residents' meal trays and throwing the discarded items into trash and proceeding to retrieve a clean meal tray for another residents. During a review of facility's policy and procedure (P&P) titled, Policy and Procedure Handwashing, the P&P stated, All staff members will wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of nosocomial infections. During an interview on 8/26/25 at 11:25 a.m. with CNAs 3 and 4 in the large dining room, CNAs 3 and 4 both acknowledged they did not perform hand hygiene after touching potentially contaminated surfaces and before serving a new meal tray to another resident. During a concurrent interview and facility practice review on 8/29/25 at 10:02 a.m. with the Infection Preventionist (IPN) and the Director of Staff Development (DSD), the IPN and DSD stated the facility's hand hygiene process for meal tray service includes: staff must wash hands prior to receiving the meal trays from the kitchen and before passing them in the dining room. Staff must perform hand hygiene after touching dirty surfaces such as wheelchairs, trash cans, tables, residents and any sources that are considered dirty before setting up a meal for another resident. The IPN and DSD acknowledged CNAs 3 and 4 should have performed hand hygiene after coming in contact with dirty sources such as adjusting the resident's wheelchair, touching the table, throwing discards into trash before getting a new meal tray and serving it to another resident.

Based on observation, interview, and record review, the facility failed to implement their policy and procedure on smoking.This failure had the potential to result in serious risk of fires and injuries for vulnerable residents with cognitive and physical impairments.Findings:During a concurrent observation and interview on 8/27/25 at 9:30 a.m. with the IPN, a resident on a wheelchair self-propelled towards the nursing station and left a cigarette lighter on the nursing station counter for approximately three minutes without any staff noticing the cigarette lighter. The IPN took the cigarette lighter and stated was going to keep it for safe keeping. IPN also stated only alert residents are allowed to to keep smoking materials.During a review of the facility's policy and procedure (P&P) titled, Smoking Policy and Procedure, [undated], the P&P indicated, 2. Smoking materials/paraphernalia such as cigarettes, cigars, lighters, etc. shall be kept in a locked container for safe keeping. No resident shall be allowed to keep their own smoking materials/paraphernalia for safety purposes.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the door for one of one walk-in refrigerators in the kitchen was maintained in safe, operating condition when the door would not remain closed after being pushed shut. As a result, temperature abuse (lack of adherence to strict temperature control) could occur which could lead to food spoilage and/or growth of pathogens that placed the residents at an increased risk for foodborne illness. 2. Ensure there was an appropriate air gap between the dish machine drain and the floor sink drain to prevent contaminated water from backing up into the dish machine should a problem arise with the floor drain. Findings: 1. During a concurrent observation and interview on 08/19/24 at 8:59 a.m. with Registered Dietitian (RD) in the kitchen, inside a walk-in refrigerator was a large wall thermometer, and RD stated, it read 50 degrees F (Fahrenheit). During a concurrent observation and interview on 8/19/24 at 8:41 a.m. with RD and dietary aide (DA) 1, the RD obtained an individual sized milk carton from the walk-in refrigerator and took the internal temperature using the facility's digital thermometer, and RD stated, It's 53 degrees F. DA 1 stated the facility had not had a food delivery that morning. DA 1 showed the refrigerator temperature monitoring log that showed the refrigerator was at 41 degrees F or less, with not out of compliance days per the August 2024 log. DA 1 stated the dietary staff utilized the external thermometer that was affixed to the walk-in refrigerator to record the temperatures on the log. During a concurrent observation and interview on 8/19/24 at 09:16 a.m. with RD and DA 1, DA 1 stated the external thermometer to the walk-in refrigerator indicated 53 degrees F. RD and DA 1 observed the door not completely shut at that time, as the door was on the outside of the latch/hinge although dietary staff were observed shutting the refrigerator door completely when exiting the refrigerator earlier. DA 1 pointed to a sign on the wall next to the walk-in refrigerator that reminded staff to shut the door to the refrigerator. RD acknowledged there was a problem with the door that prompted dietary staff to put up a sign for dietary staff to always check to make sure the door was shut. During an interview on 08/19/24 at 9:15 a.m. with the Dietary Manager (DM), DM stated she put the sign up for staff reminding them to shut the door to the walk-in refrigerator because it tended to not shut easily. DM stated if the door could remain closed the refrigeration unit was able to maintain appropriate temperature for food safety. During a concurrent observation and interview on 08/19/24 at 9:40 a.m. with maintenance supervisor (MS) in the kitchen, MS observed the door to the walk-in refrigerator. MS stated about two months ago he put a strip at the bottom of the door hoping that would get the door to have a tighter seal and stay shut. MS stated he had not been back to follow up to ensure the strip fixed the problem. MS was asked if he thinks there was anything that could be done for the door to get it to function properly. MS stated he might be able to work on the door hinges to help or he might need to call a refrigeration company. During an observation on 08/19/24 at 11:12 a.m. in the kitchen, all dietary staff were observed working at trayline (assembly of resident lunch meal trays). During a concurrent observation and interview on 08/19/24 at 12:10 p.m. with DA 1 in the kitchen, while the dietary staff continued to work on trayline, DA 1 was available to go observe the refrigerator to see who the manufacturer was. Concurrently, the refrigerator door was observed not shut all the way, as the door was observed outside of the latch, and there was a visible gap in which you could see inside the walk-in refrigerator. DA 1 stated dietary staff would shut the door and upon return the door could be found not completely shut, again. In addition, from a distance, such as from trayline, the door appeared to be shut because it was a dark brown/blackish colored door and was not visible from a short distance that the door was not closed. During a concurrent interview and record review on 8/19/24 at 3:45 p.m. with MS, invoices (Inv) from an outside service for refrigeration, air conditioning and heating were reviewed. An Inv, dated 4/15/24 indicated, Other-Labor/Service PM [preventative maintenance] service on refrigeration and ice machine equipment.clean out condenser coils, check door gaskets. An Inv, dated 8/7/24, indicated, Other-Labor/Service PM service on refrigeration., clean out condenser coils, check door gaskets. MS was asked what check door gaskets written on the invoice meant. MS stated that the outside vendor had not left recommendations related to the door of the walk-in refrigerator. MS 1 stated there were no manufacturer labels on the refrigerator, and he did not know who the manufacturer was, as it was a very old refrigerator. The refrigerator's manufacturer's guidelines were unable to be obtained for review. During an interview on 08/19/24 at 04:07 p.m. with Administrator (Admin), Admin was informed of the observations above starting with the internal thermometer indicated 50 degrees F and the refrigerator door observed to be outside of the latch after observing dietary staff shutting the door, as if the door gradually opens on its own. Admin was informed due to the door not functioning properly the concern was temperature abuse occurring throughout the day, had the potential to accumulate to four hours in the danger zone which could place the residents at risk for foodborne illness. The Admin stated he understood and did not have any questions. During a review of the facility's policy and procedure (P&P) titled, Interior Maintenance, undated, the P&P indicated, Dietary Inspection Procedures:.a) Vacuum (or blow out) coils on large refrigerators quarterly to prevent dangerous collection of dirt and dust, b) Clean condenser and lubricate motors as designated in manufacturer's instructions, c) Check door gaskets, d) Refrigerator temperature should be 36 degrees F - 40 degrees F. During a review of the Food and Drug Administration Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. (4-501.11 Good Repair and Proper Adjustment) 2. During an observation on 8/19/24 at 8:39 a.m. in the kitchen, observed dietary aide (DA) 2 operating the low temperature (temp) dishmachine. A black plastic pipe was observed draining wastewater from the low temp dishmachine. The outlet end of the black plastic pipe was near the floor of the floor sink drain. There was not an appropriate air gap observed between the outlet end of the waste pipe and the flood-level rim of the floor sink drain. During a concurrent observation and interview on 08/19/24 at 09:29 a.m. with maintenance supervisor (MS), MS observed the low temp dishmachine in use. MS stated the copper pipe, and the black plastic pipe was connected to the dish machine. MS stated the black pipe was primarily used to drain water from the dish machine. MS was asked if the drainpipes had an appropriate air gap. MS stated he did not know what an appropriate air gap should be per a plumbing code nor the FDA food code. During a concurrent observation and interview on 8/19/24 at 9:31 a.m., with Registered Dietitian (RD), RD observed the black pipe connected to the dishmachine and RD stated, there was not an appropriate air gap in accordance with the FDA food code and there was potential for backflow of contaminated water to go back up through the pipe and contaminate dishes. During a review of the facility's policy and procedure (P&P) titled, Interior Maintenance, undated, the P&P indicated, Dietary Inspection Procedures: .Check major kitchen equipment, and plumbing connections and drains. Service per manufacturer's recommendations. During a review of the Food and Drug Administration (FDA) Food Code (FDAFC), dated 2022, the FDAFC indicated, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). (FDA Food Code 5-202.13 Backflow Prevention, Air Gap.) During a review of the FDA Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. (FDA Food Code Annex 5-202.13)

Based on observation, interview, and record review, the facility failed to ensure the policy on checking resident room temperatures was implemented for three of nine sampled residents (Resident 45, 50 and 78). This failure placed residents at risk to have an environment were the room temperatures were not regulatred and folloiwed for a comfortable daily living . Findings: During a concurrent observation and interview on 8/19/24, at 10:28 a.m., in room [ROOM NUMBER], Resident 50 was observed lying in bed with no clothes on and a bed sheet that covered the legs. Resident 50 stated, It's too hot in here. I don't want to wear any clothes. During a concurrent observation and interview on 8/19/24, at 03:37 p.m., in room [ROOM NUMBER], Resident 78 had two small fans blowing towards her. Resident 78 stated, It gets hot in here, so I have two fans to blow air on me and I still get hot because it's just hot air blowing on me. During a concurrent observation and interview on 8/20/24, at 09:55 a.m., in room [ROOM NUMBER], Resident 45 was observed using a fan that was attached to the siderail of the bed. Resident 45 stated, The room is too hot. During a concurrent interview and record review on 08/21/24, at 10:10 a.m., with the Maintenance Supervisor (MS), MS stated the room temperatures are checked and recorded daily at 10:00 a.m. A review of the Resident Room Daily Temperature Monitoring Log (RRDTML), dated August 2024, was conducted. The RRDTML did not have a time indication of when the temperature was taken. MS stated that there would be no way to know what time the temperature checks were done because there is no time written on the log. MS further stated that he was not aware if the policy had a specific time to check the temperature of the rooms. During a concurrent interview and record review on 08/21/24 at 02:03 p.m. with MS, the facility's policy and procedure (P&P) titled, Heating, Ventilation and Room Temperatures, dated 10/3/2016 was reviewed. The P&P indicated, Maintenance Supervisor to check and record room temperatures between 12 noon and 4pm daily where temperature normally peaks. MS stated, Oh I didn't know, he has been using the same form that was given to him when he started working as an MS in January 2023. MS further stated he will start taking room temperatures at the time indicated per policy and develop a log with a place to record the time.

Based on record review and interview, the facility failed to complete a CMS (Centers for Medicare & Medicaid Services) required discharged Minimum Data Set (MDS - an assessment tool and plan of care for residents in a nursing facility) assessment for one discharged resident (Resident 74). This failure resulted in an MDS discharge assessment not completed timely. Findings: During a review of the facility's policy and procedure (P&P) titled, Minimum Data Set (MDS) Assessment Schedule, dated May 2016, the P&P indicated in part, The facility shall adhere to Resident Assessment Instrument (RAI) Manual Assessment schedules as required by federal and state agencies .Resident Assessment Coordinator (RAC) is an RN (Registered Nurse) who is responsible for the effective and efficient interdisciplinary care coordination .and completion of a comprehensive plan of care from admission to discharge . During a review of Resident 74's Admission Record (AR), dated 8/21/24, the AR indicated, Resident 74 was admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare of surgical amputation (surgical removal of a body part). During a review of Order Summary Report (OSR), dated 3/21/24, the OSR indicated, Resident 74 is to be discharged home on 3/23/23. During a review of the Nursing Progress Notes (NPN), dated 3/23/24, the NPN indicated, that Resident 74 was discharged home, and left the facility in a private car. During a concurrent record review and interview with the RAC/MDS Coordinator (MDSC), dated 8/21/24, at 9:50 a.m. Resident 74's MDS electronic record was reviewed. The MDS record indicated, an entry tracking, and Admission was completed and accepted by CMS, and a Discharge Assessment was 137 days overdue. The MDSC acknowledged being responsible for completion of the Resident 74's missed discharged assessment. MDSC further acknowledged, that she could have opened the assessment prior to resident's discharge and completed the assessment on time.

Based on observation, interview, and record review, the facility failed to ensure an accurate assessment, reflective of the resident's status at the time of the assessment, was done for one of five (Resident 86) sampled residents. This failure resulted in an inaccurate assessment and had the potential to result in life threatening consequences for Resident 86. Findings: During an observation on 8/19/24, at 9:12 a.m., in room [ROOM NUMBER], Resident 86 was observed in bed, watching TV. Resident 86's left upper arm had an AV shunt (Arteriovenous [AV] shunt or fistula is a surgically created connection between an artery and a vein for dialysis [a medical procedure that removes waste and excess fluid from the blood when the kidneys are unable to do so] access/use). The left upper arm AV shunt/fistula was clean, had thrill (vibration/pulse caused by blood flowing through the shunt/fistula), skin over the AV shunt/fistula was clean and well moisturized. Resident 86 stated, I go for dialysis every Monday, Wednesday, and Friday at 12 noon. During a concurrent record review and interview with a registered nurse (RN1), on 8/20/24, at 9:18 a.m., in the nursing station, Resident 86's scheduled dialysis was Monday, Wednesday, and Friday at 12:40 p.m. The Dialysis Communication Record (record of pre, post dialysis [in dialysis clinic], and post dialysis [in facility upon arrival vital signs] dated 8/2/24, was missing Facility Pre and Post Dialysis Assessment vital signs. The Dialysis Communication Record dated 8/7/24, was missing Facility Pre-Dialysis Assessment vital signs. The Dialysis Communication Record dated 8/14/24, was missing Facility Post Dialysis Assessment vital signs. RN1 reviewed the records and confirmed that the vital signs were missing on the following dates and stated, It wasn't done. The MRD (Medical Records Director) reviewed the records and confirmed the vital signs were missing on the following dates. The MRD stated, It was missed. Record review of the facility Policy and Procedure (P&P), titled Hemodialysis Care, dated 5/22/13, indicated in part, While at the skilled facility: This facility has direct responsibility for the care of the resident, including the customary standard of care provided by the facility and the following resident assessment and dialysis management process, including: a. Conducting pre and post-dialysis assessment per facility protocol.

Based on observation, interview and record review, the facility failed to develop a care plan for three of three residents (Resident 49, 86 and 54) related to: 1. A pad alarm that was considered as a restraint for Residents 49 and 86 2. A diagnosis of Hepatitis C (a liver disease caused by the hepatitis C virus, which is primarily transmitted through exposure to infectious blood or body fluids that contain blood) for Resident 54. These failures had the potential for Resident 49, 86 and 54 not to receive the appropriate care and services, based on problem areas identified. Findings: 1. During an observation on 8/19/24 at 9:18 a.m. and at 9:28 a.m., in Resident 86 and Resident 49 rooms respectively (room [ROOM NUMBER] B and room [ROOM NUMBER] A). Resident 86 was observed in bed, watching TV with a pad alarm (a pressure sensitive pad positioned beneath resident attached to a control unit that emits a loud alarm) attached to a control unit on the bed. Resident 49 was observed seated on a wheelchair, with a pad alarm attached to a control unit on her wheelchair. During a concurrent record review and interview with RN1 (Registered Nurse), on 8/20/24, at 9:18 a.m., in the nursing station, Residents 86 and 49 were missing care plans for their pad alarm restraints. Both RN1 and MRD (Medical records Director) reviewed Resident 86 and 49's medical records and concurred with the finding. RN1 stated, It was missed, while MRD stated, It was an oversight. 43019 2. During a review of the Admission Record (AR) of Resident 54, the AR indicated in part a diagnosis of Hepatitis C (a viral infection that causes liver swelling, called inflammation). During a review of clinical record of Resident 54, there was no documented evidence of a care plan regarding Hepatitis C. During an interview with Licensed Vocational Nurse (LVN) 3 on 8/20/24 at 12:30 p.m., LVN 3 validates that there is no care plan for Hepatitis C. During a review of the Policy and Procedure (P&P) titled, Care Plans, undated, the Care Plans indicated in part, 1. Assess the resident upon admission and initiate a care plan for the key problems or possible problems identifies. The care plan will be completed within seven days. Review of the facility Policy and Procedure (P&P) titled, Care Plans, undated, indicated in part, It is the policy of this facility to assure that all disciplines coordinate the care of each resident .6. After the Resident Assessment Protocol is completed, the care plan will be updated to include any additional information gained within seven days of completion . 7. Any changes in the resident's status will be put on the care plan as they occur.

Based on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated competency in medication administration when: 1. A licensed vocational nurse (LVN) 1 administered the wrong laxative (medication that treats constipation) to one unsampled resident (Resident 53). 2. Blood pressure and heart rate readings were not accurately documented for one of five sampled residents (Resident 68) prior to receiving the medication Carvedilol (medication to treat heart failure and high blood pressure after a heart attack). 3. Monitoring for medication side effects and bleeding complications was not implemented for one of five sampled residents (Resident 344) receiving the medication Apixaban (medication that prevents blood clots). These failures had the potential to harm these residents as a result of unsafe medication administration. Findings: 1. During a review of Resident 53's Admission Record (AR), dated 8/21/24, the AR indicated in part, Resident 53 was an [AGE] year-old male, who was admitted to the facility on [DATE], with admission diagnoses including history of seizures (a sudden, uncontrolled burst of electrical activity in the brain), and age-related physical debility. On 08/20/24 at 09:10 AM, an observation of the Medical Administration Task, with LVN1 was performed. LVN1 was observed to give Resident 53 a medication called Senna Plus (A medication used to treat constipation). Upon inspection of the bottle, the ingredients indicated Senna Plus contains Senna (a laxative) 8.6 mg (miligram) plus Docusate sodium (a stool softener) 50 mg. On 8/20/24 at 3:00 PM, a record review was performed for Resident 53 in the Electronic Medical Record (EMR), for the Order Summary Report (OSR), dated 8/20/24. The OSR indicated a medication order for Senna Oral Tablet 8.6 mg (Sennosides [also known as Senna]). On 8/20/24 at 3:30 PM, an interview and record review was conducted with LVN1. LVN1 logged into the EMR and pulled up the medication orders for Resident 53. LVN1 verified that the order was for Senna 8.6 mg PO (by mouth) QD (every day). LVN1 acknowledged that he gave the resident Senna plus. LVN1 stated that it was the correct medication. LVN1 was made aware that it is not the same medication because Senna plus also has docusate sodium 50 mg. LVN1 stated he believes this was the correct medication to give the resident. On 08/20/24 at 3:45 PM, an interview and observation was conducted with LVN1. LVN1 brought a bottle of Senna plus. LVN1 stated he went to his cart and verified that it was Senna plus that he gave Resident 53. LVN1 stated that Senna plus was the medication he gave Resident 53. On 08/20/24 at 04:25 PM an interview was conducted with the DON (Director of Nursing). The DON was made aware of the medication administration error of Senna Plus given to Resident 53 by LVN1. The DON acknowledged the medication administration error by LVN1. On 08/21/24 at 2:00 PM, an interview was conducted with LVN1. LVN1 stated he is aware he made a medication administration error. LVN1 stated, he should have taken his time and asked for clarification of the order and brought it to the attention of his DON for assistance. 43745 2. During a review of Resident 68's, AR, dated 8/22/24, the AR indicated in part, Resident 68 was a [AGE] year-old, male who was initially admitted to the facility on [DATE] with admission diagnoses including chronic kidney disease, chronic atrial fibrillation (irregular heart rhythm) and presence of a pacemaker (a small, battery-powered device that prevents the heart from beating slowly). During a review of Resident 68's, OSR, dated 8/22/24, the OSR indicated the medication order, Carvedilol oral tablet 6.25 milligrams (mg), Give one (1) tablet by mouth two times a day for HTN (hypertension - high blood pressure). Hold if SPB (systolic blood pressure - the top number in a blood pressure reading that measures the pressures in the arteries when the heart beats) is below 108 mmHg (millimeters of mercury - unit of measure for blood pressure) or HR (heart rate) below 55 bpm (number of beats per minute) with a start date of 7/27/24. During a concurrent interview and record review, on 8/21/24 at 2:20 p.m., with LVN1, Resident 68's, Medication Administration Record (MAR), for the month of 8/2024, was reviewed. When reviewing the administration record for Resident 68's Carvedilol, only four (4) blood pressure readings and no heart rate readings were documented. LVN1 verbalized that staff should have checked Resident 68's blood pressure and heart rate prior to administering Carvedilol and documented the readings in Resident 68's MAR. During a concurrent interview and record review, on 8/21/24 at 3 p.m., with DON, Resident 68's MAR, dated 8/2024, was reviewed. DON was informed that staff failed to accurately document Resident 68's blood pressure and heart rate readings prior to the resident receiving the medication Carvedilol and confirmed the finding after reviewing the resident's MAR. 3. During a review of Resident 344's, AR, dated 8/22/24, the AR indicated in part, Resident 344 was a [AGE] year-old, male who was admitted to the facility on [DATE] with admitting diagnoses including type 2 diabetes mellitus (a group of diseases that affect how the body uses blood sugar), end stage renal disease (a condition where the kidney reaches advanced state of loss of function), and chronic atrial fibrillation. During a review of Resident 344's, OSR, dated 8/22/24, the OSR indicated the medication order, Apixaban oral tablet , give one (1) tablet by mouth two times a day for AFIB (atrial fibrillation) with a start date of 8/14/24. During a concurrent interview and record review, on 8/21/24 at 2:35 p.m., with LVN 1, Resident 344's MAR, for the month of 8/2024, was reviewed. When reviewing the administration record for Resident 344's Apixaban, the MAR failed to indicate accompanying monitoring orders for medication side effects and bleeding complications. LVN1 verbalized that there should have been monitoring orders entered while the resident is on this medication. During a concurrent interview and record review, on 8/21/24 at 3:05 p.m. with DON, Resident 344's MAR, dated 8/2024, was reviewed. DON was informed that no monitoring order for medication side effects and bleeding complications was entered for Resident 344's use of the medication Apixaban. DON confirmed the finding and verbalized that staff should have entered an accompanying monitoring order for this medication. During a review of the facility's policy and procedures (P&P), titled, Medication Administration General Guidelines, dated 2019, the P&P indicated in part, Procedures: Medication Preparation .3) Prior to administration, the medication and dosage schedule on the resident's MAR is compared in the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. The P&P indicated further, Medication Administration .2) Obtain and record any vital signs necessary prior to medication administration . Documentation .8) Observe resident for medication actions/reactions and record on the PRN (as needed) effectiveness sheet as appropriate.

Based on interview and record review, the facility failed to ensure monitoring for side effects and manifestation of behaviors was done for Mirtazapine (a drug used to treat depression) for one Resident (Resident 54). This failure had the potential for unrecognized side effects of the Mirtazapine and occurrence of manifested of behaviors. Findings: During a review of the Admission Record (AR) of Resident 54, the AR indicated a diagnosis of Major Depressive Disorder (a serious mental disorder that affects how a person feels, thinks, and act). During a review of the Order Summary Report (OSR) dated 8/20/24 for Resident 54, the OSR indicated in part, Mirtazapine Oral Tablet was prescribed on 4/24/24 for Depression manifested by lack of interest in food. During a review of the Resident 54's care plans dated 5/2/24, this indicated in part, interventions monitor for occurrences of depressive behavior every shift and update MD as needed and monitor/document side effects and effectiveness every shift. During a review of Resident 54's Medication Administration Record (MAR), for the month of August 2024, the MAR indicated, monitoring episodes of depression manifested by: lack of interest in food and/or poor meal intake every meals and record meal intake order and monitoring of side effects of the anti-depressant; however, this was initiated on 8/20/24. There was no other documentation that showed the facility staff had monitored the side effects and manifestation of behaviors for Resident 54 from 4/24/24 to 8/19/24. During an interview with 8/20/24 at 12:30 pm, Licensed Vocational Nurse (LVN) 3 confirmed there was no monitoring for behavior occurrences or side effects for Mirtazapine. During a review of Policy and Procedure (P&P) titled, Psychotropic Medications and Behavior Management, the Psychotropic Medications and Behavioral Management indicated in part D. Documentation Requirements: 4. Occurrences of behaviors for which psychotropic medications are in use will be entered with hash/hatch marks on the Monthly Behavior Monitoring Sheet and/or Medication Administration Record every shift.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled resident's (Resident 19, Resident 1) therapeutic mechanical soft, chopped diet order was plated correctly in the kitchen in accordance with the physician's order and facility's planned menu/diet manual. As a result, of not implementing the chopped diet safely residents were at an increased risk of choking. Findings: 1. During a concurrent observation and interview on 8/19/24 at 11:12 a.m. with Registered Dietitian (RD), Resident 19's lunch meal was plated with chopped pieces of baked chicken that appeared larger than 1/2 [half inch] in size. Resident 19's lunch meal tray ticket indicated mechanical soft, chopped, renal [diet for kidney disease] diet order. Resident 19's meal tray was observed placed on the meal delivery cart for distribution by dietary aide (DA) 3. RD was asked to remove Resident 19's meal tray from the meal delivery cart and check it for accuracy. RD observed the size of the pieces of chopped chicken, and RD stated, The chopped diet is okay. RD was asked to review the facility's diet manual for direction on what size of food constitutes chopped. RD then informed DA 3 to place Resident 19's lunch meal tray back onto the meal delivery cart for distribution to Resident 19. During a concurrent interview and record review on 8/19/24 at 11:23 a.m. with the RD, in the presence of the Certified Dietary Manager (CDM), the facility's diet manual (DM), dated 1/9/24, was reviewed. The DM indicated, Mechanical Soft [diet] intended use: To provide a nutritionally adequate diet that requires a reduced amount of mastication [chewing]. Normally this order is for residents who have a limited chewing ability and intact swallowing ability., As with all diets, .mechanical soft diet should be individualized according to the resident's ability to masticate and swallow. If residents are experiencing swallowing issues, they should be assessed by Speech-Language Pathologist (SLP).Recommendations: All meat (such as beef, fish, poultry, and pork) should be ground or chopped.Definitions of Menu Terms: Chopped: 1/4 - 1/2 pieces. RD stated, Resident 19 pieces of chopped baked chicken were larger than 1/2 in size. RD stated the mechanical soft, chopped diet was not followed for Resident 19. During a review of Resident 19's Speech Therapy Treatment Encounter Note(s) (ST), dated 7/9/2024, the ST notes indicated, Pt [patient] was seen for Dysphagia tx [treatment for difficulty with swallowing]. Response to session interventions: d/c [discontinue] pureed [texture].and advance to Mech [mechanical] Soft/chopped.diet. MAX [maximum] instruct is needed to use swallow safety guidelines and decrease bit size. During a review of Resident 19's diet order (DO), dated 8/16/2024, the DO indicated, Order Summary: Double portion of mechanical soft/chopped renal diet. During a review of Resident 19's meal tray card (MTC) (individualized direction on how to plate/serve patient's meals), dated 8/19/24, the MTC indicated Consistency: Mechanical Soft, Chopped, Renal. There was no direction to dietary staff preparing Resident 19's meal tray in the kitchen to provide double portions to ensure the physician ordered diet was implemented. . 2. During an observation on 8/19/24 at 11:53 a.m., in the facility's dining room, Resident 1 was observed eating lunch. The lunch menu included chicken chow mein, spring roll, and scalloped cinnamon peaches. Resident 1's meal tray ticket indicated the resident was on an NAS (no added salt), CCHO (controlled carbohydrates) diet with mechanical soft, chopped consistency. The food served to Resident 1 was not chopped. During a concurrent observation and interview, on 8/19/24 at 11:58 a.m., with a licensed nurse (LN) 5, LN 5 verbalized that prior to serving the resident meals, nursing staff ensured the food served to the residents matched their prescribed diet and food consistency. After inspecting Resident 1's meal tray, LN 5 verified that the food was not chopped as indicated on the prescribed diet. During a review of Resident 1's RD Nutrition Assessment Readmission Note, dated 6/12/24, the note indicated in part Resident 1 was on a CCHO NAS mechanical soft chopped meat thin liquids diet. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated process for clinical assessment of residents in nursing homes) Assessment, dated 6/15/24, Section K - Swallowing/Nutritional Status . Nutritional Approaches of the assessment indicated in part Resident 1 is on a mechanically altered diet - require change in texture. During a concurrent interview and record review on 8/19/24 at 11:26 a.m. with the CDM, in the presence of the RD, the facility's Utilization Review Committee Quarterly Meeting Attendance signature page, dated 1/9/24, was reviewed. CDM stated during that meeting was when the facility's diet manual was reviewed and approved. The signature page contained the signature for the CDM next to Dietary Supervisor. There was no RD signature nor line designated on the form with the title of RD to indicate the RD reviewed and approved the facility's diet manual. CDM stated, that was the approval signature page for the facility's diet manual. During a review of the facility's policy and procedure (P&P) titled, Section D: Food Production (FP), the P&P indicated, II. Food Preparation (Basic Guidelines); Policy: The preparation of food will be done following standard food handling techniques. Standardized recipes, quantity cookbooks, safe food handling procedures and an approved diet manual will be made available to assist Nutrition Services Employees. During a review of the facility's policy and procedure (P&P) titled, Tray Service Protocol, dated 2014, the P&P indicated, Policy: Food will be served in a manner that meets the individual needs of each resident. During a review of the facility's policy and procedure (P&P) titled, Section D: Food Production (FP), the P&P indicated, II. Food Preparation (Basic Guidelines); Policy: The preparation of food will be done following standard food handling techniques. Standardized recipes, quantity cookbooks, safe food handling procedures and an approved diet manual will be made available to assist Nutrition Services Employees. During a review of the facility's policy and procedure (P&P) titled, Tray Service Protocol, dated 2014, the P&P indicated, Policy: Food will be served in a manner that meets the individual needs of each resident.

Based on observation, interview, and record review, the facility failed to ensure resident's lunch was served in an attractive manner when the food items on the plate were similar color (brown) and the noodles were mushy when the food was hot held for a prolonged period of time prior to the lunch meal service. Three residents expressed dissatisfaction with the facility's food during the survey(Resident 48, Resident 43, Resident 2). As a result, hot holding food for a prolonged period of time was not a method of food preparation that conserves nutritive value or appearance. In addition, food that was served lacked a variety of color creating an unappetizing appearance and could cause less food intake and weight loss. Findings: .During a concurrent observation and interview on 8/19/24 at 08:37 a.m. with [NAME] 1 upon entrance into the kitchen to begin survey, steamtable was observed empty as breakfast meal had been completed. [NAME] 1 was observed cooking at the stove range, and [NAME] 1 stated she was preparing lunch for residents. During a concurrent observation and interview on 08/19/24 at 9:40 a.m. with [NAME] 1, in the kitchen, [NAME] 1 was observed stirring chow mein noodles in a large pot over the stove range. The chow mein noodles appeared to have cooked vegetables and the noodles appeared done. [NAME] 1 stated it was chicken chow mein. [NAME] 1 stated she had already cooked the chicken and the vegetables earlier that morning, and they were already added to the chow mein that she was stirring. During an interview on 8/19/24 at 9:50 a.m. with Resident 48, Resident 48 stated vegetables were mushy at lunch and dinner. Resident 48 stated he wished the kitchen staff would use more fresh vegetables, as he thought they primarily used frozen vegetables. During a review of Resident 48's Order Summary (OS), dated 5/9/24, the OS indicated, Regular Renal [for kidney disease] NAS [no added salt] CCHO [consistent carbohydrate] Diet. During a concurrent observation and interview on 08/19/24 at 011:14 a.m., in the kitchen, during trayline a lunch plate was plated with pureed texture food. There were only two items located on the white plate which was a round scoop size of a brown colored food, and another round scoop size of a brown colored food. No additional food/items were placed on the plate. RD stated it was a standard of practice in menu planning to include a variety of color to present the food in an appetizing manner. RD stated the chow mein had vegetables with color but they were pureed so the color was not visible. RD stated, the other pureed scoop of brown colored food was pureed Asian blend vegetables. RD acknowledged there was lack of color from the food located on the plate, as they were both brownish in color, as RD stated they had a little difference in the shade of brown. From observing the pureed food the two circled portions of food appeared brown in color and one could not distinguish what type of food it was without a menu in front of them detailing what it was. During a review of the facility's Spring/Summer - Week III menu, dated 8/19/24, the planned menu for puree texture indicated Pu [pureed] chicken chowmein, Pu Asian Blend Vegetables, Pu Scalloped cinnamon peaches. The pureed peaches were served in a small dessert dish that was placed on the tray, and not on the plate that only contained two round portions of brown colored food that had not appeared appetizing. During a concurrent observation and interview on 08/19/24 at 012:20 p.m., in the South hall way, with the RD, the test tray with a regular diet was observed. The chicken chow mein appeared mushy and the vegetables had small thin slices of carrots that appeared dull in color and overcooked. Overall, the regular diet appeared with slim amount of color and overall brown colored foods with mushy appearing noodles. The peaches were served in a dessert cup that was placed to the side and located on the meal tray, not on the meal plate. RD verified the noodles appeared mushy. One the two brown scoops of food on the pureed texture test tray appeared to resemble refried beans, but RD stated it was a pureed Asian vegetable blend. RD acknowledged the lunch meal was not varied in color which was a standards of practice in menu planning. During a review of an article published by Association of Nutrition & Foodservice Professionals (ANFP) titled Menu Planning Thinking Beyond Color, Flavor & Texture, dated February 2013, the article indicated, Everyone knows the basics - provide good-tasting, attractive dishes that feature a variety of colors and flavors. But think of other considerations when you develop your spring cycle menus. Appealing combinations, pleasant aromas, varied textures. During an interview on 8/19/24 at 3:40 p.m. with [NAME] 1 and [NAME] 2, [NAME] 1 stated she placed the cooked chicken chow mein noodles in the oven to hot hold them at about 9:45 a.m. Both [NAME] 1 and [NAME] 2 stated they were hot held in the oven at 350 degrees F until about 10:30 a.m. when they were then placed in the steam table to hot hold until lunch trayline began at about 11:00 a.m. During an interview on 8/19/24 at 3:45 p.m. with RD, in the presence of Certified Dietary Manager (CDM), the above interview was shared with RD and CDM and they were asked if there was a reason why staff had to prepare noodles and vegetables so early as they were done by 9:40 a.m. at the latest, on hot held at 350 degrees F in the oven, and RD stated, That's too early. I will talk to them. CDM stated that was still a cooking temperature, not hold holding. During a review of the facility's policy and procedure (P&P) titled, VII. Menu Posting, dated 2014, the P&P indicated, The [name of menu company] provides attractive daily and weekly menus for posting including non-select and select menu styles. During a review of the facility's policy and procedure (P&P) titled, Section D: Food Production (FP), the P&P indicated, II. Food Preparation (Basic Guidelines); Policy: The preparation of food will be done following standard food handling techniques. Standardized recipes, quantity cookbooks, safe food handling procedures and an approved diet manual will be made available to assist Nutrition Services Employees. During a review of the facility's recipe titled, Chicken Chow Mein (CCM), dated 3/13/24, the recipe indicated, Slice chicken into strips. Saute' chicken in oil until meat is browned. Add chicken stock to meat and simmer for 15-30 minutes, or until done. (The chicken was already cooked prior to 9:40 a.m.) The CCM recipe indicated when the chicken chow mein was done to Hold or serve hot at or above 140 degrees F. During a review of the facility's policy and procedure (P&P) titled, II. Food Preparation (Basic Guidelines), dated 2014, the P&P indicated, Saute'/Pan Fry:.In preparing meat, the finished product should be tender, juicy, tasty, and have a minimum of shrinkage. This is achieved by cooking or roasting slowly at low to moderate temperatures (275 - 350 degrees F).Vegetable Preparation; Vegetables should be prepared as close to serving time as possible.Vegetables are high in nutritive value and contribute to the attractiveness and acceptability of the meal. Care should always be taken to prevent destroying their nutritive value.Be careful not to overcook.

Based on record review and interview, the facility failed to demonstrate it notified a physician of a change in condition in a timely manner and per policy and procedure, for one of two sampled residents (Resident 1). This facility failure had the potential for emergency medical care to be delayed for Resident 1. Findings: During a review of Resident 1's Change In Condition form dated 6/7/24, indicated in part, Resident 1 had a change in condition when experiencing Hypoxia (a potentially life-threatening situation which results in low levels of oxygen in a person's tissues and cells) during PT (physical therapy). The Change In Condition form indicated this event started on 6/7/24, in the morning. The Change In Condition form indicated in part Resident (Resident 1) noted with hypoxia and diaphoresis (excessive sweating) during PT, resident (Resident 1) was fluctuating between 88%-95% RA (room air). Resident (Resident 1) moaning when transferred back to bed. The Change In Condition form indicated in part Resident 1's physician was notified at 12:00 p.m. on 6/7/24 of Resident 1's change in condition, wherein physician orders were given to transfer Resident 1 To the ER (emergency room ) for hypoxia. During a review of Resident 1's Physical Therapy Treatment Encounter Note dated 6/7/24, indicated in part During rest break while seated in Wheel Chair patient (Resident 1) appeared to be increasingly fatigued and became diaphoretic. We immediately notified charge nurse and returned patient back .over to nursing. During an interview on 6/24/24, starting at 12:36 p.m., with the physical therapy assistant (PTA 1), the PTA 1 verbalized Resident 1 became diaphoretic and lethargic (decreased, or lack of energy) during a physical therapy session on 6/7/24. The PTA 1 verbalized a belief this occurred between 10:30 a.m. to 11:00 a.m. During an interview on 6/4/24, starting at 1:00 p.m., with licensed nurse (LN 1), the LN 1 verbalized at around 11:00 a.m., Resident 1 was returned to bed due to becoming hypoxic and diaphoretic during a physical therapy session on 6/7/24. The LN 1 verbalized Resident 1 was placed on two liters of oxygen due to hypoxia at around 11:00 a.m. The LN 1 was asked why two liters of oxygen was administered to Resident 1, as Resident 1 had no physician orders for oxygen. The LN 1 stated We just did it because it was an emergency. During a review of the facility's policy and procedure titled REPORTING CHANGES IN RESIDENT CONDITION undated, indicated in part Report changes in condition to MD immediately and follow up on necessary interventions.

Based on record review and interview, the facility failed to follow their policy and procedures pertaining to Residents going out on a leave of absence, for two of two sampled Residents (Resident 1 and Resident 2). This failure had the potential for the facility not to know where residents were going, while out on pass from the facility or when they returned. Findings: During a review of the facility's policy and procedure titled POLICY AND PROCEDURE FOR RESIDENT'S LEAVE OF ABSENCE/OUT ON PASS dated 3/13/24, indicated in part Residents before leaving the facility shall fill out the Release of Responsibility for Leave of Absence Form. This form shall record the name/signature of the person accompanying the resident. If self-responsible, resident will sign out for himself. The time the resident left the facility and the place/location the resident is going to must also be written in the form. Once the resident is back, License nurse or facility representative shall confirm that the resident came back by filling out the time they came back and by placing his/her signature. During a review of Resident 1's Release Of Responsibility For Leave Of Absence form, undated, indicated in part, Resident 1 left the facility a total of 14 times from 4/24/24, though 5/2/24, to go out on pass. Out of the 14 times Resident 1 left the facility, on 13 occasions, a licensed nurse or facility representative, failed to document when Resident 1 returned to the facility, by signing their name and noting the date and time Resident 1 returned. During a review of Resident 2's Release Of Responsibility For Leave Of Absence form, undated, indicated in part, Resident 2 left the facility a total of 22 times from 5/7/24, through 5/19/24. Out of the 22 times Resident 2 left the facility, on 21 occasions the form did not indicate where Resident 2's destination was. The form also indicated on two occasions on 5/8/24, and once each on 5/15/24, and 5/16/24, a licensed nurse or facility representative, failed to document when Resident 2 returned to the facility, by signing their name and noting the date and time Resident 2 returned. During a concurrent record review and interview, on 5/20/24, starting at 4:24 p.m., with the Director of Nursing (DON 1), both Resident 1 and Resident 2's Release Of Responsibility For Leave Of Absence forms were reviewed. The DON 1 acknowledged both Resident 1 and Resident 2's forms were incomplete and were missing information, as indicated in the facility policy on those specified dates. During a concurrent record review and interview, on 5/22/24, with the Director of Staff Development (DSD 1), both Resident 1 and Resident 2's Release Of Responsibility For Leave Of Absence forms were reviewed. The DSD 1 verbalized for both Resident 1 and Resident 2, the forms were filled out incorrectly as indicated in the facility policy on those specified dates.

Based on record review and interview, the facility failed to ensure turning and repositioning as stated in the resident's care plan for one of three sampled residents (Resident 2) was documented to reflect the care plan was implemented. This failure had the potential for pressure ulcer development or skin breakage on the resident. Findings: During a review of Resident 2's Admission Record, dated 5/12/22, the Admission Record indicated, upon admission to the facility, Resident 2 had a diagnosis of dementia (memory loss that disrupts daily life). During a review of Resident 2's Care Plan, dated 4/20/23, the Care Plan indicated, Resident 2 had a problem with actual pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) related to right heel, with a facility intervention of Turn and repositioning (moving a resident into a different position to redistribute pressure from a particular part of the body) at least q (every) 2-3 hours . During a review of Resident 2's Wound Evaluation and Treatment Progress Notes, dated 4/13/23, 4/20/23, 4/27/23, 5/4/23, 5/11/23, 5/18/23, 5/25/23, the notes indicated, Resident 2's treatment plan for the pressure ulcer included, Every 2 hours turning and Turn patient (Resident 2) every two hours. During a review of Resident 2's Documentation Survey Report, dated 4/23 and 5/23, the reports indicated, Resident 2 was not turned/repositioned every 2-3 hours multiple times. During an interview on 7/27/23 at 2:47 p.m. with licensed nurse (LN) 1, LN 1 verbalized, I do the training for CNA ' s on repositioning residents but I don ' t know how they document it, let me get a CNA and they can explain it. During an interview on 7/27/23 at 2:55 p.m. with certified nursing assistant (CNA) 1, CNA 1 verbalized, we are supposed to document every time we reposition the resident and if it wasn ' t documented then it wasn ' t done.

Based on record review and interview, the facility failed to implement care planned interventions for turning/repositioning, for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to experience negative outcomes related to skin care. Findings: During a review of Resident 1's Admission Record, dated 12/28/22, the record indicated in part, upon admission to the facility, Resident 1 had a diagnosis of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (lower back), stage one (reddened, painful area on the skin that does not turn white when pressed). Resident 1's Admission Record, further indicated, Resident 1 developed a stage three (the sore gets worse and extends into the tissue beneath the skin, forming a small crater) pressure ulcer on 1/10/23. During a review of Resident 1's Care Plan, dated 1/2/23, the Care Plan indicated in part, Resident 1 had a problem with repositioning (moving a resident into a different position to redistribute pressure from a particular part of the body), with a facility intervention of Repositioning at least q (every) 1-2 hours. Resident 1's Care Plan further indicated, Resident 1 had a problem with Redness location sacrococcygeal (lower back), with an intervention to Reposition every 2 hours or often if needed. During a review of Resident 1's Wound Evaluation and Treatment Progress Notes, dated 1/12/23, and 1/19/23, the notes indicated in part, Resident 1's treatment plan for the pressure ulcer included, Every 2 hours turning and Turn patient (Resident 1) every two hours. During a review of Resident 1's Documentation Survey Report, dated 1/23, the report indicated in part, Resident 1 was turned/repositioned a total of three times on 1/1/23 and 1/2/23, two times on 1/3/23, 1/4/23 and 1/5/23, one time on 1/6/23, two times on 1/7/23, 1/8/23 and 1/9/23, three times on 1/10/23, two times on 1/11/23, three times on 1/14/23 and 1/15/23, two times on 1/16/23 and 1/17/23, three times on 1/18/23, two times on 1/19/23, one time on 1/20/23, two times on 1/21/23, and three times on 1/22/23. During an interview on 3/7/23, at 1:00 p.m., with the director of nursing (DON 1), the DON 1 verbalized, the facility could not produce further documentation, indicating Resident 1 was turned/repositioned every two hours, as per Resident 1's care plan, and wound evaluation and treatment recommendations. During a review of the facility policy and procedure P&P titled Wound Management/Skin Integrity Process, undated, the P&P indicated in part, Care plan implementation of a preventative program to maintain skin integrity will be implemented at the time of admission for at risk residents.

Based on interview and record review, the facility failed to ensure professional standards of practice were implemented, by the nursing staff, when licensed vocational nurse (LVN) performed one of two sampled Residents (Resident 1's), admission comprehensive assessment, initiated, and re-evaluated a skin condition care plan, without having the data collection validated by a registered nurses (RN). This facility failure resulted in Resident 1's coccyx (tailbone) and left buttock's redness, not being assessed and re-evaluated appropriately, thus progressing to a deep tissue pressure injury (DTPI) without being treated properly. Findings: According to the Nursing Practice Act, Business & Professions Code, Chapter 6, Nursing Section 2725, indicates, (b) The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: RN is accountable for an ongoing comprehensive assessment that includes data collection (LVN data collection contribution), analysis, and drawing conclusions/making judgments in order to: formulate diagnoses and update diagnoses, formulate or change the plan of care, decide on specific activities to implement the plan of care (immediate and long-term), prioritize and coordinate delivery of care, delegate to nursing care competent staff to deliver required care . RN uses scientific knowledge and experience to make clinical judgments/assessments about observed abnormalities and changes based on a series of complex, independent and collaborative decision-making activities. According to the Standards Of Competent Performance, California Code Of Regulations, Title 16, Section 1443.5, indicates, A registered nurse . consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows: formulates a care plan in collaboration with the client, which ensures that direct and indirect nursing care services provide for the client ' s safety, comfort, hygiene, and protection, and for the disease prevention and restorative measures. RN role necessitates rapid information processing and application of scientific knowledge to coordinate, delegate and supervise the delivery of safe, timely care. This includes knowledge, skill, and ability to: Check accuracy/reliability of information (LVN data collection); Identify patterns by case type, standards of treatment, familiar circumstances, and relevance of data (LVN data collection); Recognize inconsistencies and missing information; Search for additional information; Generate a hypothesis about disease conditions, health problems, patient needs; Make predictions about findings, needs, use of interventions, outcomes; Set priorities for implementation of nursing care, priorities regarding urgency of patient concerns. Evaluate and revise based on review of new information; LVN is not prepared by formal education to make RN level nursing judgments/assessments that include independent analysis, synthesis, and decision-making. RN is responsible for collecting (LVN data collection), analyzing, and collaborating with all information sources to ensure a comprehensive written plan of care that is based on current standards of safe practice. According to the Scope of Vocational Nursing Practice, section 518.5, indicates, The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. The data collection performed by the LVN is integrated to the data collection the RN collects to analyzed, synthesized, and make decisions regarding patient/residents care as outlined above. During a review of Resident 1's clinical record, the clinical record indicated, Resident 1's admission comprehensive resident assessment was performed by a licensed vocational nurse (LVN). Resident 1's Care Plan for Minor Skin Conditions, initiated on 11/16/22, and re-evaluated on 11/30/22, was performed by the treatment nurse (TN) who is an LVN. During a concurrent interview and record review, on 12/16/22, at 1:05 p.m., Resident 1's Care Plan for Minor Skin Conditions, dated 11/16/22, was reviewed with the TN. The care plan indicated, the TN initiated and revised the care plan, without validation by an RN. The TN confirmed, initiating and revising, or re-evaluating this care plan, without the collaboration on a registered nurse (RN). During a concurrent interview and record review, on 12/16/22, at 2:26 p.m., Resident 1's admission assessment, minor skin conditions care plan,was reviewed with the director of nursing (DON). The admission assessment and care plan indicated, LVN performed the assessments. The DON confirmed, Resident 1's admission comprehensive assessment, and skin conditions care plan, were performed by an LVN.

Based on record review, interview, and observation, the facility failed to maintain an infection prevention program to help prevent and control a suspected Scabies (infestation of the skin by the human itch mite) outbreak (the occurrence of cases of disease in excess of what would normally be expected in a defined community). This failure resulted in an immediate jeopardy (IJ - situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident), resulting in nine of 77 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, and 9) and eight employees (Emp 1, 2, 3, 4, 5, 6, 7, and 8) exhibiting symptoms of potential Scabies. This failure also placed the remaining 68 of 77 residents currently residing at the facility, the remaining facility staff, and all the visitors at risk for acquiring this highly contagious communicable disease (disease transmissible by direct and indirect contact from one person to another). On 11/19/19, at 3:37 p.m., the survey team notified the Administrator (Admin) and the Director of Nursing (DON) of the IJ situation due to uncontained suspected Scabies outbreak. On 11/19/19, at 8:37 p.m., the IJ was removed in the presence of the Admin after a temporary acceptable plan of correction (P[NAME]), which addressed the immediacy of the situation, was provided by the Admin. The P[NAME] included the following: 1. Ventura county public health (a local health department, which is a government agency in the United States on the front lines of public health) staff conducted skin scraping (test used to identify mites or their eggs, eggshell fragments, or feces; this is best undertaken by placing a drop of mineral oil directly over the burrow on the skin and then superficially scraping longitudinally and laterally across the skin with a scalpel blade) of residents in rooms (room numbers listed) with suspected cases of scabies to rule out/confirm the diagnosis. Results will be provided once available. 2. On 11/19/19, all residents will be assessed for skin rashes and itchiness. Director of Nursing (DON) and Director of Staff Development (DSD) will conduct the skin check/assessment. DON and DSD will provide results of skin assessment of all residents except those who were previously identified to CDPH (The California Department of Public Health is the state department responsible for public health in California). Should additional residents be identified with rashes, contact isolation (keeping residents separated from other people while a series of procedures are followed, designed to minimize the transmission of infectious organisms by direct or indirect contact with an infected person or his environment) protocol will be initiated immediately and skin scraping will be conducted on 11/20/19. Attending physicians will be informed of the results. 3. On 11/19/19 and 11/20/19, all staff on all shifts will be assessed for rash and itchiness by the RN (Registered Nurse) Supervisor for any presence of skin rashes. Symptomatic staff will be referred to facility's occupational clinic for [DIAGNOSES REDACTED]. 4. On 11/19/19, contact isolation precautions will be implemented on the affected and symptomatic residents in rooms (room numbers listed) and any additional rooms identified. All affected rooms and residents will remain in contact isolation precautions until results are made available. 5. On 11/19/19, precautionary signs will be posted in all affected rooms regarding the skin infection, availability of gloves and gowns. 6. On 11/19/19 and 11/20/19, DSD to in-service all staff regarding scabies and the infection control measures/protocol such as avoidance of direct skin-to-skin contact and handwashing protocol to prevent the infection from spreading. Attending physicians will be informed. DSD will provide all staff with a list of all affected residents. 7. Pending results for county public health for residents in rooms (room numbers listed), we will perform skin scraping of all residents previously identified and any newly identified residents/staff. 8. If results come up positive, attending physicians will be informed. Attending physicians' orders will be carried out as ordered. 9. On 11/20/19, will consult with attending physician regarding the county public health treatment recommendation to have two step treatment of [REDACTED]. 10. On 11/20/19, wound consult will be referred to see the affected residents and staff. 11. Infection surveillance and monitoring of affected residents and staff daily will be done for 6 weeks starting 11/20/19 unless otherwise instructed by county public health. 12. CDPH will be regularly informed and updated of the status of the skin infections. 13. Upon receipt of official results from county public health, all family members of affected residents will be notified and provided. 14. Family members of affected residents whose laundry is being done by the family will be provided the CDC (The Centers for Disease Control and Prevention is the leading national public health institute of the United States) guidance on proper laundering procedures. 15. All affected rooms will be cleaned per CDC recommendations. Findings: The Department received a complaint indicating multiple facility residents, multiple employees, and a facility visitor currently were infected with Scabies. According to the Centers for Disease Control and Prevention, (https://www.cdc.gov/parasites/scabies/health_professionals/institutions.html), Resources for Health Professionals in Institutional Settings Scabies is an infestation of the skin by the human itch mite (Sarcoptes scabiei var. hominis). The microscopic scabies mite burrows (makes a hole or a tunnel) into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Scabies is found worldwide and affects people of all races and social classes. Scabies can spread rapidly under crowded conditions where close body and skin contact is frequent. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks . Crusted scabies is a severe form of scabies that can occur in some persons who are immunocompromised (have a weak immune system), elderly, disabled, or debilitated. It is also called Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs. Persons with crusted scabies are very contagious to other persons and can spread the infestation easily both by direct skin-to-skin contact and by contamination of items such as their clothing, bedding, and furniture. Persons with crusted scabies may not show the usual signs and symptoms of scabies such as the characteristic rash or itching (pruritus). Persons with crusted scabies should receive quick and aggressive medical treatment for [REDACTED]. If a person has never had scabies before, symptoms may take as long as 4-6 weeks to begin. It is important to remember that an infested person can spread scabies during this time, even if he/she does not have symptoms yet. In a person who has had scabies before, symptoms usually appear much sooner (1-4 days) after exposure . The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash. The itching and rash each may affect much of the body or be limited to common sites such as the wrist, elbow, armpit, webbing between the fingers, nipple, penis, waist, belt-line, and buttocks. The rash also can include tiny blisters (vesicles) and scales (a thin piece of the outermost layer of skin resembling a fish scale). Scratching the rash can cause skin sores; sometimes these sores become infected by bacteria. Tiny burrows sometimes are seen on the skin; these are caused by the female scabies mite tunneling just beneath the surface of the skin. These burrows appear as tiny raised and crooked (serpiginous) grayish-white or skin-colored lines on the skin surface. Because mites are often few in number (only 10-15 mites per person), these burrows may be difficult to find. They are found most often in the webbing between the fingers, in the skin folds on the wrist, elbow, or knee, and on the penis, breast, or shoulder blades. The head, face, neck, palms, and soles often are involved in infants and very young children, but usually not adults and older children. Persons with crusted scabies may not show the usual signs and symptoms of scabies such as the characteristic rash or itching (pruritus) . [DIAGNOSES REDACTED]. Whenever possible, the [DIAGNOSES REDACTED]. This can be done by carefully removing a mite from the end of its burrow using the tip of a needle or by obtaining skin scraping to examine under a microscope for mites, eggs, or mite fecal matter. It is important to remember that a person can still be infested even if mites, eggs, or fecal matter cannot be found; typically fewer than 10-15 mites can be present on the entire body of an infested person who is otherwise healthy. However, persons with crusted scabies can be infested with thousands of mites and should be considered highly contagious . On a person, scabies mites can live for as long as 1-2 months. Off a person, scabies mites usually do not survive more than 48-72 hours. Scabies mites will die if exposed to a temperature of 50°C (Celsius) (122°F - Fahrenheit) for 10 minutes .Scabies outbreaks have occurred among patients, visitors, and staff in institutions such as nursing homes, long-term care facilities, and hospitals. Such outbreaks frequently are the result of delayed [DIAGNOSES REDACTED]. The characteristic itching and rash of scabies can be absent in such persons, leading to frequent mis[DIAGNOSES REDACTED]. Scabies often is not recognized until it begins to appear among staff and other patients at the institution . Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching). New patients and employees should be screened carefully and evaluated for any skin conditions that could be compatible with scabies. The onset of scabies in a staff person who has had scabies before can be an early warning sign of undetected scabies in a patient. Skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. Appropriate isolation and infection control practices (e.g. gloves, gowns, avoidance of direct skin-to-skin contact, etc.) should be used when providing hands-on care to patients who might have scabies. Epidemiologic and clinical information about confirmed and suspected scabies patients should be collected and used for systematic review in order to facilitate early identification of and response to potential outbreaks. Most recent reports recommend an aggressive approach to preventing and controlling scabies in institutions, particularly when crusted (Norwegian) scabies is confirmed or suspected . A scabies outbreak suggests that transmission has been occurring within the institution for several weeks to months - thus increasing the likelihood that some infested staff or patients may have had time to spread scabies elsewhere in the community, including to other facilities. Measures to control scabies in an institution depend on factors such as how many cases are diagnosed or suspected, how long infested persons have been at the institution while undiagnosed and/or unsuccessfully treated, and whether any of the cases are crusted (Norwegian) scabies. Because it is so highly transmissible, crusted scabies requires rapid and aggressive detection, diagnosis, infection control, and treatment measures to prevent and control spread. The local health department should be notified of any outbreak that may have community implications, including possible spread by patients or staff to other institutions. Control measures for a single case of non-crusted scabies should consist of heightened surveillance for early detection of new cases, proper use of infection control measures when handling patients (e.g. avoidance of direct skin-to-skin contact, handwashing, etc.), confirmation of the [DIAGNOSES REDACTED]. Skin-to-skin contact with scabies patients should be avoided for at least 8 hours after treatment. Control measures for multiple cases of non-crusted scabies should consist of heightened surveillance for early detection of new cases, proper use of infection control measures when handling patients (e.g. avoidance of direct skin-to-skin contact, handwashing, etc.), confirmation of the [DIAGNOSES REDACTED]. Skin-to-skin contact with scabies patients should be avoided for at least 8 hours after treatment. In addition, an institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread. Epidemiologic and clinical data should be reviewed to determine the extent of the outbreak and risk factors for spread. Control measures for an outbreak involving one or more cases of crusted scabies should involve rapid and aggressive detection, diagnosis, infection control, and treatment measures because this form of scabies is so highly transmissible. Unrecognized crusted scabies often is the source of institutional outbreaks of scabies. Infection control personnel and dermatologists (medical practitioners qualified to diagnose and treat skin disorders) should be involved as soon as scabies is suspected in an institution. An institution-wide information program should be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread. Until successfully treated, patients with crusted scabies should be isolated from other patients who do not have crusted scabies. Assigning a cohort of caretakers to care only for patients with crusted scabies can reduce the potential for further transmission. Direct skin-to-skin contact between a patient with crusted scabies and his/her caretakers and visitors should be eliminated by following strict contact precautions, including the use of protective garments such as gowns, gloves, and shoe covers. The patient's room should be cleaned thoroughly. Bedding and clothing used by a person with scabies should be machine-laundered using the hot water and hot dryer cycles. All staff, volunteers, and visitors who may have been exposed to a patient with crusted scabies, or to clothing, bedding, or furniture used by such a patient, should be identified and treated. Treatment should be strongly considered even in equivocal circumstances because of the complexity of controlling an institutional outbreak and the low risk associated with treatment. All suspected and confirmed cases, as well as all potentially exposed patients, staff, visitors, and family members should be treated at the same time to prevent reexposure. Remember that symptoms of scabies can take weeks to appear the first time a person is infested; however, the person still can spread scabies during this asymptomatic (no symptoms) period. Persons with crusted scabies generally require treatment at least twice, a week apart. Topical treatment with [MEDICATION NAME] or oral treatment with ivermectin has been used successfully, although ivermectin currently is not FDA - approved (The Food and Drug Administration is a federal agency of the United States Department of Health and Human Services, one of the United States federal executive departments) for treatment of [REDACTED]. All new patients and staff should be screened and treated for [REDACTED]. The local health department and neighboring institutions should be notified of the outbreak and of any patients who may have been transferred to or of staff who may have worked in other institutions. According to the American Journal of Clinical Dermatology, (https://link.springer.com/article/10.2165/ 071- 5010- , (MONTH) 2004, Volume 5, Issue 1, pp 31-37), Controlling Scabies in Institutional Settings Scabies is a global problem and a significant source of morbidity in nursing home residents and workers because of its highly contagious nature. It is also a problem in hospitals that care for the elderly, the debilitated, and the immunocompromised. New outbreaks continue to occur, despite controlling the recurrent epidemics. Scabies manifests as papules (small, raised, solid pimple or swelling, often forming part of a rash on the skin and typically inflamed but not producing pus), pustules (a small blister or pimple on the skin containing pus), burrows (a hole or tunnel), nodules (a small swelling or aggregation of cells in the body, especially an abnormal one), and occasionally urticarial (a rash of round, red welts on the skin that itch intensely, sometimes with dangerous swelling, caused by an allergic reaction) papules and plaques (semi-hardened accumulation of substances from fluids). Most of the patients with scabies experience severe pruritus (itching). A subset of patients have crusted or Norwegian scabies. These patients, who are usually debilitated or immunocompromised, do not experience the urge to scratch, and therefore do not scratch their own skin. [DIAGNOSES REDACTED]. Scabies can be treated with topical or oral therapies. Topical treatments include 5% [MEDICATION NAME] cream, 1% [MEDICATION NAME] (gamma benzene hexachloride) lotion, 6% precipitated [MEDICATION NAME] in [MEDICATION NAME], crotamiton, malathion, allethrin spray, and [MEDICATION NAME] benzoate. Ivermectin, the only oral treatment, is not approved for scabies in the US (United States). Most authorities advocate using a scabicide (a drug that destroys the itch mite causing scabies) several times, specifically once a week over a period of 2-3 weeks. In an outbreak of scabies in a nursing home, residents, staff, and frequent visitors should all be treated even if they are not symptomatic. Ivermectin is useful in treating patients with Norwegian or crusted scabies, or who are debilitated. Ivermectin has no serious reported adverse effects. Model treatment plans to stop scabies epidemics have been developed. These plans coordinate treatment of [REDACTED]. Failure to coordinate notification, education, treatment, and disinfection leads to failure to control scabies epidemics. Control of epidemics of institutional scabies requires attention to treatment effects and logistics. Treatment is low risk, but cumbersome because many individuals need be treated. It is advisable to restrict, where possible, the number of staff members that deal with scabies patients to limit the spread of the scabies. Prolonged surveillance is required for the eradication of institutional scabies. While the foregoing plans require coordination of all involved personnel and sustained efforts, they are necessary to halt the spread of scabies to patients and staff, to enhance their morale, and to prevent deterioration of labor and public relations. According to California Department of Public Health (CDPH), the All Facilities Letter (AFL), dated 1/13/19, To: General Acute Care Hospitals (GACH), Skilled Nursing Facilities (SNF). Subject: Requirements to Report Outbreaks and Unusual Infectious Disease Occurrences . This AFL reminds providers of the requirements to report outbreak and unusual infectious disease occurrences to the local public health officer and the California Department of Public Health (CDPH), and provides definitions and examples of reportable incidents . Definitions: Outbreak - The occurrence of cases of a disease (illness) above the expected or baseline level, usually over a given period of time, in a geographic area of facility, or in a specific population group. The number of cases indicating the presence of an outbreak will vary according to the disease agent, size and type of population exposed, previous exposure to the agent, and the time and place of occurrence. Thus, the designation of an outbreak is relative to the usual frequency of the disease in the same facility or community, among the specified population, over a comparable period of time. A single case of a communicable disease long absent from a population or the first invasion by a disease not previously recognized requires immediate reporting and epidemiologic investigation .Unusual Occurrences - Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors .If in doubt, report . The facility infection prevention program policy and procedure titled Infection Control, updated 1/12/16, indicated Purpose: To provide infection control policies and procedures required for a safe and sanitary environment. Policy: The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infection. Procedure: The facility's infection control policies and procedures equally apply to all facility staff, consultants, contractors, residents, visitors, volunteer workers, and the general public alike regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status or payor source. Objectives: Prevent, detect, investigate, and control infections in the facility. Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors and the general public. Establish guidelines for implementing isolation precautions for personnel, residents, visitors, and the general public . Maintain records of incidents and corrective action related to infections . Procedures . Health care associated infections - H.[NAME]I (Nosocomial) considerations: If a facility outbreak is suspected, the local public health nurse is to be notified and appropriate written notification (Confidential Morbidity Report) shall be completed as directed. The Health Facilities Division of the State Health Department hall be notified . During an interview with a Licensed Nurse (LN 1), on 11/19/19, at 12:42 p.m., LN 1 stated We had residents with rash and itchiness on and off since May. Different residents. Some got rash and itchiness more than once. Some were diagnosed with [REDACTED]. During an interview with LN 1, on 11/19/19, at 1:15 p.m., LN 1 confirmed residents, who are exhibiting symptoms of Scabies (rash and itchiness), are currently not being isolated from others. LN 1 indicated the only isolation of residents with identified Scabies the facility had, was back in 5/19, when two residents (Residents 1 and 2) were diagnosed and treated for [REDACTED]. They are just being treated for [REDACTED]. Even staff, when they report itching or rash, we send them to their doctors and tell them to get scraped, but no one is scraping them . During an observation, and a concurrent interview with the Director of Nursing (DON), on 11/19/19, at 11:41 a.m., the DON confirmed currently the facility has only one room in isolation due to [MEDICAL CONDITION] (bacterium that causes gastrointestinal symptoms, such as diarrhea and stomach cramps) infection and no other isolations are in place. During record review of the clinical record for Resident 1, on 11/19/18, the physician orders, dated 5/7/19, indicated Resident 1 was prescribed [MEDICATION NAME] cream (topical ointment) to be applied once and repeated in a week for Scabies. The orders also indicated Resident 1 was prescribed Ivermectin oral medication to be administered once and repeated in a week for Scabies. The orders also indicated Resident 1 was prescribed to be on contact isolation for 24 hours from 5/7 to 5/8/19 due to Scabies. Resident 1's physician order, dated 11/12/19, indicated Resident 1 was prescribed another treatment of [REDACTED]. During an observation, and a concurrent interview with Resident 2, on 11/19/19 at 5:32 p.m., Resident 2 was observed to have a rash on the right shoulder, on the chest, and on the back. Resident 2 stated she has had this rash for couple of weeks. During record review of the clinical record for Resident 2 on 11/19/19, the physician orders, dated 5/7/19, indicated Resident 2 was prescribed [MEDICATION NAME] cream to be applied once and repeated in a week for Scabies. The orders indicated Resident 2 was prescribed Ivermectin oral medication to be administered once and repeated in a week for Scabies. The orders also indicated Resident 2 was prescribed to be on contact isolation for 24 hours from 5/7 to 5/8/19 due to Scabies. The clinical record did not have any documentation Resident 2 was placed on contact isolation when Resident 2 exhibited the current symptoms of potential Scabies. During an interview with a Licensed Nurse (LN 2), on 11/19/19, at 12:47 p.m., LN 2 stated Some residents lately have been itching a lot, about five residents, and noted with a rash. Their providers (doctors) assess them, they do not know what it is, because they did not do scraping. Referred to Dermatologists, but they did not do the scraping either. We treated them with other creams, [MEDICATION NAME] (used to relieve skin inflammation, itching, dryness, and redness) cream, [MEDICATION NAME] (used to reduce swelling, itching, and redness) cream, but all ineffective. Currently five residents are being treated for [REDACTED]. During an interview with LN 1, and LN 2, on 11/19/19, at 12:52 p.m., indicated Back in May, a wound specialist came and assessed particular residents, residents with rash, and Scabies were confirmed. Then, on and off, we get new batches of residents with itching and rash. No, we do not isolate them. During an interview with LN 2, on 11/19/19, at 1:04 p.m., LN 2 stated Resident (Resident 3's name), we sent him to a Dermatologist on 8/23/19 for dry skin, but resident (Resident 3) was sent back with a [DIAGNOSES REDACTED]. During record review of the clinical record for Resident 3, the Dermatologist's order, dated 8/23/19, indicated Resident 3 was prescribed Ivermectin oral medication to be administered once and repeated in a week for Scabies. During an observation, and a concurrent interview with Resident 4, on 11/19/19, at 5:20 p.m., Resident 4 was observed to have a rash throughout both arms and both legs. Resident 4 stated I've had it for couple weeks now. It's itchy everywhere. No, I have not been seen by a doctor or anyone else, except for the treatment nurse. During record review of the clinical record for Resident 4, on 11/19/19, the record did not have any documentation Resident 4 was placed on contact isolation once the current symptoms of potential Scabies were identified. During an observation, and a concurrent interview with Resident 5, on 11/19/19, at 5:57 p.m., Resident 5 was observed to have a rash on both legs as well as on the abdomen. Resident 5 indicated she has had this rash for one month and stated the rash is itchy. Resident 5 also indicated she was last seen by a doctor a month ago, but for something else, not for the rash and itchiness. During record review of the clinical record for Resident 5, on 11/19/19, the physician's orders [REDACTED]. The clinical record did not have any documentation Resident 5 was placed on contact isolation once the current symptoms of potential Scabies were identified. During an observation, on 11/19/19, at 6:07 p.m., Resident 6 was observed to have a rash throughout her body (on the legs, buttocks, abdomen, and on the back). Resident 6 was observed scratching herself. During record review of the clinical record for Resident 6, on 11/19/19, the physician order, dated 11/18/19, indicated Resident 6 was prescribed to be treated with [MEDICATION NAME] cream one time. Clinical record did not have any documentation Resident 6 was placed on contact isolation once the current symptoms of potential Scabies were identified. During an observation and a concurrent interview with Resident 7, on 11/19/19, at 5:57 p.m., Resident 7 was observed to have a rash on both legs. Resident 7 was curled up in bed and with a voice that expressed sadness, kept on repeating over and over I am very itchy. It's very itchy, very itchy . During review of the clinical record for Resident 7, on 11/19/19, the physician order, dated 5/1/19, indicated Resident 7 was prescribed to be treated with [MEDICATION NAME] cream one time. The physician order, dated 11/18/19, indicated once again Resident 7 was prescribed to be treated with [MEDICATION NAME] cream one time. Clinical record did not have any documentation Resident 7 was placed on contact isolation, when Resident 7 exhibited symptoms of potential Scabies back in 5/19 and currently, on 11/18/19. During record review of the clinical record for Resident 8, on 11/19/19, the physician order, dated 11/12/19, indicated Resident 8 was prescribed to be treated with [MEDICATION NAME] cream one time. The order also indicated in addition to the [MEDICATION NAME] cream, Resident 8 was prescribed to be treated with Ivermectin oral medication once and repeated in a week. Clinical record did not have any documentation Resident 8 was placed on contact isolation when Resident 8 developed symptoms of potential Scabies. During record re

Based on observation, interview and record review, the facility failed to ensure the right of one unsampled resident (Resident A) to be free from abuse. On the afternoon of 6/25/11, three Certified Nursing Assistant (CNA) students witnessed Staff 1 abuse the cognitively impaired, dependent resident. The students reported that Staff 1 used verbal and gestured language to threaten Resident A, spoke to the resident in a derogatory manner, and deliberately sprayed water into his face while showering him. Findings: On 6/28/11 at 5:12 p.m., the Administrator received a faxed report alleging that three CNA students witnessed Staff 1 abuse Resident A in a facility shower room on 6/25/11 at approximately 1:30 p.m. In the report, the students stated that Staff 1 was rough with Resident A, told the resident , "I will cut your balls off", tapped the resident on his scrotum, talked to another CNA about how bad Resident A smelled, and called the resident "stinky". Staff 1 was suspended by the facility pending investigation of the allegation. The allegation of abuse was substantiated, and Staff 1 and was terminated by the facility following the investigation. During a tour of the facility on 6/27/11 beginning at 10:00 a.m., Resident A was observed sitting in his wheelchair in his room. An attempt was made to communicate with the resident, but was not successful. The resident did not speak when spoken to. Resident A's record was reviewed on 6/30/11 and indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent comprehensive assessment dated [DATE], noted the resident's language preference as Spanish, and that his cognition, decision making skills and ability to communicate were severely impaired. According to the assessment, Resident A rarely or never understood what was said to him, and was rarely or never understood others. The assessment also noted that Resident A was dependent on staff for activities of daily living including bathing, dressing, toileting and personal hygiene, and that he was wheelchair bound and dependent on others for mobility in his wheelchair. On 6/30/11 between 3:40 p.m. and 4:50 p.m., the three CNA students who witnessed the alleged abuse of Resident A on 6/25/11 at 1:30 p.m., were in the facility and were interviewed. The students indicated that they were new, and that Saturday, 6/25/11, was their first day at the facility and at a clinical site. According to the students, they reported what they saw and heard in the shower room to their instructor, on Monday, 6/27/11, when they returned to class, and their instructor told them to write down what they witnessed, then notified the facility and faxed the report. Student 1 was interviewed on 6/30/11 at 3:40 p.m. regarding her observations in the shower room on 6/25/11, between Staff 1 and Resident A. She indicated that she was following Staff 2, that Staff 2 took Resident A to the shower room, and that Staff 1, the shower aide, told Resident A that he stunk. Student 1 also stated that Staff 1 handed her the water wand to wash Resident A, then took the wand away from her and sprayed water in the resident's face. She reported that Resident A winced when the water hit his face, and indicated that the way Staff 1 spoke to Resident A was degrading. On 6/30/11 at 4:05 p.m., Student 2 was interviewed regarding the report and her observations in the shower room on 6/25/11 at 1:30 p.m. Student 2 stated that she was shadowing (following and observing a competent worker) Staff 2, and that Staff 2 took Resident A to the shower room and left him with Staff 1. She indicated that Student 1 and Student 3 were also in the shower room, and Staff 1 told the students to shower Resident A. According to Student 2, Resident A was holding his body stiffly and they asked for assistance. Student 2 stated that Staff 1 bent down in front of Resident A, told the resident in Spanish and in English that she would cut off his balls, used her hand to mimic a pair of scissors, and placed her hand beneath the seat of the shower chair and flicked her fingers, as if to hit his scrotum. Student 2 indicated there was another CNA (Staff 3) in the shower room and Staff 1 was speaking to her in Spanish and in English about how bad Resident A smelled. She also stated that Resident A was taken into the shower, and while the students were trying to wash him, Staff 1 took the water wand, sprayed water in the resident's face two times, and stated, "oops I'm sorry (resident name)", each time. In an interview on 6/30/11 at 4:50 p.m., Student 3 stated that Resident A was taken to the shower room for a shower on the afternoon of 6/25/11. Staff 1 was in the shower room, was rough when taking off Resident A's pants, and pulled his pants off quickly. She indicated that Resident A leaned forward and Staff 1 told him in Spanish and in English that she would cut his balls off. Student 3 stated Staff 1 pushed the resident into the shower area, told the students to shower him, and while they were showering Resident A, Staff 1 took the water hose and sprayed water in the resident's face two times. She indicated that Resident A couldn't talk and that she was shocked and horrified by Staff 1's treatment of [REDACTED].