Every finding on record at Napa Post Acute

Based on interview and record review the facility failed to implement the care plan of one of six sampled residents (Resident 1) when nurses did not document pain assessments for three shifts during Resident 1's first two days of admission. This failure caused Resident 1 to feel panicked when her pain became out of control.During a phone interview on 5/20/26 at 11:03 a.m., Family Member (FM) stated Resident 1 was in quite a bit of pain during Resident 1's first day at the facility. FM stated that Resident 1 had suffered multiple fractures (broken bones) just three days prior to her admission to the facility, two in her spine and one in her pelvis. FM stated Resident 1 was on round-the-clock pain medications when she was at the hospital, taking oxycodone (a narcotic pain medication) every six hours. FM stated when Resident 1 was transferred to the facility from the hospital she did not receive any pain medication her first day and this caused Resident 1 a lot of panic because her pain was getting out of hand. FM stated that family had to be there with Resident 1 every day to advocate for her because when she asked for pain medication she would have to wait hours for the nurses to bring it. Review of Resident 1's face sheet indicated she was admitted on [DATE] with multiple diagnoses including acute pain due to trauma, fall on/from stairs, fracture of thoracic vertebra (bone in the middle of the back), fracture of sacrum (bone at the bottom of the spine), fracture of left pubis (the front of the pelvis), and panic disorder, among others. Review of Resident 1's April 2026 medication administration record (MAR) indicated the first dose of pain medication given to Resident 1 was oxycodone 5 mg (milligrams) administered on 4/26/26 at 7:42 a.m. with a pain score of 8 (on a scale of zero to 10, where zero is no pain and 10 is worst pain imaginable). Further review of Resident 1's April 2026 MAR indicated Resident 1 was not given a second dose of pain medication until the next day, 4/27/26, when Resident 1 was given oxycodone 5 mg at 8:15 a.m. Review of Resident 1's nurse progress notes, dated 4/25/26, written by Licensed Nurse A, indicated Resident 1 arrived to the facility from the hospital on 4/25/26 at 6 p.m. with no complaints of pain stating, I am comfortable in this position. Review of Resident 1's care plan for pain, dated 4/25/26 indicated interventions included assessing her pain every shift and as indicated. Review of Resident 1's pain assessments indicated no pain assessments were documented between her arrival on 4/25/26 at 6 p.m. and 4/26/26 at 7:42 a.m. (over 13 hours, including all of Noc shift), and no pain assessments between 4/26/26 at 7:42 a.m. and 4/27/26 at 8:15 a.m. (over 24 hours, including all of PM shift and Noc shift). During an interview on 6/1/26 at 1:12 p.m., Licensed Nurse A stated she remembered Resident 1's admission to the facility. Licensed Nurse A stated she recalled that when she did Resident 1's skin assessment, Resident 1 did not want to roll onto her side so that Licensed Nurse A could look at her back because rolling on her side would cause too much pain. Licensed Nurse A verified that when she wrote in her progress note that Resident 1 said, I am comfortable in this position, Resident 1 was saying she did not want to move because it caused her pain to move. Licensed Nurse A stated she did not give Resident 1 pain medication because Resident 1 stated she was not having any pain in that moment. During a record review and concurrent interview on 6/1/26 at 1:57 p.m., Director of Nursing (DON) reviewed Resident 1's care plan and verified one of the interventions was to assess pain every shift. DON verified there was only one pain assessment documented between Resident 1's arrival at 6 p.m. on 4/25/26 and 8:15 a.m. on 4/27/26 and verified nurses' documentation of pain assessments had been missed. DON stated it was her expectation that if a pain assessment was conducted, the nurse should document the assessment. DON stated that if the care plan included assessing pain every shift, the admission nurse should have entered a nursing order so that the nurses would be prompted to document a pain assessment on the MAR. DON stated pain assessments were important because they want to address the resident's comfort and medicate them as appropriate. Review of facility policy and procedure, Care Plans, Comprehensive Person-Centered, last revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview and record review the facility failed to maintain the dignity of two of six sampled residents (Residents 2 and 3) when they were not assisted with toileting timely. This failure caused both Resident 2 and Resident 3 to be left in bedding soaked in urine for over an hour and caused Resident 2 to feel dirty and gross.During an observation and concurrent interview on 5/20/26 at 11 a.m., Resident 2 was sitting in bed with her husband seated at her bedside. Resident 2 stated she had long waits for call light response. Resident 2 stated every evening she would sit for hours in a wet bed. Resident 2's husband verified he had witnessed this. Resident 2 stated she could not say how long she had to sit in a wet bed, but it was long enough that the urine on the sheets dried and she smelled like urine. Resident 2 stated it made her feel dirty and gross. During an observation and concurrent interview on 5/20/26 at 11:47 a.m., Resident 3 was in a wheelchair at Resident 4's bedside. Resident 3 stated she and Resident 4 were roommates. Resident 3 stated she had long waits for a response to her call light, sometimes over 30 minutes. Resident 4 verified it took over 30 minutes for staff to respond when Resident 3 pressed her call light. Resident 3 stated she was continent but had had accidents in her bed every other day since admission due to long waits for assistance to the bathroom. Resident 3 stated the staff told her not to get up without them. Resident 3 stated she could get to the bathroom in time if they would just let her go by herself. Resident 3 verified she was sitting in a wet bed the whole time she was waiting. Resident 3 stated yesterday (5/19/26) in the morning she was just soaked [with urine] and her aide was interrupted multiple times while cleaning her up, the therapist came to work with her, and had to leave because she had not finished cleaning her up. During an interview on 5/21/26 at 1:28 p.m., Unlicensed Staff (US) B stated it was her goal to answer the call light as soon as possible. US B stated it was important to answer lights quickly because the residents need something, they need help, there were a lot of reasons. US B stated Resident 2 and Resident 3 were on her assignment. US B stated Resident 2 was sometimes continent and sometimes not, and Resident 3 was continent. US B stated that today (5/21/26) Resident 3 had to wait over an hour for help to the bathroom. US B stated Resident 3 needed help but she (US B) was tied up with another resident who had therapy waiting for them. US B stated since she was not able to help right away, she asked another staff to help Resident 3. US B stated that when she came back, no one had helped Resident 3, so it was at least an hour or more she was waiting for help. US B stated Resident 3 needed help to the bathroom, to get cleaned up, and to get dressed because she wanted to go to the dining room for lunch. When queried, US B stated that if a resident who was continent had an accident in bed, they often felt bad and apologized, but she tells them it's ok, not to worry, no need to be sorry.During an interview on 5/21/26 at 3:30 p.m., Director of Staff Development (DSD) stated it was her expectation that residents get assistance within two minutes when they pressed their call lights. DSD stated 30 minutes was too long for residents to wait for help. DSD stated if a resident was sitting in wet bedding from having an accident in bed, they should be changed immediately, have their bedding changed, and be helped to the shower. DSD stated that if a resident who was continent had an accident in bed, it would probably be embarrassing for them.Review of Resident 2's face sheet indicated an admission date of 5/9/26 and multiple diagnoses including cerebral infarction (stroke, a blockage of the blood flow to the brain), abnormality of gait and mobility, and need for assistance with personal care, among others. Review of Resident 2's MDS (minimum data set, an assessment tool) indicated Resident 2 was completely dependent on staff assistance for toileting.Review of Resident 3's face sheet indicated an admission date of 5/13/26 and multiple diagnoses including falls, overactive bladder, and abnormalities of gait and mobility, among others. Review of Resident 3's document titled Bowel and Bladder Observation/assessment dated [DATE], indicated Resident is continent of bowel and bladder with occasional bladder incontinence. [Wheelchair] bound with moderate 1 person transfers.Review of facility policy Resident Rights, last revised 8/2009, indicated, Employees shall treat all residents with kindness, respect, and dignity.Review of facility policy Call System, Residents, last revised 9/2022, indicated, Calls for assistance are answered immediately. Urgent requests for assistance are addressed immediately.Review of facility policy, Activities of Daily Living (ADL), Supporting, last revised 3/2028, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview and record review, the facility did not initiate the process to replace or reimburse missing dentures for one of three sampled residents (Resident 1) after they were lost at the facility, and instead, filed a claim with Resident 1's own dental insurance company for replacement, rather than assuming financial responsibility.This failure may have contributed to Resident 1 experiencing a weight loss of over nine pounds over the past month, as well as feelings of discomfort regarding dental status leading her to wear a mask. In addition, this had the potential to result in dental insurance fraud.A review of Resident 1's admission Record (facility demographic) indicated she was admitted to the facility on [DATE] with medical diagnoses which included ataxia (lack of muscle coordination), diabetes mellitus (chronic medical condition characterized by high levels of glucose [sugar] in the blood) and feeding difficulties. This document also indicated Family Member XX was Resident 1's responsible party (RP) and financial decision maker.Record reviewof Resident 1's Minimum Data Set (MDS, an assessment tool) dated 2/24/26 indicated her BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 12, which indicated her cognition was moderately impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact).During a phone interview on 4/07/26 at 9:04 a.m., Family Member XX reported that the facility had informed her around 3/20/26 of the loss of Resident 1's partial dentures, which Resident 1 had upon admission. Family Member XX stated that Resident 1 last observed the dentures placed on her meal tray and suspected they may have been inadvertently disposed of by staff during tray collection. Family Member XX indicated that Resident 1 was now experiencing difficulty eating and felt self-conscious about the absence of teeth, as demonstrated by consistent mask-wearing. Family Member XX further stated that she was notified by facility staff that a dental insurance claim for replacement of Resident 1's dentures had been denied, appealed, and could require additional time for resolution. Family Member XX expressed concern regarding the management of this situation.A review of Resident 1's inventory sheet (list of personal belongings) dated 2/23/21, and signed by a facility representative, verified Resident 1 possessed partial dentures when admitted to the facility.During an interview on 4/07/26 at 9:35 a.m., Social Services Director A (SSD A) stated that the facility's dentist (Dentist B) had evaluated Resident 1 following the loss of her dentures, which occurred around 3/23/26. SSD A stated that Dentist B submitted a claim to Resident 1's dental insurance for denture replacement, which was denied, however, an appeal of the denial was in the process of being filed and a response was pending. Additionally, SSD A explained that the case was complex because Dentist B had informed her that functional well-fitting dentures could not be created for Resident 1 without extractions of her remaining teeth prior to creating new dentures; however, Resident 1 was reluctant to have her natural teeth extracted. SSD A provided Dentist B's contact information, but efforts to reach Dentist B by phone were unsuccessful after two attempts.During a concurrent observation and interview with Resident 1 in her room on 4/07/26 at 11:05 a.m., she was observed wearing a face mask unlike other residents. Prior to this interview, the resident was observed in the activities room with other residents also wearing her mask. During the interview, when asked about the circumstances regarding her missing dentures, Resident 1 stated, A girl [staff member] threw them away. Resident 1 acknowledged she was wearing a mask due to feeling self-conscious about not having teeth. Resident 1 confirmed she needed her dentures, which had not been replaced yet. When questioned about her willingness to undergo extraction of her natural teeth for new dentures, she stated that she was agreeable to the procedure.A review of SSD A's progress note dated 4/02/26 at 6:41 a.m., indicated, SSD [SSD A] received a message from [health insurance company] informing SSD that [Family Member XX] was concerned with pt. [patient, Resident 1] not eating due to not having her partial [partial dentures]. [Dentist B] replied back stating that an authorization was submitted to insurance with denied claim due to pt. not wanting to proceed with extractions. [Dentist B] spoke with [Family Member XX] who advised [Dentist B] to proceed with an appeal.During a second phone interview with Family Member XX on 4/07/26 at 11:53 a.m., she stated that the facility did not offer her the option to pay directly for Resident 1's missing dentures, and instead, she was given the choice to file a claim with Resident 1's dental insurance company for replacements, which she accepted, not being conscious of other solutions. Family Member XX further stated that both she and Resident 1 initially disagreed with proceeding with tooth extractions in December of 2025, however, they had not been asked again after the dentures went missing. Family Member XX stated consent for the extraction of Resident 1's remaining teeth should it be necessary for the provision of new dentures.During a second interview on 4/07/26 at 12:05 p.m., SSD A confirmed that there were no notes or documentation on Resident 1's medical record, from Dentist B regarding her missing dentures, although Resident 1 had been evaluated by Dentist B, last week, with no specific date provided. When questioned about the rationale for filing a claim with Resident 1's insurance company for the replacement of the missing dentures rather than having the facility bear the cost, SSD A stated, [Dentist B] stated he would try the insurance first and go from there. SSD A was also asked whether Family Member XX or Resident 1 had been consulted about tooth extractions required for the replacement of the dentures after their loss; she responded that she did not know, as she was not present during Dentist B's discussion with them. Additionally, when asked about the required timeframe for initiating the replacement or reimbursement process for missing dentures, SSD A stated that the facility was required to begin within three days of the dentures being reported missing. A review of Resident 1's weight records for March and April of 2026, indicated she lost 9.6 pounds from 3/06/26 to 4/07/26, which was 3% of her total body weight. Yet, from 2/05/26 to 3/05/26, when Resident 1 still had her dentures, she had only lost one pound.A review of an email sent by the Surveyor to the Medical Records Director on 4/07/26 at 11:40 a.m. indicated that the Surveyor requested the facility's policy regarding lost or missing personal items belonging to residents. The facility responded by emailing a policy titled, Investigating Incidents of Theft and/or Misappropriation of Resident Property, on 4/08/26 at 12:24 p.m. This policy did not address the facility's financial responsibility for residents' possessions lost during their stay, instead, it outlined procedures for conducting investigations following incidents involving theft or misappropriation.

Based on observation, interviews and record reviews, the facility failed to develop and maintain an effective infection prevention and control program and a system for preventing, identifying, reporting, investigating, and controlling infections, including establishing policies and procedures, when A. facility staff could not prevent a C-Diff (C. diff- a highly contagious bacteria that causes severe diarrhea) outbreak, B. facility did not follow water management requirements for Legionella (a type of bacteria naturally found in freshwater, that becomes a health concern when it grows in man-made water systems; people get sick (severe pneumonia) by inhaling mist that contains the bacteria), and C. and open sewage pipe was observed in a communal shower room which also stored medical equipment.These failures had the potential to cause the spread of infection among a vulnerable resident population and resulted in harm to at least 8 residents who were confirmed positive for C. Diff. between 11/12/25 and 1/24/26, and three residents (Resident 31, Resident 60, Resident 102) who were identified with active C.Diff. on 2/2/26. On 2/4/26 at 3:25 p.m., the Administrator was notified verbally by the nurse surveyor in his office of an IMMEDIATE JEOPARDY (IJ) (Immediate Jeopardy is a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. (State Operations Manual, Appendix Q), was identified, under S483.80 Infection Control, due to the facility's failure to maintain an effective infection control program which had resulted in three sampled residents (Resident 31, Resident 60, and Resident 102) who were in Isolation for active infection of Clostridium Difficile (Cdiff) on the day of entrance 2/2/26. The Administrator was informed that the survey team's findings were: 1. Eight residents were confirmed positive for C. Difficile between 11/12/25 through 1/24/26. 2. The Infection Preventionist (IP) was unable to describe the facility's surveillance program to monitor communicable diseases. 3. The IP was unable to provide a tracking log for communicable diseases. 4. Bedside care staff were unable to verbalize the appropriate disinfectant to use for shared care equipment to prevent the spread of C. Difficile. 5. Staff failed to use an appropriate blood pressure cuff for contact isolation. 6. The facility did not have a policy and procedure for C. Difficile. 7. The hand-washing station at the nurses station next to a room with a resident with C. Difficile was not fully stocked and did not have warm water. 8. Two residents with C. Difficile had a shared bathroom with residents who did not have C. Difficile. 9. Staff were observed providing direct care to a resident on contact precautions without gowns.On 2/5/2026 at 10:30 a.m. the Administrator and Director of Nursing were notified the facility plan of removal of IJ draft #1 was not acceptable and were informed of needed revisions. On 2/5/26 at 2:17 p.m., the Administrator provided plan of removal of IJ draft #2.On 2/5/26 at 3:29 p.m., the Administrator was notified plan of removal of IJ draft #2 was rejected.On 2/5/2026 at 3:45 PM the survey team left the facility, and the Administrator was notified to send the plan of removal for IMMEDIATE JEOPARDY via email. On 2/5/2026 at 5:50 p.m. the facility emailed plan of removal of IJ draft #3.On 2/6/2026 at 12:15 p.m. the plan of removal of IJ draft #3 was accepted via email. Draft #3 included facility actions that included: 1. The C. Diff policy and procedure was updated to include the use of bathroom, frequency of cleaning and disinfecting of equipment, rooms, and bathrooms. 2. The IP was trained on the infection surveillance program/monitoring and tracking as well as the facility's Infection Control and Prevention Program. 3. The IP completed in-services with all Licensed Nurses and Certified Nursing Assistants on the policy and procedure for C.diff, including appropriate use of personal protective equipment. 4. The IP or designee will be responsible for ensuring every isolation room has its own dedicated vital signs equipment and cleaning solution. 5. All 116 residents' medical records were reviewed by the Director of Nursing (DON) and IP to determine whether they have had any change of conditions that would indicate C.diff infection. 6. The Medical Director will be responsible for providing solutions and measures to prevent the spread of infections.On 2/7/26 at 11:45 a.m., validation of the removal of the IMMEDIATE JEOPARDY (IJ) under S483.80 Infection Prevention was conducted in the presence of Administrator after interviews, observations, and record review confirmed the facility implemented the removal plan. Findings: A. During an observation and interview on 2/3/26 at 3:40 p.m., Housekeeper P on the East Wing stated that when he cleaned the rooms of residents with C. Diff he used Clorox and he held up a spray bottle of Clorox disinfectant spray. During an interview on 2/3/26 at 4 p.m., Licensed Nurse N stated residents with C. Diff should have their own dedicated vital signs equipment. During an interview on 2/3/26 at 4:10 p.m., Unlicensed Staff II explained the isolation precautions for a resident with C-Diff. The staff member said they must gel in, wear a gown, gloves, and mask, dispose of the gown and gloves in the room's trash cans, and wash hands with soap and water. The portable blood pressure device should be sanitized with wipes that have a lavender top. During an observation and concurrent interview on 2/3/26 at 4:10 p.m., Unlicensed Staff JJ noted that designated equipment should be used in the C-Diff isolation room. However, the portable blood pressure device is often brought into the room and cleaned with the provided lavender-topped Medline MicroKill One germicidal alcohol wipes, rather than the blue topped Medline MicroKill Bleach disinfection solution for C-Diff. During an observation and interview on 2/3/26 at 4:20 p.m. Unlicensed Staff J was observed to exit Resident room [ROOM NUMBER] and did not engage in hand hygiene. He stated he was supposed to wash his hands with soap and water and he forgot. He stated the risk to residents if he did not wash his hand was the spread of infection. During a concurrent observation and interview on 2/3/26 at 4:20 p.m. in west hallway with Unlicensed Staff BB, Unlicensed Staff BB stated for Resident's that are on isolation precautions she checked their vital signs using the shared vitals equipment tower and would then disinfect using the violet topped wipes. Unlicensed Staff BB reviewed the active ingredients list on violet topped wipes and concurred it lists ethyl alcohol as the active ingredient and the container did not indicate that it was effective against Clostridium Difficile (C. diff- a highly contagious bacteria that causes severe diarrhea). Unlicensed Staff BB further stated she could not recall receiving infection control education when she started working at the facility in 09/2025, only what she had learned in school for certification. During an interview on 2/3/26 at 4:30 p.m. with Unlicensed Staff PP he stated If a resident was on precautions for C.diff it would mean they were on isolation and stated residents were supposed to have dedicated equipment that stays in the room. During an interview on 2/3/26 at 4:41 p.m. in the east hallway with Unlicensed Staff D, Unlicensed Staff D stated she used the shared vitals equipment tower for Resident 31 who is on Isolation Precautions and disinfected the vitals tower using the blue top bleach wipes in Resident 31's room. Unlicensed Staff D further stated that Resident 31 used to have her own vitals equipment in her room but it had broken. During an observation and interview on 2/3/26 at 4:30 p.m., Housekeeping Supervisor removed a bottle of Clorox disinfectant spray from the housekeeping cart for the [NAME] Wing and stated it was the product the housekeeper used to clean rooms for residents with C. Diff. During an observation and interview on 2/3/26 at 4:45 p.m. with Housekeeping Supervisor and IP, Housekeeping Supervisor stated she just found out the Clorox product the housekeepers were using was not effective against C. Diff and they were now in-servicing the housekeeping staff to use the blue-top bleach wipes. Housekeeping Supervisor held up a container of the bleach wipes. The label indicated, Kills C. Diff spores in 3 minutes. When asked if she reviewed the products the housekeeping staff used, IP stated she was not involved with which products the housekeeping department ordered. During an observation on 2/4/26 at 11:15 p.m. in Contact Precautions room [ROOM NUMBER] for Resident 60, no blood pressure cuff was observed hanging or in the drawers of the bedside table. No blood pressure cuff was observed in the bathroom. During an interview on 2/4/26 at 11:30 a.m. in east hallway with Unlicensed Staff CC, Unlicensed Staff CC stated she was educated today by the DON to use the blue top bleach wipes to disinfect the shared vitals equipment tower but that Residents who are on isolation precautions should have their own equipment. During an interview on 2/4/26 at 11:35 a.m., Unlicensed Staff GG stated she had a resident with C. Diff on her assignment, Resident 31, and stated she used the same vital signs tower to take all her residents' vital signs including the resident with C. Diff. Unlicensed Staff GG stated she cleaned the vital signs equipment with the container of disinfecting wipes with the violet top after use in between residents. During an interview on 2/4/26 at 11:43 a.m., Licensed Nurse Z verified she had a resident with C. Diff on her assignment, Resident 31. Licensed Nurse Z stated residents with C. Diff should have dedicated vital signs equipment. During an interview on 2/4/26 at 11:50 a.m. in the east hallway with Unlicensed Staff DD, Unlicensed Staff DD stated for Residents on isolation precautions she would use the shared vitals equipment tower and disinfect with the blue top bleach wipes and allow to sit for 3 minutes. Unlicensed Staff DD further stated she had not received any additional infection control education this morning when she started her shift. During a concurrent observation and interview on 2/4/26 at 12:15 p.m. with Licensed Nurse EE and Resident 31 inside Resident 31's room, no dedicated vitals equipment is observed, Licensed Nurse EE confirms this. Resident 31 stated she used to have her own equipment but it broke and staff clean the shared vitals equipment after use using the blue top bleach wipes. After exiting Resident 31's room Licensed Nurse EE went to wash her hands at the nurses station in east hallway. Licensed Nurse EE concurred the water from sink remained very cold after 4 minutes of running and there were no paper towels in the dispenser. At this time the vitals tower in east hallway is observed with the violet top disinfectant present in basket. Licensed Nurse EE stated staff should be using the blue top bleach wipes now because the violet top disinfectant does not kill C-Diff. Licensed Nurse EE could not verbalize if the BP cuff on vitals tower was able to be properly disinfected due to its porous Velcro surfaces. During an interview on 2/10/2026 at 3:02 p.m., Unlicensed Staff J stated the way to clean a blood pressure cuff that would come out of a contact precautions room for C.diff would be to use bleach wipe on the blood pressure cuff for 3 minutes and let it air dry. During an observation and interview on 2/4/26 at 11:58 p.m. Licensed Nurse Q observed Contact Precautions room [ROOM NUMBER] for Resident 60 and stated she did not see any dedicated vital sign equipment in the room. She stated staff had to take one of four shared vital sign rolling towers into the room to take vital signs and then wipe it down with a bleach wipe when you brought it out of the room. She stated Resident 60 shared a bathroom in two residents in room [ROOM NUMBER]. She stated the resident in room [ROOM NUMBER] were not on isolation precautions. During an observation and interview on 2/4/26 at 12:50 p.m. DON observed that Resident 60's room [ROOM NUMBER] was a clostridium difficult contact precautions room and he shared a bathroom with room [ROOM NUMBER], who were two residents in a non isolation. She stated the residents in room [ROOM NUMBER] did not have C.diff. She stated sharing a bathroom was not an infection risk. She stated Resident 60 would not take a shower because he had Cdiff and would have to take a bed bath. She said the bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] would have to be cleaned every time Resident 60 used it. She was unable to explain how that would be monitored and who would clean the bathroom. DON stated you could put a commode (portable toilet) in Resident 60's room and not have him use the bathroom. She could not describe how the commode would be emptied by staff after use if they did not use the shared bathroom between room [ROOM NUMBER] and room [ROOM NUMBER]. She stated the blood pressure cuff and reuseable vital signs Tower would be used in a contact precautions room. She stated staff wiped it with a bleach wipe inside the contact precaution room. An observation in room [ROOM NUMBER] did not indicate a bleach wipe cannister immediately available for staff to sanitize and disinfect the reusable vistal sign equipment. She stated staff had to ask the licensed nurse to get the wipes out of their medication carts. DON stated staff used reuseable stethoscopes in contact precaution rooms. She went into the west nursing station and opened a drawer and stated these are the stethoscopes used in contact precaution rooms. She stated staff wipe them with a bleach wipe before returning them to the drawer. She stated there were only a couple of vital sign towers in the facility and the facility could not leave them in the isolation rooms and be a dedicated contact precaution vital sign tower. During an interview on 2/4/26 at 12:59 p.m. Licensed Nurse Q, she stated she thought the infection preventionist had purchased a new vital sign tower and was not sure if the vital sign tower goes into the contact precautions rooms or not. During an interview on 2/4/26 at 1:15 p.m., Infection Preventionist stated a person in a contact precautions room should be the last person on the unit to take a shower in the shower room. She stated expectations were staff are supposed to communicate to housekeeping to come in and disinfect the shower afterwards, She stated there was no documentation about that communication and there's no way to tell If the shower has been disinfected after the last person took a shower or not. Infection Preventionist stated that room [ROOM NUMBER] and room [ROOM NUMBER] shared a bathroom and staff would have been cleaning the bathroom after each use with bleach wipes. She stated staff have to get the bleach wipes from the nurse's station because they are not left in the room. She could not state how staff would know when to go in and clean up the bathroom after use if the residents are independently using the bathroom. She stated the facility would set up a bedside commode and put a sign on the door not to use the bathroom, and she could not answer how staff were supposed to empty a commode that had been used if the bathroom was off limits. During an interview on 2/4/26 at 3:20 p.m., DON stated she was not concerned about a Cdiff resident sharing a bathroom with non Cdiff residents. She stated there was no process to have staff clean the bathroom with bleach wipes every time a resident used it to reduce the risk of cross contamination. DON stated that they would put a commode in the contact precautions room. She did not respond when asked where staff would empty the commode if the bathroom was not being used. She did not respond when asked if there was an infection risk for non-contact precautions residents to share a bathroom with a contact precautions resident if they used the bathroom to brush their teeth. She stated she did not know if housekeeping was using disinfecting solution in their cleaning buckets that would eliminate Cdiff and would have to ask them. During a phone interview on 2/5/26 at 10:47 a.m., Medical Director stated the Infection Control Safety Committee Meetings were monthly and he attended the January 2026 meeting. When queried, Medical Director stated the committee told him they needed to do more hand hygiene surveillance and he told them to follow through on that. Medical Director verified he acted as a consultant for the facility when he came to the facility to do his rounds and the staff asked him questions. Medical Director stated he was also available by phone. Medical Director verified he was concerned about the eight residents who had tested positive for C. Diff and verified he was concerned it was an outbreak. Medical Director stated he advised the facility staff to keep doing proper hand hygiene and follow the C. Diff guidelines, but stated he could not supervise the nurses, he could only make sure they did what was needed for the residents' medical care. During an interview and observation on 2/10/26 at 7:15 a.m., Unlicensed Staff G stated the resident in room [ROOM NUMBER]B was originally in room [ROOM NUMBER]C but then she was positive for Clostridium difficile and move to 1B on February 9th 2026. He looked at the contact precautions signage next to the door on 1B and stated in contact precautions you were supposed to wear PPE, and do hand hygiene. He stated he did not know he was supposed to use soap and water for 20 seconds for contact precautions. He stated there was no difference between the contact precautions room [ROOM NUMBER]B and the Transmission-based precaution room [ROOM NUMBER]. During an observation and interview on 2/10/26 at 8:55 a.m. Nurse Practitioner U was observed to walk out of room [ROOM NUMBER] towards the west nursing station. She stated she was walking to the nursing station to wash her hands with soap and water. She stated she did not wash her hands in room [ROOM NUMBER] bathroom because it was considered dirty and contaminated and the hand hygiene sink in the west nursing station had the lowest risk of infection. She was not able to state what the facility Policy and Procedure was for hand hygiene was after providing direct care in a contact precaution room. During a review of Resident 102's medical records on 2/3/26, it was noted in a Change of Condition report dated 11/6/25, that the resident had experienced several loose stools. The physician was notified and subsequently ordered a stool specimen to test for Clostridium difficile (C-Diff). The specimen was collected on 11/6/25. The results, dated 11/6/25, indicated that Resident 102's specimen was positive for C-Diff. Medical orders dated 10/21/25 included an order for Vancomycin 125 mg to be administered orally four times a day for C-Diff, starting on 11/6/25. A bed transfer report dated 11/10/25 indicated that Resident 102 was moved to an isolation room on 11/10/25, several days after the positive C-Diff report. During a review of Resident 31's medical records on 2/3/26, Resident 31's MD orders for 12/19/25 to 2/28/26 included order Stool sample for possible C-diff. one time only for 3 days, ordered 1/10/26. Resident 31's laboratory report dated 1/13/26 indicated the stool specimen was collected on 1/11/26 and resulted on 1/13/26 showing Resident 31 was positive for C-diff. MD orders also included: Enteric precautions (isolation) for c-diff infection every shift, ordered 1/14/26, and Vancomycin HCL oral Suspension 50 mg/ml Give 5 ml by mouth every 6 hours for positive C. Diff for 14 days ordered 1/13/26 started 1/14/26. Nurse Progress note dated 1/14/26 indicated Resident 31 was moved to the isolation room [ROOM NUMBER]/14/26 due to the laboratory report. During a review of Resident 7's medical records on 2/3/26, it was noted in the CNA task sheet that Resident 7 had loose stools between 1/22/26 and 1/23/26. Resident 7's MD orders dated 1/1/26 to 1/3126 included: Labs-test of c-diff one time only for 1 day please collect sample .date 1/22/26. Resident 7's laboratory report dated 1/27/26 indicated the stool specimen was collected on 1/23/26 and resulted on 1/27/26 showing Resident 7 was positive for C-diff. MD orders also included: Diffcile Oral Tablet 200 mg, give 1 tablet by mouth two times a day for c-diff for 14 days, start date 1/27/26 and Contact Precautions (isolation) related to a positive c-diff result every shift, start date 1/28/26. Nurse progress notes dated 1/27/26 indicated the roommate was relocated. During a review of Resident 60's medical records on 2/3/26, it was noted that the CNA task sheet indicated Resident 60 had 12 loose, runny stools on 1/15/26, 1/18/26, 1/20/26, to 1/21/26. Nurse Progress notes dated 1/18 /26 indicated Notes: Stool specimen collected and picked up. Results pending. All needs attended by staff accordingly. Will continue to monitor. Change of Condition notes dated two days later on 1/20/26 at 11:30 a.m. indicated a Change of Condition Resident lab results came in today. Clarifying that res. is positive for C.Diff. Res. BM (Stool) is loose, soft, foul smelling and had a discharge like consistency. An Infection Notes dated 1/21/26 at 11:08 a.m., two days after sending in a stool specimen for suspicion of Cdiff, indicated On 1/20/26 Resident stool specimen results came back with +C Diff. Contact precautions were initiated. A document titled Care Plan, revised 1/21/26 indicated Resident requires[+}Contact Precaution due to +Clostridium Difficile (+C.Diff). During a record review on 2/3/26, of the facility Infection Prevention Policy and Procedure Manual, revised 9/2023 on 2/3/25, approved by the Patient Care Committee on 1/15/25, it indicated [name of affiliated facility] Infection Control Plan. No Policy and Procedure or protocol for Clostridium Difficile was observed, and no national standards for infection control were cited as a resource. POLICY: It is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. In LTC (Long Term Care) , it is appropriate to individualize decisions regarding resident placement (share or private), balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission . Room Placement: will depend on the epidemiology of the specific microorganisms, the ability of the resident to assist in confining and containing the microorganisms and the temporal relationship of the known infected or colonized residents to newly identified cases. Dedicated use of non-critical care equipment (i.e. sphygmomanometer (blood pressure cuff and equipment), stethoscope, and thermometer) will be provided to MDRO (Multi drug resistant organism) and other pathogenic microorganism. Review of a facility document titled Surveillance Info Log date 2025 and 2026, it indicated a total of 11 resident cases of Cdiff were identified between 2/6/25 to 2/6/26. A document titled CDC (Centers for Disease Control) C.Diff Facts for Clinicians, dated 3/5/24, indicated Clinical features, Watery diarrhea, fever, Loss of appetite, Nausea, Abdominal pain or tenderness. Treatment and recovery. If a patient has had three or more stools in 24 hours: Isolate patients with possible C. diff immediately, even if you only suspect CDI. During a record review on 2/3/26, the facility Infection Prevention Policy and Procedure Manual, was observed to include Appendix PP F880 documentation that indicated The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: .When and to whom possible incidents of communicable disease or infections should be reported; Standard and transmission-based precautions to be followed to prevent spread of infections; When and how isolation should be used for a resident; including but not limited to: The type and duration of the isolation, depending upon the infectious agent or organism involved. The hand hygiene procedures to be followed by staff involved in direct resident contact. A record review of a document titled M3 Vital Signs Monitor Version 2.5 USER MANUAL, not dated, indicated WARNING The monitor and reusable accessories shall be disinfect to avoid patient cross infection. Disinfecting the Blood Pressure Cuff: .1. Take out the air bladder (The balloon inside a material blood pressure cuff that inflates during a blood pressure reading) before disinfection. 2. Wipe the cuff and the air bladder with a soft cloth dampened with the disinfectant solution. 3. Leave the cuff and air bladder to air dry for at least 30 minutes. B. During an interview on 2/11/25 at 8:45 a.m., the Infection Preventionist could not to fully describe the facility's Legionella prevention program or monitoring activities related to the facility's Water Management Program (WMP, a documented plan to systematically prevent and control germs in water systems). She stated the facility had the water tested in February 2025. She was unable to state what the results were or what was being done to ensure residents risk of exposure to Legionella was reviewed and monitored. The Infection Preventionist confirmed that Legionella monitoring and prevention were not discussed in the Infection Control Committee (ICC) meetings, since the only ICC meeting that she was aware since she became the Infection Preventionist, took place the first week of February 2026. She stated the Medical Director and Infection Prevention Consults did not attend. She stated that Legionella should have been discussed in the ICC meetings after the germs were identified in the water system. During an interview and document review on 2/11/25 at 8:45 a.m. the Administrator stated the facility water system had been tested in February 2025 and had been positive for Legionella. He stated he was not Administrator at that time and was unsure of what was done about the positive test results. He stated he thought the facility had replaced the water heaters and the water lines as a result of the test results. A review of a document provided by the Administrator indicated a document titled LEGIONELLA TEST RESULTS SUMMARY LOG, dated 2/27/25, indicated results of Legionella Bacterium testing on 10 samples taken in the facility on 2/18/25. The document indicated total number of Legionella samples 10, % Positive 90% (9 out of 10 sampled tested positive for Legionella). During an interview with Regional Corporate Director and prior administrator of the facility on 2/11/26 at 11:52 a.m., in the conference room, the Regional Corporate Director confirmed that the water test results indicated the facility's water system contained Legionella in February 2025. The Regional Corporate Director stated that the water system had not been tested since Legionella was first identified on February 27, 2025. During an interview and document review on 2/11/2026 11:52 a.m., Regional Corporate Director and prior administrator of the facility, stated the water testing company had informed him Legionella was common in Napa and it was recommended to perform a hot water flush of all lines would manage the positive test results. He stated the facility conducted a RUN FLUSH for sinks and showers for 30 minutes where the water temp was set at 170-degree Fahrenheit per the water treatment company's recommendations. He stated that was completed on 3/6/25. Regional Corporate Director stated that was supposed to manage the Legionella and a 15-minute run flush every week was performed according to the contractor's suggestion to keep the system safe. He stated a water treatment system was installed later to remove the legionella risk and work completed 8/30/25. He stated the only other testing for Legionella occurred in January or February 2026. He stated the contractor recommended to not test for Legionella again until this year. During an interview with the Administrator on 2/12/26 at 10:35 a.m. he stated that testing for Legionella bacteria in February of 2025 was part of their yearly testing. He stated he was uncertain if there was monitoring for pneumonia after becoming aware of the Legionella contamination. He stated he did not know if the water testing program was discussed in the Quality meeting and he would have to check. During an interview and concurrent record review on 2/12/26 at 12:52 a.m. the Administrator and Facility Nurse Consultant presented a water management plan binder that had been in the facilities office. They stated it indicated that the most recent Legionella test took place on February 9th, 2026, the preliminary test results were not available because the actual Sample hadn't even made it into the lab yet. During an interview and record review on 2/12/26 at 2:01 p.m., the Administrator reviewed a document titled QAPI (Quality Assurance and Performance Improvement) Minutes 2025. It indicated on 3/10/25 that a discussion about the legionella testing results lead to development of a Performance Improvement Plan (PIP) on 3/10/25 with goals to implement a monitoring of the weekly hot water flushing of the water system, review the monitoring and flushing results at QAPI meetings, and implementation of a water management program to monitor results of project and safety of residents. Further review of the minutes did not reflect any further QAPI follow up, discussion or recommendations for repeat testing or completion of a water management plan based on national standards through the end of 2025. The review of the facility's document titled LEGIONELLA TEST RESULTS SUMMARY LOG, dated 2/27/2025, indicated that the facility's water was tested on [DATE]. The test results indicated that the facility's water system contained Legionella. During a record review on 2/11/25 in the conference room the document titled Legionella Test Results Summary Log, dated 2/27/25, it indicated Breakdown of Findings The excessively high levels of legionella along with low to zero chlorine residuals in the hot water system demonstrate that the temperature and stagnancy conditions are favorable for bacterial growth. Occupant Susceptibility VERY HIGH The presence of legionella SGI at such high concentrations represents an immediate risk to patient health. COMMENTS, SUMMARY OF FINDINGS AND RECOMMENDATIONS: Very high levels of legionella SGI and non-pseudomophila legionella were detected at multiple hot water points of use. We strongly recommend the immediate implementation of a water management program to best address specific equipment risks throughout the facility. A water management program is mandated by CMS for any Medic-aid/Medic-care facility. Given the extremely high levels of Legionella SCI, we recommend addressing these results immediately. Legionella SGI is the specific legionella strain most associated with legionella-related deaths. A review of the facility's Infection Control Committee (ICC, a mix of health and care professionals responsible for developing, implementing, and monitoring policies to prevent healthcare-associated infections) minutes, dated February 2025 to February 2026, was conducted. The ICC minutes indicated that there was no discussion or documentation of Legionella monitoring, water system oversight, or risk management (a process to identify potential hazards, reduce risks, and take steps to keep residents safe). C. During a concurrent observation on the northwest resident shower room and interview with the Infection Preventionist on 2/11/26 at 9:50 a.m., the room appeared dim and on the left of the doorway was a space where a toilet might have been and a large diameter pipe close to the floor was observed to be stuffed with wet paper towel. She stated it was an infection risk to have wet paper towels[TRUNC

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 19) sampled for pain management received professional treatment when Licensed Nurse S did not assess, evaluate, treat, or reassess Resident 19's migraine pain.This failure resulted in persistent migraine pain for Resident 19 and affected her overall well-being. A review of Resident 19's admission record indicated she was admitted in 08/2024 with diagnoses of Chronic pain (persistent pain lasting longer than 3-6 months), a burn wound to her left thigh, and Migraine with Aura (severe headaches with visual disturbance such as zig-zag lines, flashing lights or blind spots).A review of Resident 19's Minimum Data Set (MDS-a resident assessment tool) dated 11/17/25 indicated no cognitive impairment.A review of Resident 19's Care Plan last revised 12/15/25 indicated interventions to assess pain at least every shift and as indicated and administer medications as ordered to attain a tolerable pain level per resident report.A review of Resident 19's Physician Order Summary dated 2/11/26 indicated Resident 19 had an injectable medication Sumatriptan Succinate ordered every 12 hours as needed for migraine pain.During an interview on 2/10/26 at 9:20 a.m. with Resident 19 in her room, Resident 19 presented with legs hugged towards her chest, avoided eye contact, fatigued, and grimaced at times during interview. Resident 19 stated pain was her largest obstacle and even with her scheduled pain medications her overall pain level was usually between 7-9 on a scale of 0-10 severity, 0 being lowest level and 10 being the highest level.During a concurrent observation and interview on 2/11/26 at 8:00 a.m. with Licensed Nurse S and Resident 19, medication administration is observed. Resident 19 presented with tired eyelids, and slow speech, she reported migraine pain to Licensed Nurse S. Licensed Nurse S did not further assess her pain level or quality. Resident 19 informed Licensed Nurse S that she had an injectable medication for her migraine pain. Licensed Nurse S went to the med cart and could not find the medication, he checked to see if it had been ordered, and it had been ordered on 2/10/26 at 10:10 a.m. No further action was taken by Licensed Nurse S.A review of Resident 19's eMAR ( an electronic document that records medications, assessments and treatments administered by nurses) on 2/11/26 at 9:38 a.m. indicated no pain level was documented and the migraine medication had not been given.During an interview on 2/11/26 at 10:35 a.m. with Licensed Nurse S, Licensed Nurse S stated he had not assessed Resident 19's pain because she always wanted any pain medication available to her and he concurs he should have obtained a pain level and the migraine medication should be delivered soon.During a concurrent observation and interview on 2/11/26 at 2:00 p.m. with Resident 19 during wound care procedure to left thigh wound, Resident 19 gasped and grimaced during wound care despite the team pre-medicating her, and stated she was feeling extra sensitive due to ongoing migraine pain reported at a level of 7-8.During an interview on 2/11/26 at 3:19 p.m. with Licensed Nurse S while he was sitting at nurses' station east, Licensed Nurse S stated, the migraine medication had been delivered yesterday on 2/10/26 and he had since located it. Licensed Nurse S further stated he had not reassessed Resident 19's migraine pain since 8:00 a.m. this morning nor had he offered her the migraine medication now that it was located.A review of a facility invoice of medication delivery indicated the migraine medication had been delivered on 2/10/26 at 3:52 p.m. A review of Resident 19's eMAR ( an electronic document that records medications, assessments and treatments administered by nurses) at 4:42 p.m. indicated Licensed Nurse S documented Resident 19's pain level at the end of his shift at a 7, and the migraine medication was never administered that day During an interview on 2/12/26 at 12:45 p.m. with the Director of Nursing (DON), DON stated pain should be assessed by nurses throughout the shift and pain source, level and quality should have been obtained, especially if the resident was reporting migraine pain, all medications ordered should be available, and if not an alternative should have been requested. DON further stated not treating a resident's pain did not meet her expectation as pain was a vital sign and should be effectively managed.A review of a facility policy titled, Pain Assessment and Management, revised 03/2015 indicated, the facility pain management program is based on a facility-wide commitment to resident comfort and pain management interventions shall reflect the sources, type and severity of pain and .shall address the underlying causes of the residents pain.pain should be reassessed to determine if the residents pain is being adequately controlled.A review of a facility policy titled, Administering Pain medications, revised 04/2025, indicated, provide the resident privacy, explain the purpose of the pain assessment to the resident, conduct a pain assessment as indicated, administer pain medications as ordered, re-evaluate the residents pain level 30-60 minutes after medication is administered.

Based on interview and record review, the facility Quality Assurance Performance Improvement Committee failed to identify multiple quality of care issues. This failure resulted in a systemic breakdown of the infection control and prevention program which potentially could have led to harm of vulnerable residents, and other poor outcomes for residents in the care of the facility.During an interview on 2/12/26 at 2:25 p.m., the Administrator stated the Quality Assurance Performance Improvement (QAPI) Committee met monthly. The Administrator stated the QAPI committee developed performance improvement projects based on information they got from department heads, grievances, the resident council, monthly all-staff meetings, and an anonymous suggestion box. The Administrator stated QAPI was the umbrella for all of those sources of information so if something was an ongoing struggle then it would go to QAPI for monitoring. The Administrator stated a performance improvement project for infection prevention was started on 2/3/26, the day after the survey began. The Administrator verified no other quality of care issues found by the survey team were captured by the QAPI committee as areas of improvement. Review of facility document Quality Assurance and Performance Improvement Plan, dated 2026, indicated, [Facility] will put in place systems to monitor care and services, drawing data from multiple sources. The QAPI team at [facility named] will decide what data to monitor routinely. Examples of areas to consider included clinical care areas, such as infections, and medications, such as those requiring close monitoring and antipsychotics.

Based on observations, interviews, and record review the facility failed to ensure Resident Rights were honored when:Dignity and respect for residents was not provided when residents complained staff were observed being disrespectful, rude and unprofessional.Access to call lights for assistance and emergencies was not available when the call lights of three resident (Resident 15, Resident 24, and Resident 110) were not within reach on multiple observations.Access to visitors was denied to one resident (Resident 16) when she requested a visit from her daughter and the facility prevented her daughter visitation.Four out of five sampled residents (Resident 39, Resident 41, Resident 42, and Resident 69) were not treated with dignity and respect when staff were overheard speaking in a foreign language throughout the facility.These failures prevented the residents their right to safety, a dignified existence, self-determination, communication with and access to persons and services inside the facility, and residents feeling insecure and wondering if they were being talked about by staff. Findings: 1. Review of Resident 83's medical record document titled admission RECORD, indicated he was admitted [DATE] with diagnoses that included Chronic Ulcer of Right Foot, Cellulitis (Infection of skin and tissue), Dialysis (A treatment for kidney failure that filters waste, toxins, and excess fluid from the blood.), and Diabetes. Review of the Brief Interview of Mental Status (BIMS) score (An assessment that determine how cognitively intact a resident was.) indicated a score of 15 (A score of 12 - 15 indicated a resident was cognitively intact.). During an interview with Resident 83 on 2/3/26 at 10:55 a.m., he stated he had heard night nurses outside his room yell F**k you outside of his room all the time. He stated staff speak Spanish or some foreign language to each other in front of him all the time. He stated the staff are really unprofessional and he has informed nurses, but nothing ever changes so I stopped complaining. He stated it made him feel like staff did not care and it made him mad. During an observation on 2/10/26 at 2 p.m., 2:45 p.m. and 3:30 p.m. Licensed Nurse S was observed to exit through the main lobby and emit a cloud of blue, white vapor out of his mouth and nose, after he inhaled from something he pulled out of his pocket, immediately outside the double doors, where resident and family members enter the facility. During an interview on 2/3/26 at 8 a.m., Activity Director stated staff were never supposed to be on the phone during patient care hours or speak in a foreign language in front of residents or their families. Activity Director stated if a resident had a concern or was upset by something they could fill out a complaint form and report it to Social Services. She stated as Activity Director she assisted Residents at the monthly Resident Council meeting and the most recent complaints were related to staff sitting in patient room, taking their breaks and charging their phone. During an interview and concurrent record review with Social Services on 2/3/26 at 8:35 a.m., she stated she was responsible for the Grievance from residents or their families. She stated she would document the complaint, investigate and would follow up with a resolution. She stated she would communicate to the Director of Nursing (DON) and Administrator any grievances she received. She stated the Administrator review all of the grievances from the residents at the morning meetings that take place Monday through Friday at 9 a.m She stated most of the grievances were about staff taking a long time to answer call lights and lost items. She stated she had not heard about any grievance that staff behavior was unprofessional. During a concurrent record review of a document titled GRIEVANCE TRACKING LOG, it indicated what resident or family member expressed a grievance on what date, the nature of the grievance, how it was resolved and follow up. The grievance log indicated 25 instances of unprofessional staff behavior from April 2025 through December 2025. Further review indicated 13 were specifically about staff tone, Health Information Portability and Protection Act (HIPPA) documentation and public discussion about private care concerns, inappropriate bedside manners, bad communication, care need expectations, lack of professionalism from staff, and night shift care inconsistency. Social Services stated she had not documented details of each grievance and could not recall specific details. During an interview on 2/3/26 at 1 p.m., with the Director of Nursing, she stated she had not heard about any grievances or complaints from residents or family members about unprofessional staff behavior. She stated Social Services is responsible for management of grievances and complaints. She could not state if the facility reviewed the grievances for any trends to see if there was a larger problem than one or two complaints. During an interview with the Administrator on 2/2/26 at 4:15 p.m. he stated he had to discipline one night nurse (Licensed Nurse S) for unprofessional behavior. He stated Licensed Nurse S was a little rough around the edges and based on no specific issue he moved him to the AM shift so that he could keep an eye on him. Administrator stated he had a disciplinary action documented in his employee file for professionalism. During an observation and interview at 2/10/26 at 2:15 p.m. , the Infection Preventionist observed Licensed Nurse S outside the main entrance of the facility exhaling a cloud of vapor or smoke. She stated he is not supposed to be doing that. She stated that was very unprofessional. During an interview with the Director of Nursing on 2/12/26 at 8:30 a.m., she stated Social Services was responsible for investigating any grievance of complaint from a resident or family member. During an interview with the Administrator on 2/12/26 at 10:35 a.m. he stated he was not aware of any grievances (Complaint) from any resident or family of residents in the facility regarding unprofessional staff behavior. He stated he had not reviewed the grievance log and that the Social Services Director was responsible for grievances and would inform him in the morning meeting if there were any grievances. He stated there was a nurse who worked night shift that had a disciplinary action in his file. Administrator stated his expectation of all staff was that everyone was treated with dignity and respect. During review of an employee file document for Licensed Nurse S titled EMPLOYEE DISCIPLIANRY ACTION FORM, dated 1/16/26 it indicated NATURE OF INFRACTION Complaints from staff of being loud and lack of professionality in the workplace. During a record review of a facility Policy and Procedure titled Grievances/Complaints, Filing, revised April 2025, it indicated Residents and their representative have the right to file grievances, either orally or in writing, to the facility staff. Actions on such issues will be responded to in writing, including a rationale for the response. The administrator will review the findings with grievance officer to determine what corrective actions, if any, need to be taken. 2. During a concurrent observation and interview on 2/2/26 at 10:52 a.m. with Resident 15 in his room, Resident 15 stated, staff moved his call light away from him and this meant he had to yell out for help, but staff did not come. Resident 15's call light could not be visualized near him or his bed. During a concurrent observation and interview on 2/2/26 at 11:00 a.m. with Resident 15 in his room with Unlicensed Staff AA, Unlicensed Staff AA stated he could not find Resident 15's call light and that it was not ok and forced the resident to yell out for help. During a concurrent observation and interview on 2/2/26 at 11:15 a.m. with Resident 24 in his room, Resident 24's call light was seen on the floor on the far side of his bedside table and was not accessible to Resident 24. Resident 24 stated he had a bowel movement and had been waiting for 2 hours to be changed, this has happened frequently and made Resident 24 feel like staff did not want to help him. During a concurrent observation and interview on 2/2/26 at 11:20 a.m. with Resident 110 in his room, Resident 110's call light was seen pinned to the wall to the left of Resident 110 far out of reach. Resident 110 stated he had left sided weakness after his stroke and could not use his left arm. Resident 110 stated he felt like staff pinned the call light away from him on purpose so he could not call for help. During a concurrent observation and interview on 2/2/26 at 11:25 a.m. in Resident 15, Resident 24, and Resident 110's room with Licensed Nurse Z, Licensed Nurse Z confirmed that Resident 15's call light was anchored on the wall near Resident 24's bed and was far out of reach. Licensed Nurse Z confirmed that Resident 24's call light was on the floor on the opposite side of the bedside table and was far out of reach. Licensed Nurse Z confirmed that Resident 110's call light was anchored to the wall far out of reach on Resident 110's left side which was his affected side. Licensed Nurse Z stated that none of the Resident's in the room had access to their call lights and this could have lead to delays in care and could be dangerous in an emergency. During an interview on 2/12/26 at 12:45 p.m. with the Director of Nursing (DON), DON stated call lights should always be in reach for all Residents. DON further stated if anchored out of reach or on the floor residents would be unable to call for assistance and this did not meet her expectation. A review of a facility policy titled, Call System, Residents, revised 09/2022, indicated each resident is provided with a means to call staff directly for assistance from his or her bed and that calls for assistance are to be answered immediately. A review of a facility policy titled, Resident Rights, revised 08/2009, indicated the facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity. 3. During a record review of Resident 16 on 2/10/26 the Face Sheet, (some key health information of the resident) dated 2/10/26, it indicated that Resident 16 was admitted to the facility 10/16/23. Resident 16 had the diagnosis of Osteoarthritis to knees, heart disease, chronic pain, Glaucoma, Degenerative nerve syndrome and Cognitive impairment. Resident 16's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/7/26 indicated Resident 16 needed substantial assistance with Activities of Daily Living. During an interview on 2/10/26 at 2:15 p.m., Social Services stated we are following the guidance of Resident 16's Durable Power of Attorney (DPOA.) The DPOA instructed the facility to prevent Resident 16's daughter from visiting, as the daughter's presence continues to be detrimental to Resident 16's well-being. During an interview on 2/10/26 at 2:30 p.m., Resident 16 voiced her desire to see her daughter. Resident 16 was in her room and sitting in a wheelchair. A Spanish interpreter was on the phone to facilitate the communication. Resident 16 expressed a preference for her daughter, stating that she helps with getting out of bed, cleaning, and feeding. Resident 16 did not mention any negatives. As the interview ended, Resident 16 was pleading and crying Bring back my daughter, I miss my daughter, I need my daughter! During an interview on 2/10/26 at 2:50 p.m., the Administrator stated that Resident 16's documented DPOA requested the facility not allow the daughter to visit because she interfered with staff care and was potentially detrimental to Resident 16's well-being. The Administrator stated the facility was not allowing this daughter to visit and had asked the Ombudsman (patient advocate agency) to work with the family. 4. A review of Resident 39's admission record indicated he was last admitted in 10/18 with the diagnosis of unspecified sequelae of cerebral infarction (long-term health problems caused by a stroke). A review of Resident 39's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/13/26, indicated he had no memory impairment. A review of Resident 41's admission record indicated he was last admitted in 4/24 with the diagnosis of acute coronary thrombosis not resulting in myocardial infarction (a condition when a sudden blood clot forms in a heart artery, but it doesn't block blood flow enough to damage the heart muscle or cause a heart attack). A review of Resident 41's MDS, dated [DATE], indicated he had no memory impairment. A review of Resident 42's admission record indicated he was last admitted in 3/25 with the diagnosis of intraspinal abscess (an infection inside the spine that creates a pus-filled pocket which can press on nerves and cause pain) and granuloma (small lump of immune cells that form when the body is trying to block of something it sees harmful like bacteria). A review of Resident 42's MDS dated [DATE], indicated he had no memory impairment. A review of Resident 69's admission record indicated he was last admitted in 8/23 with the diagnosis of other speech and language deficits following cerebral infarction (problems with speaking or understanding language after a stroke). A review of Resident 69's MDS dated [DATE], indicated he had no memory impairment. During an interview on 2/3/26 at 10:12 a.m., with Resident 39, Resident 39 stated he hears staff speaking foreign languages all the time. Resident 39 stated this makes him uncomfortable because he does not know if they are talking about him. During an interview on 2/3/26 at 10:30 a.m., with Resident 41, Resident 41 stated he hears staff speaking foreign languages usually when multiple staff members are helping one of the other residents he shares his room with. Resident 41 also stated this makes him uncomfortable. During an interview on 2/3/26 at 10:42 a.m., with Resident 42, Resident 42 stated he hears staff speak foreign languages in the hallways and it makes him feel uncomfortable because he does not know what they are saying. During an interview on 2/3/26 at 11:10 a.m., with Resident 69, Resident 69 stated he hears staff speaking foreign languages all the time. Resident 69 also stated it really bothered him especially when staff would speak a foreign language while providing direct care to him. During an interview on 2/3/26 at 11:49 a.m. with Licensed Nurse (LN) A, LN A stated staff occasionally speak foreign languages, and she recalls there has been an in-service addressing the issue. During an interview on 2/5/26 at 11:19 a.m., with the Director of Nursing (DON), the DON stated staff is expected to speak in the same language the resident speaks, especially when around resident care areas. During a review of the facility's in-service records dated 8/27/25 which covered Communication/Foreign Language, the records indicated the objective of the in-service was After 1 hour of in-service the staff are expected to only speak in a language that is recognized and understood by the residents.

Based on observation, interview and record review, the facility failed to ensure residents had a safe, sanitary, homelike environment when: Patient care areas and laundry processing were observed to have broken and cracked floor tiles, exposed and unsealed medication cart work surfaces, unsealed cement on floors, exposed plaster, rusty and non-functioning equipment, and unsealed woodwork.These failures resulted in an environment for residents and staff that did not appear homelike, increased the risk of cross contamination and the spread of contagious disease.Cross Reference F880Findings: During an observation on 2/9/26 at 10:30 a.m. the floors and door jambs in resident rooms 56, 58, 59, 60, 61, 62 were observed to have chipped and cracked floor tiles, chipped paint on the doors and door jambs. The hand-washing sink in the east nursing station was observed to have exposed and damaged plaster in the entire area behind the faucet. The corner wall of the east nursing station where staff exited and entered the station was observed to have exposed plaster on the entire area around the alcohol-based hand sanitizer gel dispenser.During an observation on 2/10/2026 at 2:40 p.m., the hand-washing sink in the west nursing station was observed to have cracked, exposed plaster across the area behind the faucet and handles.During an observation on 2/10/2026 at 2:58 p.m. the clean utility room near the west nursing station was observed to have a grey black sticky substance on the high touch areas. An observation of scratched, chipped and worn paint indicated high use.During an observation and interview on 2/10/2026 at 2:47 p.m. at the west nursing station hand washing sink, Licensed Nurse QQ stated the water was too hot to wash her hands. She stated she could not hold her hands under the hot water without adjusting the temperature. She stated she did not know if exposed plaster could be sanitized. She stated it did not look like anyone cared.During an interview and observation on 2/10/2026 at 2:54 p.m., at the west nursing station hand washing sink, Administrator stated the exposed plaster behind the faucet was not good. He stated he was unsure if the exposed plaster could be disinfected and stated it needed to be repaired.During an interview and observation 2/10/2026 at 3:19 p.m., at the west nursing station, Licensed Nurse Q observed the medication cart and stated she observed a crack and open area on the surface of the medication cart. She stated she observed wood in the area of missing surface. She stated she was unsure if the crack and exposed wood could be disinfected.During an observation and interview on 2/11/26 at 8:45 a.m., with Housekeeping Director and Infection Preventionist, the room where dirty laundry was washed, was observed to have one out two functioning washing machines. The functioning washing machine on the left was observed to have a heavy band of white, rusty, powdery material that resembled corrosion. Housekeeping Director stated dirty laundry is brought outside the room with the washing machines to be sorted. An observation of the door that led to the outside dirty laundry area indicated to the left of the door was a red hose and spigot. The hose was plumbed inside the washing room and was fed through a hole in the wall to the outside dirty laundry sorting area. Close observation of the hole in the wall where the red hose exited the facility indicated a gap between the hose and the wall that let sunlight through to the inside of the washing room. Outside the doorway in the facility back parking lot the red hose was hanging up, and a steady drip of water was observed to have accumulated a pool of water on the cement in front of the doorway. The Infection Preventionist and the Housekeeping Director could not explain why the hose was plumbed in this manner or if it met California plumbing code. They stated the functioning washing machine was observed to have rust and corrosion on the lower left area where the machine was closest to the floor. They stated the Administrator was aware one out of two washing machines were not working and aware of the age and condition of the one remaining functioning washing machine. They stated they did not hear what the follow up was for the washing machines. An observation of the ceiling in the room with the washing machines indicated a ceiling mounted metal box that had been painted white. Observations indicated the surface was rough, appeared rusty and had been painted over. Infection preventionist and Housekeeping Director stated they did not know if you could disinfect rust or corrosion. An observation of the ceiling in the area that contained three laundry dryers indicated two out of three dryers were functional. The room had broken floor tiles, scratched walls that exposed unpainted and unsealed plaster where laundry carts were moved, and a ceiling with a large rough area of exposed plaster. Observation in the room indicated a folding table where clean resident laundry was folded had exposed unsealed wood edges and the white laminate surface had cracks and what appeared to be bubble that interrupted the smooth laminate. Infection preventionist and Housekeeping director stated they did not know if exposed plaster, chipped paint, or unsealed wood could be disinfected or sanitized. They stated Administrator was aware of the chipped floor tiles, exposed plaster and non-functional dryer but they did not hear about what the follow up plan was.During an observation and interview on 2/11/2026 at 9:50 a.m. with the Infection Preventionist, the utility room on the east nursing station was observed to have chipped paint on the door jambs in high touch areas, exposed plaster on the walls where carts had gouged through the paint and had exposed plaster. Infection preventionist stated the chipped paint, exposed plaster and unsealed wood could not be disinfected and the risk was cross contamination in infection.During the observation and concurrent interview with the Infection Preventionist of the west utility room door, it appeared to have black, grey sticky area around the high use door handle and door jamb. Scratches and worn paint exposed a wood surface in patches. Inside the utility room a large rectangle of exposed and unsealed concrete was observed on the tile floor in front of the hand-washing sink. Exposed plaster on the walls and chipped paint was observed inside the room. The infection preventionist stated exposed concrete, chipped floor tiles, exposed plaster could not be disinfected. She stated it looked dirty and if residents or family were looking at it, they would think it was dirty.During an interview on 2/12/26 at 8:30 a.m. in the Administrator's office, the Director of Nursing stated for environmental issues like chipped floor tiles and chipped paint and exposed plaster or wood, and for broken medication cart surfaces, staff were supposed to communicate the needed repairs to maintenance by documentation of the needed repairs in the maintenance binder located at the nursing stations. She stated the maintenance staff would fix the issues. She stated she knew about the medication cart and the top had just been ordered but had not arrived yet.During a concurrent observation and interview on 2/12/26 at 9 a.m., Administrator, Director of Nursing and Maintenance Director observed the shower room in the northwest hallway. The overhead light was observed not to turn on. Maintenance Director stated it needed to be replaced. During an observation in the northwest hallway, resident rooms 5, 6, 9, 10 were observed to have chipped paint on the door jambs, doors with chipped paint and black, grey streak, chipped and missing part of floor tiles and based boards with exposed wood. Maintenance Director stated the floor tiles had been ordered and were available to repair floors, but it was difficult to get the time to complete the repairs because the rooms were always full of residents.A review of the facility Policy and Procedure titled Maintenance Service, revised 12/2009, indicated Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 7. Maintenance personnel shall follow established infection control precautions in the performance of their daily work assignments.SEE PHOTOS

Based on interview and record review, the facility failed to protect one of five residents sampled for medication review from chemical restraint when Resident 4 had lorazepam (an anti-anxiety medication) ordered as needed without a frequency, duration, or monitoring for target symptoms. This failure had the potential to result in Resident 4 receiving an anti-anxiety medication unnecessarily, which can cause sedation, dizziness, weakness, and unsteadiness. During a record review on 2/11/26 at 8:08 a.m., review of Resident 4's face sheet revealed an admission date of 2/9/24, age over [AGE] years old, and medical diagnoses that included cerebral infarct (a blockage in a blood vessel to the brain), major depressive disorder in full remission, and dementia without behavioral disturbance. Review of Resident 4's physician orders revealed an active order dated 1/28/26 for lorazepam 1 mg (milligram) PRN (pro re [NAME], Latin for as needed) for anxiety manifested by inability to relax. The order did not include a frequency or a stop date. Further review of Resident 4's physician orders revealed no order to monitor for anxiety or inability to relax. During an interview on 2/12/26 at 8:37 a.m., Licensed Nurse (LN) FF verified Resident 4 was on her regular assignment. LN FF stated Resident 4 had lorazepam added recently because she was constipated and agitated. LN FF stated they were able to resolve her constipation and Resident 4 calmed down. LN FF verified the order for lorazepam did not have a time frame or frequency indicated. LN FF stated the order should include a frequency. LN FF stated psychotropic medications (drugs that affect a person's mental state) that were ordered PRN needed to be renewed once a month. LN FF stated she reviewed her residents' orders and if a PRN psychotropic medication was getting close to 30 days, she would let her Director of Nursing know or reach out to the physician herself to ask about getting it renewed. LN FF stated psychotropic medications should have behavior monitoring for the target behavior. LN FF stated the behavior monitoring was important to see if the resident was having any outbursts, and to document what intervention was used. LN FF stated the nurses count the outbursts and then let the physician know so they can re-evaluate if the dosage needed adjusting.During an interview at 2/12/26 at 1 p.m., Director of Nursing (DON) stated she and the nursing supervisor reviewed all new orders daily. DON stated they printed out all new orders from the previous day and reviewed them. DON stated Resident 4's lorazepam order with no frequency should have been caught during their review. DON stated that PRN psychotropic medications should be limited to 14 days and a specific stop date should be entered with the order. DON stated the charge nurse would review their orders for medications that were about to reach the stop date and reach out to the doctor to discuss if the order needed to continue. DON stated PRN psychotropic medications should have an order for behavior monitoring on the medication administration record. Review of website DailyMed.nlm.nih.gov, accessed 2/18/26, revealed the package insert for lorazepam indicated, In a sample of about 3,500 patients treated for anxiety, the most frequent adverse reaction to lorazepam was sedation (15.9%), followed by dizziness (6.9%), weakness (4.2%), and unsteadiness (3.4%). The incidence of sedation and unsteadiness increased with age. Review of facility policy policy and procedure Psychotropic Medication Use, last revised 2/2025, indicated, Medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: . Anti-anxiety medications . Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes: a. determining adequate indications for use; b. establishing appropriate dose . and duration; c. adequate monitoring for efficacy and adverse consequences . PRN orders for psychotropic medications are limited to 14 days.

Based on observation, interview, and record review, the facility failed to ensure one of three residents sampled for nutrition (Resident 19) Care Plan was evaluated and revised to include new means by which to monitor her weight after Resident 19 had refused to have her weight measured using the Hoyer Lift (a mechanical device used to lift and/or transfer a person) for 7 months.This failure caused the facility to be unable to properly assess a vulnerable resident, Resident 19, for significant weight loss, under nutrition, and worsening health status.A review of Resident 19's admission record indicated she was admitted in 08/2024 with diagnoses of Chronic pain (persistent pain lasting longer than 3-6 months) and a large burn wound to her left thigh.A review of Resident 19's Minimum Data Set (MDS-a resident assessment tool) indicated she had no cognitive impairment.A review of Resident 19's weight measurements indicated her last weight was obtained on 7/1/25 and was 135.6 lbs.A review of Resident 19's Care Plan indicated Resident 19 was at risk for weight fluctuations and mal-nutrition, interventions were ordered to monitor her weight per protocol and notify the physician of any significant weight loss or weight gain. It further indicated no revisions to the Care Plan beyond 08/29/25.During an interview on 2/10/26 at 9:20 a.m. with Resident 19 in her room, Resident 19 stated she refused to have her weight measured using the Hoyer Lift once or twice as the sling caused pain and bleeding to her left thigh wound and staff had not asked to measure her weight in a long time.During an interview on 2/12/26 at 10:15 a.m. with Licensed Nurse FF, Licensed Nurse FF stated, Resident 19 refused weights consistently and the team had not discussed other options for obtaining her weight. Licensed Nurse FF concurred that 7 months is a long time and a lot could change during that time.A review of most recent Interdisciplinary Team meeting notes dated 8/19/25 indicated no current weight and weight refusal with no new interventions documented.During an interview on 2/12/26 at 12:45 p.m. with the Director of Nursing (DON), DON stated if weight measurements are ordered they should be done monthly, if a resident refused we should have used alternative options as the resident could have significant weight loss and we wouldn't know.A review of a facility policy titled, Weighing and Measuring the Resident, indicated, weight is monitored on admission and monthly during a residents stay. to provide a baseline and ongoing record of the residents body weight as an indicator of the nutritional status and medical condition of the resident. and. the appropriate scale should be used.Platform scale for non-ambulatory residents or a tape measure for non-ambulatory or bedfast residents. and. to Notify the Nurse Supervisor if resident refuses.A review of a facility policy titled, Care Plans, Comprehensive and Person Centered, revised 03/2022, indicated Assessments of Residents are ongoing and care plans are revised as information about the residents and the residents conditions change.

Based on observation, interview, and record review, the facility failed to ensure effective participation and oversight of resident medical care by Physician R when,The infection Prevention and Control Program for a census of 116 was not provided oversight by Physician R for antibiotic stewardship and monitoring of infectious diseases in the facility designed to slow and prevent the spread of Clostridium Difficile (C. diff- a highly contagious bacteria that causes severe diarrhea), and prevention of water borne illness related to positive Legionella (a type of bacteria found in water that causes Legionnaires Disease a severe pneumonia) results.(Cross reference F 880).Physician R did not ensure resident care policies for informed consent were implemented according to facility policy for two of five residents (Resident 10 and Resident 12) sampled for psychotropic medications, andPhysician R did not ensure adequate diagnostic evaluation for a new diagnosis of Schizophrenia (a mental illness that is characterized by disturbances in thought) for two of five residents (Resident 2 and Resident 10) sampled for freedom from chemical restraint.These failures put residents at risk for negative outcomes related to severe infectious diseases, improper diagnoses of a serious mental illness, and psychotropic (any medication that affects brain activity associated with mental processes and behavior) medications. add F880 language 2. A review of Resident 12's informed consent form dated 3/16/25 for psychotropic medication Risperidone for visual hallucination was not signed by the resident's representative and verbal consent is not indicated. A review of Resident 12's informed consent form dated 9/11/25 for psychotropic medications Mirtazapine for depression and Risperidone for visual hallucination, was not signed by the resident's representative and verbal consent was not indicated. During an interview on 2/12/26 at 11:25 a.m. with Resident 10's representative, the representative stated she had never heard from the medical doctor at the facility and had not signed any forms concerning psychotropic medications. The resident representative further stated she felt she was not kept in the loop and expected the facility would communicate more. During an interview on 2/17/26 at 9:04 a.m. with Resident 12's representative, the representative stated she had not spoken to anyone about psychotropic medications and if she had she would have told them she did not want Resident 12 to take these psychotropic medications because she felt they made Resident 12 less functional. During an interview on 2/12/26 at 12:45 p.m. with the Director of Nursing (DON), DON stated her expectation for informed consent was Physician R would reach out to the resident representatives for education and treatment planning prior to notifying the nurses to obtain confirmation and signature. DON further stated she was surprised that the resident representatives had not heard from Physician R. During an interview on 2/13/26 at 9:45 a.m. with Physician R, Physician R stated he could not do all the education and depended on the nurses to do the teaching and notify him if the representatives had concerns. A review of a facility policy titled, Psychotropic: Medication Use, revised 02/25, indicated prior to initiating the use of, increasing the dose, or switching to a different psychotropic medication, the staff and physician will review non pharmacological alternatives, indications and rationale for recommendation, the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings) and the resident or resident's representative's rights to accept or decline the treatment. 3 a. A review of Resident 10's admission record indicated she was admitted in 12/22 with diagnoses of Dementia (a progressive state of decline in mental abilities), Major Depressive disorder (MDD-a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified psychosis. A review of Resident 10's Minimum Data Set (MDS-a resident assessment tool) dated 12/22/25 indicated severe cognitive impairment. A review of Resident 10's Physician Order Summary indicated a psychotropic medication, Seroquel, prescribed for schizoaffective disorder (a chronic mental health disorder blending Schizophrenia symptoms with mood disorder episodes), manifested by visual hallucinations. A review of Resident 10's CHE Behavioral Health Services Psychiatry note dated 9/13/23 indicated active diagnoses of Dementia and MDD with no reported auditory hallucinations. A review of Physician R's SOAP note (physician progress notes) dated 10/12/23 indicated no new diagnosis of schizoaffective disorder with active diagnoses of Dementia and MDD. A review of a fax sent to Physician R by facility staff on 10/16/2023 indicated Resident 10 was taking Seroquel without an assigned diagnosis and facility staff asked to have Physician R update Resident 10's diagnoses list. A review of Resident 10's diagnoses list indicated the diagnosis of schizoaffective disorder was added on 10/16/23 by Physician R. A review of Resident 10's CHE Behavioral Health Services Psychiatry note dated 12/27/23 indicated active diagnoses of Dementia and MDD with no recent hallucinations and recommended a decrease in Seroquel dose. No new diagnosis of Schizoaffective is mentioned. A review of Physician R's SOAP note (physician progress notes) dated 12/02/23 indicated no new diagnosis of schizoaffective disorder, and confirmed active diagnoses of Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the most recent CHE Behavioral Health Services Psychiatric note dated 12/24/25 indicated an active diagnosis of Dementia without behavioral disturbance, MDD manifested by auditory hallucinations, sadness, insomnia and tearfulness with no new medication recommendations. During an interview on 2/12/26 at 11:25 a.m. with Resident 10's representative, she stated, Resident 10 had no history of schizoaffective disorder, and she had never spoken to a medical doctor from the facility about this diagnosis. During an interview on 2/12/26 at 12; 45 p.m. with the Director of Nursing (DON), DON stated a diagnosis of a serious mental illness should not be added for medication alone, it should be properly diagnosed first by a behavioral health provider, if not this could lead to residents inappropriately being labeled as having a serious mental illness. During an interview on 2/13/26 at 9:45 a.m. with Physician R, Physician R stated, for a diagnosis of schizoaffective disorder we refer residents to psychiatric services to evaluate, if psychiatry did not confirm the diagnosis, then it should have been removed. Physician R further stated he may have added the diagnosis of schizoaffective disorder for Resident 10 because it was likely based on evolving symptoms. During an interview on 2/13/26 at 10:40 a.m. with Nurse Practitioner KK, she stated residents with a diagnosis of schizoaffective disorder usually have a history prior to coming to the facility and she would have expected a diagnosis of serious mental illness to be evaluated by the physician applying the diagnosis. A review of a facility policy titled, Schizophrenia and Related Disorders-Clinical Protocol, revised 03/2025, indicated The practitioner will not newly diagnose a resident with a serious mental illness without evidence based criteria that are documented in the residents record.the presence and duration of symptoms, behaviors, and disturbances consistent with current Diagnostic and Statistical Manual of Mental Health Disorders criteria for Schizophrenia. 3b. Review of Resident 2's electronic medical record (eMR) revealed a face sheet that indicated Resident 2 was admitted to the facility on [DATE], his age was in his 60s, and his medical diagnoses included cerebral infarction (blockage in the blood vessels to the brain) with right sided weakness, epilepsy (a seizure disorder), diabetes (a chronic illness that effects the way blood sugar is metabolized), anxiety, and psychotic disorder with delusions (a psychiatric condition characterized by one or more persistent, often non-bizarre, false beliefs). Further review of Resident 2's medical diagnoses indicated that on 2/6/24 a schizophrenia diagnosis was entered. Review of Resident 2's behavioral health note, dated 11/29/23, written by Nurse Practitioner (NP) LL indicated she recommended starting Risperdal (an antipsychotic medication) 0.25 mg daily to help manage his delusions and paranoia. Further review of this behavioral health note revealed no indication Resident 2 had a diagnosis of schizophrenia. Review of Resident 2's physician progress notes and behavioral health notes for November 2023 through May 2024 revealed no mention of a schizophrenia diagnosis. During a phone interview on 2/11/26 at 1:30 p.m., Nurse Practitioner (NP) KK verified Resident 2 was a patient seen by her behavioral health group. NP KK reviewed Resident 2's medical record and stated Resident 2 was originally seen by NP LL, and he was prescribed Risperdal. NP KK verified NP LL's progress notes did not mention schizophrenia at the time the Risperdal was prescribed but stated the diagnosis of schizophrenia was based on his symptoms of delusions, his BIMS score of 3, and the fact that his symptoms improved on the Risperdal. NP KK verified Resident 2's progress note written by NP LL in December 2024 was the first documentation of schizophrenia as a diagnosis. During a record review on 2/11/26 at 2:30 p.m., a fax dated 2/6/24 sent to Physician R by MDS Nurse NN regarding Resident 2 indicated, Hi Doctor. Res[ident] on antipsychotic [medication] 'Risperdal' and no [diagnosis] of schizophrenia? Can we [please] update [medical] diagnosis Y[es] or N[o]. Thank you. Further review of the fax indicated Physician R responded Yes with an undated signature. During a phone interview on 2/11/2026 at 2:58 p.m., Physician R reviewed Resident 2's chart. Physician R stated he based his diagnosis of schizophrenia on Resident 2's behavior. Physician R verified he consulted with the behavioral health consultants when he responded yes to the fax from MDS Nurse NN but was unable to find documentation of the clinical rationale. During an interview on 2/11/2026 at 5:25 p.m., Psychologist MM verified he was Resident 2's psychologist. Psychologist MM reviewed Resident 2's medical record and stated Resident 2 did have a delusional disorder mentioned in his progress notes but stated that diagnosis was not interchangeable with schizophrenia. Psychologist MM verified his progress notes did not mention a diagnosis of schizophrenia. Psychologist MM stated he may have discussed with Physician R the new diagnosis of schizophrenia in February 2024. Psychologist MM stated he recalled he referred Resident 2 to NP LL, for prescribing of psychiatric medications, but she left the practice shortly after she started seeing Resident 2 as consultant. During an interview on 2/12/26 at 8:49 a.m., MDS Nurse NN stated the reason she sent the fax to Physician R was that when she completed the MDS (minimum data set, an assessment tool) for Resident 2, the system triggered a note that they needed the right diagnosis entered for the medication. MDS Nurse NN stated she asked Physician R since he was the medical director and she knew he would answer her request. MDS Nurse NN verified that Risperdal was a new medication for Resident 2 that was started at the facility. MDS Nurse stated she was not aware of any documentation that a clinician diagnosed Resident 2 with schizophrenia in February 2024 or prior to that time. During an interview on 2/12/2026 at 10:20 a.m., MDS Nurse OO stated there was no documentation in Resident 2's record that a clinician diagnosed Resident 2 with schizophrenia at the time MDS Nurse NN entered the diagnosis in the eMR in February 2024 or prior to that time. Review of facility policy Schizophrenia and Related Disorders - Clinical Protocol, last revised 3/2025, indicated, 1. The practitioner will not newly diagnose a resident with a serious mental illness without evidence-based criteria that are documented in the resident's medical record. 2. The rationale for the diagnosis will be based on a comprehensive assessment of the resident's physical, behavioral, mental status, psychosocial status, and comorbid conditions. Documentation will include: a. the findings from the comprehensive assessment; b. the presence and duration of symptoms, behaviors, and disturbances consistent with current Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for schizophrenia; c. that the symptoms, behaviors, and disturbances are not attributable to substances, medications, or other conditions; and d. the effect the disturbance is having on the resident's function, self-care, or interpersonal relationships, in comparison to before the onset of the disturbance.

Based on observation, interview and record review, the facility did not securely attach the bed rails to the bedframe for one of seven residents who use bed rails, (Resident 105.) Resident 105's bed rails were loose and wobbly, easily swinging away from the bed. Resident 105 stated she did not feel safe using the bed rails for repositioning or getting in and out of bed and stated she almost fell to the floor.During an interview and concurrent observations on 02/09/2026 at 4:26 p.m., in Resident 105's room, Resident 105 reported that broken bed rails nearly caused a fall while repositioning. She stated, the rail just fell down and demonstrated how the left rail could move side to side, creating a 2 to 3-inch gap between the mattress and rail . The surveyor confirmed the rail could swing towards the middle of the room, forming a large gap which posed a fall risk. The right bed rail was also loose and could be pushed away from the bed towards the wall.During an interview and concurrent observations on 02/10/2026 7:45 a.m., in Resident 105's room, Licensed Nurse (LN HH) came into the room and evaluated Resident 105's bed rails. LN HH tested the bed rail and found that it was loose and could be pulled out away from the bed and the resident. LN HH stated the bed rail was not safe for resident use and needed to be reported to maintenance as soon as possible and added the broken bed rails to the facilities Maintenance log.During an interview and concurrent observations on 02/10/2026 at 8:20 a.m., Maintenance staff was seen examining the bed rails for Resident 105. Maintenance staff identified that the rails were not properly attached to the bed frame. Maintenance staff stated any problem with bed rails should be reported and repaired as soon as possible for resident safety.During a review of Resident 105's Medical Records, Resident 105's Face Sheet (some key health information of the resident) dated 2/11/26, indicated that Resident 105 was admitted to the facility on [DATE]. Resident 105's records included a document titled The Bed Rail and Entrapment Risk Observation dated 12/22/25 and indicated bed rails that were on the bed were recommended for Resident 105 to use when the resident was in bed to enhance mobility, including moving within the bed and transferring in and out of it. The section titled entrapment risk evaluation confirmed that no gaps were observed between the mattress and the bed rails.During a review of Resident 105's Nursing Care Plan, dated 12/23/25, the use of bed rails was documented. The stated goals included: (Resident) Will be compliant with using device. (Resident) will not have any complications or injuries related to the device. The Interventions included: Assess use of bedrail for appropriateness of use as indicated, Complete Bed Rail observation evaluation as indicated and ensure the device is clean and in good repair.During a review of the facilities procedure titled Bed Safety and Bed Rails, dated 8/2022, this indicated bed frames, mattresses and bed rails are checked for compatibility and size prior to use. Maintenance is to routinely inspect all beds to identify risks and problems, and any worn or malfunctioning bed system components are repaired or replaced.

Based on interview, and record review, the facility failed to ensure advanced knowledge and approval of ongoing treatment with psychotropic medications ( any medication that affects brain activity associated with mental processes and behavior) for two of five sampled residents ( Resident 10 and Resident 12) for unnecessary medications when resident representatives did not recall contact from the facility and the informed consent ( a document that confirms residents or resident representatives were informed on the risks, benefits, and alternatives of a medical intervention) forms were not signed nor was verbal consent documented.This failure prevented the resident's representative's from participating in their right to determine treatment interventions for Resident 10 and Resident 12.A review of Resident 10's admission record indicated she was admitted to the facility in 12/2022 with diagnoses of Dementia (a progressive state of decline in mental abilities) and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).A review of Resident 10's Minimum Data Set (MDS-a resident assessment tool) indicated she had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 01 indicating significant cognitive decline.A review of Resident 10's informed consent form dated 12/19/25 for psychotropic medication Paroxetine for depression was not signed by the resident's representative and verbal consent was not indicated.A review of Resident 10's informed consent form dated 12/19/25 for psychotropic medication Trazodone for depression and inability to sleep was not signed by the resident's representative and verbal consent was not indicated.A review of Resident 12's admission record indicated she was admitted to the facility in 03/2025 with diagnoses of Dementia and Schizophrenia (a mental illness that is characterized by disturbances in thought).A review of Resident 12's MDS indicated she had a BIMS score of 4 indicating significant cognitive decline.A review of Resident 12's informed consent form dated 3/16/25 for psychotropic medication Risperidone for visual hallucination was not signed by the resident's representative and verbal consent is not indicated.A review of Resident 12's informed consent form dated 9/11/25 for psychotropic medications Mirtazapine for depression and Risperidone for visual hallucination, was not signed by the resident's representative and verbal consent was not indicated.During an interview on 2/12/26 at 11:25 a.m. with Resident 10's representative, the representative stated she had not heard from the medical doctor at the facility ever, and the nurses had not reached out to her in a very long time. Resident 10's representative further stated she had not signed any forms about medication and felt she was not kept in the loop and expected the facility would have communicated more.During an interview on 2/17/26 at 9:04 a.m. with Resident 12's representative, the representative stated she had not spoken to anyone about psychotropic medications and if she had she would have told staff she did not want Resident 12 to take psychotropic medications because she felt they made Resident 12 less functional.During an interview on 2/12/26 at 12:45 p.m. with the Director of Nursing (DON), DON stated her expectation was that Physician R reached out to the resident representatives for education and the nurses would then obtain confirmation of their consent by documenting verbal consent or obtaining the representatives' signature. DON further stated if there is no education done, no verbal consent or signature we should not be giving the medication.During an interview on 2/13/26 at 9:45 a.m. with Physician R, Physician R stated resident representatives should have heard from Physician R or the nurses and that without documented verbal consent or representative signature it would be difficult to confirm informed consent occurred.A review of a facility policy titled, Psychotropic: Medication Use, revised 02/25, indicated prior to initiating the use of, increasing the dose, or switching to a different psychotropic medication, the staff and physician will review non pharmacological alternatives, indications and rationale for recommendation, the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings) and the resident or resident's representative's rights to accept or decline the treatment.

Based on interview and record review, one of two residents sampled for tube feeding (Resident 140), who was at risk for constipation, had no bowel movement (BM) for five days and was not given bowel care medications as indicated on the care plan. This failure contributed to Resident 140 developing a fecal impaction (a severe, solid, or hard mass of stool stuck in the rectum or colon, typically resulting from chronic, untreated constipation).During an electronic medical record (eMR) review on 2/3/26 at 3:30 p.m., Resident 140's face sheet indicated an admission date of 1/9/26, age in his 70s, and medical diagnoses that include traumatic subdural hemorrhage (a type of bleeding near the brain that can happen after a head injury), broken facial bones, aphasia (language disorder resulting from brain damage that impairs speaking, writing, reading, and comprehension while leaving intelligence intact), dysphagia (difficulty swallowing), and a gastrostomy (the surgical creation of an opening (stoma) into the stomach to insert a feeding tube (G-tube) for direct nutrition). Review of Resident 140's Constipation Risk assessment dated [DATE] indicated Resident 140 was at high risk for constipation. Review of Resident 140's care plan dated 1/10/26 revealed a focus area Bowel: At risk for complications with bowel regimen due to constipation, with the goal, Will have satisfactory bowel movements every 1 to 3 days as evidenced by soft, formed stools, and interventions that included administering medications per physician order. Review of Resident 140's physician orders revealed no bowel care medications such as laxatives (increase muscle contractions in the intestines) or stool softeners (increase water absorption into the colon to soften stool) were ordered except MiraLax (a laxative) ordered 1/26/26 to be given once every 24 hours as needed for constipation. Review of Resident 140's medication administration record indicated MiraLax was administered on 1/26/26 and 1/27/26 by Licensed Nurse Q. Review of Resident 140's documentation of bowel movements indicated Resident 140 had a small putty-like BM on 1/21/26 and no subsequent BMs were documented. During an interview on 2/3/26 at 11 a.m., Licensed Nurse Q reviewed Resident 140's eMR and verified Resident 140 had not had a bowel movement for five days when she obtained an order from the doctor for Miralax on 1/26/26. Licensed Nurse Q stated she obtained the order for Miralax because Resident 140 did not have orders for any bowel care medications. Licensed Nurse Q verified she administered the Miralax to Resident 140 on 1/26/26. When queried, Licensed Nurse Q stated not having a bowel movement for five days was a big deal. Licensed Nurse Q stated the potential outcome to the resident included a lot of pain, fissures, hemorrhoids, bowel obstruction, or a gassy formation that could cause delirium. Licensed Nurse Q stated Resident 140 re-admitted from the hospital on 1/21/26 and then was transferred back to the hospital on 1/27/26 when he became unresponsive. During a phone interview on 2/4/26 at 9:21 a.m., Resident 140's family member stated that when Resident 140 was re-admitted to the hospital (on 1/27/26), he was constipated and the nurses were pulling fecal matter out of his stomach from his G-tube. During a medical record review on 2/11/26 at 10:30 a.m., Resident 140's hospital records revealed a hospitalist (a physician who specializes in the care of patients solely while they are admitted to the hospital) progress note dated 1/30/26 indicated, . found to have bowel obstruction . Bowel obstruction vs ileus (a temporary condition where the intestine cannot push food and waste out of your body) - no BM since 1/21 . Review of Resident 140's Critical Care Consult Note dated 1/30/26 indicated that the G-tube output was black/feculent in appearance, belly distended and tense, no reported BM from nursing. Review of Resident 140's abdomen x-ray dated 1/30/26 indicated, Large amount of gas and fecal material within the colon suggesting an ileus. During an interview on 2/12/26 at 1 p.m., Director of Nursing (DON) stated it was her expectation that the nurses monitor for their residents' last bowel movement, and if a resident had gone beyond three days, the nurse should initiate bowel care. DON stated the residents' last BM was on the eMR, there was an alert with the date of the last BM. DON verified the nurses did not have to go looking for documentation of the last BM, it was easy to see. DON stated it was her expectation that if a resident was at risk for constipation, the nurse should have called and notified the doctor to get orders for bowel care. DON stated routine bowel care should be obtained when the care plan for constipation was developed. Review of facility policy and procedure Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, last revised 9/2017, indicated, As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms.Examples of lower gastrointestinal tract conditions and symptoms include: .Alteration in bowel movements . In addition, the nurse shall assess and document/report the following: . Presence of fecal impaction . Abdominal assessment . Onset, duration, frequency, severity of signs and symptoms; all current medications .

Based on observation, interview and record review, the facility failed to provide adequate supervision and monitoring for one out of two sampled Residents (Sampled Resident 60) when Resident 60 left the facility unnoticed by staff (eloped) on 12/27/25.This failure contributed to Resident 60 being found outside the facility by the police and had the potential to lead to injuries for Resident 60. Review of Resident 60's medical record document titled admission RECORD, indicated he was admitted [DATE], with diagnoses that included Heart Disease, Encounter for Aftercare Following Surgery on the Circulatory System, Muscle Weakness, Need for Assistance with Personal Care, and Unspecified Psychosis (A person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not.).During an observation on 2/2/26 at 9 a.m., the front doors of the facility faced north onto a busy street with consistent traffic.During an interview with Resident 60's Public Guardian I (A court-appointed official or agency that acts as a legal conservator for adults unable to manage their own personal care or finances due to severe cognitive impairment, dementia, or disability) on 2/3/26 at 1:56 p.m., she stated someone from the facility had informed her that Resident 60 had eloped on the weekend. She stated the person who had informed her stated a licensed nurse had observed Resident 60 in his room with the door shut and Didn't know he had actually gone missing. She stated the police had been notified and was found by the police.On 2/3/26 at 5:06 p.m., the Infection Preventionist Nurse (IP) stated she had spoken with Resident 60's Public Guardian I after he eloped. The IP stated she remembered seeing a text chain on the text system the facility utilized to communicate important things. She stated she received it on the weekend, and it was about Resident 60 missing, and everyone had looked for him and the police were called.During an interview with Licensed Nurse Q on 2/4/26 at 11:58 a.m., she stated she knew that Resident 60 had eloped and stated she was at lunch when he went missing. She stated he did not have a Wander alarm (wireless monitoring system, usually in form of a bracelet that a resident wears, and an alarm will sound if the resident approaches a door sensor) on at that time. She stated if a wander alarm was recommended on the assessment of wandering and elopement, it should have been put on right away and it Would have prevented his elopement. She stated the police brought him back and stated that Resident 60 had walked for quite some time and he kept saying he wanted to go home. Nurse Q stated it was very risky to walk the street in front of the facility because it was very busy and full of cars. She stated he could have fallen or got hit by a car.During an interview on 2/5/26 at 11:15 a.m. with Administrative Staff T, she stated she was aware of the elopement of Resident 60. She stated she remembered looking at the group text used by the facility to communicate important information like an elopement. She reviewed the text history, and it indicated 12/27/2025 at 11:53 a.m. the text indicated Resident 60 was missing and police returned him to the facility at 1:27 p.m A request for a copy of the group chat text made and not received at the conclusion of the survey.During an interview with the Director of Nursing (DON) on 2/12/26 at 8:30 a.m., she stated Resident 60's original elopement wandering assessment score was an 8 and it was not considered high risk. She stated a score of more than 10 was a high risk. She stated the risk assessment dated [DATE], recommendation for a Wander alarm was a mistake. She stated the nurse that had been assigned to Resident 60 observed him in his room after morning medication administration and did not notice that he walked out of his room and out of the facility. She stated, there was not enough supervision of Resident 60 to prevent him from eloping.During an interview with Administrator on 2/12/26 at 10:35 a.m., he stated Resident 60 had eloped. He stated staff did not see Resident 60 exit his room and leave the facility. He stated, The facility did not supervise Resident 60 close enough to prevent him from leaving the facility.A review of the facility Policy and Procedure titled Wandering and Elopements, revised March 2019, indicated If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.A review of a document titled ELOPEMENT AND WANDERING RISK OBSERVATION/ASSESSMENT, (An assessment based on 36 questions regarding wandering and elopement behaviors, history, and expressions of wanting to leave made by residents.) dated 12/27/25, indicated a score of 8 (0 -9 was low risk, and 10-30 was high risk). It also indicated: Based on Elopement and Wandering Risk Observation/Assessment Findings: a. Yes, a wander alarm IS indicated.A review of a facility document titled Investigation Report: Elopement, dated 12/28/25, indicated Date of Incident: 12/27/25, Time of Incident: Approximately 11:45 a.m. The resident was medically cleared and returned to the facility via BLS transport at approximately 1500 (3 p.m.) hours. Conclusion: This event was determined to be an elopement related to resident disorientation and believe of discharge status.Record review of a document titled CARE PLAN REPORT, dated 12/26/25, indicated a focus titled Falls: Resident is at risk for fall with or without injury related to unsteady gait.dementia.Muscle weakness. Interventions/Tasks.Keep within supervised view as much as possible.Record review of a document titled CARE PLAN REPORT, dated 1/2/26, indicated a focus titled Elopement: Resident is at risk for elopement/exit seeking/wandering. Intervention/Tasks.Wander alarm as Ordered. No intervention for supervision or monitoring was indicated.

Based on observation, interview, and record review, the facility failed to ensure one out of one resident's sampled for ostomy care( a surgical opening in the abdomen that redirects waste outside the body into a wearable pouch system) ( Resident 110), received care according to professional standards of practice when Licensed Nurse S disregarded Resident 110's verbal and non-verbal signs of pain with old appliance removal, did not follow the correct procedure for appliance change to minimize skin exposure to feces and urine, and did not notify the supervisor of any abnormal findings. This failure caused Resident 110 to have pain, discomfort, and had the potential to contribute to further skin breakdown around his stoma(a surgically created opening in the abdomen that diverts stool flow). A review of Resident 110's admission record indicated he was admitted in 09/2024 with left sided hemiparesis (a neurological condition characterized by weakness on one side of the body affecting the arm, leg, and trunk) after a stroke, chronic pain, and had an ostomy.A review of Residents 110's Minimum Data Set (MDS-a resident assessment tool) dated 1/29/26 indicated he had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 indicating minimal cognitive impairment.A review of Resident 110's Order Summary Report, indicated his ostomy appliance was to be changed every 3 days and as needed and specified that the wafer (the adhesive baseplate designed to protect the skin around the stoma and secure the pouch) should be cut to fit the ostomy size. It further indicated Resident 110 had medication for both mild and moderate pain levels.A review of Resident 110's Care Plan indicated he was at risk for skin breakdown related to his ostomy site and the skin integrity surrounding the stoma should be observed and any abnormal findings or complications should be reported to the physician.During an interview on 2/2/26 at 11:20 a.m. with Resident 110 in his room at bedside, Resident 110 reported he didn't feel the nurses that were caring for his ostomy knew what they were doing. Resident 110 stated they did not use skin prep (liquid-based wipes that form a protective barrier film on intact skin) and the appliance leaked feces and urine all over his skin daily, and staff did not clean him timely.During a concurrent observation and interview on 2/11/26 at 10:00 a.m. for Resident 110's ostomy appliance change procedure with Licensed Nurse S, Licensed Nurse S began to remove old, adhered appliance. Resident 110 grimaced and stated, Ow, that pulls and stings, Licensed Nurse S replied, it'll be over quick, you're a tough guy. Licensed Nurse S continued with removal without any interventions to lessen pain. Licensed Nurse S stated, the skin around the stoma looks red and irritated. Licensed Nurse S did not measure stoma size using measurement guide or trace the opening size on the ostomy wafer. Licensed Nurse S cut the opening much larger than actual stoma size leaving approximately 1/3 inch of exposed skin around the stoma. Licensed Nurse S did not assess Resident 110's tolerance of the procedure and did not notify the physician of pain with removal or skin breakdown. Licensed Nurse S left the room and Resident 110 stated ,it really stung when the old appliance was removed and skin was cleansed, and he did not feel Licensed Nurse S cared about that.During an interview on 2/11/26 at 10:35 a.m. with Licensed Nurse S, Licensed Nurse S stated he did realize that Resident 110 was having pain with the old appliance removal but felt Resident 110 didn't need medication and getting it over quickly was the best way to address it, he was not sure what else could have been done. Licensed Nurse S concurred the skin around the stoma was red and looked irritated and stated he was not sure what else could be done for skin breakdown but supposed he could have reached out to the treatment nurses. Licensed Nurse S concurred he used his finger to measure the stoma size instead of using the measurement guide and may have cut the opening too big which could expose the skin to feces and urine.During an interview on 2/12/26 at 12:45 p.m. with the Director of Nursing (DON), DON stated she expected that any pain during a procedure should be assessed and addressed, she would never expect a resident's pain to be ignored. DON further stated the ostomy wafer opening should be measured to fit the stoma, if not this could cause skin breakdown, our treatment nurses should have been consulted.A review of a facility document titled, Colostomy Care; Changing Pouch, Licensed Nurse Competency Evaluation, indicated in step 4, to assess resident for pain and medicate as indicated, in step 13, to gently remove faceplate from skin by pushing skin from the appliance rather than pulling the appliance from skin, in step 16, assess the condition of the surrounding skin, in step 18, measure stoma using measurement guide, in step 19, trace the same size opening on the back of the new faceplate and cut the opening to be 1/8 inch larger than stoma size, in step 27, notify physician of any abnormal findings.A review of a facility policy titled, Colostomy /Ileostomy Care, revised 10/2010, indicated, The following information should be recorded in the resident's medical record.any breaks in the resident's skin.how the resident tolerated the procedure. It further indicated, Notify the supervisor of any abnormal findings (i.e. breaks in the skin, excoriation, signs of infection, etc).

Based on observations, interview, and record review the facility failed to properly maintain the residents' food refrigerator for a census of 116 when food items were not properly labeled.This failure had the potential to result in residents consuming contaminated food, increasing the risk of foodborne illness and adverse health outcomes.During a concurrent observation and interview on 2/2/26 at 9:40 a.m., with the Dietary Services Manager (DSM), the freezer unit of the resident refrigerator contained one opened 16 oz container of Dean's French Onion Dip and two (8-pack) unopened packages of El Monterey Beef and Bean Chimichangas the DSM stated, he did not see any identifying labels on the french onion dip container or either of the chimichanga packages. During an interview on 2/12/26 at 10:27 a.m., with the Director of Nursing (DON), the DON stated she expected items placed in the resident refrigerator were labeled properly with dates and who the item belonged to, otherwise resident food could be shared with another resident if not properly labeled. The DON also stated she would expect foods to be removed and thrown out right away if it is unlabeled to prevent the risk of contamination and possible stomach upset for the residents.During a review of the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, revised 2/14, the P&P stipulated, items left for the residents to consume later will be labeled and stored in a distinguishable manner with the resident's name, the item, and the use by date.

Based on observation, interview and record review, the facility failed to provide adequate nursing services for 4 residents (Resident 2, Resident 3, Resident 4, and Resident 5) of 5 sampled residents to ensure residents achieved the highest level of physical and emotional well-being when the facility failed to make a sufficient number of nursing staff available to meet residents' needs. This failure had the potential to place residents at greater risk for dehydration, skin breakdown and placed their safety in jeopardy.A review of Resident 2's admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of Acute on Chronic Heart Failure ( a worsening of a clinical condition when the heart cannot pump enough blood to meet the body's needs for oxygen and nutrients), End Stage Renal Disease (kidney function has declined to 15% of normal capacity) and Diabetes Mellitus (DM-disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 2's care plans indicated the following:A care plan, revised on 10/25/22, indicated Resident 2 was at risk for dehydration. Resident 2's goal was to be free from signs and symptoms of dehydration. To meet this goal, the nursing staff was expected to encourage Resident 2 to drink fluids within Resident 2's 1500 mL (Milliliter-a unit of measure)/day fluid restriction as ordered by her physician.A care plan, dated 6/3/25, indicated Resident 2 was at risk for skin breakdown. To meet Resident 2's goal of reducing the risk of skin impairment, the nursing staff were expected to monitor for incontinence [involuntary leakage of urine or stool] and provide pericare [the process of cleaning a resident's genital and anal areas] after each incontinent episode.A review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 11/19/25 indicated Resident 2 had a Brief Interview for Mental Status (BIMS- an assessment used to measure cognition (a person's ability to process information and understanding)) score of 15 which indicated Resident 2's cognition was fully intact.A review of Resident 3's admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of Cholecystitis (redness and swelling (inflammation) of the gallbladder), Cystitis (inflammation of the bladder most commonly caused by a bacterial urinary tract infection (UTI)) and Hemiplegia and Hemiparesis (weakness and paralysis on one side of the body) following Cerebral Infarction (stroke) affecting right dominant side. A review of Resident 3's care plans indicated the following:A care plan, dated 4/1/24, indicated Resident 3 was at risk for dehydration. To meet Resident 3's goal of having adequate hydration, nursing staff were expected to offer fluids in between meals and at snack time, provide additional fluid during activities, and a water pitcher was to be left within Resident 3's reach at bedside.A care plan, dated 9/23/24, indicated Resident 3 was at risk for skin breakdown and pressure ulcer development. To meet this goal, the nursing staff were expected to assist Resident 3 to turn and reposition.A care plan, revised on 10/3/25, indicated Resident 3 was at risk for falls. To minimize Resident 3's risk for falls, the nursing staff were expected to anticipate and meet Resident 3's needs, and educate/remind [Resident 3] to call [via the call light system] for assistance with all transfers.A review of Resident 3's MDS dated [DATE] indicated Resident 3 had a BIMS score of 15 which indicated Resident 3's cognition was fully intact.A review of Resident 4's admission record indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis of Metabolic Encephalopathy (syndrome of brain dysfunction caused by chemical imbalance in the blood due to organ failure).A review of Resident 4's care plans indicated the following:A care plan, dated 9/15/24, indicated Resident 4 was at risk for dehydration. To meet Resident 4's goal of adequate hydration, the nursing staff were expected to encourage increased fluid intake, offer fluids in between meals and at snack time, provide additional fluid during activities, and a water pitcher to be left within Resident 4's reach at bedside.A care plan, dated 9/15/24, indicated Resident 4 was at risk for skin breakdown. To meet the goal of adequate.hydration to prevent skin breakdown, the staff would encourage fluids.A care plan, dated 9/15/24, indicated Resident 4 was at risk for falls. To minimize Resident 4's risk of falls, the staff were expected to educate and remind Resident 4 to call for assistance with all transfers and to keep the call light within reach.A review of Resident 4's MDS dated [DATE] indicated Resident 4 had a BIMS score of 15 which indicated Resident 4's cognition was fully intact.A review of Resident 5's admission record indicated Resident 5 was admitted to the facility on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side. A review of Resident 5's care plans indicated the following:A care plan, dated 8/9/23, indicated Resident 5 was at risk for dehydration. To meet Resident 5's goal of adequate hydration, the staff were expected to encourage increased fluid intake, offer fluids in between meals and at snack time, provide additional fluid during activities, and a water pitcher was to be left within Resident 5's reach at bedside.A care plan, dated 8/12/23, indicated Resident 5 had bowel incontinence. To meet the goal of maintaining comfort and dignity daily, the nursing staff were expected to encourage fluid during daytime hours, encourage use of call light for toileting assistance, provide incontinence care during rounds, upon request or as needed. A care plan, dated 2/26/25, indicated Resident 5 was at risk for skin breakdown. To meet the goal of adequate.hydration to prevent skin breakdown, the staff would encourage fluids and keep the skin clean and dry.A review of Resident 5's MDS dated [DATE] indicated Resident 5 had a BIMS score of 15 which indicated Resident 5's cognition was fully intact.During a concurrent observation and interview on 1/21/26 at 1:12 p.m., in Resident 2's room, Resident 2 stated, [The] Fresh water is not fresh. The water on the table is from last evening. Who drinks water that has been sitting for a long time? It's gross! You have to ask for it [fresh water]. Upon observation the water in the clear water bottle was less than half full, did not contain ice and temperature was room temperature. Resident 2 stated she needed assistance for toileting and that the average time for a call light to be answered was 30 minutes, especially during the night shift [11 p.m. -7 a.m.] Resident 2 further stated she has had to sit in her own bowel movement for a long time to the point that it burned her skin causing pain. Resident 2 stated she gathered several complaints from other residents to bring to the monthly Resident Council meetings regarding the lack of Certified Nursing Assistants (CNAs) to help with care of the residents.During a concurrent observation and interview on 1/21/26 at 1:44 p.m., Resident 3 stated, The call lights are bad on [the swing shift]. I put the call light on at 9:30 p.m., they [staff] answered at 10:30 p.m. This is not unusual. Resident 3 stated he had an incontinent bowel movement at that time and has had the same experience an additional 2 or 3 times in the past few months. Resident 3 added, It is not a nice feeling. My skin turns red and burns my groin. It makes me feel like, I have no dignity. Upon observation Resident 3's water bottle was nearly full and placed on the far corner of his overbed tray table. Resident 3 was unable to reach his water bottle and stated he needed to call his CNA for help.A review of the Resident Council Meeting Minutes dated January 2025 to January 2026 indicated the following resident requests:March 2025: CNAs going in to [residents'] room to sleep or charge phones.May 2025: When are we getting [facility] CNAs rather than registry?September 2025: NOC [night shift] shift CNAs do not answer call lights.December 2025: Hire more CNAs.January 2026: Need to have CNAs to help.During an observation on 1/22/26 at 11:29 a.m., while in the facility conference room, this surveyor heard a call light sound from the room directly across from the conference room. This surveyor observed the call light above entryway of the room was illuminated. One staff member entered threshold of door, took a pair of latex gloves and left. The staff member did not enter room or address the resident's need. This surveyor witnessed several different facility staff pass by the room without stopping to check in with the resident whose call light had been on for 20 minutes. The surveyor observed the resident's call light was answered by a staff member at 11:48 a.m.During a concurrent observation and interview on 1/22/26 at 11:49 a.m., Resident 4 stated she was dependent on nursing staff to assist her with brief changes as she was unable to walk to the bathroom. Resident 4 stated she removes her own brief when it becomes soiled because it takes too long for the staff to respond to her call light. She stated it took about 15 minutes for call lights to be answered which was too long if you have to do #2 [bowel movement]. Upon observation two water bottles were at Resident 4 bedside. One bottle was empty. The other bottle contained 10 milliliters (mL, a unit of volume) of room temperature water. Resident 4 stated the water on her table was from last evening and further stated residents only received additional water if they asked staff for it.During a concurrent observation and interview on 1/22/26 at 12:10 p.m., in Resident 5's room, this surveyor observed a water bottle half full of room temperature water. Resident 5 stated the water bottle was only changed and filled once per day. Resident 5 stated the water bottle present on the table was brought to him last night. Resident 5 stated the water tasted bad when it's warm. I won't drink it like that. Resident 5 stated, [It] sometimes took staff an hour to answer [the call light] Especially the graveyard shift. They don't answer because they don't like to change you [resident briefs]. Resident 5 stated he has had to sit in his own bowel movement and urine on several occasions. He stated he had lost count how many times this has happened. Resident 5 further stated, I don't like it at all, makes me feel bad but I'm used to it now.During an interview on 1/22/26at 12:21 p.m., CNA 1 stated it was important for the residents to have water throughout the day in order to stay hydrated. CNA 1 further stated it was important to answer call lights quickly, within five minutes, because you don't know what the residents need.During an interview on 1/22/26 at 1:21 p.m., the Director of Nursing (DON) stated the expectation was for the nursing staff to refresh the ice and refill the water for the residents every shift. The nursing staff were expected to offer and encourage sips of water with every care intervention. The DON further stated call lights were everyone's responsibility, including leaders of the facility noting there were several people working in the building at any given time, so wait times for a call light to be answered should not be long. The DON stated residents left in soiled briefs was unacceptable. During an interview on 1/22/26at 1:45 p.m., the Administrator in Training (AIT) stated the facility did not have any staffing waivers on file. A review of the facility's policy titled Staffing, dated 2001, indicated, The facility provides adequate staffing to meet needed care and services for our resident population. Our facility maintains adequate staffing on each shift to ensure that our residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan.

Based on interview and record review, the facility failed to initiate a baseline care plan for one resident (Resident 1) of three sampled residents when licensed nurses did not create a care plan for Resident 1's indwelling urinary catheter (a flexible tube inserted into the bladder to allow urine to drain from the bladder and into a bag which collects the urine).This failure decreased the facility's potential to prevent urinary tract infections (UTI) among residents with urinary catheters in place.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Fracture of Left Patella (kneecap), Intervertebral Disc Degeneration (progressive breakdown of shock absorbing discs in the spine), Muscle Weakness, Obstructive and Reflux Uropathy (two distinct conditions that interrupt the one way flow of urine from the kidneys to the outside of the body) and Need for Assistance with Personal Care.A review of Resident 1's care plans, dated 11/6/25, indicated licensed nurses did not initiated a care plan for Resident 1's risk of developing a UTI (a bacterial infection of the urinary system) related to having an indwelling urinary catheter.A review of Resident 1's document titled SNF [Skilled Nursing Facility] admission History & Physical dated 11/7/25 at 10:43 a.m. indicated, Issues to be Addressed.Urinary retention.[urinary catheter] in place.failed voiding [ability to urinate] trial.Consider voiding trial next week.A review of Resident 1's Minimum Data Set (MDS- an assessment tool) dated 11/13/25 indicated Resident 1 had a urinary indwelling catheter and was always incontinent (accidental or uncontrolled leakage) of stool.A review of Resident 1's progress note dated 11/13/25 at 10:07 a.m., indicated Resident 1 had a fever of 100.2 F (Fahrenheit-measurement of temperature). Resident 1's oxygen saturation (O2 sat- the percentage of oxygen being carried in the blood) was in the 80's (a normal range would be 95% to 100%). The physician placed an order for Resident 1 to be given up to 6 liters (L- a unit of measurement) of oxygen and for staff to call emergency services and send Resident 1 to the hospital.A review of Resident 1's medical record from the local hospital emergency department indicated Resident 1 arrived for urgent treatment on 11/13/25 at 11:28 a.m. Upon arrival, Resident 1 was placed on 15 L non-rebreather (high concentration oxygen delivery device used for patients in respiratory distress or medical emergency). Resident 1's temperature had increased to 102.8 F with a pulse (heartbeat) of 126, respirations (breaths) were 33 (normal respiratory rate between 12-20) and blood pressure of 105/67. The MD noted Resident 1's mucus membranes were tacky (feel sticky or dry instead of slick and wet), the physician further indicated Resident 1's elevated white blood cell (cells in the body that fight against infection) count was indicative of an infection. Resident 1's urinalysis (a diagnostic test for urine) indicated there were many bacteria in the urine sample along with large leukocyte esterase (a marker indicative of a significant infection). Resident 1 was admitted to the hospital with a diagnosis of sepsis with an etiology (cause, source) of a UTI.During an interview on 1/7/26 at 1:04 p.m., the Director of Nursing (DON) stated she could not find documentation of staff completing urinary indwelling catheter care. In a subsequent interview at 2:18 p.m., the DON stated catheter care should be completed every shift and as needed.During an interview on 1/7/26 at 1:43 p.m., the Director of Staff Development (DSD) stated indwelling catheter care was not documented in residents' charts as it is considered a standard of care.During an interview on 1/8/26, at 11:17 a.m., the DON confirmed there was no documented evidence for the development and implementation of a person-centered care plan for Resident 1's indwelling catheter which placed Resident 1 at risk for UTI. The DON stated a risk for UTI care plan should be in place for all residents that have an indwelling catheter. A review of facility policy titled Catheter Care, Urinary, dated 2001, indicated, The purpose of this procedure is to prevent catheter associated urinary tract infections.Review the resident's care plan to assess for any special needs of the resident.The following information should be recorded in the resident's medical record.The date and time that catheter care was given.The name and title of the individual(s) giving the catheter care.All assessment data obtained when giving catheter care.Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor.Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain.Any problems or complaints made by the resident resident.How the resident tolerated the procedure.If the resident refused the procedure, the reason(s) why and the intervention taken.The signature and title of the person recording the data.Report other information in accordance with facility policy and professional standards of practice.

Based on interview, observation, and facility policy review, the facility failed to ensure the most recent survey results were readily accessible for all residents to review. This deficient practice had the potential to affect all residents who resided in the facility. Findings included: A facility policy titled, Examination of Survey Results, revised 04/2017, indicated, 2. A copy of the most recent survey report and any plans of correction are kept in a binder in the residents' dayroom. During observations on 03/05/2025 beginning at 8:15 AM of readily accessible areas to residents, the state survey results could not be found in the facility. During an interview on 03/05/2025 at 8:24 AM, the Activities Director revealed she did not know where the survey results were posted. She stated she did not know the survey results were required to be available without asking. During an interview on 03/05/2025 at 9:40 AM, the Social Services Director (SSD) stated the survey binder was on the table near the building's entrance. She said she last saw the survey binder when the state surveyors were at the facility, which was about three weeks prior. During an interview on 03/05/2025 at 9:50 AM, the Administrator stated he did not know where the survey binder was, but it was supposed to be on the table across from the conference room. During an interview on 03/05/2025 at 10:26 AM, the Director of Nursing (DON) stated she took the survey results binder on Monday (03/03/2025) to add the most recent survey and she had forgotten to return it. She confirmed that the survey results binder had not been in its usual location for that week, and she further confirmed that the survey results binder was supposed to be available without having to ask. During an interview on 03/07/2025 at 10:56 AM, the Administrator stated the survey results binder should be available for all residents. During an interview on 03/07/2025 at 11:31 AM, the DON stated the survey results binder was supposed to be posted in the lobby for residents to access.

Based on Observation, interviews and records review, the facility failed to ensure a safe environment for one of three sampled residents (Resident 1) when the facility staff were aware that Resident 1 attempted to leave the facility a few hours after his admission and did not develop and implement interventions to prevent Resident 1 from leaving the facility unsupervised. This failure resulted to Resident 1 leaving the facility unnoticed few hours after midnight and ended at the hospital with Hypothermia (a medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature) and Traumatic (relating to or denoting physical injury) hematoma (occurs when a blood vessel ruptures and blood collects in the area) of left elbow. Findings: During a telephone interview with Family Member A on 11/17/23 a 2:38 p.m., Family Member A stated he received a call from the facility on Sunday 11/12/23 at 3 a.m. to inform him that Resident 1 was missing. Family Member A stated the nurse told him that Resident 1 managed to leave the building through an unlocked back door outside of Resident 1's room. Family Member A stated Resident 1 was missing for seven hours until a concerned citizen found him on some street corner and called for an ambulance. Family Member A stated Resident 1 was admitted to the ICU (Intensive Care Unit - unit in a hospital providing intensive care given to patients who are acutely unwell and require critical medical care) for Hypothermia and cuts and bruises on his legs and his left elbow. During a review of the Face Sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnosis including but not limited to Diabetes Mellitus (disease that result in too much sugar in the blood); Psychosis (severe mental disorder); and Epilepsy (a disorder of the brain characterized by repeated seizures [alteration of behavior due to a temporary change in the electrical functioning of the brain.]). During a review of the Progress Notes for Resident 1 titled Admission Summary dated 11/11/23 at 4:48 p.m. indicated, Resident 1 arrived at the facility after discharge from a hospital at approximately 4:40 p.m. The Progress Note indicated Resident 1 was alert and oriented with intermittent confusion. The progress note indicated, at the end of PM (evening) shift, [Resident 1] attempted to leave facility but staff was able to reorient him to room. The Progress Note indicated Resident 1 calmed down after talking to Family Member A. The Progress Note indicated, Report given, and patient's care was endorsed to charge nurse on duty. During a review of the Progress Notes for Resident 1 titled Nurse ' s Note dated 11/12/23 at 4:13 a.m. indicated, Resident 1 was alert and oriented with intermittent confusion. The Progress Note indicated Licensed Staff B saw Resident 1 during her room rounds (a process of checking on residents) at approximately 12:45 a.m. and a CNA (Certified Nursing Assistant) saw Resident 1 at approximately 1:00 a.m. The Progress Note indicated staff noted Resident 1 was missing from his bed at 3 a.m. and staff attempted to search the facility grounds and adjoining streets for Resident 1. The Progress Note indicated the hospital emergency department was called at 3:23 a.m. to inquire if Resident 1 was admitted back to the hospital, however, there was no record of Resident 1 being admitted back to the hospital. The Progress Note indicated Resident 1's roommate saw Resident 1 leave through the back door at approximately 2:00 a.m. During a review of the hospital document titled Emergency Department (ED) History and Physical dated 11/12/23 at 8:41 a.m., indicated an ambulance brought Resident 1 to the Emergency Department on 11/12/23 at 8:20 a.m. The document indicated a bystander found Resident 1 on the corner of the street with multiple abrasions and altered mentation (disruption in how your brain works that causes a change in behavior). The document indicated Resident 1 presented to the ED with Hypothermia due to cold environment and traumatic hematoma of left elbow. During an interview and concurrent record review with the DON (Director of Nursing) on 11/20/23 at 2:19 p.m., when the DON was asked if she was aware that Resident 1 attempted to leave the facility few hours after his admission to the facility, the DON stated she was not informed of the above incident. After review of the Progress Note dated 11/11/23 at 4:48 p.m. with the DON, the DON verified there was a nurse's note indicating Resident 1 attempted to leave the facility at the end of PM shift on 11/11/23. When the DON was asked what interventions were put in place to ensure Resident 1 did not leave the facility unsupervised, the DON stated a wanderguard (bracelet that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time) was not necessary at that time because Resident 1 calmed down after talking to Family Member A and Resident 1 did not appear he was adamant to leave the facility. The DON stated staff did their routine check, however, she stated there was no set time for staff to check the resident. When the DON was asked how Resident 1 managed to leave the facility unnoticed, the DON stated Resident 1's room was at the far back of the nurse's station and Resident 1 exited through the back door. When the DON was asked how staff would know if a resident left the facility unsupervised through the back door, she stated the door was equipped with an alarm system triggered by a wanderguard. The DON stated if a resident did not have a wanderguard, there was no way for staff to know if a resident left the back door. The DON stated that a room change (closer to a nurse's station) was not considered for Resident 1 after his first attempt to leave the facility because Resident 1 calmed down and was not adamant to leave. During a review of the facility document titled Elopement (A situation in which a resident leaves the premises or a safe area without the facility ' s knowledge and supervision) Risk Observation/ Assessment for Resident 1 dated 11/11/23 at 4:49 p.m., with the DON on 11/20/23 at 2:29 p.m. indicated, If the total score is 10 or greater, the Resident would be considered At Risk for Elopement. Interventions would be implemented as determined by the facility. The document indicated Resident 1 was able to propel self/some assist (2 points); Resident 1 had mood-altering medication (2 points) and Resident 1 had any type of cognitive impairment (2 points) giving Resident 1 a total elopement risk score of six (6). The document did not show checkmarks for the following items: is disoriented and/or confused with no wandering (2 points); and has made 1 or more attempts in the last year (10 points); however, the DON verified that the Progress Note dated 11/11/23 at 4:48 p.m. indicated Resident 1 had intermittent confusion and had attempted to leave the facility. The DON stated the assessment was completed prior to Resident 1's attempt of leaving the facility and concurred that the assessment should have been updated after the incident to reflect an accurate elopement risk score of Resident 1 which could have triggered him as high elopement risk. During an observation, and concurrent interview with the DON on 11/20/23 at 2:36 p.m., the DON stated Resident 1's room was located in the west wing of the building which was observed to be at the far back of the nurse's station. Beside Resident 1's room there was a glass exit door going to the parking lot. The DON stated the doors were locked from the outside during the night to restrict people from outside going in, however, people inside the facility could open the door to go outside. During an interview with Licensed Staff D on 11/20/23 at 2:53 p.m., when asked about the facility policy when a resident was observed attempting to leave the facility unsupervised, Licensed Staff D stated she would notify the doctor and obtain an order for wanderguard or could also use one-to-one supervision (intervention aimed to keep residents safe through observation by staff) as needed. During an interview with Licensed Staff E on 11/20/23 at 2:57 p.m., when asked about the facility policy when a resident was observed leaving the facility unsupervised, Licensed Staff E stated the resident would be listed on the elopement binder and obtain an order from the doctor for wanderguard immediately. Licensed Staff E stated the exit doors (including the glass exit door on west wing) were equipped with alarm systems triggered by a wanderguard to alert the staff of resident's attempt to leave the facility unsupervised. When asked how staff were notified if a resident with no wanderguard left the facility without notice during the night, Licensed Staff E stated the staff would not know unless the resident was observed leaving. Review of the Facility policy and procedure titled Elopements (revised December 2007) with the DON on 11/20/23 at 4:13 p.m., the DON verified the policy did not address how the facility would assess, identify, monitor, and manage residents at risk for elopement. The DON stated the facility did not have other policies and procedure related to elopement other than what was reviewed. During a telephone interview with Licensed Staff B on 11/21/23 at 4:12 a.m., Licensed Staff B stated Unlicensed Staff C informed her that Resident 1 was missing at around 3:00 a.m. on 11/12/23. Licensed Staff B stated Resident 1 ' s roommate said Resident 1 left the facility around 2:00 a.m. using the back door. Licensed Staff B stated staff looked for Resident 1 in and out of the facility. Licensed Staff B stated they did not find Resident 1 during their search. She stated she called the hospital to check if Resident 1 was brought to the hospital but there was no report that Resident 1 was at the hospital. When Licensed Staff B was asked if she received a report from the PM shift nurse that Resident 1 attempted to leave the facility during PM shift, she stated, yes. When Licensed Staff B was asked how she made sure that Resident 1 did not leave the facility again without supervision, Licensed Staff B stated there was only one attempt on PM shift of Resident 1 leaving the facility. Licensed Staff B stated no interventions were put in place to ensure a resident did not leave the facility other than doing her routine room checks every two hours for all residents. Licensed Staff B stated applying a wanderguard to Resident 1 was not necessary because Resident 1 was calm until he was found missing. During a telephone interview with Unlicensed Staff C on 11/21/23 at 4:18 a.m., Unlicensed Staff C stated he looked for Resident 1 all over the facility when he noticed Resident 1 was not in his room before he reported to Licensed Staff B. Unlicensed Staff C stated he and another CNA drove around the area to look for Resident 1, however, they did not find Resident 1. Unlicensed Staff C stated he was aware that Resident 1 had already attempted to leave the facility from the previous shift and stated, that is why I was checking the resident every two hours.

Based on interview and record review, the facility failed to ensure 1 of 3 sampled resident's (Resident 1) maintained adequate hydration (fluid status in the body) and nutrition (food intake) during his approximate 3.5 week stay at the facility. Resident 1 was transferred to the facility from Hospital 1 (approximately 90 miles North of the facility) after having his right toe amputated (removed) and his plan of care included post-surgical (after surgery) rehabilitation at the facility, with an ultimate goal of returning home to his wife. Upon admission to the facility, Resident 1 required the assistance of staff for eating and drinking and nursing staff documented he was at risk for dehydration and malnutrition. Although Resident 1 was a Full Code (directs a patient's medical care regarding life-sustaining interventions; full support): 1) Nursing staff and the Registered Dietitian (RD) did not notify Resident 1's physician (Physician F), Nurse Practitioner (NP G), or family when he had a 30.8 (31) pound weight loss 18 days after admission; 2) Nursing staff and the RD did not identify Resident 1's consuming too little fluid, dating back to his admission; 3) Resident 1's severe weight loss was not presented and discussed during the Weight Committee (also known as the Nutritionally at Risk [NAR] Committee; RD and nursing staff monitor/intervene in patient care as it relates to weight loss and weight gain) nor during an IDT meeting (interdisciplinary team of healthcare professionals including nursing, social workers, pharmacy, and dietary staff); 4) Nursing staff did not implement a Change of Condition (COC; clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) in response to Resident 1's severe weight loss and failed to document it in his medical record; and, 5) Certified nursing assistants (CNA's) did not consistently and accurately document Resident 1's oral fluid intake in his medical record. These failures: 1) Caused Resident 1 to lose approximately 30.8 pounds during his first 18 days at the facility; 2) Contributed to Resident 1 ' s approximate 44-pound weight loss (an approximate 27% weight loss) between hospital discharge (on 5/24/23) and hospital ED re-admission (6/18/23), Resident 1 ' s approximate 3.5 week stay at the facility; 3) Caused Resident 1 to become severely dehydrated and severely malnourished, 4) Prevented Physician F and NP G from being aware of Resident 1's decline and therefore, prevented them from evaluating and treating his severe weight loss; 5) Caused Resident 1's family, after observing his condition during a visit, to remove him from the facility AMA (Against Medical Advice) and drive him to Hospital 1; 6) Caused Resident 1 to be admitted into Hospital 1's Intensive Care Unit (hospital department in which dangerously ill patients are under constant observation); 7) Prevented Resident 1's family from being aware of his decline, thereby denying them the opportunity to support and comfort him; 8) Contributed to an exacerbation (make worse) of Resident 1's kidney injury; 9) Contributed to a urinary tract infection and aphasia (loss of ability to understand or express speech); and, 10) Potentially contributed to Resident 1 being placed on Hospice care (End of Life Care). Online review of the Mayo Clinic website revealed dehydration occurs when a person uses or loses more fluid than they take in; the body doesn't have enough water and other fluids to carry out its normal functions; if lost fluids are not replaced, dehydration occurs. One common cause is vomiting and older adults and people with chronic illnesses are most at risk. Severe dehydration requires immediate medical treatment. One complication of dehydration is kidney failure, a potentially life-threatening problem. (https://newsnetwork.mayoclinic.org/discussion/dehydration-can-lead-to-serious-complications/). Findings: Review of Resident 1's medical records from Hospital 1 (first admission, prior to his stay at the facility) indicated he was admitted on [DATE] and discharged to the facility on [DATE] (six-day hospital stay). The physician Discharge Summary (physician documentation summarizing the hospital stay), dated 5/24/23, indicated, Hospital Course . male with history of . DM2 (diabetes type 2; chronic disease characterized by elevated levels of blood glucose [blood sugar]), CVA (stroke), and dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) who presents with generalized weakness .1. Right food diabetic ulcer (wound) .right fifth toe amputation (on 5/19/2023) . 2. Fever, positive for group B strep (bacteria) on admission . received ceftriaxone (antibiotic) .3. AKI (Acute kidney injury; an abrupt decrease in kidney function, which encompasses both injury [structural damage] and impairment [loss of function]) present on admission: Baseline serum creatinine (chemical waste product; indicates how well the kidney works; Creatinine is removed from the body entirely by the kidneys) approximately 0.9 mg/dL (milligrams per deciliter - unit of measure showing concentration of a substance), presented (on hospital admission) at 1.3 mg/dL, now (at discharge, 5/24/23) 1.1 mg/dL (normal). Likely . due to dehydration. Received maintenance fluids (intravenous fluids) with normalization of his creatinine . 5. Type 2 diabetes . 6. Physical deconditioning per the family, weak beyond his baseline in the setting of acute (new/current) illness . Discharge details indicated, Follow-Up Plans: Per SNF (skilled nursing facility) orders .Discharge Activity: Ambulates (walks) with Assist (assistance) Discharge Diet: Pureed diet (food with soft, pudding-like consistency; pureed diet continued at the facility) . Wound care: (physician name) from podiatry (medical specialty devoted to the study/diagnosis/treatment of foot and ankle disorders) has been consulting on this patient . Daily dressing changes by nursing at (facility name) . Review of Resident 1's medical records from Hospital 1 (second admission, after his 3.5 week stay in the facility), dated 6/18/2023 at 8:05 p.m., revealed documentation by Physician C titled, Emergency Department Reports, subtitled, History (History of Present Illness). Physician C documented, Family went to go visit Patient (Resident 1) today at (facility name) where the patient has been . since discharge (5/24/2023) to that facility from here (approximately twenty-five days/3.5 weeks). He was noted to be markedly more emaciated (abnormally thin or weak, especially because of illness or lack of food) and nonverbal than he was on their previous visit which was approximately 3 weeks ago. Family elected to sign him out of that facility and bring him here for evaluation. Patient does apparently have a history of being verbal and ambulatory (able to walk) and now is neither . by report, the patient has not been eating much at this post-acute facility for some time . Physician C documented his diagnosis to include acute (new onset) renal failure, dehydration, urinary tract infection, and encephalopathy. Physician C documented Resident 1 was, .clearly quite ill ., and in, critical condition. Physician C documented he was admitting Resident 1 into the Intensive Care Unit. Continued review of Resident 1's medical records from Hospital 1 (second admission), dated 6/18/2023 at 10:11 p.m., revealed documentation by Physician D (a nephrologist; specialist in kidney function) that indicated, Per (family member) at bedside, reports visiting (at the facility) with other family members today, (and) noticed significant weight loss, was non-verbal, unintelligible when (he, Resident 1) attempted to speak. (Family member) reports (the facility) mentioned that he (Resident 1) hasn't eaten or had water in days; even vomited a few times a few days ago . Physician C documented his impression (diagnosis) included, #AKI, oligoanuris (condition lying between anuria [no urine output] and oligouria [low urine output], when less than 100 cc (cubic centimeters) of urine is produced per day; normal urine output is [PHONE NUMBER] cc each day) . etiology (cause) suspect to be due to . severe volume depletion in the setting of significant caloric and water deprivation; as family mentions days without food/water and significant weight loss . Physician D documented a second impression to include, #Electrolytes (minerals in blood/body fluids that affect how the body functions in many ways including the amount of water in the body and the acidity of blood) . HyperNA (increased sodium concentration in the blood; causes lethargy/confusion/excessive thirst) HyperCl (excessive Chloride level in the blood; sign of dehydration, kidney disease, and too much acid in the blood), Hypo K (low potassium) . suspect related to lack of access to free water and poor nutritional intake . Continued review of Resident 1's medical records from Hospital 1 (second admission), dated 6/19/2023 at 10 minutes after midnight and 6/19/2023 at 4:56 a.m., indicated Physician E documented Resident 1's History and Physical assessment (documentation of physician's thorough medical history and physical exam). Physician E's history and physical indicated, . pt (patient) . admitted in May 2023 (first admission) for R fifth toe infection s/p (status post) amputation . who was discharged to (facility name) . who presents to the (Hospital 1 name) ED from the care home (facility) via private transportation [his family drove him] . They (family) visited him for Father's Day and found him to be in terrible condition: generalized weakness, dehydration, non-verbal, oral thrush (fungal infection of the mouth), and significant weight loss . They were concerned enough to remove him from the care home (facility) and drive him to (Hospital 1's) ED . His weight in the ED was 44 kg (kilograms), whereas upon hospital discharge on May 24th, it had been recorded as 64 kg, representing a 20 kg (44 lbs [pounds]) weight loss in just 3.5 weeks. Labs (laboratory blood work) showed significant AKI, with a serum Cr (creatinine) of 6.2, whereas it had been 1.1 on May 23rd . UA (urinalysis) was positive for UTI (urinary tract infection). He was given 1 L NS (one liter [1000 cc's] normal saline [intravenous fluids]) as well as Rocephin (antibiotic) . He appeared gaunt and weak and was non-verbal. His tongue was white. His abd (abdomen) was scaphoid (abdominal wall is sunken; concave). Continued review of Physician E's History and Physical (dated 6/19/2023 at 10 minutes after midnight and 6/19/2023 at 4:56 a.m.) indicated Physician E's active diagnoses included, AKI. Due to severe dehydration . Severe dehydration. Probably due to significantly reduced oral intake, for whatever reason (not sure if dysphagia [difficulty or discomfort in swallowing] precluded oral intake, or if he was refusing, or if he was being neglected). Aggressive IVFs (aggressive intravenous fluid treatment) . Severe Acute Protein-Calorie Malnutrition; Unintentional Weight Loss . Aphasia. Could be due to TME (toxic-metabolic encephalopathy; encephalopathy caused by toxins (substances that are poisonous [toxic] to humans; can be produced inside the body), AKI, and hypernatremia (elevated blood sodium level) . Acute Encephalopathy on Chronic Dementia. Acute component most likely a TME due to dehydration . Oral thrush . UTI . S/P (status post) R (right) 5th toe amputation May 2023 . Physician E documented Resident 1's code status was, Code: Full and his disposition was, ICU. Expected stay 2 or greater midnights. Continued review of Resident 1's medical records from Hospital 1 (second admission), dated 6/25/23, indicated Nurse Practitioner K documented a Discharge Summary (summary of hospital stay) that indicated, . removed by family from (facility) . found to have (in the ED) acute renal failure . Thought related to severe dehydration. Also with significant malnutrition with weight loss of 20 kg (kilograms) in last month . 1. Acute kidney injury . likely secondary to severe dehydration . 3. Severe dehydration this is likely the result of very poor oral intake . 5. Severe acute protein calorie malnutrition . Discharge planning: Palliative care (comfort measures only) . Confirmed that patient will be receiving services from hospice . Review of Resident 1's facility electronic medical record (EMR; at the facility) Facesheet (a demographic) indicated he was admitted from Hospital 1, and into the facility on [DATE]. Resident 1's facility Facesheet indicated his diagnoses included sepsis (infection; treated at the hospital), aftercare following surgical amputation (his right toe), generalized weakness, difficulty walking, dementia, diabetes type 2, acute kidney failure, Cerebral infarction (history of stroke), blindness in one eye, and dysphagia (difficulty swallowing). Review of Resident 1's facility EMR revealed a nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes), dated 5/24/2023, that indicated, Nutrition: Resident at nutrition & hydration risk . Goals on the care plan indicated, Maintain po (oral) intake (greater than) 75% (for) most meals . maintain CBW (current body weight) 146# (146 pounds) +/- (plus or minus) 5# (5 pounds) . Adequate fluid intake . No sign/symptoms of dehydration . Nursing interventions included, Assess for signs/symptoms of dehydration . Assist with meals . Encourage adequate fluids as tolerated, monitor % of intake . RD evaluation as needed .Weight as ordered . A second nursing care plan, dated 5/24/2023, indicated, Dehydration: At risk for dehydration .Interventions .Encourage increase p.o. fluid .monitor for s/s (signs/symptoms) of dehydration . provide adequate fluids . A third nursing care plan, dated 6/5/2023 indicated, Resident is in facility for short term placement . Lives in (city name) w/ (with) his wife and support from his adult children . Wife plans for him to return home . Resident 1's facility EMR contained one provider (physician or nurse practitioner) progress note documented by NP G on 6/2/2023 at 1:49 p.m. (nine days after admission) that indicated, .Seen today for initial exam . Here for rehab (rehabilitation) following hospitalization for AKI, R (right ) diabetic foot ulcer s/p (status post) partial amputation of the R 5th (toe) . PMH (past medical history) DM II (diabetes type 2) Dementia . Glaucoma (increased pressure within the eyeball, causing gradual loss of sight) - R eye blind .CODE status: FULL . NP G documented her assessment and plan for Resident 1's stay was, Weakness/ambulatory impairment - PT/OT (physical therapy/occupational therapy) - Supportive care Dementia .(medication for treatment listed) .AKI - Resolving: CR (creatinine) 1.1 (normal level) at time of discharge (from hospital, 5/24/23) . DMII - controlled - R foot wound s/p R (sic) - Wound care per nursing - F/u (follow up with) podiatry . During a tour of the facility and concurrent interview on 8/16/2023 at 1:30 p.m., LN H was asked how staff handled residents with weight loss. LN H stated the RD came to the facility three times per week and made recommendations (for nutritional interventions) and the resident would be discussed at the Weight Committee. LN H stated staff monitored resident intake and output and RNA's (restorative nursing assistants; help residents perform tasks that restore/maintain physical function as directed by the established care plan) weighed residents. Review of Resident 1's medical record revealed one assessment from the RD (dated 5/31/2023 - one week after admission) that indicated, E Physical and Mental Functioning . e. Feeds Self . (MDS assessment indicated he required assistance of one staff to eat/drink). RD documented the following data regarding Resident 1: L. Fluid Intake . 1. Consumes 1,500 and over cc/day . M . 5a. Meal Intake % 76% . Under the category titled, S. Nutrition Goals/Monitoring and Evaluation, the RD documented, . Recommendations: Continue with current POC (plan of care) Goals: Maintain CBW (current body weight) 146# (pounds) +/- (plus or minus) 5# (pounds). Maintain po intake (greater than) 75% x (for) most meals. Maintain (+) [positive] hydration status. Eval (evaluation): Resident with dementia and currently tolerating puree texture diet . Will continue to monitor PRN (as necessary) . (Resident 1 ' s facility diet order was CCHO (consistent, constant, or controlled carbohydrate diet - secondary to DM), puree consistency, with thin liquids). During an interview and concurrent record review on 8/16/2023 at 2:20 p.m., the Registered Dietitian (RD) was asked how the facility handled resident weight loss and specifically, Resident 1's weight loss. RD stated residents who were newly admitted to the facility had their weights monitored weekly for four weeks. She stated weekly weights were discontinued until the resident's weight was stable, at which time the resident would be weighed monthly. RD stated interventions to address the weight loss included a root cause analysis (determining the potential causes) including assessing the resident's appetite/food preferences, determining if medications may be a contributing factor, and considering absorption [absorbing nutrients from the small and large intestines] issues. The RD stated additional interventions included discussing the weight loss at the Weight Committee (Registered Dietitian, DON and/or the Assistant DON, and the treatment nurse [nurse who treats wounds]) and calling/faxing the physician if necessary. The RD stated the physician was always faxed to notify him/her and to suggest interventions. During the same interview and concurrent record review on 8/16/2023 at 2:20 p.m., Resident 1's medical record titled, Weights and Vitals Summary indicated Resident 1 was weighed 5/25/23 (the day after admission) and his weight was 148 pounds; his weight on 5/31/23 was 146 pounds; and his weight on 6/12/23 was 117.2 pounds (a 30.8-pound weight loss in approximately eighteen days). The RD stated in addition to the three documented weights, Resident 1 had an undocumented weight obtained on 6/8/23 which was 119 pounds. During the same interview and concurrent record review on 8/16/2023 at 2:20 p.m., RD stated Resident 1's family took him out of the facility on 6/18/23 AMA. When asked why the family took Resident 1 out AMA, RD stated the family wanted to take him because he was declining. When asked if she thought Resident 1 had been declining, RD stated he had a vomiting issue. RD stated she did not remember the details but Resident 1 had been eating well but was vomiting. RD stated Resident 1 was eating everything until he began having nausea and vomiting. She stated Resident 1 stopped eating two days prior to his family taking him to the Emergency Department. During the same interview and concurrent record review on 8/16/2023 at 2:20 p.m., RD was asked about the interventions implemented to address Resident 1's weight loss and she stated there were, none. RD stated her normal process was to ask for a re-weight (to ensure the weight was accurate) and then document the re-weight. When asked why that was not done for Resident 1, RD stated she did not know. RD stated she had added additional items to his tray such as yogurt, but this was written in her binder and did not show up in the medical record. When asked if the CNAs or nursing staff informed her of Resident 1's weight loss, RD stated she tracked resident weights herself. When asked why Resident 1's medical record did not have an RD progress note (with one exception of the RD assessment on 5/31/2023), RD stated she normally wrote a note. RD stated she was not sure why (his weight loss) was not caught. RD stated the weight loss was missed. Review of a document titled, Weekly Weights 6/4/22 - (facility name), provided by the RD (weight loss tool; not located in Resident ' s EMR), indicated Resident 1 had an 18.49% weight loss. RD stated she assumed that number was incorrect. During the same interview and concurrent record review on 8/16/2023 at 2:20 p.m., RD stated the facility received a call from Adult Protective Services (APS) on 7/18/23 (after Resident 1 had left the facility) regarding Resident 1. RD stated APS was requesting Resident 1's medical progress notes. Review of facility policy titled, Weight Assessment and Intervention, subtitled, Weight Assessment (revised March 2022) indicated, .4. The threshold for significant unplanned and undesired weight loss will be based on the following . a. 1 month - 5% weight loss is significant; greater than 5% is severe . During a telephone interview on 9/11/2023 at 3:31 p.m., Adult Protective Services Social Worker (APS S.W.) stated (an anonymous complainant) had filed a complaint with her department (Adult Protective Services). APS S.W. stated the complaint indicated that Resident 1's family had gone to visit him at the facility and found him in a, bad situation. APS S.W. stated the family was very upset the facility had not communicated (with them) that he had declined (in health status). APS S.W. stated the family took Resident 1 (out of the facility) and brought him to Hospital 1. APS S.W. stated the family had not been able to visit Resident 1 at the facility for three weeks and when they saw him at the facility (on 6/18/2023), they took him straight to Hospital 1. Review of a nursing progress note from Resident 1's medical record (dated 6/18/2032 at 11:50 a.m.), documented by Licensed Nurse A (LN A), indicated, Approx (approximately) 0930 (9:30 a.m.) residents ' family .want the resident to be discharged AMA (against medical advice) . They (family members) said that they are very concerned that the resident seems to be declining and he has lost weight. They want to take him home so they can . take care of him better . During an interview and concurrent record review on 9/14/23 at 2:33 p.m., Certified nursing assistant B (CNA B) stated she had worked with Resident 1 once or twice in the past. When asked how she monitored a resident's intake (oral) and output (urine and stool), CNA B stated she looked at the meal tray and marked down how much they ate and drank. She stated if a resident only drank a little, she would tell (verbally) the nurse. During an interview on 9/14/23 at 2:55 p.m., LN A stated she had some recollection of Resident 1 and he had been her patient when she worked in the morning (morning shift). When asked what she recalled, LN A stated Resident 1's family took him out of the facility AMA. LN A stated she remembered they said, they could take care of him better (than the facility). During the same interview and concurrent record review on 9/14/23 at 2:55 p.m., LN A stated Resident 1 was a fall risk and therefore, his room was near the nurse's station. LN A stated, he's a feeder (unable to feed himself; requires staff assistance to eat). LN A reviewed the Weights and Vitals Summary (that indicated Resident 1 lost 30.8 pounds between 5/25/23 and 6/12/23) and stated it was a, significant weight loss. When asked if she was aware of Resident 1's weight loss, LN A stated she did not remember. When asked what she would have done if she had been aware, LN A stated she would have called the doctor, notified the RD, and documented a note (in the nurse progress notes). LN A confirmed Resident 1's EMR did not contain a nurses note indicating Resident 1's physician (Physician F) or family were notified of the significant weight loss. LN A confirmed Resident 1's medical record did not contain a Change of Condition (COC) or an SBAR (Situation-Background-Assessment-Recommendation; communication technique between health care team members regarding a patient's condition) nursing note identifying the significant weight loss. During the same interview and concurrent record review on 9/14/23 at 2:55 p.m., LN A confirmed a COC, dated 6/16/23 (four days after his documented significant weight loss), was located in Resident 1's medical record. LN A stated the form was completed due to Resident 1 experiencing nausea and vomiting. LN A stated Resident 1 had emesis (vomiting) three times in an eight-hour period and NP G had been notified. LN A confirmed NP G had ordered medication (Zofran) to treat Resident 1's nausea and vomiting after she was notified. LN A confirmed Resident 1's weight loss was not addressed in the COC dated 6/16/23. Review of facility policy titled, Change in a Resident's Condition or Status, subtitled, Policy Statement (revised February 2021) indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition . Under subtitle, Policy Interpretation and Implementation, the policy indicated, 1. the nurse will notify the resident's attending physician . when there has been a(an): .d. significant change in the resident's physical/emotional/mental condition . 2. A significant change of condition is a major decline . in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard . interventions . c. requires interdisciplinary review and/or revision to the care plan . 3. Prior to notifying the physician . the nurse will make detailed observations and gather relevant and pertinent information . 4 . a nurse will notify the resident's representative when: .b. there is a significant change in the resident's physical, mental .status .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition . During an interview and concurrent record review on 9/14/23 at 3:57 p.m., the Social Worker (SW) stated her memory of Resident 1 was that he lived in a nearby city with his wife, he was at the facility for therapy and nursing care, and the plan for him was to return home with his wife (after discharge from the facility). Review of an IDT progress note (dated 6/12/2023 at 4:46 p.m. - after Resident 1's weight loss was documented in his medical record) indicated the following: Note Text: Psychoactive Medication Review. The IDT note indicated the DON, LN H and the SW were the members present at the meeting. SW reviewed the IDT note and confirmed the meeting was, just (a) psychoactive (medication) review and did not address his weight loss. When asked if she had been aware of Resident 1's significant weight loss, the SW stated she was, not aware at that point. SW stated she had called Resident 1's family member two days after he left the facility AMA and his family member informed SW that Resident 1 was in the Hospital 1's Intensive Care Unit. During an interview and concurrent record review on 9/14/2023 at 4:29 p.m., the DON was asked if she had had any interaction with Resident 1 during his approximately three and a half-week stay at the facility and she stated, no, just rounding (proactive, systematic, nurse-driven, evidence-based intervention that helps anticipate and address patient needs). The DON stated she had not spoken to his family, either. The DON reviewed the Weights and Vitals Summary, documenting weights from 5/25/23, 5/31/23 and 6/12/23, (indicating Resident 1's 30.8-pound significant weight loss) and stated it was a huge weight loss. When asked what staff should have done with this information, the DON stated normally staff would recheck the weight to ensure accuracy, notify the RD for her review and recommendations, notify the DON or ADON (assistant DON), call (notify) the provider (physician or nurse practitioner), notify the family and/or responsible party, document (interventions and actions taken), and write a COC note to document and monitor the issue. When asked if any of these interventions had been taken for Resident 1, the DON stated, Unfortunately, I do not remember and further stated she did not remember if she was notified. The DON confirmed the EMR did not contain evidence Resident 1's weight had been rechecked or that the DON, RD, or ADON had been notified of the weight loss. During the same interview and concurrent record review on 9/14/2023 at 4:29 p.m., the DON confirmed the RD had provided a nutritional evaluation for Resident 1 on 5/31/23 but the medical record did not contain documentation by the RD of Resident 1's significant weight loss. During a concurrent interview and review of Resident 1's medical record on 9/14/23 at 4:45 p.m., the Director of Staff Development (DSD) and the DON reviewed the documents titled, Documentation Survey Report v2 (report generated when the CNA's charted resident's intake/output). The documents indicated that from 5/24/23 (admission) until 6/18/23 (leaving AMA), the CNA's documentation of Resident 1's fluid consumption was both incomplete and reflected he had a low fluid intake; the DSD and DON confirmed this information. The report indicated on 5/25/23, CNA's documented Resident 1 consumed a total of 360 cc of fluid (the RD's assessment indicated he consumed 1500 cc/day) but his fluid intake at night was left blank; on 5/26/23, the CNA's documented he consumed a total of 580 cc. During Resident's stay at the facility, the CNA's failed to document his fluid intake on approximately seven occasions (Day shift: 6:30 a.m. to 2:30 p.m. - on 6/3/2023; Night shift: 10:30 p.m. to 6:30 a.m. - on 5/24/2023, 5/25/23, 5/29/23, 6/1/23, 6/3/23, 6/14/23); the DSD and DON confirmed this trend. During his stay at the facility, the documents indicated Resident 1 consumed between 100 cc - 1110cc of fluid per day. The documentation indicated Resident 1 consumed less than 500cc in twenty-four hours on approximately eight occasions (5/25/23, 5/27/23, 5/29/23, 5/31/23, 6/3/23, 6/9/23, 6/14/23, 6/15/23 and 6/17/2023). The DSD and DON confirmed nursing staff did not document Resident 1's low oral intake trend on their daily nursing notes titled, Nursing - Daily Skilled Charting Form - V 3.0 or on the MAR (Medication Administration Report) from 5/24/23 through 6/18/23. During a telephone interview on 9/18/2023 at 2:17 p.m., Physician F (Resident 1's doctor and the facility's Medical Director at the time of Resident 1's admission) stated Nurse Practitioner G (NP G, Resident 1's NP during his stay) worked under him (he supervised her work). Physician F was asked about Resident 1's weight loss, poor fluid intake, lack of nurse monitoring of intake, and lack of RD and nurse response to his severe weight loss. When asked if he had been notified Resident 1's weight loss, Physician F stated he did not recall being notified. Physician F stated if a resident who was a Full Code (like Resident 1) had a thirty-one-pound weight loss, he and/or the NP would act on the information. He stated they would recheck the weight for accuracy, assess any medical trends with the resident, call and notify the family, have a Care Conference to discuss the issue, get a written nutritional evaluation, possibly order an appetite stimulant, possibly order intravenous fluids, and order stat (immediate) labs (laboratory tests such as albumin (a simple form of protein that is found in blood serum). Physician F stated if he had known about Resident 1's decline, he would have intervened. When asked if he thought the facility's failure to monitor and intervene in Resident 1's fluid status and weight loss contributed to his diagnosis in Hospital 1 (kidney injury, severe dehydration, severe malnutrition, etc.), Physician F stated yes he would agree. Physician F stated he wanted to review Resident 1 ' s medical record (did not have it in front of him) and would call back. During a follow-up telephone interview on 9/19/2023 at 11:49 a.m., Physician F stated he reviewed Resident 1's medical record and spoke to NP G. Physician F stated NP G told him she was not notified by the facility of Resident 1's thirty-one-pound weight loss. Physician F stated both the RD and Nursing Staff should have notified him (or NP G) of the weight loss so they could have[TRUNCATED]

Based on observation, interview, record review, and policy review, the facility failed to develop and implement interventions to assure a resident with dementia received person centered care for activities of daily living for one of 26 sampled residents (Resident (R) 98), selected for review. As a result of this deficient practice, R98's dementia care needs were not addressed resulting in the inability to achieve the highest level of psychosocial and mental well-being. This deficient practice had the potential to affect the other 28 residents identified by the facility with a [DIAGNOSES REDACTED]. Findings include: Review of the Admission Record located in the front of R98's paper medical record, indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 30 day Minimum Data Set (MDS), an assessment tool completed by the facility staff to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end point of the evaluation period, of 07/09/19, located under the MDS tab in the electronic medical record (EMR), Section C: Cognitive Patterns, a Brief Interview of Mental Status (BIMS) score of 3 of 15, indicating severely impaired cognitive abilities; Section E: Behaviors, rejection of care was not present; Section H: Bladder and Bowel, the resident was always incontinent of bowel and bladder. The Care Plan dated 06/27/19, located under the Care Plan tab of the EMR, documented a focus area of refusing therapy services. The goal documented, he would be comfortable and have his needs met, with approaches of encouraging the resident to attend therapy, monitor for ill effects of his refusals, monitoring his vital signs each shift, and notifying his physician of his refusals. The Care Plan dated 06/27/19, located under the Care Plan section of R98's paper medical record, indicated a focus area for Activities of Daily Living (ADL). The focus area indicated the resident required assistance for bathing, with the Goal, the resident would be well-groomed and free of odor, and the Intervention, the resident should be provided or assisted with a shower or bed bath as scheduled. The Care Plan dated 07/23/19, located under the Care Plan tab of R98's EMR indicated the resident was incontinent of bowel and bladder, and was on a check and change program. Review of 98's EMR failed to reflect the [DIAGNOSES REDACTED]. Observation on 08/06/19 at 11:40 AM, identified R98 was lying in bed on his back, wearing a hospital gown. He was not visibly soiled, and there was no odor in the room. The resident was leaning slightly to his left with the head of his bed elevated to approximately 30 degrees. There was an overbed table to the resident's left which contained a water mug approximately half full of water. There were no snacks or other food items visible in the room. The resident stated he was hungry and wanted something to eat. At 11:42 AM, Certified Nurse Aide (CNA) 1 entered the room and offered the resident a bed bath. The resident stated he did not want a bath but wanted something to eat. CNA1 responded by stating, I have to change you. The resident became agitated and stated, No you don't Goddammit. You try to do that every damn day. I don't need to change clothes that much, I'll exchange (the bath) for something to eat. As CNA1 turned to leave the room, the resident again asked for something to eat. CNA1 left the room without responding. Observation identified that at 11:58 AM, CNA1 returned with CNA3. No other staff were observed to enter the resident's room after CNA1 left the room. CNA3 approached R98's bed as CNA1 went into the bathroom and filled a basin with soapy water. CNA3 told R98 they were there to clean him. R98 stated, No, I'm clean enough. I'm not going to do this every day. I don't want that water here either (referring to the basin of soapy water). The resident stated he fought in World War II in Japan and knew when he was dirty. CNA3 asked some questions about the food the resident ate in Japan while she and CNA1 attempted to reposition the resident in bed. CNA1 and CNA3 did not inform the resident they were going to reposition him. As they moved the resident's right arm, he yelled out, Ow, stop it. Stop it. I feel like a damn piece of sandpaper. CNA1 stated, I'm being gentle. CNA1 then used a washcloth to wash the resident's face. He was agitated and yelled, Ow, ow, ow, you're rubbing too hard. You're rubbing too Goddamned hard, Stop. CNA1 stated, I'm not rubbing, I'm patting, and continued the task. The resident stated in a loud tone of voice, Lady will you stop that. Both of you. I'm hungry. CNA1 and CNA3 continued to bathe the resident's neck and arms, with the hospital gown in place. CNA3 told the resident it was almost lunchtime. The resident stated, That don't mean a Goddamn thing. I'm hungry now. That's f***ing hot water. I hurt. I'm going to find somewhere else to live. Continued observation identified, CNA3 and CNA1 began to remove R98's hospital gown, so the observation continued from the hallway. The privacy curtain around the resident's bed was drawn, but the door to the room was open. From the hallway outside the room, the resident could be heard calling out, Ow, ow, ow, I'm hungry, that hurts, and You two knock it off repeatedly. At 12:07 PM, the resident yelled, Quit touching my Goddamn ass. At 12:09 PM, the resident began to call out, Ow, let go of my Goddamn legs At 12:10 PM, CNA3 left the room. CNA1 remained in the room and stated, It's almost lunchtime. Now you can have your lunch. R98 began to call out that he needed to urinate. CNA1 told him she would get him another blanket. The resident stated loudly, Blanket, hell I've got to pee. CNA1 went into the bathroom, emptied the basin of water into the sink, and said that she would bring the resident another blanket. CNA1 gathered the soiled towels used for the bed bath and left the room. R98, alone now in the room, began calling out loudly, Please help me, where's my food, I've got to pee. At 12:14 PM, CNA1 returned to the room with a blanket. R98 stated, I'm hungry. Can I get some food? I'll take anything. CNA1 stated she would get some ice cream, left the room, and returned a minute later with a pudding cup. She assisted the resident to eat the pudding without speaking to him, then left the room. No staff entered the room until 12:40 PM. Observation continued at 12:22 PM, the surveyor approached the resident in his room. He was lying in bed, dressed again in a hospital gown, leaning slightly towards the left, with the head of his bed elevated to approximately 30 degrees. The resident stated, I'm hungry and I have to pee. When asked about the pudding cup, the resident stated, I ate it. It wasn't very good. I want some f***ing food. They keep saying they'll bring it and then they never do. I'm going to pee my pants, I'm hungry, and I f***ing hurt. Staff did not enter R98's room until 12:40 PM, though he continued to call out that he was hungry and had to urinate. At 12:40 PM, LVN1 entered the room and asked R98 if he was in pain. The resident responded, Yes, hunger pains. LVN1 offered R98 ice cream, and he stated he would like vanilla. LVN1 left the room and returned a minute later with a small Styrofoam container of strawberry ice cream. She removed the lid, began to set the container down on the resident's overbed table, then stopped herself and stated, Oh, it's too frozen. We'll have to wait for it to thaw. As she placed the lid back on the container, R98 shouted, No please I'm hungry, I can eat it, just leave it please. LVN1 told R98 again that the ice cream was too frozen and he would have to wait. At 12:44 PM as LVN1 turned to leave the room with the ice cream, CNA1 brought the resident's lunch tray and began to cut up his food. The resident asked her to hurry, and cut it into big bites damn it, I'm hungry. Interview on 08/06/19 at 12:50 PM, LVN1 stated CNA3 informed her after R98 had been bathed that he was complaining of pain, so she went into the room to assess his pain level. LVN1 stated R98 ate breakfast that morning, and had a snack mid-morning, so it was acceptable for the CNA's to bathe him before his lunch was served, even though he was complaining of hunger. LVN1 stated she brought ice cream in response to the resident's statements that he had hunger pains, but the ice cream was too frozen for the resident to eat so she planned to let it thaw for a few minutes once she removed the lid. LVN1 stated she was planning to keep the ice cream on her medication cart until it was thawed enough to eat, since the resident needed assistance to eat. LVN1 stated she knew the resident wanted her to leave the ice cream, but she also knew his lunch would be delivered shortly so felt it was acceptable to take the ice cream. Interview on 08/06/19 at 1:55 PM, CNA3 stated she did not normally take care of R98, but CNA1 asked for assistance to give him a bed bath on 08/06/19. CNA3 acknowledged R98 was complaining of hunger and pain throughout the bath. CNA3 stated, He was not my resident, but if he was, I would have stopped when he said no. CNA3 stated she thought CNA1 just wanted to hurry through it. CNA3 stated, I had the authority to stop CNA1, but I didn't. He was her resident, not mine. Interview on 08/07/19 at 08:48 AM, R98's physician, who is the facility's Medical Director (MD) stated the resident frequently complained of hunger, and frequently refused cares. The MD stated if staff were forcing R98 to bathe, especially when voicing complaints of other physical discomforts, the facility needed to review its approaches. The MD stated in general, the resident had the right to refuse cares, but there is a line if the resident lacks the capacity to understand the social consequence of his decision, then staff have to proceed. The MD stated the parameters defining at what point staff should halt or proceed with cares during resident refusals should be identified in the resident care plan, but for R98 he would consider odor to be a reason to proceed with a bath against the resident's objections, and weight gain to be a reason to not provide food when the resident complained of hunger. Interview on 08/07/19 at 9:00 AM, the Master Social Worker (MSW)1 stated she would typically be informed of continued resident refusals of care, so there could be further evaluation of the root cause and a care plan could be developed. MSW1 stated she was not informed R98 was resistive during care. MSW1 reviewed R98's care plan and confirmed the care plan did not include a focus area for dementia and dementia care interventions were not implemented for R98. Interview on 08/07/19 at 9:36 AM, the Director of Nursing (DON) said she agreed the CNA's should have listened to the resident, even though he had a [DIAGNOSES REDACTED]. Interview on 08/07/19 at 12:26 PM, CNA1 stated she was often assigned to care for R98, and when assigned to care for him she often gives him a bed bath. When questioned about the observation on 08/06/19, CNA1 said, I know I didn't do a thorough job. I wanted to wash his hair, but it's hard because he's always in pain when we move him, and he's really confused. I always ask him if I can change him, and he usually says yes even though he always tells me he is clean or just changed himself. If he says no, I leave and come back, but if he still says no, we just have to go ahead and do it (provide care). Regarding the resident's statements that he was hungry, CNA1 stated, He's so confused, he thought he hadn't eaten yet, even though he ate breakfast that morning. I knew he was hungry again, because it was almost lunchtime, which is why I wanted to hurry. I told him I would get him some ice cream. He has the right to refuse, but if he is dirty, we have to just go ahead and clean him. He's just so confused. On 08/07/19 at 1:00 PM, LVN5 in interview stated, she has been one of R98's regular nurses since he had moved to his current room several weeks ago, and it would be her expectation that CNA's stop performing cares when a resident refused, so long as the resident was covered and safe, and inform the nurse. Interview on 08/08/19 at 9:00 AM, the Staff Development Coordinator (SDC) stated she was responsible for training staff to provide care to residents with dementia. The SDC stated it would be her expectation that CNA's would stop providing care when a resident refused and inform the nurse for further evaluation. The SDC stated the CNA's should listen to the needs expressed by a resident, no matter how confused, and respond to those needs. Regarding the 08/06/19 observation, the SDC stated the CNA's should have stopped the bath, provided the resident with something to eat, and informed the nurse of his complaints of pain. Interview on 08/08/19 at 10:27 AM, the administrator stated the CNA's should have stopped the bath and reported the resident's concerns to the charge nurse. The administrator said he would make sure all staff received re-education on this matter. The facility policy titled Requesting, Refusing and/or Discontinuing Care or Treatment Policy Statement, revised (MONTH) (YEAR) and provided by the Administrator on 08/08/19 at 4:09 PM documented, The resident is not forced to accept any medical care or treatment and may refuse or discontinue care or treatment at any time. This includes care or treatment prescribed by a physician, care or treatment that has been administered previously and/or care or treatment that the resident has previously agreed to but has not yet been administered.

Based on observation, interview and record review, the facility failed to ensure resident safety when staff did not implement adequate supervision and assistance for 2 of 22 sampled residents (Resident 13 and 20) who had poor safety awareness and a history of falls, which led to harm, and 1 of 22 sampled residents (Resident 21), who was known to the facility to be a flight risk. This failure contributed to: 1a. Resident 13 fell 5 times in a three month period from 12/30/16 to 3/25/17. Resident 13 sustained a fractured right hip (a projection of the pelvis and upper thigh bone on each side of the body) from the fall on 12/30/16 and a fractured left hip from the fall on 3/25/17. 1b. Resident 20 fell on [DATE] while getting out of bed unassisted and developed severe sepsis (body's response to infection causes injury to its own tissues and organs) and a fractured pelvis (the large bony structure near the base of the spine). 2. Resident 21 wandering outside the facility unsupervised. Findings: 1a. Review of Resident 13's Admission Record, dated 2/23/17, and an initial admission date of [DATE], Resident 13's Order Summary Report, dated 12/9/16, the physician History and Physical, dated 12/10/16, and hospitalist's (physician) History and Physical, dated 12/5/16, revealed Resident 13 had [DIAGNOSES REDACTED]. (injury caused by a blow to the body but does not break the skin) of left eyelid, injury of the head, multiple fractures of the ribs, and unable to stand up. Resident 13's Clinical Health Status, dated 12/9/16, indicated Resident 13's Risk for Falls had a score of 19 (a score of ten or greater represented high fall risk), short and long term memory problem, and needed assistance with decisions. Resident 13's Admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 12/16/16, revealed a BIM (Brief Interview of Mental Status) score of 11, which indicated Resident 13 was moderately cognitively (the act of thinking, perceiving, and understanding) impaired, he needed one person physical assistance with transfer and walking, used a wheel chair and a walker, and Resident 13 had fallen within the last month. Resident 13's Physical Therapist Care Plan, dated 12/10/16 through 2/16/16, was dependent on transfer, stand to sit, required 100 percent assistance by one or more persons to walk, maximal assistance to maintain position, and unable to move without loss of balance. First Fall Resident 13's Progress Notes, dated 12/30/16, indicated Resident 13 was found by daughter on floor near entrance to bathroom next to wheelchair. Resident 13's Care Plan for at risk for falls, dated 12/10/16, indicated fall risk interventions included assess wheel chair is of appropriate size, bed in low position, call light and personal items in easy reach or provide reacher (device that enables a disabled or elderly person to pick up objects that are difficult to reach), therapy referral, footwear to prevent slipping, gait belt (device used to transfer people from one position to another, from one thing to another or while walking people that have problems with balance), and grab bar (a bar attached to a wall to provide a grip). Review of the Hospital Discharge Summary, dated 1/5/17, indicated Resident 13 sustained a right hip fracture and was operated on 1/1/17. Fall 2 Resident 13's Progress Notes, dated 3/12/17, indicated Resident 13 had an unwitnessed fall. Resident 13 rolled out of bed while trying to reach for his night table. Resident Admission MDS, dated [DATE], indicated Resident 13's cognitive skills for daily decision making were severely impaired, needed one person physical assistance with transfer, walking did not occur, used a wheel chair, and Resident 13 had fallen within the last month prior to admission. Resident 13's Clinical Health Status, dated 2/23/17, indicated Resident 13's Risk for Falls had a score of 12 (a score of ten or greater represented high fall risk), short and long term memory problem, sometimes understands others, and needed assistance with decisions. Resident 13's Physical Therapist Progress, dated 3/8/17, indicated Resident 13 still had deficits (deficiency) in walking, which limited his ability to perform safe transfers without physical assistance and required verbal cues for safe walking. Resident 13's Care Plan, dated 3/8/17, indicated new fall risk interventions included encourage Resident 13 to use call light, educate Resident 13/family/caregivers about safety reminders and what to do if a fall occurs, anticipate and meet residents' needs, and resident needed to be evaluated and supplied appropriate adaptive equipment or devices as needed; re-evaluate every day and as needed for continued appropriateness and to ensure least restrictive device or restraint. Fall 3 Resident 13's Progress Notes, dated 3/18/17, indicated Resident 13 was seen by his roommate sliding from his wheelchair, nurse was called and Resident 13 was transferred back to wheelchair. Resident 13's Care Plan, dated 3/14/17, indicated one new fall risk interventions included mat at bedside. Resident 13's Progress Notes, dated 3/18/17, indicated frequent rounds were made to ensure safety, anticipate Resident 13's needs, and bed alarm in place, but there were no updated care plan interventions indicating frequent rounds to ensure safety, bed alarm in place, and no indication supervision was provided. Fall 4 Resident 13's Progress Notes, dated 3/23/17, indicated Resident 13 had an unwitnessed fall and was found on the floor. Resident 13's Care Plan, dated 3/14/17, indicated one new fall risk intervention a non-slip mat in wheelchair to prevent sliding. Fall 5 Resident 13's Progress Notes, dated 3/25/17, indicated Resident 13 had an unwitnessed fall on 3/25/17 at 2:45 p.m. and was transferred to an acute care hospital. Resident's Quality Improvement Tool, dated 3/28/17, and X-ray report, dated 3/26/17 indicated Resident had a left hip fracture due to fall. Resident 13's fall risk care plan (initial care plan on 12/10/16 and last updated on 3/14/17) did not specify any additional monitoring interventions specific to Resident 13's known behavior of self-transferring and walking without supervision, how the facility was going to provide supervision, and how the facility was going to monitor and anticipate Resident 13's needs. During an interview on 5/24/27 at 5:30 p.m., Unlicensed Staff O stated Resident 13 was alert, but forgetful and confused at times. Unlicensed Staff O stated Resident 13 did not use the call light all the time. Resident 13's Significant Change in Status MDS (a decline or improvement in resident's status) dated 4/5/17, indicated Resident 13's BIM of 9 (moderately cognitively impaired). During a concurrent observation and interview on 5/24/17 at 5:40 p.m., Resident 13 was sitting in his wheelchair positioned at the side of his bed unsupervised and no roommate in room. Resident 13's call light was not in close proximity to reach. Resident 13's call light was located near the center of his bed. When Resident 13 was asked where his call light was located, he had to search for it and finally found it after being guided by way of pointing to his call light. When Resident 13 was asked what month it was he said, February. When Resident 13 was asked what meal he was about to have he said, Breakfast. During an interview on 5/23/17 at 12:30 p.m., Administrative Staff A stated Resident 13 fractured right hip from the fall on 12/30/16 and a fractured left hip from the fall on 3/25/17 were not unusual occurrences due to: 1. Resident 13 had a history of [REDACTED]. preventative measures to prevent falls were in place. DON stated, How do we know the fall caused the left hip fracture due to Resident 13's medical conditions, such as cancer, cognitive behavior, and osteoporosis. The facility's policy and procedure titled, Falls and Risk Management, revised 12/07, indicated if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 1b. Review of Resident 20's Admission Record, dated 11/16/16, and initial admission, dated 6/17/14, indicated Resident 20's [DIAGNOSES REDACTED]. Resident 20's Quarterly MDS, dated [DATE], indicated Resident 20's BIM of 3 (severely cognitively impaired) and needed a one person physical assistance with transfer and walking. Resident 20's Care Plan, initiated 6/17/14, indicated Resident 20 was at risk for falls and interventions included call light or personal items available and in easy reach or provide reacher and keep environment well-lit and free of clutter. One new fall intervention initiated on 7/24/14, included observe and report unsafe transfer and reorient Resident 20 with safely wheeling self to prevent sliding from wheelchair. Another fall risk intervention initiated 10/6/14, included encouraging Resident 20 to ask for assistance and explain the risk of falling to Resident 20. Resident 20's Progress Notes, dated 11/10/16 at 3:43 p.m., indicated Resident 20 had been transferred to another room temporarily where she had an unwitnessed fall. Resident 20 was found lying flat on the floor. Resident 20 told the nurse she could not find her clothes and was looking for her room. Resident 20 was assessed and a bump was noted on the right side of her head, and Resident 20 was screaming because she had pain at the tailbone (centered at the bottom of your spine, right above your buttocks) area. Resident 20 was transferred to an acute care's emergency room (ER) for further evaluation. Resident 20's X-ray and CT scan (computerized tomography: imaging method that uses X-rays to create pictures of cross-sections of the body) were all clear, so Resident 20 returned to the facility on [DATE] at 6:30 p.m. Resident 20 was sent back to theER on [DATE] at 3:00 a.m. due to she was hypotensive (condition in which your blood pressure reading is lower than normal: less than 90/60. Resident 20's blood pressure had dropped to 77/39. A document titled, Fall with Injury, dated 11/14/16, indicated Resident 20 was admitted to the acute care facility on 11/11/16 where Resident 20 was diagnosed with [REDACTED]. During an interview on 2/7/17 at 1:50 p.m., Administrative Staff B stated Resident 20 was transferred on 11/10/17 from the East Wing to the West Wing of the facility temporarily because linoleum tiles needed to be replaced in Resident 20's room. Administrative Staff B stated Resident 20 was transferred across from the nurse's station because Resident 20 would forget to use call light and would try to get up on own, but needed assistance when standing because Resident 20 was unsteady. During an interview on 4/4/17 at 4:00 p.m., Licensed Staff Q, who was assigned Resident 20's room upon her transfer to the West Wing, stated she could not remember when Resident 20 was transferred, but she thought it was after breakfast. Licensed Staff Q stated she never received report from the nurse who had been caring for Resident 20 on the East Wing, so she was not aware of Resident 20's needs. During an interview on 4/5/17 at 12:40 p.m. and 5/4/17 at 12:45 p.m., Administrative Staff B stated the nurse who was caring for Resident 20 on the East Wing should have informed the nurse assigned to Resident 20 on the West Wing Resident 20 needed to be watched closely because of her dementia and forgetfulness. Administrative Staff B stated even if the resident's transfer was temporary, the nurse and CNA assigned to the room were responsible for the resident's care. During an interview on 5/3/17 at 4:35 p.m. and 5/24/17 at 3 p.m., Licensed Staff R stated Resident 20 was transferred to the West Wing, located on the other side of the facility, directly across from the nurse's station along with her roommate. Licensed Staff R stated she gave Licensed Staff Q report, but she did not want to tend to Resident 20 or give her medication because it was getting close to the change of shift. Licensed Staff R stated she continued to give Resident 20 her medication. Licensed Staff R stated she told Licensed Staff Q she could not possibly keep an eye on Resident 20 from the other side of the facility. Licensed Staff R stated Licensed Staff Q and the other staff working on the West Wing were aware of Resident 20's temporary transfer because a Notification of Room Change was posted at the West Wing's nurse's station. Licensed Staff R stated Resident 20 was restless at times and would try to transfer herself, but she was to weak to transfer herself. Licensed Staff R stated Resident 20 needed assistance with transfer and walking. During an interview on 5/3/17 at 5:10 p.m., Unlicensed Staff S, who had been assigned to Resident 20 on the East Wing, could not remember Resident 20's transfer to the West Wing on 11/10/16. Unlicensed Staff S stated when a resident was transferred to another room the nurse assigned to the room would receive report from the nurse who had been caring for the resident. Unlicensed Staff S stated she always informed the certified nursing assistant (CNA) assigned to the resident's room any concerns, such as the resident being a fall risk, and the need for supervision or physical assistance with transferring. During a concurrent interview and record review on 5/24/17 at 3 p.m., the Notification of Room Change, dated 11/10/17, indicated Resident 20 was going to be moved temporarily from the East Wing to the West Wing on 11/10/17. Administrative Staff D stated a Notification of Room Change for Resident 20 transfer was posted at the West Wing nurse's station on 11/10/17. During an interview on 5/24/17 at 3:00 P.M., Unlicensed Staff T stated she could not remember getting report on Resident 20. Unlicensed Staff T stated she thought she went home before Resident 20 was transferred to the West Wing. During an interview on 5/23/17 at 5:10 p.m., Administrative Staff V stated the nurse and CNA who were assigned to Resident 20's room upon her transfer to the West Wing were responsible for attending to her needs and making sure she was supervised. Administrative Staff A agreed with Administrative Staff V. The facility's policy and procedure titled, Safety and Supervision of Residents, revised 2007, indicated: 1. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by individual resident's assessed needs and identified hazards in the environment and 2. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased if there is a change in the resident's condition.

Based on observation, interview and record review, the facility failed to prevent 1 of 22 Sampled Residents (Resident 6) from developing pressure ulcers when Resident 6 developed a Stage 3 pressure ulcer (areas of damaged skin caused by staying in one position for too long and commonly form where bones are close to the skin) on her coccyx/sacrum (tailbone) which was not present on admission. This failure resulted to pain and long-term treatment of [REDACTED]. Findings: Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nurse's Note dated 11/29/16, at 6: 37 p.m. indicated Resident 6 had stated pressure ulcer on mid back and blanchable redness (reddened area that temporarily turns white or pale when pressure is applied with a fingertip and then immediately turns red again when pressure is removed. This indicates for pressure ulcer prevention. Tissue exhibiting blanchable [DIAGNOSES REDACTED] usually resumes its normal color within 24 hours and suffers no long-term damage, if not prevented; it can lead to Stage 1 non-blanchable pressure ulcer. Lippincott Nursing Center, 2009) on coccyx and both heels. The admission Minimum Data Set, (MDS- an assessment tool) dated 12/5/16 indicated Resident 6 had one pressure ulcer. The Wound Care Service Progress Note dated 12/6/16 indicated Resident 6 had a stage 2 pressure ulcer (partial thickness loss of skin presenting as shallow open ulcer with red pink wound bed) on the left mid back only; no other pressure ulcer documented. The quarterly MDS dated [DATE] indicated Resident 6 had two pressure ulcers. During the Initial Tour observation and interview on 5/22/17, at 9:16 a.m., Resident 6 was on low air loss mattress (alternating pressure mattress systems designed to prevent pressure ulcer or assist in healing) and receiving oxygen via nasal cannula (tubing put in the nostril delivering oxygen). Resident 6 stated she had upper back wound when she came into the facility and it was now healed. However, I got the sore while here located near the rectum which is attached to a [DEVICE] (a device using a sealed sponge wound dressing on connected to a vacuum pump used to promote healing). When asked about bed repositioning, Resident 6 stated, They asked me to do that on my own. During a record review on 5/24/17, and /25/17, on 2/11/17, the Care Plan indicated the planned care for sacrum Stage 3 pressure ulcer (Full-thickness skin loss in which fat is visible, rolled wound edges are often present but bone, tendon or muscle is not exposed (The National Pressure Ulcer Advisory Panel) was initiated. The planned interventions included turning and repositioning schedule per assessment. The Care Plan intervention initiated on 4/19/17 indicated, Resistive to repositioning - remind as to risk/benefits regarding the importance of frequent repositioning. There was no prior care plan related to skin problem addressing prevention of sacrum pressure ulcer. During a wound care observation and concurrent interview on 5/25/17, at 10:04 a.m., Licensed Staff I, a wound care nurse, stated the sacral wound had rolled edges with no tunneling (empty space under the skin that can extend in any direction from the wound). Licensed Staff I packed the wound with foam, covered with dressing, and attached to the [DEVICE]. With tears in her eyes, Resident 6 stated the dressing change was painful. Licensed Staff I stated Resident 6 received pain medication before dressing change. During an interview on 5/25/17, at 12:34 p.m., Licensed Staff I stated Resident 6 did not want to be turned and wanted to stay on her back and sit up right because of her breathing. During an interview on 5/25/17, at 4: 10 p.m., Licensed Nurse X, a certified wound care nurse, stated Resident 6's pressure ulcer on mid the back was healed. Resident 6's blanchable redness on coccyx became stage 3 pressure ulcer. During an interview on 5/25/17, at 5:42 p.m., the DON did not provide care plan and documentation indicating interventions were provided to prevent the blanchable redness on coccyx/sacrum from becoming stage 1, stage 2, and stage 3 pressure ulcer. The DON stated she would get from the previous corporate office the clinical records for Resident 6 related to documentation of interventions provided to prevent coccyx/sacrum pressure ulcer. During a review of the clinical records for Resident 6 received from the facility on 6/2/17, there were no care plans provided to prevent pressure ulcer on coccyx/sacrum prior to 2/11/17. The Treatment Administration Record (TAR) for 1/17, provided by the facility on 6/2/17, indicated Resident 6 was receiving Santyl Ointment (medicine that removes dead tissue from wound so they can start to heal) on lower back/sacrum every shift for wound care with a start date on 11/29/16 and a discontinuation date of 1/5/17; Santyl was not reordered. The facility policy and procedure titled Prevention of Pressure Ulcer dated 9/13 indicated, The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Beginning of Citation F 314 Citation #: ______________________ The following reflects the findings of the California Department of Public Health during an ANNUAL RECERTIFICATION SURVEY. Representing the California Department of Public Health: Health Facilities Evaluator Nurse: . A State - Class A Citation: # was issued under F-314. (b) Skin Integrity - (1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that- (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual ' s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to provide intervention to prevent Stage 3 pressure ulcer (areas of damaged skin caused by staying in one position for too long and commonly form where bones are close to the skin) on Resident 1's coccyx/sacrum (tailbone). Findings: Clinical record review on 5/22/17, revealed Resident 6 was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nurse's Note dated 11/29/16, at 6: 37 p.m. indicated Resident 6 had stated pressure ulcer on mid back and blanchable redness (reddened area that temporarily turns white or pale when pressure is applied with a fingertip and then immediately turns red again when pressure is removed. This indicates for pressure ulcer prevention. Tissue exhibiting blanchable [DIAGNOSES REDACTED] usually resumes its normal color within 24 hours and suffers no long-term damage, if not prevented; it can lead to Stage 1 non-blanchable pressure ulcer. Lippincott Nursing Center, 2009) on coccyx and both heels. The admission Minimum Data Set, (MDS- an assessment tool) dated 12/5/16 indicated Resident 6 had one pressure ulcer. The Wound Care Service Progress Note dated 12/6/16 indicated Resident 6 had a stage 2 pressure ulcer (partial thickness loss of skin presenting as shallow open ulcer with red pink wound bed) on the left mid back only; no other pressure ulcer documented. On 2/11/17, the Care Plan indicated the planned care for sacrum (tailbone) Stage 3 pressure ulcer (Full-thickness skin loss in which fat is visible, rolled wound edges are often present but bone, tendon or muscle is not exposed (The National Pressure Ulcer Advisory Panel) was initiated. The planned interventions included turning and repositioning schedule per assessment. There were no prior care plans that address the Resident 6's sacrum until the facility identified a Stage 3 pressure ulcer. On 2/23/17, the quarterly MDS dated [DATE] indicated Resident 6 had two pressure ulcers. During the Initial Tour observation and interview on 5/22/17, at 9:16 a.m., Resident 6 was on low air loss mattress (alternating pressure mattress systems designed to prevent pressure ulcer or assist in healing) and receiving oxygen via nasal cannula (tubing put in the nostril delivering oxygen). Resident 6 stated she had upper back wound when she came into the facility and it was now healed. However, I got the sore while here located near the rectum which is attached to a [DEVICE] (a device using a sealed sponge wound dressing on connected to a vacuum pump used to promote healing). When asked about bed repositioning, Resident 6 stated, They asked me to do that on my own. During a record review on 5/24/17, and /25/17, The Care Plan intervention initiated on 4/19/17 indicated, Resistive to repositioning - remind as to risk/benefits regarding the importance of frequent repositioning. During a wound care observation and concurrent interview on 5/25/17, at 10:04 a.m., Licensed Staff I, a wound care nurse, stated the sacral wound had rolled edges with no tunneling (empty space under the skin that can extend in any direction from the wound). Licensed Staff I packed the wound with foam, covered with dressing, and attached to the [DEVICE]. With tears in her eyes, Resident 6 stated the dressing change was painful. Licensed Staff I stated Resident 6 received pain medication before dressing change. During an interview on 5/25/17, at 12:34 p.m., Licensed Staff I stated Resident 6 did not want to be turned and wanted to stay on her back and sit up right because of her breathing. During an interview on 5/25/17, at 4: 10 p.m., Licensed Nurse X, a certified wound care nurse, stated Resident 6's pressure ulcer on mid the back was healed. Resident 6's blanchable redness on coccyx became stage 3 pressure ulcer. During an interview on 5/25/17, at 5:42 p.m., the DON did not provide care plan and documentation that indicated interventions were provided to prevent the blanchable redness on coccyx/sacrum from becoming stage 1, stage 2, and stage 3 pressure ulcer. The DON stated she would get from the previous corporate office the clinical records for Resident 6 related to documentation of interventions provided to prevent coccyx/sacrum pressure ulcer. On 6/2/17, the facility provided Resident 6's clinical records that included Treatment Administration Record (TAR) for 1/17. The TAR indicated Resident 6 was receiving Santyl Ointment (medicine that removes dead tissue from wound so they can start to heal) on lower back/sacrum every shift for wound care with a start date on 11/29/16 and a discontinuation date of 1/5/17; Santyl was not reordered. During a review of the clinical records for Resident 6 received from the facility on 6/2/17, there were no care plans provided that would indicate preventions were provided to prevent pressure ulcer on Resident 6's coccyx/sacrum before 2/11/17. The facility policy and procedure titled Prevention of Pressure Ulcer dated 9/13 indicated, The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Therefore, the facility failed to provide intervention to prevent Stage 3 pressure ulcer on Resident 6's coccyx/sacrum. These violations presented either imminent danger that death or serious hard would result or a substantial probability that death or serious physical harm would result. End of Citation

Based on observation, interview, record review and document review, the facility failed to ensure safe water temperature levels (between 95 and 120 degrees Fahrenheit according to facility's policy as below) for 66 out of 107 residents when: two bathroom sinks used by four residents (R 1, R 2, R 3, R 4) in the West Wing; two bathroom sinks used by five residents (R 5, R 6, R 7, R 8, R 9) and 2 out of 2 spas in the East Wing used by 61 residents (R 5, R 6, R 7, R 8, R 9, R 10, R 11, R 12, R 13, R 14, R 15, R 16, R 17, R 18, R 19, R 20, R 21, R 22, R 23, R 24, R 25, R 26, R 27, R 28, R 29, R 30, R 31, R 32, R 33, R 34, R 35, R 36, R 37, R 38, R 39, R 40, R 41, R 42, R 43, R 44, R 45, R 46, R 47, R 48, R 49, R 50, R 51, R 52, R 53, R 54, R 55, R 56, R 57, R 58, R 59, R 60, R 61, R 62, R 63, R 64, R 65) and 1 resident (R 66) who showers independently had hot water temperatures fluctuating between 58.5 degrees F to over 120 degrees F (Fahrenheit is a temperature scale that bases the boiling point of water at 212 and the freezing point at 32). This failure had the potential to cause low body temperatures from water that was too cold for bathing or burns to residents from scalding water. Findings: During a solitary testing on 2/2/17 at 10:15 a.m., the Spa on the East Hall across Room 43 had a hot water temperature of 58.5 degrees F after running for four minutes. During an interview on 2/2/17 at 10: 32 a.m., in the Spa across from Room 43 Unlicensed Staff A stated that it takes a little while for water to get warm and the residents can get cold while waiting for warm water. During an interview on 2/2/17 at 10:40 a.m., Maintenance B, when asked if he calibrated (correlate the readings of an instrument with those of a standard in order to check the instrument's accuracy) the facility's thermometer used to test water temperatures replied, Never. I also do not know how to calibrate. Maintenance B also stated during the interview that on 1/27/17, the water temperatures were 126 to 129 degrees F. He adjusted the boiler and could not get it below 126, which was still high. We reported to the Administrator and he called a guy who came to fix it last week. Maintenance B stated he used the infrared gun (widely used throughout many industries and work environments to determine surface temperature ) to check the water temperature because it's more accurate. Review of the manufacturer's safety information for the infrared thermometer indicated not to use around explosive gas, vapor, or in damp or wet environments and with warning to use the Product only as specified or hazardous laser radiation exposure can occur. During an interview on 2/2/17 at 11 a.m., Maintenance C stated he uses a manual thermometer when checking the water temperatures. Maintenance C also stated he had not calibrated his thermometer. Nobody showed him how to calibrate a thermometer. When asked if he could read the thermometer Maintenance C stated he forgot to bring his eyeglasses and without them he cannot read the thermometer. Maintenance C checked the water temperatures on the morning of 2/2/17 and, because he forgot to bring his eyeglasses to properly read them, they could have been higher than 120 to 140 degrees F range as indicated in the maintenance checklist. Maintenance C when asked about today's temperatures stated that temperatures were high and should be within 116-120 degrees F. During concurrent observation and interview on 2/2/17 at 11:50 a.m., with Maintenance B and C present, the Dietary Director demonstrated how to calibrate a thermometer and stated that a manual thermometer must be calibrated before each use. The Facility's thermometer indicated 90 degrees F before calibration, after calibration it was at 44 degrees F. The thermometer after calibration should read 32 degrees F. The Surveyor's thermometer read at 32 degrees F. Water temperature readings observed during the tour on 2/2/17 with Maintenance B and C present were as follows: Observation of the sinks in Bathroom 23 on 2/2/17 at 11:26 a.m. was 123 degrees F; Bathroom 38 at 12:20 p.m. was 122 degrees F; at 12:24 p.m. Bathroom 35 was at 124 degrees F; the Spa across the Medical Records Room at 12:27 p.m. was 123.8 degrees F and at 12:32 p.m., Bathroom 11 was 127.7 degrees F. Record review of the facility's daily maintenance checklist of water temperatures from 1/1/17-2/2/17 indicated a temperature range of 62 to 140 degrees F for random checks of bathroom sinks and spas. Document review of the facility's policy and procedure titled Safety of Water Temperatures indicated tap water in the facility shall be kept within a temperature range to prevent scalding of residents and temperatures set at no more than 120 degrees F. Document review of the facility's policy and procedure titled Bath: Tub, Shower under procedure 8 stated that the water should be comfortably warm (between 95 and 120 degrees F). The Administrator and the Regional Director were verbally notified of the IMMEDIATE JEOPARDY (IJ) on 2/2/17 at 5:27 p.m. under 483.25 (h) Quality of Care for F-323 for putting residents with the potential for harm by burns with water temperatures above 120 degrees F. Residents who shower independently are potentially affected. The IMMEDIACY was removed on 2/2/17 at 7:38 p.m. when the facility presented an acceptable Plan of Action that specified: 1) The Maintenance Director will test 29 of 29 resident bathrooms using the same technique and thermometer used by the Surveyor; 2) An outsider provider was called in to examine the hot water, boiler and mixing valve in the facility; 3) All direct Care Staff will be inserviced on safe water temperatures, what to look out for, what to do and whom to report with findings of high water temperatures; 4) All Supervisors will be inserviced on the process of observing and properly testing water temperatures; 5) The Maintenance Assistant Director will be inserviced to use his glasses while on the clock and performing any work duties and 6)The Maintenance Director will be trained by the outside provider on how to properly calibrate a thermometer. The Administrator and the Regional Director were present when the IMMEDIACY was removed. During concurrent interviews and observations on 2/7/17 at 9:42 a.m. to 11:45 a.m., a check of water temperatures in the bathroom sinks and spas with Maintenance B and the Administrator found water temperatures were in the range of 100 -110.3 degrees F. Unlicensed Staff E, Unlicensed Staff F, Unlicensed Staff G and Licensed Staff H and Licensed Staff I all responded accurately to questions of safe water temperatures, what to observe, what to do and whom to report. Maintenance B was able to demonstrate accurately how to calibrate a manual thermometer. On 2/7/17 at 12 noon, the IMMEDIATE JEOPARDY was removed in the presence of the Administrator.

Based on observation, interview, and record review, the facility failed to ensure license staff followed infection control procedures when: 1. Three of three observed licensed staff members did not follow the disinfectant manufacturer's instructions and the facility's policy and procedure for glucometer (a blood testing meter device for blood sugar testing) disinfection between or after use for one of 22 sampled residents (Resident 11) and five residents (Unsampled Resident 23, 24, 25, 26, and 27). The facility had 21 residents who required blood sugar testing. This failure resulted in the potential for transfer of blood borne organisms, infections, and disease between residents through cross contamination. Due to the facility's failure to disinfect the glucometer per the manufacturer's instructions to prevent the transmission of blood borne organisms, infections and disease, The Administrator and the Director of Nurses were verbally notified of an Immediate Jeopardy situation on 3/15/16 at 6 p.m. The Administrator and the Director of Nurses were informed of the observation of three licensed staff members who did not followed the manufacturer's instructions for contact time (time required to keep the glucometer wet with the disinfectant in order to kill bacteria, viruses, spores, and etc.) and to allow air dry when cleaning the glucometer between resident uses. On 3/15/16, at 8:45 p.m., the facility presented and implemented a corrective plan of action, including but not limited to: 1) Train all Licensed Nurses on duty 3/15/16. Licensed nurses not on duty will receive training prior to working on the floor, with returned demonstration regarding facility's policy and procedure and the manufacturer's instructions; 2) the facility conducted direct observations of licensed nurses on glucometer cleaning and disinfecting to ensure compliance. Removal of the Immediate Jeopardy occurred in the presence of the Administrator, Director of Nurses, and the Area Vice President on 3/17/16 at 2:25 p.m., after observations confirmed the licensed staff members followed the manufacturer's instructions and facility ' s policy and procedures to clean and disinfect the glucometer between resident uses. 2. Resident care equipment, including blood pressure cuff, stethoscope, inhaler, and pulse oximeter, was not disinfected properly, which had the potential to cause cross contamination, and 3. License staff did not label Residents' personal items and keep them in sanitary condition, which could potentially cause cross contamination. Findings: 1. During a concurrent observation and interview on 3/15/16, at 6:48 a.m., Licensed Staff G brought the supplies including a glucometer, a small strip inserted into the glucometer to obtain blood sample, and a lancet (sharp pointed surgical instrument used to make a small incision) to Resident 23's bedside table. Licensed Staff G pricked Resident 23's finger, squeezed the finger for a blood sample, held the glucometer with the strip inserted to the glucometer, and obtained a blood sample on the strip to complete the blood test. After finishing and disposing of the lancet and strip, Licensed Staff G placed the unclean and un-disinfected glucometer on the facial tissues on top of the medication cart. Licensed Staff G took out one singled sheet of MicroKill Bleach wipe (one pre-saturated disinfectant wipe 3 inches x 3 inches), held it over the trash can, squeezed out some of the solution, and then wiped the glucometer for less than 20 seconds. Licensed Staff G then placed the glucometer back on top of the same facial tissues. Licensed Staff G stated she squeezed the bleach wipe before wiping the glucometer to make it dry a little bit because if too wet the wipe could make the glucometer malfunction. In addition, it would take less than one minute to air dry the glucometer. Licensed Staff G did not reapply any additional bleach wipe. During an observation on 3/15/16, at 7 a.m., Licensed Staff G brought the same glucometer, which she wiped, to Resident 11's bedside table with a new strip inserted. Licensed Staff G pricked Resident 11's finger with a lancet, then procured the blood sample. After Licensed Staff G disposed of the strip and the lancet, she placed the glucometer onto the facial tissues on top of the medication cart. Licensed Staff G took out one sheet of MicroKill Bleach wipes held it over the trash can, squeezed out some of the solution then wiped the glucometer for 15 seconds. Licensed Staff G put the glucometer back on the same facial tissues. Licensed Staff G did not reapply any additional bleach wipe. During an observation on 3/15/16, at 11:55 a.m., Licensed Staff H pulled out a glucometer from a medication cart. Licensed Staff H used one MicroKill Bleach, wipe and wiped the glucometer for less than 15 seconds, and immediately wiped the glucometer with facial tissues. Licensed Staff H brought the glucometer with a strip inserted in it to Resident 24's room. Licensed Staff H pricked Resident 24's finger, squeezed the finger, and obtained a blood sample on the strip in the glucometer. Licensed Staff H brought the uncleaned and un-disinfected glucometer back and put the glucometer directly on top of the medication cart. The glucometer was in contact with the document on the medication cart and the medication cart surface. Licensed Staff H wiped the glucometer with one MicroKill Bleach wipe for 15 seconds, immediately wiped the glucometer with facial tissues, and put the glucometer back into the drawer of the medication cart. Licensed Staff H did not disinfect the medication cart surfaces where she placed the uncleaned and un-disinfected glucometer and proceeded to prepare insulin for the resident. During an observation on 3/15/16, at 4:30 p.m., Licensed Staff K took a glucometer out from the medication cart. Licensed Staff K brought the glucometer to Resident 25's bedside table and inserted a strip into the glucometer. Licensed Staff K pricked Resident 25's finger and obtained a blood sample to the tip of the strip in the glucometer. Licensed Staff K's gloved hand touched the strip with the blood. He then took off his gloves, and took the glucometer, that Resident 25 handed to him, back to the medication cart. Licensed Staff K put the uncleaned and un-disinfected glucometer onto a facial tissue on top of the medication cart. Licensed Staff K used the computer and touched the keyboard, mouse, and the documents on top of the medication cart. Licensed Staff K did not washed hands or use hand sanitizer between these procedures. After using the computer, Licensed Staff K opened the medication cart and took one MicroKill Bleach wipe, put on gloves, and wiped the glucometer for 14 seconds and immediately took some paper towels from the paper dispenser in the resident's bathroom to wrap the glucometer. Licensed Staff K did not reapply any additional bleach wipe. During an observation on 3/15/16, at 4:45 p.m., Licensed Staff K took the same glucometer with a new strip and one MicroKill Bleach wipe to Resident 26's bedside table. Licensed Staff K pricked Resident 26's finger with a lancet and obtained a blood sample to the strip in the glucometer. After Licensed Staff K removed the strip from the glucometer, Licensed Staff K wore the same gloves from obtaining blood sample to pick up the MicroKill Bleach wipe packet, which he dropped on the floor near Resident 26's bedside table, and took the glucometer to the resident's bathroom. Licensed Staff K used the MicroKill Bleach wipe from the packet, which he dropped to the floor, to wipe the glucometer for 15 seconds and immediately put the glucometer to a paper towel on top of the counter top in the bathroom sink. Licensed Staff K wrapped the glucometer with the same paper towel on the counter top and brought the glucometer back to the medication cart. Licensed Staff K disposed of the paper towel into the trash and put the glucometer on top of the medication cart. Licensed Staff K did not apply an additional bleach wipe. During an observation on 3/15/16, at 4:55 p.m., Licensed Staff K took the same glucometer from the medication cart to Resident 27's bedside table. Licensed Staff K pricked Resident 27's finger and obtained a blood sample to the strip in the glucometer. After Licensed Staff K removed the strip from the glucometer, Licensed Staff K brought the glucometer to the resident's bathroom, took one paper towel from the paper dispenser in the bathroom, and put the paper towel on the counter top of the bathroom sink. Licensed Staff K wrapped the uncleaned and un-disinfected glucometer with the paper towel and placed the wrapped glucometer on top of the medication cart. During a concurrent observation and interview on 3/15/16, at 5:10 p.m., the wrapped uncleaned and un-disinfected glucometer was on top of the medication cart. Licensed Staff K stated he should use the MicroKill Bleach wipe to wipe the glucometer at least 15 seconds between resident uses. With Administrative Staff B's cue, Licensed Staff K stated to wait for air dry the glucometer. Licensed Staff K stated the glucometer was not air dried when he wrapped the glucometer with a paper towel immediately after using the bleach wipe. During an interview on 3/15/16 at 5 p.m., Administrative Staff C (who was the Director of Staff Development and infection control nurse) stated that each medication cart had two glucometer's to check residents' blood sugar levels and that the licensed nurses used Sani-Wipes (MicroKill Bleach wipes) to disinfect the glucometer between residents. Staff was to follow the instructions on the packet as to contact time with the wipe and drying time after use of the wipe. Next, place the drying glucometer on a clean tissue from a plastic bag and allowed to air dry on the medication cart; the other glucometer would be used while the first one was drying after disinfection with the wipe. The MicroKill Bleach wipes manufacturer's directions for use, undated, indicated: .4. Apply pre-saturated towelette and wipe desired surface to be disinfected. 5. A 30-second contact time is required to kill HBV (hepatitis B virus) and HCV (hepatitis C virus). A 3-minute contact time is required to kill Clostridium difficle spores. A 5-minute contact time is required to kill HIV (human immunodeficiency virus) and other organisms on the label. Reapply as necessary to ensure that the surface remains wet for the entire contact time. 6. Allow surface to air dry and discard used wipe and empty packet . The facility's policy and procedure titled BLOOD GLUCOSE MONITOR DECONTAMINATION, dated 11/10/2015, indicated .II. After performing the glucose testing, the nurse, wearing gloves, will use a disposable wipe to clean all external parts of the monitor. III. A second wipe will be used to disinfect the blood glucose monitor. IV. The disinfected monitor will be placed on another clean surface . During an interview on 3/15/16, at 7:30 p.m., Administrative Staff B, who was the Director of Nurses, stated the facility used a different disinfectant Clorox Healthcare bleach germicidal wipes (multi-wipes container) prior to using the MicroKill Bleach wipe. Administrative Staff B stated she had been teaching the nurses to clean the glucometer for one minute and did not know the different contact time required for MicroKill Bleach wipe. During a subsequent interview with Administrative Staff C on 3/21/16, at 1:35 p.m., when showing her the MicroKill Bleach wipes, she stated the facility had been using this bleach wipe for glucometer disinfection since she had been working in the facility for approximately three months. Reviewed the Clorox Healthcare bleach germicidal wipes manufacturer's instructions indicated .registered to kill [DIAGNOSES REDACTED]icile spores in 3 minutes - the fastest contact time available .30 second kill times on 30 bacteria, 30 seconds to 1 minute on 14 viruses, 1 minute on norovirus, 3 minutes on [DIAGNOSES REDACTED]icile spores, TB and fungi . During a concurrent interview and record review of the competency checklist for Licensed Nurse G, H, and K with Administrative Staff B on 3/22/16, at 11:50 a.m., Administrative Staff B acknowledged the competency checklist did not included glucometer cleaning or disinfecting. The facility's policy and procedure titled Infection Control Program, dated 12/1/14, indicated: A facility may designate an IP (Infection Preventionist) to serve as the coordinator of an Infection Prevention and Control Program . Responsibilities may include .and implementing evidence-based infection control practices, including those mandated by regulatory and licensing agencies, and guidelines from the Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention (CDC) guidelines dated 5/2/12 indicated, If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. The CDC guidelines indicated the risk of blood glucose testing is the opportunity for exposure to blood borne viruses (hepatitis B virus, hepatitis C virus, and human immunodeficiency virus) through contaminated equipment and supplies if devices used for testing (e.g., blood glucose meters .) are shared. The glucometer manufacturer's instructions indicated to use EPA registered disinfectant to clean and disinfect the glucometer between patient uses. 2. During an observation on 3/15/16, at 7:15 a.m., Licensed Staff G measured the blood pressure for Resident 11. After finishing, Licensed Staff G did not clean/disinfect the blood pressure cuff and put the blood pressure cuff back in to the medication cart. During an observation on 3/15/16, at 8:45 a.m. and 9 a.m., Licensed Staff L measured blood pressure for Resident 28 and 27 using a blood pressure cuff and a stethoscope. After Licensed Staff L finished measuring blood pressure for each of the residents, Licensed Staff L used alcohol pads to wipe a small portion on one side of the blood pressure cuff and the bell and two earpieces of the stethoscope. Licensed Staff L did not wipe the entire blood pressure cuff and the stethoscope. Licensed Staff L placed the blood pressure cuff back in the medication cart and hung the stethoscope around her neck. During the same observation on 3/15/16, at 8:45 a.m., Licensed Staff L administered [MEDICATION NAME] inhalation medication through an inhaler (the inhaler contain multiple doses of the medication) to Resident 28. Licensed Staff L did not clean the inhaler and put the inhaler back in the medication cart for further use. During an interview on 3/15/16, at 10:55 a.m., Licensed Staff L stated she forgot to wipe the inhaler with facial tissue. Licensed Staff L stated she should wipe the inhaler with facial tissues after resident used. During an observation on 3/15/16, at 9:12 a.m., Licensed Staff H used a pulse oximeter (a device that measures the blood oxygen level) on Resident 29. Licensed Staff H used a MicroKill Bleach wipe to wipe the oximeter. After wiping the oximeter once, Licensed Staff H immediately used facial tissues to dry the oximeter. During an interview on 3/21/16, at 1:35 p.m., Administrative Staff C stated, staff should clean the inhaler after each resident used; the entire blood pressure cuff and stethoscope and the pulse oximeter with the bleach wipes and air-dried. The MicroKill Bleach wipes manufacturer's directions for use undated, indicated .4. Apply pre-saturated towelette and wipe desired surface to be disinfected. 5. A 30-second contact time is required to kill HBV and HCV. A 3-minute contact time is required to kill Clostridium difficle spores. A 5-minute contact time is required to kill HIV and other organisms on the label. Reapply as necessary to ensure that the surface remains wet for the entire contact time. 6. Allow surface to air dry and discard used wipe and empty packet . The facility's policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated 12/20/14, indicated .Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes .) .Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions . 3. During an observation on 3/14/16, at 10:15 a.m., in the bathroom shared by residents in room [ROOM NUMBER] and 41, an unlabeled tube of toothpaste was on the counter top of the sink. During an observation on 3/14/16, at 10:20 a.m. and 10:37 a.m., in the bathroom shared by residents in room [ROOM NUMBER] and 42, had one unlabeled electric toothbrush and an unlabeled charger unattended on the sink. Yellow and brown substance covered the bristles and handle of the toothbrush. Licensed Staff E validated the observation and stated the CNA should clean the electric toothbrush and charger placed them in the resident's bedside drawer. During a concurrent observation and interview on 3/14/16, at 10:43 a.m., in the bathroom shared by residents in room [ROOM NUMBER] and 46, there was unlabeled personal items including shave cream, aftershave, and mouthwash. There was an unlabeled basin containing unlabeled toothpaste and toothbrush on the counter top. There was light yellow fluid on the floor around the toilet. The bathroom floor was sticky. Licensed Staff E validated the observations. Licensed Staff E stated the CNA should clean the residents' personal items and return them to the residents' bedside drawer. During an observation on 3/14/16, at 11 a.m., in the bathroom used by two residents in room [ROOM NUMBER], there was an unlabeled hair clip and an unlabeled nail file left unattended on the counter top of the washing sink. Licensed Staff E stated a resident in the room might have left the hair clip here but not the nail file. During an interview on 3/21/16, at 1:35 p.m., Administrative Staff C stated residents' personal items are suppose be labeled with resident is name and put in a plastic bag. Administrative Staff C stated staff should put the personal items back to the resident's bedside table drawer after used. Administrative Staff C stated it was not acceptable to leave the unlabeled and unprotected personal items in the bathroom because you don't know who use it and could cause cross contamination. When requested, the facility did not provide the policy and procedure for labeling residents ' personal items.