Every finding on record at Napa Valley Care Center

Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) were protected from abuse when Resident 1 and Resident 2 threw fluids at one another, exchanged verbal profanities, and Resident 2 hit Resident 1 on the shoulder. This failure resulted in an altercation between Resident 1 and Resident 2 and placed both residents at risk for physical and psychological harm. A review of Resident 1's admission record indicated she was admitted to the facility in April 2025 with medical diagnosis which included cirrhosis of the liver (permanent scarring of healthy liver [an organ that filters toxins, produces bile for digestion and regulates blood sugar] tissue) and cerebellar ataxia (damage to a part of the brain that regulates balance, posture and muscle coordination). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 6/25/26, indicated her Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 11 which indicated her cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). A review of Resident 1's progress notes, type, 72-hour Charting, dated 6/06/26 at 11:46 a.m., indicated, S [Situation]: Resident exhibited physical aggression toward other resident. A review of Resident 1's progress notes, type, 72-hour Charting, dated 6/06/26 at 11:48 a.m., indicated, When [Resident 2] threw paint products at her, [Resident 1] then threw water at her.During altercation, per witness [Resident 2] hit her [Resident 1] shoulder twice with her first [fist] closed. A review of Resident 1's progress notes, type, IDT (interdisciplinary team, typically includes the nursing leadership, social services, and medical records) NOTE, dated 6/06/26 at 2:51 p.m., indicated, .[Resident 1] then recounts that [Resident 2] threw paint and water at her.[Resident 1] then retaliated by throwing her own drink at [Resident 2] and had admitted to calling [Resident 2] '[profanity]'. [Resident 2] then became enraged and screamed at [Resident 1], also calling her '[profanity]'.as [Resident 1] was attempting to leave the area, [Resident 2] then swung at [Resident 1] twice hitting her left shoulder.[Resident 2] has admitted to her actions. A review of Resident 2's admission record indicated she was admitted to the facility in August 2020 with medical diagnosis which included paranoid schizophrenia (a chronic mental disorder characterized by intense irrational delusions [false beliefs] and auditory hallucinations [hearing voices]), and dementia (a progressive state of decline in mental abilities). A review of Resident 2's MDS dated [DATE], indicated her BIMS score was 13 which indicated her cognition was intact. A review of Resident 2's progress notes, type, Change of Condition [COC], dated 6/06/26 at 12:19 p.m., indicated, Resident had an altercation with another resident.[Resident 2] did say she punched the other resident on her shoulder and threw water and ginger ale at her.The other resident [Resident 1] also threw water at her. During an interview on 7/02/26 at 10:47 a.m., Resident 1 stated, I was assaulted in the dining room. Resident 1 stated she was seated at a table in the dining room and was approached by Resident 2 and Resident 2 told her, This is my table. Resident 1 stated they had a verbal exchange about the table and then Resident 2 called her a [profanity]. Resident 1 further stated that in return she called Resident 2 a [profanity]. Resident 1 stated Resident 2 proceeded to throw a drink at her. Resident 1 further stated that Resident 2 picked up a bucket full of paint bottles and threw it at her hitting her right shoulder and the top of her right foot. Resident 1 stated that Certified Nurse Assistant 2 (CNA 2) was present and witnessed the entire incident. Resident 1 stated, For three days I stayed in my room. I was nervous. I didn't want to be assaulted again. Resident 1 further stated, The whole situation bothers me mentally. Mentally, it really set me back. I'm nervous and scared to move around the facility. During an interview on 7/02/26 at 11:30 a.m., Resident 2 stated, I was upset and I got in a fight with someone. I feel ashamed. Resident 2 was unable to recall further details of the incident. During an interview on 7/02/26 at 1:30 p.m., CNA 1 stated that staff were expected to respond immediately when a resident-to-resident altercation was witnessed so that physical contact could be avoided. CNA 1 confirmed that profane name calling between residents was considered verbal abuse. CNA 1 further confirmed if residents attempted to hit one another or make physical contact it was considered physical abuse. CNA 1 stated it was everyone's [all facility staff] responsibility to ensure residents were safe from abuse. During an observation and interview on 7/02/26 at 1:43 p.m. with CNA 2, when asked if he witnessed a resident-to-resident altercation between Resident 1 and Resident 2 approximately one month ago in the dining room, he stated, Yes. When asked to explain what he witnessed, CNA 2 stated both Resident 1 and Resident 2 were in the dining room and he was seated directly next to the table that Resident 1 was seated at. CNA 2 stated Resident 1 was approached by Resident 2 in her wheelchair and overheard Resident 1 say, This is bullshit, you always do this to me! CNA 2 stated Resident 2 threw her crackers and ginger ale at Resident 1. CNA 2 further stated he heard Resident 1 yell at Resident 2, You [profanity] [profanity]! CNA 2 stated Resident 1 then threw a cup of fluids at Resident 2. CNA 2 stated he saw Resident 2 stand up from her wheelchair and swung at Resident 1. CNA 2 mimicked the action made by Resident 2. CNA 2 was observed standing from a seated position with a closed fist and made an upward and downward swinging motion with his arm. CNA 2 further stated that he saw Resident 2 hit Resident 1 in the left shoulder twice. CNA 2 stated he heard a slapping sound and that is how he knew that Resident 2 made physical contact with Resident 1. CNA 2's recollection of the incident was reiterated to him, and CNA 2 confirmed that he heard the slap of Resident 2 arm or fist against Resident 1's left shoulder. CNA 2 stated that Resident 2 then proceeded to throw the bucket with paint bottles that was on the table onto the floor. When asked if Resident 2's physical contact was intentional, CNA 2 stated, Yes, because she actually stood up from her wheelchair and hit her [Resident 1]. She [Resident 2] made a fist and swung at her [Resident 1]. When asked if the verbal exchange that occurred between Resident 1 and Resident 2 was verbal abuse, CNA 2 stated, Yes. [Resident 1] did call her [Resident 2] a [profanity] [profanity]. During an interview on 7/02/26 at 2:09 p.m., Licensed Nurse 1 (LN 1) stated she was at the nurse's station when she witnessed Resident 1 coming from the dining room and she appeared very distressed. LN 1 stated that Resident 1 informed her that Resident 2 threw water at her. LN 1 stated later that shift, Resident 1 complained of bilateral (both right and left) foot pain. LN 1 stated that Resident 1 told her she thinks the pain to her foot may have been from getting hit with the cup that was thrown. LN 1 stated that Resident 1 stayed in her room for the remainder of the shift. LN 1 stated the following day Resident 1 complained of left shoulder pain and medication was given. LN 1 confirmed that profane name calling between residents was considered abuse. LN 1 further confirmed physical contact between resident's was considered abuse, and stated, Yes, actual physical contact is abuse. During an interview on 7/02/26 at 2:50 p.m., the Director of Nursing (DON) confirmed that physical contact and the verbal exchange of profanity between a resident to another was considered physical and verbal abuse. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 2021, indicated, Residents have the right to be free from abuse.This includes but is not limited freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse.Protect residents from abuse.by anyone including.other residents.

Based on interview and record review, the facility failed to ensure dignity was maintained for one of three sampled residents (Resident 1) when a staff member did not close the privacy curtain before providing incontinence care. This resulted in another resident observing Resident 1's exposed buttocks, after which the staff member laughed.This failure caused Resident 1 to experience embarrassment, humiliation, and diminished dignity, and created the potential for emotional distress, loss of trust in facility staff, and reluctance to request assistance with personal care. A review of Resident 1's admission Record (facility demographic), indicated he was admitted to the facility on [DATE] with a primary admitting diagnosis of Hemiplegia (weakness on one side of the body) and Hemiparesis (total or partial paralysis of one side of the body) following a Cerebral Infarction (brain stroke) affecting the dominant left side of his body.A record review of the report submitted by the facility's Director of Nursing (DON) to the California Department of Public Health (CDPH) on 5/14/26 indicated that Resident 1 informed the facility on the evening of 5/13/26 that, approximately one and a half to two weeks earlier during the night, an unlicensed staff member 1 (US 1) failed to close his privacy curtain before providing incontinence care. This allowed a female resident to see his exposed buttocks. The DON reported that Resident 1 stated US 1 laughed after the female resident saw him and that he found it, odd and weird, that she laughed at the incident.During an interview on 5/20/26 at 10:46 a.m., the Director of Nursing (DON) confirmed that US 1 was suspended during a facility investigation of the incident reported by Resident 1. Following the investigation, US 1 was no longer permitted to provide care on Resident 1's hall and was reassigned to another hall with no further contact with Resident 1. The DON stated the facility staff could benefit from additional training.During an interview on 5/20/26 at 10:58 a.m. in the hallway outside the DON's office, Resident 1 stated that a few weeks earlier, during nighttime incontinence care, US 1 began the task without closing the privacy curtain. He stated that a female resident (Resident 2) entered the room, briefly apologized, and left after seeing his exposed buttocks as he was lying on his side. Immediately afterward, he heard US 1 laughing. Resident 1 stated he felt embarrassed and humiliated, particularly because of US 1's laughter. He reported that he formally reported the incident to the Director of Nursing.During an interview on 5/20/26 at 11:16 a.m., with Unlicensed Staff member (US 2), US 2 stated her first step in providing care for incontinence to a resident in the facility, was to provide the resident with privacy, by either pulling the resident's privacy curtain or shutting the door. During an interview on 5/20/26 at 11:19 a.m. in her room, Resident 2 confirmed she witnessed an incident a few weeks earlier when she went to see Resident 1. She said she found his door open and his privacy curtain stored at the foot of the bed, so she could not tell if he was inside. Resident 2 stated she tapped on the wall outside the room, did not hear a response, and entered. According to Resident 2, she then saw Resident 1's exposed buttocks and US 1 standing beside him. Resident 2 said US 1 looked at her and laughed. Resident 2 stated she immediately apologized and left the room, adding that she felt embarrassed by the incident and then felt bad for Resident 1 as well.During an interview on 5/20/26 at 12:36 p.m., with LN 1 at the nurses' station, LN 1 was queried about what a potential psychosocial harm risk for a resident might be due to an incident involving the resident's exposure of their buttocks to another resident during incontinence care. LN 1 stated the incident would likely cause the resident embarrassment. During a telephone interview on 5/13/26 at 3:25 p.m., with US 1 and an interpreter, US 1 confirmed she recalled an incident that happened involving Resident 1 becoming upset after Resident 2 came to his room during the time she was providing care for incontinence to Resident 1. A review of the facility policy titled, Dignity, revised in February 2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout their resident's facility stay . 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents.A review of the facility policy titled, Resident Rights, revised in February 2021, indicated, Employees shall treat all residents with kindness respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness and dignity. t. privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to ensure food was stored in safe and sanitary conditions in the food service department when:1. The walk-in fridge contained food items that were not labeled.2. The walk-in fridge and freezer number #3 contained food items that were expired.These failures had the potential to place residents at risk for developing food-borne illnesses (sickness by consuming contaminated food or drinks) by exposing residents to contaminated food and unsanitary practices.Findings:1.During a concurrent observation and interview on 7/21/2025 at 1:35 p.m. with the Dietary Manager (DM) in the kitchen's walk-in fridge, there was an opened bag of parsley with the date of 7/20/2025, a container with eight red onions with an expiration date of 7/12/2025, and two boxes of fully cooked bacon with no date. The DM stated that the parsley, red onions and fully cooked bacon were expired and should be discarded to prevent food-borne illnesses.During an interview on 7/24/2025 at 8:10 a.m. with the Registered Dietitian (RD), the RD stated the kitchen staff had not been labeling the received date and the expiration date of food items, because the kitchen staff expected the DM to perform this task. The RD stated this was not an acceptable practice and the kitchen staff were also responsible for accurately labeling and dating any food products to prevent cross-contamination and food-borne illnesses. The RD further stated the expiration date was important to ensure the residents consumed a safe food product.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated November 2022, the P&P stated 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use-by-date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date.or discarded. 2. During a concurrent observation and interview on 7/21/2025 at 4:00 p.m., with the Kitchen Aide (KA 2) in the kitchen's freezer number #3, there was a bag of gluten free white bread, unopened, and a used-by-date of 7/6/2025. KA 2 stated this item was expired and should be discarded to prevent food contamination. During an interview on 7/24/2025 at 8:10 a.m. with the Registered Dietitian (RD), the RD stated the kitchen staff had not been labeling the received date and the expiration date of food items, because the kitchen staff expected the DM to perform this task. The RD stated this was not an acceptable practice and the kitchen staff were also responsible for accurately labeling and dating any food products to prevent cross-contamination and food-borne illnesses. The RD further stated the expiration date was important to ensure the residents consumed a safe food product.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated November 2022, the P&P stated 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use-by-date). 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date.or discarded.

Based on observation, interview, and record review, the facility failed to follow and implement infection control practices and maintain a sanitary environment when:1. A contact precaution order was not in place when Resident 125 was identified to have a multidrug resistance organism (MDRO, a bacteria that have developed resistance to multiple antibiotics).2. Dirty items were found stored in the clean shower.3. An unlabeled urinal was found stored in a bathroom sink next to oral hygiene items in room [ROOM NUMBER]. Unlabeled oral hygiene items were found stored on top of a toilet lid in room [ROOM NUMBER].4. Enhanced Barrier Precautions (EBP- safety measures in place for residents with wounds or indwelling devices) was not implemented for one of 30 sampled residents (Resident 7) with a wound vac (medical device that heals slow-healing wounds by using gentle suction).These failures had the potential to result in the spread of infectious diseases amongst residents, staff, and visitors.Findings: 1. During a review of Resident 125’s “admission Record,” dated 7/22/2025, the admission record indicated Resident 125 was admitted to the facility on [DATE] with diagnosis of facial weakness following a cerebral infarction (when blood supply to part of the brain is blocked or reduced). During a review of Resident 125’s “Progress Notes,” dated 5/12/2025 at 1:25 p.m., the progress notes indicated a wound was noted with MRSA (Methicillin-Resistant Staphylococcus Aureus, a type of bacteria that has become resistant to many of the antibiotics used to treat an ordinary staph infection) and contact isolation precautions were started. The progress notes further indicated the IP nurse was updated on the new orders and culture results. During a review of Resident 125’s Contact Precautions Order, dated 6/12/2025, the order indicated an order for contact precautions related to MRSA in wound. During an interview on 7/21/2025 at 5:17 p.m., with the Infection Preventionist (IP), the IP stated Resident 125 was on contact precautions (infection control measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with a patient or their environment), because Resident 125 had a wound on his scrotum which tested positive for MRSA. During a concurrent observation and interview on 7/21/2025 at 5:42 p.m., a “Contact Precautions” sign was posted on the outside of Resident 125’s room. The “Contact Precautions” sign indicated that everyone must clean their hands, including before entering and when leaving the room. The “Contact Precautions” sign further indicated providers and staff must also put on gloves before room entry, discard gloves before room exit, put n gown before room entry, and discard gown before room exit. During an interview on 7/23/2025 at 11:34 a.m., with the Director of Nursing (DON), the DON stated when a culture was received and the culture indicated a MDRO requiring contact precautions, then contact precautions would be initiated right away and there should be an order for contact isolation in place at that time. During a review of the facility’s policy and procedure (P&P) titled, “Isolation-Initiating Transmission-Based Precautions,” dated September 2024, the P&P indicated, “Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. 4. Transmission-Based Precautions shall remain in effect until the Attending Physician or Infection Preventionist discontinues them, which should occur after pertinent criteria for discontinuation are met.” 2. During a concurrent observation and interview on 7/21/2025 at 1:59 p.m. with the Infection Preventionist (IP) in the shower room on Unit 1A, two dirty linen barrels and one rolling commode were found stored in the clean shower. IP stated the dirty linen barrels and rolling commode should be stored in the dirty utility area, not the clean shower area. The facility was unable to provide a policy regarding the storage of dirty items at the time requested. 3. During a concurrent observation and interview on 7/22/2025 at 12:14 p.m. with Certified Nursing Assistant (CNA 3), in room [ROOM NUMBER]’s shared bathroom, an unlabeled urinal was observed in the sink next to oral hygiene items (toothbrush and toothpaste) that were uncovered and left open to the air. CNA 3 stated that the urinal should not be kept in the bathroom. CNA 3 further stated that the urinal should be stored at the resident's bedside. CNA 3 confirmed that the urinal was not labeled, and that the urinal should have been labeled with the resident's name. During a concurrent observation and interview on 7/23/2025 at 11:15 a.m. with Licensed Vocational Nurse (LVN 5), in room [ROOM NUMBER]’s shared bathroom, an unlabeled emesis basin containing a toothbrush, mouth wash, toothpaste, and a razor was observed sitting on top of the toilet tank and left uncovered and open to the air. LVN 5 stated she did not know which resident the hygiene items belonged to and confirmed the items were unlabeled. LVN 5 stated that the hygiene items should have been labeled and stored in the bedside cabinet and should not be stored on top of the toilet. During a review of the facility’s policy and procedure (P&P) titled, “Cleaning and Disinfecting Non-Critical Resident-Care Items,” dated June 2022, the P&P indicated, “Single resident use items are for single resident use only. [NAME] with the resident’s name and/or room number. Bedpans…Return the bedpan or urinal to resident’s bedside cabinet.” 4. During a review of Resident 7’s Minimum Data Set (MDS, a health status screening and assessment tool), dated 7/24/2024, the MDS indicated, Resident 7 was admitted on [DATE] with diagnoses that included unspecified fracture of left pubis (anterior bone of the pelvis). During a review of Resident 7’s Physician Orders, dated 6/10/2025, the physician orders indicated, an order for a wound vac was placed on 6/10/2025 for Resident 7. During a review of Resident 7's Physician Orders, dated 7/22/205, the physician orders indicated, an order for Enhanced Barrier Precautions on 7/22/2025 (42 days later), indication: Wound Vac, with PPE (personal protective equipment, specifically gown and gloves) required for high resident contact care activities. During an observation on 7/21/2025 at 2:50 p.m. in Resident 7’s room, the door was observed as having no notable signage present. During a concurrent observation and interview on 7/22/2025 at 8:51 a.m. with Resident 7, in Resident 7’s room, a new sign on Resident 7’s door indicated Enhanced Barrier Precautions were in place directing staff to wear gowns and gloves for high-contact resident care activities, such as dressing, transferring, providing hygiene, device care and wound care. A dispenser stocked with isolation gowns and gloves was observed on the front of Resident 7’s door for staff use. Resident 7 stated that she had a wound vac and confirmed that staff have not consistently worn isolation gowns when providing hygiene or wound care to her in the last month. During an interview on 7/23/2025 at 2:30 p.m., with Licensed Vocational Nurse (LVN 2), LVN 2 stated Enhanced Barrier Precautions (EBP) requires that a gown and gloves are worn for resident care tasks when a resident is on EBP. LVN 2 stated, EBP was for the protection of the residents. LVN 2 further stated, when staff members provide care to residents on EBP without wearing gowns and gloves, they put the residents at increased risk for infection. During an interview on 7/24/2025 at 3:08 p.m., with the Director of Nursing (DON), the DON stated a staff member responding to a call light is not likely to know that a resident requires Enhanced Barrier Precautions if EBP signage is not in place on the resident’s door. The DON stated, a possible consequence of not implementing EBP was infection and EBP is for the protection of residents. During a review of the facility’s policy and procedure (P&P) titled “Enhanced Barrier Precautions,” revised December 2024, the P&P indicated, “Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. Enhanced Barrier Precautions apply when; a resident is not know to be infected or colonized with any MRDO, has a wound or indwelling medical devices. EBP are in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that place that resident at higher risk. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required…with personal protective equipment and alcohol-based hand-rub…readily accessible to staff.”

Based on observation, interview and record review, the facility failed to ensure the garbage was disposed of properly, when a garbage can lid and a garbage compactor (a machine that reduces the volume of trash by compacting it), were not closed and the surrounding area had piles of trash bags on the ground.This failure resulted in pest attraction and odor in the garbage disposal area.Findings:During a concurrent observation and interview on 7/23/2025 at 11:50 a.m., with the Housekeeping Supervisor (HS), in the garbage disposal area, the garbage compactor was not closed, the surrounding area had piles of trash bags on the ground with flies and a foul odor. The HS stated the compactor should be covered when not in use to prevent odor and to prevent attracting pests.During a concurrent observation and interview on 7/24/2025 at 7:50 a.m., with Housekeeping (HK), in the garbage disposal area, one of the garbage can lids was opened with birds flying in and out of the garbage can. Housekeeping (HK) stated the garbage can lid needed to be closed to prevent harborage of rodents or pests.During an interview on 7/24/2025 at 8:10 a.m. with the Infection Preventionist (IP), the IP stated the garbage can lid had to be closed at all times and the area around it had to be clean. The IP further stated this was important to prevent attracting rats and pests to the facility.During a review of the Food and Drug Administration (FDA) Food Code 2022, Section 5-501.110 Storage Refuse, Recyclables, and Returnable, dated January 2023, the FDA food code indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview and record review, the facility failed to ensure the medication error rate was not greater than five percent when four identified medication errors out of 27 opportunities were observed:1. Vancomycin (antibiotic used to treat serious bacterial infections) solution was not administered per medication label instructions for one of 30 sampled residents (Resident 50).2. Insulin Aspart (rapid acting medication used to decrease blood sugar) was administered at the wrong time for one of 30 sampled residents (Resident 39).3. Albuterol (medication used to prevent and treat breathing difficulties) was not administered per physician instructions for one of 30 sampled residents (Resident 16).4. Eliquis (medication to prevent and treat blood clots) was not administered per physician instructions for one of 30 sampled residents (Resident 16).These failures resulted in an overall facility medication error rate of 14.81% and had the potential to result in negative health outcomes for Resident 16, Resident 39, and Resident 50.Findings:1. During a review of Resident 50's Face Sheet (Resident Demographics), the Face Sheet indicated, Resident 50 was admitted to the facility on [DATE] with diagnoses which included Abscess of the Liver (localized infection in the liver that forms pus-filled pocket), and Type 2 Diabetes Mellitus (disease that causes blood sugar levels to be high).During an observation on 7/23/2025 at 12:03 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was observed preparing Resident 50's Vancomycin. The label on the Vancomycin bottle indicated, Shake Well. LVN 4 partially tipped Resident 50's Vancomycin solution bottle once and poured the medication into a medication cup for administration. LVN 4 administered Vancomycin solution to Resident 50.During an interview on 7/24/2025 at 2:03 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated medications with Shake Well label should be inverted several times prior to administration.During an interview on 7/24/2025 at 2:17 p.m. with the Pharmacist, the Pharmacist stated Vancomycin solution should be shaken well prior to administration to prevent the solution from separating. The Pharmacist stated the Vancomycin solution bottle should have been fully tilted for a minimum of 2 times.During a review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures, dated June 2021, the P&P indicated, To administer medications in a safe and effective manner. Check MAR (Medication Administration Records) for order.Read medication label three (3) times.prior to removing the medication from the package/container.2. During a review of Resident 39's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus (disease that causes blood sugar levels to be high).During an observation on 7/23/2025 at 3:35 p.m. with Licensed Vocational Nurse (LVN 2) in Resident 39's room, LVN 2 was observed preparing Resident 39's Insulin Aspart. The Insulin Aspart medication label indicated give before meal. LVN 2 administered Insulin Aspart 2 units (unit of measure) via flex pen (inject device) to Resident 39. LVN 2 did not instruct Resident 39 to eat or offer food to Resident 39 after administering the medication. No food items were observed in Resident 39's room.During an observation on 7/23/2025 at 4:46 p.m. in Resident 39's room, Resident 39 was seated in his wheelchair with no food in his room.During a concurrent observation and interview on 7/23/2025 at 5:16 p.m. with Resident 39 in Resident 39's room, Resident 39 was sleeping in his wheelchair. Resident 39 aroused when his name was called. No food or snacks were observed in Resident 39's room. Resident 39 stated he usually gets his insulin before meals and was unsure why his Insulin was administered early. Resident 39 confirmed he had not eaten since his insulin administration.During an interview on 7/23/2025 at 5:25 p.m. with Director of Nursing (DON), the DON stated meals should be given approximately 15-30 minutes after rapid acting insulin administration.During an interview on 7/24/2025 at 1:40 p.m. with LVN 2, LVN 2 stated she administered Resident 39's insulin too early.During a review of Resident 39's Physician Orders dated 6/11/2025, the Physician Orders indicated Insulin Aspart Injection Solution 100 unit/ml (milliliter, unit of measure) inject subcutaneously (under the skin) before meals.During a review of the facility's policy and procedure titled, Specific Medication Administration Procedures, dated June 2021, the P&P indicated, To administer medications in a safe and effective manner. Check MAR (Medication Administration Records) for order.Read medication label three (3) times.prior to removing the medication from the package/container.3. During a review of the Resident 16's Face Sheet (Resident Demographics), [undated], the Face Sheet indicated Resident 16 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD, group of lung diseases that cause ongoing breathing problems) and chronic atrial fibrillation (disorder where upper chambers of heart beat irregularly and rapidly).During an observation on 7/23/2025 at 4:20 p.m. with Licensed Vocational Nurse (LVN 2) in Resident 16's room, LVN 2 prepared Resident 16's evening medications. LVN 2 shook Resident 16's Albuterol inhaler twice and handed the inhaler to Resident 16. Resident 16 administered one puff of Albuterol inhaler, exhaled and administered a second puff immediately after. LVN 2 did not instruct Resident 16 to rinse his mouth with water after Albuterol administration.During a review of Resident 16's Physician Orders, dated July 2025, the physician orders indicated, Albuterol Inhaler wait 1 minute between puffs and rinse well after administration.During an interview on 7/24/2025 at 2:03 p.m. with LVN 2, LVN 2 stated Resident 16 should not have administered his Albuterol inhaler puffs consecutively. LVN 2 confirmed Resident 16 did not rinse his mouth with water after Albuterol administration. LVN 2 also stated the resident's mouth should be rinsed after Albuterol inhaler administration to prevent thrush (fungal infection) and bacteria in his mouth.During an interview on 7/24/2025 at 2:17 p.m. with the Pharmacist, the Pharmacist stated a one minute wait between Albuterol inhaler puffs was needed to ensure the medication had the proper time to work in the lungs. The Pharmacist stated Albuterol medication may not be effective if a one minute wait period was not adhered to.During a review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures, dated June 2021, the P&P indicated, To administer medications in a safe and effective manner. Check MAR (Medication Administration Records) for order.Read medication label three (3) times.prior to removing the medication from the package/container.4. During a review of Resident 16's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 16 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD, group of lung diseases that cause ongoing breathing problems) and chronic atrial fibrillation (disorder where upper chambers of heart beat irregularly and rapidly).During an observation on 7/23/2025 at 4:20 p.m. with Licensed Vocational Nurse (LVN 2) in Resident 16's room, LVN 2 prepared Resident 16's Eliquis for administration. The Eliquis label indicated Take with full glass of water. LVN 2 administered one tablet of Eliquis to Resident 16. Resident 16 drank approximately 2 sips of water after consuming Eliquis tablet. LVN 2 did not instruct Resident 16 to consume additional water after Eliquis administration. During a review of Resident 16's Physician Orders, dated July 2025, the physician orders indicated, Eliquis 5 mg (milligram- unit of measurement) tab, take with full glass of water.During an interview on 7/24/2025 at 2:03 p.m. with LVN 2, LVN 2 stated Resident 16's Eliquis administration instructions indicated to take Eliquis with full glass of water. LVN 2 confirmed Resident 16 did not consume full glass of water after Eliquis administration.During a review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures, dated June 2021, the P&P indicated To administer medications in a safe and effective manner. Check MAR (Medication Administration Records) for order.Read medication label three (3) times.prior to removing the medication from the package/container.

Based on observation, interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 39) remained free from significant medication error when rapid acting insulin (medication used to decrease blood sugar) was administered at the wrong time.This failure had the potential to result in Resident 39 experiencing adverse complications from hypoglycemia (condition in which blood sugar level drops below normal) including dizziness, sleepiness, passing out or death. Findings:During a review of Resident 39's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 39 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus (disease that causes blood sugar levels to be high).During an observation on 7/23/2025 at 3:35 p.m. with Licensed Vocational Nurse (LVN 2), in Resident 39's room, LVN 2 administered Insulin Aspart (rapid acting medication used to decrease blood sugar) 2 units (unit of measurement) via flex pen (injection device). Resident 39's Insulin Aspart medication label indicated give before meals. LVN 2 did not instruct Resident 39 to eat or offer food to Resident 39 after administration. No food items were observed in Resident 39's room.During an observation on 7/23/25 at 4:46 p.m., Resident 39 was in his room speaking with maintenance staff. No food items were observed in the resident's room.During a concurrent observation and interview on 7/23/2025 at 5:16 p.m. with Resident 39, in Resident 39's room, Resident 39 was sleeping in his wheelchair. Resident 39 aroused when his name was called. No food or snacks were observed in Resident 39's room; two unopened bottles of cola were observed on the resident's bedside table. Resident 39 stated he was tired, and staff usually administered his insulin approximately 30 minutes before he eats. Resident 39 stated I don't know why [nurse] gave it to me so early today. Resident 39 confirmed he had not eaten since his insulin administration.During an interview on 7/23/2025 at 5:25 p.m. with the Director of Nursing (DON), the DON stated meals should be given approximately 15-30 minutes after rapid acting insulin administration. The DON stated LVN 2 should not have administered insulin without feeding Resident 39.During an interview on 7/24/2025 at 1:40 p.m. with LVN 2, LVN 2 stated Resident 39's insulin was administered too early.During an interview on 7/24/2025 at 2:17 p.m. with the Pharmacist, the Pharmacist stated rapid acting insulin should be administered 30 minutes prior to meals. The Pharmacist stated Resident 39 was at risk for hypoglycemia.During a review of Resident 39's Physician Orders, dated 6/11/2025, the physician orders indicated Insulin Aspart Injection Solution 100 unit/ml (milliliters, unit of measurement) inject.subcutaneously (under the skin) before meals.During a review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures, dated June 2021, the P&P indicated, To administer medications in a safe and effective manner. Check MAR (Medication Administration Records) for order.Read medication label three (3) times.prior to removing the medication from the package/container.During a review of the facility's policy and procedure (P&P) titled Insulin Administration dated March 2025, the P&P indicated, Key characteristics of insulin are: Onset of action-how quickly the insulin reaches the bloodstream and begins to lower blood glucose; Peak effects- the time when the insulin is at its maximum effectiveness.Insulin: Rapid acting.Onset within 15 min, Peak 0.5-1.5 hrs.

Based on observation, interview, and record review, the facility failed to provide a sanitary and comfortable environment when the Stop sign banners in Hallway 3A had hair and lint on the velcro areas of the banners. This failure had the potential to negatively affect the residents' homelike environment. Findings:During a concurrent observation and interview on 7/21/2025 at 2:45 p.m., with the Director of Staff Development (DSD), three Stop sign banners were hanging on Hallway 3A rails next to rooms [ROOM NUMBER]. The Stop sign banners had hair and lint on the velcro areas. The DSD stated the Stop sign banners are put on the door to prevent wandering residents from going into residents room. The DSD confirmed the hair and lint on the velcro areas on the three Stop sign banners.During a concurrent observation and interview on 7/21/2025 at 3:25 p.m., with Housekeeping (HK), HK confirmed the hair and lint on the velcro areas on the three Stop sign banners hanging on Hallway 3A rails next to rooms [ROOM NUMBER]. HK stated the Stop sign banners were sanitized and replaced, but the facility did not have the tools to remove the hair and lint on the velcro area. HK stated the Stop sign banners did not look clean with the hair and lint on the velcro areas. During a review of the facility's policy and procedure (P&P) titled, Policies and Practices-Infection Control, dated October 2018, the P&P indicated, 2. The objective of our infection control policies and practices are to: . b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on observation, interview, and record review, the facility failed to ensure two of 30 sampled Residents (Residents 36 and 53) that:1.Resident 36's oxygen therapy was reviewed and updated to reflect her current clinical status. This failure had the potential to compromise the care provided to Resident 36.2.Residents 53's nasal cannula (a device used to deliver supplemental oxygen through the nose) was labeled and stored appropriately. This failure had the potential for residents to be exposed to infectious diseases. Findings:1. During a review of Resident 36's admission Record, dated 7/22/2025, the admission Record indicated Resident 36 was admitted to the facility on [DATE] with diagnosis of heart failure. During a review of Resident 36's Physician's order, dated 1/8/2025 and 1/17/2025, the physician's order indicated Oxygen at 2 liters/minute (unit of measurement) by nasal cannula (a device used to deliver supplemental oxygen through the nose), continuously for CHF (Congestive Heart Failure, a condition where the heart does not pump blood as well as it should), and the goal was to maintain the oxygen saturation (O2 Sat, a measurement of how much oxygen your blood is carrying), greater than 90 percent. Further review of the physician's order indicated to monitor the oxygen saturation every shift.During a review of Resident 36's Quarterly Minimum Data Set (MDS, a health status screening and assessment tool), dated 1/24/2025, under Section O - Special Treatment, Procedures, and Programs, the oxygen therapy was checked.During a review of Resident 36's Annual MDS, dated [DATE], under Section O - Special Treatment, Procedures, and Programs, the oxygen therapy was not checked.During a review of Resident 36's Oxygen Therapy Care Plan (an individualized plan that provides direction on the type of care a patient needs), revised 1/17/2025, the oxygen care plan indicated Resident 36 required the use of continuous oxygen related to CHF.During a review of Resident 36's Provider Progress Notes, dated 7/14/2025 by Nurse Practitioner (NP 1), the provider progress notes indicated Resident 36 has not been using oxygen per nasal cannula all the time and was used just as needed. During an observation on 7/23/2025 at 7:36 a.m., in Resident 36's room, Resident 36 was not on oxygen therapy. An oxygen concentration was next to Resident 36's foot of the bed and not powered on.During a concurrent observation and interview on 7/23/2025 at 11:41 a.m. with Licensed Vocational Nurse (LVN 8), outside of Resident 36's room, Resident 36 was not on oxygen therapy. LVN 8 stated Resident 36 was not on continuous oxygen therapy, but just as needed. During an interview on 7/23/2025 at 11:44 a.m., with Resident 36, Resident 36 stated she uses oxygen when she gets out of breath. Resident 36 stated she used oxygen sometimes and not continuously. Resident 36 stated the last time she used oxygen was last week.During a concurrent interview and record review on 7/23/2025 at 11:46 a.m., with the Assistant Director of Nursing (ADON), the physician's orders for oxygen therapy and the oxygen saturation documentation was reviewed. The ADON confirmed, Resident 36's current oxygen therapy dated 1/17/2025 was ordered as continuous. The ADON confirmed, Resident 36's O2 Sats Summary for the month of July 2025 indicated Resident 36 was either on room air or on nasal cannula. The ADON stated the nurses should collaborate with the interdisciplinary team to determine whether Resident 36 needed continuous or as needed oxygen therapy and then clarify the order with Resident 36's physician. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated October 2022, the P&P indicated, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2. During a review of Resident 53's admission Record, dated 7/22/2025, the admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnosis of Parkinson's Disease (a movement disorder that worsens over time).During a concurrent observation and interview on 7/21/2025 at 2:45 p.m., with Resident 53, in Resident 53's room, two portable oxygen tanks were observed in the room. One portable oxygen tank was next to Resident 53 and one portable oxygen tank was next to a console table near Resident 53's area in the room. Both portable oxygen tanks had unlabeled nasal cannulas wrapped on top of the tanks. Resident 53 stated she did not remember the last time she used the oxygen, but she uses the oxygen as needed. During a concurrent observation and interview on 7/21/2025 at 3:11 p.m., with Licensed Vocational Nurse (LVN 1), in Resident 53's room, LVN 1 confirmed the two portable oxygen tanks had unlabeled nasal cannulas wrapped on top of the tanks. LVN 1 stated the nasal cannulas should have been dated and placed in a bag.During a review of Resident 53's Physician's order, dated 11/29/2023, the physician's order indicated oxygen at two liters per minute by nasal cannula as needed for chest pain and shortness of breath and the goal was to maintain oxygen saturation (O2 Sat, a measurement of how much oxygen your blood is carrying), greater than 90 percent. During an interview on 7/22/2025 at 1:57 p.m., with the Infection Preventionist (IP), the IP stated the nasal cannulas should have been dated and placed in a bag if not being used. IP stated, the bag should be labeled with the resident's name.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of 30 sampled residents (Resident 96) when there were no documented evidence Resident 96 was exhibiting wandering behavior prior to placing a wander guard bracelet (a wearable device designed to help prevent residents at risk of wandering from leaving a designated area in a care facility). This failure resulted in Resident 96's quality of life being negatively affected when Resident 96 stated he could not do the things he likes to do.Findings:During a review of Resident 96's admission Record, dated 7/22/2025, the admission Record indicated Resident 96 was admitted to the facility on [DATE] with metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying condition such as electrolyte imbalances and infections) and generalized muscle weakness. During a review of Resident 96's Minimum Data Set (MDS, a health status screening and assessment tool) dated 6/3/2025, under Section C - Cognitive Patterns indicated Resident 96 was cognitively intact. During a concurrent observation and interview on 7/21/2025 at 4:42 p.m., in Resident 96's room, Resident 96 had a wander guard bracelet on his right ankle. Resident 96 stated he had the wander guard bracelet so that he would not go beyond the borders of the facility. Resident 96 stated he had asked the staff to remove it because he did not like it. Resident 96 stated he was restricted inside the facility and felt like he was in a police department. Resident 96 further stated that he likes to sit outside to get fresh air so that he can talk to people and make some friends. Resident 96 stated the wander guard prohibits him from going outside and making some friends. During a review of Resident 96's Order Summary Report, dated 7/23/2025, the Order Summary Report indicated an order on 6/4/2025 for a wander guard to the right ankle related to wandering/exit seeking behaviors and for the nurse to check its placement every shift until October 2027.During a review of Resident 96's MDS dated [DATE], under Section E - Behavior, indicated Resident 96 had not been exhibiting wandering behavior.During a concurrent interview and record review on 7/23/2025 at 2:59 p.m., with the Assistant Director of Nursing (ADON), Resident 96's medical record was reviewed. Resident 96's Elopement and Wandering Risk Observation/Assessment dated 5/27/2025 indicated Resident 96 had not expressed a desire to leave, had not attempted to leave the facility, and did not exhibit unsafe wandering or elopement attempts. The Elopement and Wandering Risk Observation/Assessment further indicated although Resident 96 exhibited agitation, Resident 96 may be redirected and did not warrant the use of wander alarms. The ADON confirmed that Resident 96 scored 4 on his Elopement and Wandering Risk Observation/Assessment which indicated that Resident 96 had a low risk of elopement and wandering. The ADON stated Resident 96 ambulated and there was an incident when Resident 96 attempted to leave the facility without informing the staff. The ADON confirmed Resident 96 was not reassessed for elopement and wandering risk after the incident. The ADON stated Resident 96 should have been reassessed for elopement and wandering risk.In addition, the ADON confirmed Resident 96's Informed Consent for Use of Wander/Elopement Alarm dated 6/4/2025 was incomplete. The ADON confirmed that the Informed Consent for Use of Wander/Elopement Alarm had no documentation of medical needs that address the use of wander/elopement alarm for Resident 96, had no documentation of the possible benefits of wander/elopement alarm use, had no documentation of possible risks of the wander/elopement alarm use and how will these risks be mitigated, and had no documentation of alternatives to wander/elopement alarms use that have been attempted but failed to meet Resident 96's needs. The ADON confirmed there was no documentation regarding the reason a wander guard bracelet was placed on Resident 96 on 6/4/2025. During a concurrent interview and record review on 7/23/2025 at 4:26 p.m., with the Director of Nursing (DON), the DON confirmed there was no documentation and no indication on why a wander guard bracelet was placed on Resident 96. The DON stated Resident 96 did not try to elope or had any episodes of elopement or wandering but rather Resident 96 was walking around the parameter of the facility just like what he used to do when he was at home. The DON stated she was being precautious and jumped the gun on putting a wander guard bracelet on Resident 96. The DON confirmed there was no documentation of alternative interventions done prior to putting a wander guard bracelet on Resident 96. The DON stated Resident 96 should have been reassessed for elopement and wandering behavior prior to putting a wander guard bracelet on him.During an interview on 7/24/2025 at 10:28 a.m. with the Receptionist, the Receptionist stated she works Monday to Friday from 8 a.m. to 4:30 p.m. The Receptionist stated Resident 96 would ask her if he can go out, but Resident 96 would never attempt to go out during her shift. The Receptionist stated Resident 96 would sit in the lobby and look outside. During a review of Resident 96's Progress Notes from 5/27/2025 to 6/4/2025, the Progress Notes had no documented evidence of Resident 96 exhibiting wandering behavior prior to applying a wander guard bracelet on 6/4/2025.During an interview on 7/24/2025 at 10:40 a.m. with Registered Nurse (RN) 1, RN 1 stated a cognitively intact resident does not need permission to go outside and walk around the facility. During a review of the facility's policy and procedure (P&P) titled, Elopement and Wandering Policy, [undated], the P&P indicated, Policy Explanation and Compliance Guidelines: . 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering . a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay be the interdisciplinary care plan team. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly.

Based on interview and record review, the facility failed to initiate and create a care plan (an individualized plan that provides direction on the type of care a patient needs) for one of 30 sampled residents (Resident 125), when Resident 125 was placed on contact precautions (infection control measures used to prevent the spread of infectious agents that can be transmitted through direct or indirect contact with a resident or their environment) on 5/12/2025. This failure had the potential to not provide the necessary care and treatment for Resident 125.Findings:During a review of Resident 125's admission Record, dated 7/22/2025, the admission Record indicated Resident 125 was admitted to the facility on [DATE] with diagnosis of facial weakness following a cerebral infarction (when blood supply to part of the brain is blocked or reduced).During an interview on 7/21/2025 at 5:14 p.m., with the Infection Preventionist (IP), IP stated Resident 125 was on contact precautions because Resident 125 had a wound on his scrotum which tested positive for MRSA (Methicillin-resistant Staphylococcus aureus, a type of bacteria that has become resistant to many of the antibiotics used to treat an ordinary staph infection).During a review of Resident 125's Progress Notes, dated 5/12/2025 at 1:25 p.m., the Progress Notes indicated a wound was noted with MRSA and contact isolation precautions were started. The Progress Notes further indicated IP was updated on the new orders and culture results.During a concurrent interview and record review on 7/23/2025 at 2:15 p.m., with MDS (Minimum Data Set) Coordinator 1 (MDS 1) , Resident 125's isolation precautions care plan was reviewed. MDS 1 stated IP created the isolation precautions care plan on 6/12/2025 (a month after Resident 125 tested positive for MRSA) and not 5/12/2025. MDS 1 further stated the initiation date of a care plan can be changed but not the creation of the care plan. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P 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. Policy Interpretation and Implementation . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plans: a. when there has been a significant change in the resident's condition.

Based on interview and record review, the facility failed to provide a written transfer notification to one of 30 sampled residents (Resident 6) or to his representative upon Resident 6's transfer to an acute care hospital on 4/2/2025. This failure had the potential for Resident 6 and/or his representative not to be informed of his rights to return to the facility following a hospitalization. Findings:During a review of Resident 6's admission Record, dated 7/22/2025, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide). During a review or Resident 6's Progress Notes, dated 4/2/2025, the Progress Notes indicated at 10:28 p.m., Resident 6 appeared to be jaundice (a condition characterized by the yellowing of the skin, mucous membranes, and whites of the eyes) and confused. The physician was notified of the altered mental status (a change in a person's level of consciousness, awareness, and cognitive function) and the jaundice. At 10:30 p.m., the Progress Notes indicated (name of the doctor) ordered to send Resident 6 to (name of the hospital) and if Resident 6 worsens or becomes unstable, to send him via 911. At 11:27 p.m., the Progress Notes indicated Resident 6 was picked up by two emergency medical technicians and left the facility.During a review of Resident 6's Bed Hold Policy and Notification, dated 12/31/2024, the section that indicated to be completed upon transfer was blank. This blank section identifies the name of the resident, when and where the resident was transferred to, the name, date, and time the person who was notified of the transfer, and if the person notified has been informed of their rights to hold the resident's bed. During an interview on 7/25/2025 at 9:24 a.m., with the Director of Nursing (DON), the DON confirmed that there was no documented evidence a written transfer notification was provided to Resident 6 or his representative when Resident 6 was transferred to a hospital on 4/2/2025.During a review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, dated October 2022, the P&P indicated, 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Based on observation, interview and record review, the facility failed to ensure a medication cart (a cart that contains medications for residents) was locked while not in use and unattended. This failure had the potential to allow residents, staff and visitors to gain access to the medication cart.Findings:During a concurrent observation and interview on 7/21/2025 at 1:50 p.m. with the Infection Preventionist (IP) on Unit 1A, the medication cart was observed unlocked and unattended. IP stated the medication cart should be locked when not in use.During an interview on 7/22/2025 at 8:47 a.m. with the Director of Nursing (DON), the DON stated the medication carts should be locked at all times when not in use.During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, revised April 2007, the P&P indicated, Compartments .containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on interview and record review, the facility failed to ensure a speech therapy evaluation for one of 30 sampled residents (Resident 60) was performed when ordered by the physician.This failure had the potential to result in Resident 60 receiving an inappropriate diet, choking or weight loss.Findings:During a review of Resident 60's Face Sheet (Resident Demographics), the Face Sheet indicated Resident 60 was admitted to the facility on [DATE] with diagnoses which included Myasthenia Gravis (chronic autoimmune disease that causes muscle weakness) and Parkinson's Disease (brain disorder that causes uncontrollable body movements).During a review of Resident 60's Physician Orders, dated 6/11/2025, the physician orders indicated, a speech therapy evaluation was ordered for Resident 60 on 6/11/2025 at 11:13 a.m. There was no documentation in Resident 60's record which indicated the speech therapy consult had been performed (43 days later).During an interview on 7/24/2025 at 2:44 p.m. with the Speech Therapist (ST), the ST confirmed Resident 60's speech therapy evaluation had not been completed. ST stated the order was missed.During an interview on 7/24/2025 at 2:59 p.m. with the Director of Rehabilitation (DOR), the DOR stated speech therapy evaluation orders should be completed within approximately 48 hours. The DOR confirmed Resident 60's speech therapy evaluation order from 6/10/2025 was not completed in a 48-hour time frame.During an interview on 7/25/2025 at 9:05 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated nurses were responsible for verifying speech therapy evaluation consults were completed to ensure residents were receiving the correct diet. LVN 2 stated omitted speech therapy evaluation orders could result in resident choking or receiving the incorrect diet.During a review of the facility's policy and procedure (P&P) titled, Specialized Rehabilitative Services, dated December 2022, the P&P indicated, In addition to rehabilitative nursing care, the facility provides specialized rehabilitative services by qualified professional personnel. Specialized rehabilitative services include the following: Speech pathology/audiology.Therapeutic services are provided only upon the written order of the resident's attending physician.

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff were available to respond to call lights in a timely manner for one of 30 sampled residents (Resident 113). This failure resulted in Resident 113 experiencing long wait times and feelings of neglect.Findings:During a review of Resident 113's Minimum Data Set (MDS, a health status screening and assessment tool), dated [DATE], the MDS indicated Resident 113 was admitted on [DATE] with diagnoses that included Multiple Sclerosis (disease that affects the nervous system and can lead to problems with movement and balance) and muscle weakness.During a review of Resident 113's Quarterly MDS Assessment, dated [DATE], the quarterly MDS assessment indicated in Section GG: Functional Abilities and Goals: that Resident 113 ambulated by wheelchair and required moderate assistance with the following tasks: (1) the ability to bathe and dry self, (2) the ability to dress and undress above the waist, (3) the ability to dress and undress below the waist, and (4) the ability to put on and take off footwear.During an interview on [DATE] at 2:57 p.m. with Resident 113, Resident 113 stated that he had a concern regarding staff response times. Resident 113 stated that he has sat on the toilet and waited for assistance from staff for 20 to 30 minutes multiple times before a staff member was available to assist him.During a concurrent observation and interview on [DATE] at 10:20 a.m., with Resident 113, in the hallway outside his room, his right hand and arm were observed with moderate tremor-like shaking movement. Resident 113 stated that he waited 45 minutes today after pressing his call light around 8:45 a.m., because his assigned Certified Nursing Assistant (CNA 1) was pulled for shower duty and arrived around 9:30 a.m. Resident 113 stated he had physical therapy scheduled at 10:00 a.m. and needed help from staff with getting up, using the bathroom, and getting dressed for his scheduled therapy. Resident 113 stated because he was upset he was unable to get assistance from staff to get ready, he decided to cancel his therapy. Resident 113 stated, when he gets worked up he can get a little shaky. Resident 113 stated, I feel neglected. Resident 113 stated he doesn't understand why his assigned CNA 1 is often pulled to shower duty when he requires assistance with his activities of daily living (ADLs), such as toileting and hygiene care in the morning.During an interview with Licensed Vocational Nurse (LVN 3) on [DATE] at 10:34 a.m., LVN 3 confirmed, Resident 113 approached him on multiple occasions with concerns about staff response times.During an interview with CNA 2 on [DATE] at 9:22 a.m., CNA 2 confirmed, Resident 113 voiced concerns about call light response times maybe a few times a week. CNA 2 stated, there were signs posted throughout the facility that stated, Call lights are for everyone. CNA 2 stated everyone is supposed to answer call lights but really it seems like it's only the CNAs who do. CNA 2 confirmed, staffing has been an issue and the difference between having five CNAs on the floor as opposed to four CNAs, is that each CNA has less showers to do and will have more time to assist residents and answer call lights.During an interview with the Director of Nursing (DON) on [DATE] at 3:16 p.m., the DON stated her expectation on response time for call lights was The fastest.the better. DON stated that when someone must wait after pressing their call light, that 45 minutes would be a long time to wait.During an interview on [DATE] at 8:30 a.m. with the Administrator (Admin), Admin stated the facility had experienced a shortage of CNAs. Admin confirmed that the facility's program flex called, Workforce Shortage Waiver, expired on [DATE]. Admin stated the licensed nurses should be used to replace CNAs and be responsible for specific residents, carrying a full CNA assignment and completing CNA duties.During a record review of the facility's CNA Direct Care Service Hours Per Patient Per Day (CNA DHPPD, a way to measure staffing levels by how much hands-on care time each resident gets from a CNA in a nursing home each day), [DATE] to [DATE], the CNA direct care service hours indicated, for the last 3 months, the facility did not meet the minimum staffing requirement of 2.4 CNA DHPPD hours on multiple days that included:(1) [DATE] actual CNA DHPPD: 1.95 (requirement of 2.4 not met)(2) [DATE] actual CNA DHPPD: 1.96 (requirement of 2.4 not met)(3) [DATE] actual CNA DHPPD: 2.30 (requirement of 2.4 not met)(4) [DATE] actual CNA DHPPD: 2.14 (requirement of 2.4 not met)(5) [DATE] actual CNA DHPPD: 2.02 (requirement of 2.4 not met)(6) [DATE] actual CNA DHPPD: 2.14 (requirement of 2.4 not met)(7) [DATE] actual CNA DHPPD: 2.12 (requirement of 2.4 not met)(8) [DATE] actual CNA DHPPD: 2.13 (requirement of 2.4 not met)(9) [DATE] actual CNA DHPPD: 2.12 (requirement of 2.4 not met)(10) [DATE] actual CNA DHPPD: 1.98 (requirement of 2.4 not met)During a review of the California Health and Safety Code (HSC), section 1276.65, [undated], the HSC section 1276.65, indicated facilities are required to provide prompt response by facility staff to patient calls for assistance. The minimum is 2.4 CNA DHPPD.During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, revised on [DATE], the P&P indicated Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member. Calls for assistance are answered as soon as possible.

Based on interview and record review, the facility failed to report an injury of unknown origin when one of two sampled residents (Resident 1) was found to have extensive bruising and pain to his left leg, that ultimately was found to be a fractured femur (broken thighbone, the longest and strongest bone in the human body) in the emergency department (ED), and facility staff were unable to explain how Resident 1 got the bruise. This failure prevented outside agencies from investigating the injury of a vulnerable resident who was nonverbal and unable to advocate for himself or explain how he was injured. Findings: During a record review on 5/8/25 at 11:06 a.m., Resident 1's face sheet indicated an admitted [DATE] and multiple medical diagnoses including Lewy Body dementia (a progressive brain disorder causing problems with thinking, movement, mood, and behavior). Review of Resident 1's nurse progress note dated 5/3/25 at 2:15 p.m. indicated, This nurse was called to room [approximately] 11am by CNA's [certified nursing assistants] to show me the residents [left] leg. Upon arrival this nurse noticed deep purple discoloration mid thigh to below the knee. Area was very firm when palpated [examined by touch]. Leg was in a weird position and when this nurse tried to do ROM [range of motion] to the [left] leg resident showed facial grimacing showing he was clearly uncomfortable. EMS [emergency medical services] arrived @ 1140 and they left the facility 10 minutes later with resident transferred to gurney. During a record review on 5/13/25 at 8:30 a.m., Resident 1's emergency department document titled History of Present Illness, dated 5/3/25, indicated the emergency physician's exam found Resident 1 was nonverbal and unable to provide any history. Further review of Resident 1's History of Present Illness revealed Resident 1 had a deformity present in his left upper leg and significant bruising and swelling over the distal (away from the hip) left leg. Review of Resident 1's x-ray results dated 5/3/25 at 1:30 p.m., indicated, Comminuted [occurs when a bone breaks into three or more pieces, often caused by high-impact trauma] and markedly displaced and angulated [significantly out of alignment] fracture of the left femur. Review of Resident 1's ED Triage Note, dated 5/3/25 at 12:11 p.m., indicated Resident 1 was brought in by ambulance for bruising on left upper leg. [Patient] non-verbal upon arrival . No reported fall. Obvious deformity/hematoma [bruise] to left upper leg. During an interview on 5/14/25 at 9:47 a.m., Director of Nursing (DON) stated she did not report Resident 1's injury right away (to the Department) because they had not done their investigation yet and they did not know if it was known or unknown. DON stated their investigation was started on Monday, 5/5/25. DON stated she also spoke to Resident 1's doctor, Physician A, on 5/5/25, who determined the fracture was pathalogical (caused by disease). DON stated this was her first time coming across an injury of unknown origin and was not aware it needed to be reported within two hours if serious bodily injury, or 24 hours if not. DON verified it should have been reported if that is what the policy says. DON stated Administrator usually did the reporting (to the Department) but anybody could report. DON stated they would need to have the x-ray report to know if the resident had a serious bodily injury. Review of facility policy Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last revised 4/2021, revealed, All reports of resident abuse (including injuries of unknown origin) . are reported to local, state, and federal agencies . If resident abuse . or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 'Immediately' is defined as: a. within 2 hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily harm.

Based on observation, interview and record review, the facility failed to follow infection control policy when disposable razors were found either on top or partially inserted into sharps containers (containers specifically designed for items that are both contaminated and pose a puncture risk) in three communal (used or shared by multiple residents) shower/tub rooms. This failure had the potential risk of subjecting staff and residents to injury and blood-borne pathogen (infectious bacteria, virus, or fungus that can cause disease when transmitted through blood or other body fluids) transmission. Findings: During an observation on 4/8/25 at 11:00 a.m., the station three tub room was observed. There was a blue disposable razor partially inserted through the lid mechanism. There was no protective cover observed on the razor, leaving the sharp portion exposed. During an observation on 4/8/25 at 11:17 a.m. in the station three shower room, two blue disposable razors were found atop the sharps container lid. The sharps container was full of used disposable razors. During an observation on 4/8/25 at 11:58 a.m. in the station one shower room, a blue disposable razor was found partially inserted into the sharp container lid mechanism. The sharps container was full of used disposable razors. During an concurrent observation/interview on 4/8/25 at 1:12 p.m. with Certified Nursing Assistant 1 (CNA 1) in the station three tub room, the sharps container with the razor in the lid was observed. CNA 1 stated this was dangerous and staff should never leave razors on top or partially inserted into sharps containers. During a concurrent observation and interview on 4/8/25 at 1:45 p.m. with the Infection Preventionist (IP) in the station three shower room, two razors were still seen on top of the full sharps container. The IP stated it was either the IP's or housekeeping staff's responsibility to change the sharps container when they are full. The IP stated CNAs are educated to not leave razors there, as it can be unclear if they are used or not. During a concurrent observation an interview on 4/8/25 at 1:50 p.m. with the IP in the station one shower room, one razor was again seen partially inserted into the full sharps container. The IP agreed this practice was dangerous, and that there was a pattern which needed correction. During an interview on 4/8/25 at 3:14 p.m. with the Director of Nursing (DON), the DON stated policy was not followed when sharps containers were full and not emptied, putting staff at risk for injury. The DON also stated she didn't believe CNAs would mistakenly re-use disposable razors on different residents, but it could happen if they are stored on top of sharp's containers in the shower/tub rooms. A review of facility policy and procedure titled, Sharps Disposal , revised 1/2012, it indicated Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers , designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect from punctures and/or needlesticks when attempting to push sharps into the container , and whoever observes incorrect disposal or handling of contaminated sharps should report the information to the IP (or designee).

Based on interview and record review, the facility failed to maintain the safety one of two sampled residents when a staff member solely operated a mechanical lift to transfer Resident 1 from the bed to a recliner. This failure resulted in Resident 1 to fall and sustain a hematoma (a closed wound where blood collects and fills a space) on her head. Findings: A review of Intake Information dated 2/10/25 indicated a complaint alleging Resident 1 sustaining a fall as she was transferred from bed to a chair on 2/9/25. A review of Resident 1's Face Sheet indicated she was admitted to the facility with diagnoses including multiple sclerosis (a disease resulting in the damage to the nerves in the brain, spinal cord, and nerves) and dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life). Resident 1's Progress Notes , dated 2/9/25 , indicated, Resident had a witnessed fall while transferring to chair. Aide reported that while she was transferring via [product brand] lift to chair, the chair tipped over and resident fell backwards and hit her head . Further review of Resident 1's notes from the Emergency Department titled, SNF Admission History and Physical , dated 2/10/25 , indicated, Patient presents with fall . + (positive for) head impact . hematoma to the posterior (back of) head . During an interview on 2/21/25 at 12:16 p.m., Licensed Staff A stated she recalled Resident 1's fall on 2/9/25. Licensed Staff A stated she heard calls for help coming from Resident 1's room. Licensed Staff A stated she found Resident 1 on a fallen recliner on the floor. Licensed Staff A stated Unlicensed Staff B used a mechanical lift by herself, to transfer Resident 1 from the bed to the recliner. Licensed Staff A stated Resident 1's body might have been positioned mostly over the back of the recliner, which caused it to tilt backwards. Licensed Staff A stated Resident 1 had a bump on her head and was transferred to the Emergency Department after the fall. During an interview on 2/21/25 at 12:23 p.m., with Licensed Staff C translating, Unlicensed Staff B stated she used a mechanical lift to transfer Resident 1 from the bed to a recliner. Unlicensed Staff B stated she had set Resident 1 down on the recliner and as she removed the sling from the lift, the back of the chair tipped back and fell , taking Resident 1 with it. Unlicensed Staff B stated she did not see if the back of chair was positioned too far back, nor did she expect it to fall backwards. Unlicensed Staff B stated she was alone when she used the mechanical lift to transfer Resident 1 and added it was a bad decision . Unlicensed Staff B stated there should have been two staff when using the mechanical lift. During an interview on 2/21/25 at 12:33 p.m., Unlicensed Staff D stated the mechanical lift was frequently used in the facility. Unlicensed Staff D stated having two staff present when using the mechanical lift was for resident safety. Unlicensed Staff D stated there should be two people when using the mechanical lift, with one acting as a spotter while another operated the machine. Unlicensed Staff D stated the spotter made sure the resident was positioned correctly on the receiving surface before setting them down. During an interview on 2/21/25 at 1:03 p.m., the Director of Nursing (DON) stated there should have been two staff present during a resident transfer when mechanical lifts were used to ensure their safety. The DON stated it was later identified that the recliner was tilted too far back at the time, and the imbalance caused it to fall backwards. The DON stated Resident 1's fall was preventable, had a second staff been present in the room at the time to ensure the safety of the equipment and positioning of Resident 1. A review of the facility policy titled, Lifting Machine, Using a Mechanical , dated July 2017 , indicated, At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . Be mindful of the resident's position and balance . A review of the [product brand] manufacturer guideline titled, Transfer from a Bed or Stretcher , dated March 2019 , indicated, Make sure the required number of staff members are present . Make sure the patient is safely positioned before removing the [product brand] and sling from the room .

Based on interview and record review, the facility failed to provide a written notification of the hospital transfer for one of two sampled residents (Resident 1) to her Responsible Party (RP). Failure to notify the Responsible Party (RP) of Resident 1's whereabouts had the potential for an inability for her to advocate for Resident 1's needs and preferences during the transfer process, and coordinate care with the receiving hospital. Findings: A review of Intake Information dated 12/13/24 indicated RP was not notified of Resident 1's transfer to acute care, nor of any bed hold policy. A review of Resident 1's Face Sheet indicated she was admitted to the facility with diagnoses including schizophrenia and left femur (thigh bone) fracture. Resident 1's Face Sheet indicated RP's name, call phone number and mailing address were listed under her Contacts . Further review of Resident 1's records indicated she was transferred to acute care for chest pain and fainting on 11/27/24. During an interview on 1/9/25 at 12:15 p.m., Licensed Staff B stated residents' families and responsible parties get notified of changes in condition and hospital transfers via phone calls. Licensed Staff B stated recalling Resident 1 and her hospital transfer on 11/27/24. Licensed Staff B stated that while he was handling Resident 1's care and her transfer paperwork at the time, another nurse was calling Resident 1's RP to inform her of the transfer. During an interview on 1/9/25 at 12:27 p.m., Licensed Staff C stated recalling Resident 1 and her hospital transfer on 11/27/24. Licensed Staff C stated she attempted to call RP to notify her of Resident 1's change of condition and transfer to the hospital. Licensed Staff C stated the call was unanswered and she left a message in the voicemail. Licensed Staff C stated she could not recall hearing back from RP after she left her a voicemail that day. Licensed Staff C stated it was protocol for responsible parties and families to be notified via phone call should residents experience a change of condition and/or would have to be transferred out to the hospital. Licensed Staff C stated RP had always been hard to get ahold of, staff would leave messages on her voicemail as phone calls were unanswered. During an interview on 1/9/25 at 1:29 p.m., the Social Services Director (SSD) stated she sent out written Transfer Notice Forms to residents and their responsible parties only for planned transfers or discharges to the community. The SSD stated in the case of an emergency transfer to the hospital because of a change in the resident's condition, it was up to the nurses to send out the Transfer Notices. During a concurrent interview and review on 1/9/25 at 1:33 p.m. with Licensed Staff A, Resident 1's Notice of Proposed Transfer/Discharge form was reviewed. Resident 1's form indicated a section, VI. Mailed Certified By Facility Representative - If Unable to Obtain Resident/Resident Representative Signature , which was blank. Licensed Staff A confirmed the Notice of Proposed Transfer/Discharge form as the same as the Transfer Form or Notice of Transfer . Licensed Staff A confirmed Section VI of Resident 1's Transfer Form was blank. Licensed Staff A stated it was unlikely that RP was sent a written notice of Resident 1's transfer, as families and responsible parties were usually notified via phone calls, and only the Ombudsman was sent a copy of the Transfer Notice. A review of the facility policy titled, Transfer or Discharge, Facility-Initiated dated, October 2022 , indicated, Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy . Notice of Transfer or Discharge (Emergent or Therapeutic Leave): Notice of Transfer is provided to the resident and representative as soon as practicable . Notice of Facility Bed-Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer . Notices are provided in a form and manner that the resident can understand, taking into account the resident's educational level, language, communication barriers, and physical or mental impairments .

Based on observation, interview and record review, the facility failed to ensure oxygen therapy (A medical treatment that provides supplemental or extra oxygen for breathing) was provided as ordered by the physician for two of two sampled residents on continuous supplemental oxygen (Resident 5 & Resident 6) when the nasal cannulas (A device consisting of a lightweight tube used to deliver supplemental oxygen) were not observed to be in their noses in the early morning hours of 10/08/24, and the oxygen settings were incorrect. In addition, the facility failed to ensure the administration of oxygen therapy was documented for one of three sampled residents (Resident 4). These findings had the potential to result in harm, suffering and death to the residents on oxygen therapy. Findings: Record review of Resident 4's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Parkinson's Disease (A chronic, progressive brain disorder that causes movement problems, stiffness, and other symptoms) and Acute Respiratory Failure (Acute respiratory failure is defined as the inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient). Record review of a report sent to the DEPARTMENT on 5/08/24 at 12:20 p.m., indicated, Due to his [Resident 4's] oxygen needs, he had to be on supplemental oxygen 24 hrs (Hours) a day, but on 3 seprate mornings we arrived to find his nasal cannula ON THE GROUND. We had no idea how long it had been out of his nose—perhaps all night. Record review of Resident 4's Medication Administration Record (MAR) for February of 2024, indicated Resident 4 had orders for supplemental oxygen therapy as needed via nasal cannula at 2 liters per minute. This MAR indicated supplemental oxygen was not administered to Resident 4, since the boxes to sign for the administration of it were left blank. Record review of an interdisciplinary progress note dated 2/13/24 at 2:49 p.m., indicated, on 2/13/24 while with the therapist, resident [Resident 4] was noted de-sating (With oxygen saturation in the blood) to below 88% with 5L/min (Five liters per minute) nasal cannula. Staff change (Sic) nasal cannula to nonrebreather mask (A medical device that provides oxygen therapy by delivering high concentrations of oxygen to patients who can still breathe on their own) and 02 (Oxygen in the blood) rises 97% - 98% on 5L/min and is on respiratory symptoms. Resident was sent to Ed (Emergency department) for further eval. This contradicted Resident 4's February MAR which indicated that oxygen therapy was not administered. This was confirmed by the Director of Nursing (DON) during an interview on 10/08/24 at 11:13 a.m. The DON stated oxygen therapy was required to be documented. Resident 4 had been discharged from the facility. Record review of Resident 5's Face Sheet indicated she was admitted to the facility on [DATE] with medical diagnoses including Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible). Record review of physician orders for Resident 5 for October of 2024, indicated, Oxygen-@2Liters/Min (Oxygen at two liters per minute)Via Nasal Cannula continuous. During an observation on 10/08/24 at 6:40 a.m., Resident 5 was observed in bed, with her eyes closed as if sleeping, with the nasal cannula not on her nose. The oxygen settings in the oxygen concentrator (A medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen) indicated it was delivering three liters of oxygen per minute. During a concurrent observation and interview with Licensed Staff G on 10/08/24 at 7:15 a.m., Resident 5 was observed with the nasal cannula on her nose, but the oxygen settings continued to indicate she was receiving 3 liters of oxygen per minute. Licensed Staff G stated she had not checked the oxygen settings yet, but there were required to check the position of the nasal cannula and oxygen settings at the beginning of their shifts. She proceeded to turn down the oxygen to 2 liters per minute. Resident 3 stated she had removed the nasal cannula earlier in the day for a few minutes. Record review of Resident 6's Face Sheet indicated she was admitted to the facility on [DATE] with medical diagnoses including Chronic Respiratory Failure (A long-term condition that occurs when the lungs are unable to exchange oxygen and carbon dioxide effectively). Record review of physician orders for Resident 5 for October of 2024, indicated, Oxygen-@2Liters/Min Via Nasal Cannula continuous. During an observation on 10/08/24 at 6:43 a.m., Resident 6 was observed in bed, awake, moving her sheets and visibly preoccupied because she could not find her nasal cannula. The nasal cannula was not on her nose. Resident 6 stated the nasal cannula was in her nose earlier at around 5:00 a.m. when the night shift nurse had given her a morning medication, but she fell asleep, and the nasal cannula must have fallen off. The nasal cannula was observed on the floor. An unlicensed staff was called to assist Resident 6, and she proceeded to place the nasal cannula on Resident 6's nose. The oxygen settings in the oxygen concentrator were set at 3.5 liters per minute. During an interview with Licensed Staff H on 10/08/24 at 7:00 a.m., she confirmed she was the assigned nurse for Resident 6. Licensed Staff H stated she usually checked the placement of the nasal cannula and oxygen settings for Resident 6 after change of shift report, which started at 6:30 a.m. Licensed Staff H stated she still had not checked Resident 6 to ensure the oxygen concentrator settings were correct and the nasal cannula was in place. During an interview with the DON on 10/08/24 at 10:38 a.m., she stated Licensed Nurses were required to check their residents on continuous oxygen right after end-of-shift reports, or while doing bedside reporting, prior to 7:00 a.m. Record review of the facility's undated job description for Licensed Vocational Nurses indicated, Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures .Make periodic checks to ensure that prescribed treatments are properly administered .Monitor seriously ill residents as necessary. Record review of the facility's undated job description for Registered Nurses indicated, Provide direct nursing care as necessary .Assist the Charge Nurse in monitoring seriously ill residents .Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered that that treatments are provided as scheduled.

Based on interview and record review, the facility failed to provide care, consistent with professional standards of practice, to prevent pressure injuries (bedsores) to one of two residents (Resident 1), when the facility did not frequently and regularly turn and reposition Resident 1, who could not turn and reposition herself independently, and was at risk for developing pressure injuries. This failure resulted in Resident 1 developing two unstageable (unable to determine the exact extent of the wounds) pressure injuries, one on her sacrum (the tailbone area) and one on her buttocks area. Findings: A review of Resident 1 ' s Facesheet indicated she was admitted to the facility on [DATE] with a primary diagnosis of hip fracture. A review of Resident 1 ' s Admission Assessment, which included a Skin Assessment, dated 6/7/22, indicated Resident 1 ' s skin was intact and had no pressure injuries. A review of Resident 1 ' s Braden Scale assessment (a standardized assessment that indicates the resident ' s risk of developing pressure injuries), dated 6/7/22, indicated Resident 1 was at mild risk of developing pressure injuries. The Braden Scale assessment indicated Resident 1 ' s mobility (ability to change and control body position) was very limited - make[s] occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently. The Braden Scale assessment indicated Redistributing Pressure .Turning and Re-positioning . as an intervention to prevent the formation of pressure injuries on Resident 1. A review of Resident 1 ' s care plans (documents created by the facility indicating the care and services to be provided by the facility to the resident) indicated care plan titled Resident has potential for pressure ulcer development related to . assistance required with mobility and transfers, dated 6/7/22. This care plan did not contain interventions for turning and repositioning Resident 1. A further review of Resident 1 ' s care plans indicated care plan titled Skin Care, dated, 6/7/22, which contained the intervention to turn and re-position [Resident 1] frequently. A review of Resident 1 ' s Minimum Data Set (MDS) (a standardized assessment tool), dated 6/10/22, indicated the following: - Resident 1 had no pressure injuries; - Resident 1 was at risk for developing pressure injuries; - Resident 1 required extensive assistance and the help of two or more persons for bed mobility (how [the] resident moves to and from lying position, turns side to side, and positions body while in bed); and - Interventions to prevent pressure injuries included pressure reducing device for chair and applications of ointments and medications. A review of Resident 1 ' s Medication Administration Record (MAR) (where the administration of medications is documented) and Treatment Administration Record (TAR) (where the administration of nursing treatments is documented) for the periods of 6/7/22 to 6/20/22, 7/1/22 to 7/31/22, 8/1/22 to 8/31/22, and 9/1/22 to 9/30/22, indicated no documentation of frequent turning and repositioning Resident 1. A review of Resident 1 ' s clinical record indicated document titled IDT - Skin Management, Date Observed 9/5/22, indicated Resident 1 had developed two pressure injuries, as follows: Size and size: Right buttock stage 3 . wound bed with yellow slough [dead skin cells] . Sacral [the area just above the tail bone] UTD [undetermined] . wound bed 100% yellow slough . wounds present with both pressure and MASD [Moisture Associated Skin Damage][damage to the skin caused by prolonged exposure to moisture] . High risk for skin breakdown r/t history of pelvic pressure, decreased mobility, incontinence, overactive bladder . Interventions: .turning and repositioning q 2hrs [every two hours] as determined . A review of Resident 1 ' s clinical record indicated a physician specialized in wound care, Physician A, assessed Resident 1 ' s skin on 9/19/22. Physician A ' s report, dated 9/19/22, indicated Resident 1 had developed two pressure injuries, as follows: REASON FOR VISIT: To manage the patient ' s wounds found at the left sacral and right sacrum. RISK FACTORS: Limited Mobility and Depression. WOUND LOCATION: Left Sacral ETIOLOGY [the cause of the injury]: Pressure injury/ulcer TISSUE TYPES BY PERCENTAGE: 100% Necrotic [dead skin] SIZE: LENGTH (cm) [centimeters] 1.6, WIDTH (cm) 3.0, DEPTH (cm) 0, WOUND AREA (cm2) [square centimeters] 4.8 WOUND LOCATION: Right Sacrum ETIOLOGY: Pressure injury/ulcer TISSUE TYPES BY PERCENTAGE: 100% Granulation [a type of skin tissue that develops over a wound] SIZE: LENGTH (cm) 0.6, WIDTH (cm) 1.1, DEPTH (cm) 0, WOUND AREA (cm2) 0.66 ASSESSMENT AND PLAN: The patient has wounds on the left sacrum and right sacrum. The patient has also the following risk factors: Limited Mobility and Depression . Offloading [relieving pressure on bony prominences of the body]: turn per facility protocol. A review of Resident 1 ' s MDS dated [DATE] indicated the following: - Resident 1 had pressure injuries; - Resident 1 was at risk for developing pressure injuries; - Resident 1 required extensive assistance and the help of two or more persons for bed mobility (how [the] resident moves to and from lying position, turns side to side, and positions body while in bed); and: - Interventions to prevent pressure injuries included pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, nutrition or hydration intervention, pressure ulcer/injury care, application of non-surgical dressings and applications of ointments and medications. A review of Resident 1 ' s clinical record indicated the wound care physician, Physician A, re-assessed Resident 1 ' s skin on 9/26/22. Physician A ' s report, dated 9/26/22, indicated the following: REASON FOR VISIT: To manage the patient ' s wounds found at the left sacral and right sacrum. RISK FACTORS: Limited Mobility and Depression. WOUND LOCATION: Left Sacral ETIOLOGY: Moisture Associated Skin Damage (MASD) worsened by pressure TISSUE TYPES BY PERCENTAGE: 70% Slough, 30% Granulation SIZE: LENGTH (cm) 2.5, WIDTH (cm) 3.5, DEPTH (cm) Undetermined, WOUND AREA (cm2) 8.8 PROCEDURE PERFORMED: Muscle tissue debridement [removal of dead tissue] performed by surgical excision [cutting] of devitalized [dead] skin, subcutaneous [under the skin], muscle, fascia [a type of body tissue], and tendon tissue. A total area of 8.8 sq cm of devitalized tissue was debrided. WOUND LOCATION: Right Sacrum ETIOLOGY: Pressure injury/ulcer TISSUE TYPES BY PERCENTAGE: 100% Granulation SIZE: LENGTH (cm) 0.5, WIDTH (cm) 1., DEPTH (cm) 0, WOUND AREA (cm2) 0.5 ASSESSMENT AND PLAN: This patient has wounds found on the left sacrum and right sacrum. The wound debrided today was at the left sacral. For this wound, there was confirmation of tissue decline necessitating continuing surveillance and may require future debridement. The patient also has the following risk factors: Limited Mobility and Depression . Offloading: turn per facility protocol. A review of Resident 1 ' s clinical record indicated the wound care physician, Physician A, re-assessed Resident 1 ' s skin on 10/6/22. Physician A ' s report, dated 10/6/22, indicated two pressure injuries, as follows: REASON FOR VISIT: To manage the patient ' s wounds found at sacrum . RISK FACTORS: Limited Mobility and Depression. WOUND LOCATION: Sacrum ETIOLOGY: Pressure injury/ulcer TISSUE TYPES BY PERCENTAGE: 100% Slough SIZE: LENGTH (cm) 3, WIDTH (cm) 2, DEPTH (cm) 2, WOUND AREA (cm2) 6 PROCEDURE PERFORMED: Muscle tissue debridement performed by surgical excision of devitalized skin, subcutaneous, muscle, fascia, and tendon tissue. A total area of 6.5 sq cm of devitalized tissue was debrided . WOUND LOCATION: Right Buttock ETIOLOGY: Pressure injury/ulcer TISSUE TYPES BY PERCENTAGE: 100% Slough SIZE: LENGTH (cm) 0.5, WIDTH (cm) 0.8, DEPTH (Undetermined), WOUND AREA (cm2) 0.4 PROCEDURE PERFORMED: Muscle tissue debridement performed by surgical excision of devitalized skin, subcutaneous, muscle, fascia, and tendon tissue. A total area of 0.54 sq cm of devitalized tissue was debrided . A review of Resident 1 ' s physician orders indicated order dated 10/7/22 as follows: Encourage turning and repositioning for skin integrity maintenance every 2 hours. A review of Resident 1 ' s clinical record indicated no previous physician order for turning and repositioning Resident 1 every 2 hours. During and interview on 1/10/24, at 1:05 p.m., the facility ' s Director of Staff Development (DSD) stated she oversaw training licensed nurses and Certified Nursing Assistants (CNAs), which included instruction on the prevention and treatment of pressure injuries. The DSD was asked the most important interventions to prevent pressure injuries. The DSD stated turning and repositioning residents at least every two hours and incontinence care (keeping residents clean and dry). The DSD was asked who was responsible for turning and repositioning residents. The DSD stated it was the CNAs. The DSD was asked if CNAs documented the turning and repositioning of residents. The DSD stated CNAs documented turning and repositioning in the residents ' clinical record using the CNA flowsheets, but only if there was a physician ' s order for turning and repositioning the resident. The DSD reviewed Resident 1 ' s physicians order and stated there was no physician order for turning and repositioning Resident 1 during June, July, August and September 2022, the period when Resident 1 developed her pressure injuries. During an interview on 1/10/24, at 1:15 p.m., the facility ' s Wound Care Nurse (WCN) stated she was familiar with Resident 1 and had treated her pressure injuries when Resident 1 was at the facility. The WCN stated Resident 1 had no pressure injuries upon admission to the facility. The WCN stated Resident 1 subsequently developed unstageable pressure injuries on her sacrum and buttocks, which were detected by the facility on 9/5/22. The WCN stated it was not possible to stage Resident 1 ' s pressure injuries because the wounds were covered by dead tissue. The WCN stated the pressure injuries were in the sacrum/buttocks area, but it was not possible to precise their location because the pressure injuries covered more than one area on the sacrum/buttocks area and the wounds merged and combined. The WCN stated she believed the pressure injuries were caused by Resident 1 ' s insistence in using double briefs at night, against facility advice. During an interview on 1/10/14, at 2:20 p.m., CNA B, who stated he had worked for [AGE] years at the facility, stated CNAs were responsible for turning and repositioning residents. CNA B was asked where CNAs documented it. CNA A stated resident turning and repositioning was documented in the CNA flowsheets. A review of Resident 1 ' s CNA flowsheets for June, July, August, and September 2022, indicated no documentation of turning and repositioning Resident 1 every two hours. During an interview on 1/11/24, at 12:30 p.m., the Director of Nursing (DON) was asked for documentary evidence Resident 1 had been turned and repositioned at least every two hours in June, July, August, and September 2022, prior to the development of her sacrum/buttocks pressure injuries. The DON stated documentation of turning and repositioning of Resident 1 was found in Resident 1 ' s Medication Administration Record (MAR), under the field Monitor resident through increased intentional hourly rounding asking the 5Ps (Potty, Pain, Placement, Position, Participation) for fall prevention . A review of Resident 1 ' s MAR for June, July, August, and September 2022, indicated documentation of hourly monitoring of the 5Ps but no documentation of turning and repositioning Resident 1 at least every two hours. During an interview on 1/11/24, at 12:45 p.m., the Administrator in Training (AIT) was asked for the facility ' s policies and procedure on pressure injuries prevention and treatment. None were provided. A review of the National Pressure Injury Advisory Panel (NPIAP) document titled NPIAP Pressure Injury Stages, undated, indicated A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. A further review of the NPIAP document titled NPIAP Pressure Injury Stages indicated Pressure Injuries are divided in four stages and two unstageable categories, as follows: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present . Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). A review of NPIAP document titled Pressure Injury Prevention Points, dated 2016, indicated: Repositioning and Mobilization .Turn and reposition all individuals at risk for pressure injury .Turn the individual into a 30-degree side lying position and use your hand to determine if the sacrum is off the bed . Avoid positioning the individual on body areas with pressure injury . Continue to reposition an individual when placed on any support surface . reposition weak or immobile individuals in chairs hourly . A review of the National Institute of Health document titled Preventing Pressure Ulcers, dated 2018, indicated: Most pressure ulcers (bedsores) arise from sitting or lying in the same position for a long time without moving . Regularly changing a person ' s lying or sitting position is the best way to prevent pressure ulcers. A review of the American Family Physician document titled Common Questions About Pressure Ulcers, dated 2015, indicated: Patients with limited mobility due to physical or cognitive impairment are at risk of pressure ulcers . There is . no evidence to suggest an optimal interval at which to reposition patients, although every two hours is recommended based on expert opinion. A review of the Wound, Ostomy and Continence Nurses Society (WOCN), Society Position Paper: Avoidable vs. Unavoidable Pressure Ulcers/Injuries, dated 2017, indicated avoidable pressure ulcers can occur when the provider does not define and implement interventions consistent with individual needs, individual goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.

Based on interviews and records review, the facility failed to implement a physician ' s order for pain management for two of four sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 had a physician ' s order for Dilaudid (an opioid [class of drugs that derive from, or mimic, natural substances found in the opium poppy plant] used to relieve moderate to severe pain) 4 mg (milligram-a unit of mass) to be given three times a day for pain management; however, the facility did not administer the medication according to the physician ' s order. This failure had caused Resident 1 to experience moderate to severe pain which prevented him to sleep during the night and prevented him to participate with occupational therapy (a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life). 2. Resident 2 had a physician ' s order for Hydrocodone-Acetaminophen (a combination of opioid pain medication - [Hydrocodone] and non-opioid pain medication [Acetaminophen]) to give 1 tablet every six hours as needed for moderate to severe pain; however, the facility did not administer the medication according to the physician ' s order. This failure had the potential for unmanageable pain for Resident 2. Findings: 1. Review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Fracture (break in a bone) of the Sacrum (the triangular bone just below the lumbar vertebrae [series of small bones forming the backbone]); Muscle Weakness; and Difficulty in Walking. Review of the document titled Order Summary Report for September 2023, indicated a physician ' s order for Resident 1 written on 8/28/23 to give one tablet of Dilaudid 4 mg three times a day for pain management. Review of the September 2023 Medication Administration Record (MAR) for Resident 1, indicated a physician ' s order written on 8/28/23 to give one tablet of Dilaudid 4 mg three times a day at 6:00 a.m.; 2:00 p.m. and 10:00 p.m. for pain management. Review of the document titled Order Summary Report for September 2023, indicated a physician ' s order written on 9/02/23 to give three tablets of Roxicodone (also an opioid) 5 mg every 4 hours as needed for moderate to severe pain. (A numerical scale of 0 means no pain; 1-3 means mild pain; 4-6 is moderate pain and 7-10 is severe pain). Review of the document titled Controlled Drug Record for Resident 1, indicated licensed nurses signed out one tablet of Dilaudid 4 mg on the following dates and times: 9/01/23 at 6:00 a.m. and 2:00 p.m.; 9/02/23 at 6:00 a.m.; 9/03/23 at 6:00 a.m.; 9/04/23 at 1:00 p.m. and 9/05/23 at 5:16 a.m. Review of the September 2023 MAR and concurrent interview with the DON on 9/21/23 at 12:59 p.m., indicated Resident 1 ' s scheduled Dilaudid was withheld on the following days and time: 9/01/23 at 10:00 p.m.; 9/02/23 at 2:00 p.m. and 10:00 p.m.; 9/03/23 at 2:00 p.m. and 10:00 p.m.; 9/04/23 at 6:00 a.m. and 10:00 p.m.; 9/05/23 at 2:00 p.m. and 10:00 p.m. The DON stated she did not know the reason why Resident 1 ' s scheduled Dilaudid was withheld. The DON stated nurses should administer medications to the resident ' s according to the doctor ' s order, unless there was a reason for holding the medication; however, the DON stated nurses should document in the resident ' s record for reason of not giving the medication. Review of the document titled Progress Note for Resident 1 from 9/01/23 to 9/05/23 did not have documentation for reason of withholding Resident 1 ' s scheduled Dilaudid. Review of the September 2023 MAR indicated Resident 1 received three tablets of Roxycodone 5 mg on 9/02/23 at 4:02 a.m. for pain scale of six (6). Review of the document titled Progress Note dated 9/02/23 at 4:59 a.m. indicated, Resident 1 was given Melatonin (a sleep hormone) for difficulty sleeping. The Progress Note indicated, Resident 1 continued to be restless and unable to sleep. Resident 1 was given Roxycodone for complaint of pain. Review of the September 2023 MAR indicated Resident 1 received three tablets of Roxycodone 5 mg on the following dates and times: 9/03/23 at 12:30 a.m. for a pain scale of six (6); 9/04/23 at 12:22 a.m. for a pain scale of five (5); 9/05/23 at 11:41 p.m. for a pain scale of eight (8) and 9/06/23 at 11:44 p.m. for a pain scale of six (6). Review of the document titled Progress Note dated 9/5/23 at 12:45 a.m. indicated Resident 1 was given Naproxen (used to treat pain and inflammation [swelling]) and Melatonin for complaint of generalized body pain. Review of the document titled Occupational Therapy (OT) Treatment Encounter Note(s) dated 9/05/23 at 3:37 p.m. indicated, In PM (afternoon) [Resident 1] was received in wheelchair coming back from outside with his son. [Resident 1] stated he was in pain and needed to get back to bed. Educated [Resident 1] on increased participation with therapy. The OT note indicated, [Resident 1] stating I'll do it tomorrow, I just can't today''. 2. Review of the Face sheet indicated Resident 2 was admitted on [DATE] with diagnoses including but not limited to Gout (painful form of arthritis [swelling of one or more joints]) and Fracture of the Right Femur (the bone of the thigh). Review of the September 2023 MAR for Resident 2 indicated a physician ' s order written on 1/16/23 to give two tablets of Acetaminophen 500 mg every 6 hours as needed for Mild Pain. Review of the September 2023 MAR for Resident 2 indicated a physician ' s order written on 4/24/23 to give one tablet of Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed for moderate pain to severe pain. After review of the September 2023 MAR for Resident 2 with Licensed Staff B on 9/21/23 at 12:06 p.m., Licensed Staff B verified that Resident 2 received 2 tablets of Acetaminophen 500 mg for a pain scale of six (6) on the following dates: 9/01/23; 9/03/23; 9/06/23; 9/12/23; 9/13/23; 9/14/23; 9/15/23; 9/18/23; 9/19/23; and 9/20/23. During an interview with Licensed Staff C on 9/21/23 at 10:54 a.m., when asked about the facility policy for pain assessment and management, Licensed Staff C stated residents who are verbally responsive would be asked for their level of pain using a pain scale of 1 to 10 and administer pain medication to the resident according to the doctor ' s order. During an interview with Licensed Staff B on 9/21/23 at 11:03 a.m., when asked about the facility policy on pain assessment and management, Licensed Staff B stated residents would be asked for their pain level if verbally responsive and residents who were non-verbal would be assessed for non-verbal indicators of pain like grimacing. Licensed Staff B stated she would administer pain medication to the resident according to the doctor ' s order. When Licensed Staff B was asked about the risk for the resident if the doctor ' s order for pain management was not followed, Licensed Staff B stated there would be a risk for the resident for over sedation, drug dependence and risk for unrelieved pain which could affect resident ' s daily routine. Review of the Facility policy and procedure titled Administering Medications revised in April 2019 indicated, Medications are administered in a safe and timely manner, and as prescribed. The policy indicated: Medications are administered in accordance with prescriber orders, including any required time frame; Medications are administered within one (1) hour of their prescribed time, unless otherwise specified; and The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of the Facility policy and procedure titled Pain Assessment and Management revised in October 2022 indicated, The medication regimen (a prescribed course of medical treatment) is implemented as ordered.

Based on observation, interview and record review, the facility failed to ensure that three of three sampled residents (Resident 1, Resident 2 & Resident 3) were provided with activities of daily living (ADLs-Activities related to personal care such as dressing, bathing and toileting) as required in their comprehensive care plans. The three residents were not provided with incontinence care (Cleaning the skin and changing the soiled undergarments and clothing of people with bowel or bladder incontinence [inability to control urination and defecation (The discharge of feces from the body)]), and two residents (Resident 1 & Resident 2) were not provided with bed repositioning as needed. Resident 1 indicated having suffered serious psychological and emotional harm as a result of this lack of care including depression, feelings of neglect and discrimination, and anxiety attacks. These findings also had the potential to result in skin issues, infections, feelings of loss of dignity and neglect to Resident 2 and Resident 3. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Idiopathic Gout (A condition characterized by sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints of the body), Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar) and Morbid Obesity (Being 100 pounds or more above the ideal body weight), according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Sheet-An assessment tool) dated 7/28/23 indicated his 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 13, which indicated his cognition was intact (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). Resident 1's MDS also indicated he required extensive assistance of two staff for toilet use, bed repositioning and personal hygiene. In addition, Resident 1's MDS indicated he was occasionally incontinent of urine (bladder) and always incontinent of bowel. Record review of Resident 1's care plan for ADLs last revised on 8/01/23 indicated he required extensive assistance of one to two staff for toilet use, and extensive assistance of two staff for bed repositioning. During a phone interview with Witness XX on 7/31/23 at 9:00 a.m., he stated he was notified Resident 1 was not receiving adequate care at the facility. Witness XX stated he went to the facility and visited Resident 1 himself and noticed Resident 1 had a strong body odor and was developing skin issues. Witness XX stated Resident 1 told him getting help at the facility was hard. During an observation on 7/31/23 at 10:00 a.m., Resident 1 and Resident 2 were both observed resting in their beds. Resident 1's and Resident 2's shared room had a very strong smell of feces and urine that permeated the environment and made it uncomfortable for the Surveyor to be there. During an interview and observation with Resident 1 on 7/31/23 at 10:10 a.m., he stated he did not eat much because he did not want to have a large bowel movement and have to sit in it for hours while waiting for assistance. Resident 1 stated it took him hours to get bowel and bladder incontinence care. Several large white towels were observed hanging from a trapeze above Resident 1's bed. Resident 1 stated he used those towels to urinate on them so he would not have to lay wet in bed all day. Resident 1 stated that during a 24-hour period, on an average he was changed only once. Resident 1 stated having to sit in his urine/feces for hours made him feel terrible. Resident 1 also stated he was not being provided with showers or bed baths. Resident 1 stated the smell in the room was due to his roommate's soiled briefs, as he, Went all the time, and was not provided incontinence care promptly. Resident 1 stated the strong constant offensive smell in the room was the reason he had fans to help the air circulate. Record review of Resident 1's flowsheet for July, 2023, indicated he was provided with bladder care (Incontinence care for urinary accidents) only two times on 7/02/23, 7/04/23, 7/06/23, 7/12/23, 7/16/23, 7/18/23, 7/19/23, 7/21/23, 7/24/23, 7/25/23 & 7/26/23, and only one time on 7/20/23, at 9:37 p.m. Prior to this incontinence care episode, the last incontinence care was recorded at 2:29 p.m. on 7/19/23, indicating Resident 1 did not get incontinence care for a period of more than thirty-one (31) hours. Record review of Resident 1's flowsheet for July, 2023, indicated he was provided with bowel care (Incontinence care for bowel accidents) only twice on 7/01/23, 7/02/23, 7/04/23, 7/06/23, 7/12/23, 7/13/23, 7/16/23, 7/18/23, 7/19/23, 7/22/23, 7/24/23, & 7/26/23, and only one time on 7/20/23, 7/21/23 and 7/25/23. Record review of Resident 1's flowsheet for bed mobility for July 2023, indicated he was repositioned in bed only 2 times in 24 hours on the following days: 7/03/23, 7/04/23, 7/06/23, 7/10/23, 7/12/23, 7/18/23, 7/20/23, 7/21/23, 7/22/23, 7/24/23, 7/25/23, 7/26/23, & 7/28/23, and only one time on 7/16/23. Record review of Resident 1's flowsheet for baths/showers for July 2023, indicated on 59 out of 62 shifts, baths/showers were, Not Applicable, or Resident 1 had refused them (40 shifts documented as, Not Applicable, 19 shifts documented as refused). During an interview with Resident 1 on 9/13/23 at 7:00 a.m., he stated he felt neglected and discriminated against due to the lack of ADL services provided by the facility. Resident 1 stated he felt depressed on some days, and it got so bad, he sometimes suffered anxiety attacks, where he had difficulty breathing, thinking about the lack of care provided at the facility. Resident 1 stated he never refused baths; however, he did refuse to work with certain people, and the facility had it all, Mixed-up. Resident 2 Record review indicated Resident 2 was admitted to the facility on [DATE] with medical diagnoses including Diabetes Mellitus and Cognitive Disorder with Lewy bodies (A condition that affects brain regions involved in thinking, memory and movement), according to the facility Face Sheet. Record review of Resident 2's MDS dated [DATE] indicated his BIMS score was 4, which indicated his cognition was severely impaired. Record review of Resident 2's care plan for ADL's last revised on 7/11/23 indicated he required extensive assistance of one staff for toilet use and extensive assistance of two staff for bed mobility. During an observation on 7/31/23 at 10:00 a.m., Resident 2 was observed in bed, and his disposable brief was visible because he was exposed from his waist down. Resident 2's disposable brief appeared to be soiled with urine and feces as a dark yellow moist stain was observed in the crotch area. Resident 2 could not be interviewed due to his advanced dementia (A general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During an observation on 7/31/23 from 11:20 a.m. to 11:30 a.m., the Surveyor attempted to find a staff member in Resident 1's hallway to assist Resident 2 with incontinence care. Other hospice nurses (Nurses from an outside agency involved in caring for terminally ill residents) were observed in the hallway also looking for a staff member. For 10 minutes, no staff could be located. During an interview on 7/31/23 at 11:45 a.m., Unlicensed Staff A, assigned to both Resident 1 and Resident 2, stated he last provided incontinence care to Resident 2 at around 9:45 a.m., but he was not sure of the exact time. During an interview on 7/31/23 at 12:00 p.m., with Unlicensed Staff A, Unlicensed Staff B and Licensed Staff C, they confirmed they all took their 30-minute lunch breaks at around the same time (at 11:00 a.m., 11:11 a.m., and 11:20 a.m.), leaving the hallway, where Resident 1's room was located, along with many other residents' rooms, completely unattended for 10 minutes. Record review of Resident 2's flowsheets for July 2023, indicated he was provided with bed mobility only twice on 7/02/23, 7/06/23, 7/10/23, 7/12/23, 7/18/23, 7/20/23, 7/21/23, 7/24/23, 7/26/23 & 7/28/23 and only once on 7/16/23. The bladder continence flowsheet indicated Resident 2 was provided with bladder care only twice on 7/02/23, 7/06/23, 7/12/23, 7/16/23, 7/18/23, 7/20/23, 7/21/23 and 7/24/23. The bowel care flowsheet indicated Resident 2 was provided with bowel care only twice on 7/01/23, 7/02/23, 7/06/23, 7/12/23, 7/16/23, 7/18/23, 7/20/23, 7/21/23 and 7/24/23. Record review of Resident 2's bladder care flowsheet for July, 2023, indicated that on 7/31/23 (The day he was observed soiled with feces and urine in his room at 10:00 a.m.,) he was provided with bladder care three times in a 24-hour period, at 12:34 a.m., 12:26 p.m. and 1:22 p.m. Similarly, the July flowsheet indicated Resident 1 was provided with bowel care three times on 7/31/23, at 6:08 a.m., 12:26 p.m., and 1:22 p.m. That indicated that prior to the observation on 7/31/23 at 10:00 a.m., Resident 2 had not received bowel care since 6:08 a.m. that morning (a period of almost 4 hours) or bladder care since 12:34 a.m. (a period of more than 9 hours). During a concurrent interview and record review with the Infection Preventionist (IP) on 8/23/23 at 9:02 a.m., she confirmed the lack of documentation for bowel/bladder incontinence care and bed repositioning for Resident 1 and Resident 2, for July, 2023. The IP was asked how often residents with bowel/bladder incontinence were required to be provided with incontinence care. The IP stated incontinence care should be provided every two hours. The IP was also asked how often residents who required assistance with bed repositioning needed to be repositioned. The IP stated this should be done every two hours. Resident 3 Record review indicated Resident 3 was admitted to the facility on [DATE] with medical diagnoses including Fracture (Break) of Left Femur (Thigh bone) and Asthma (A chronic disease that causes the airways of the lungs to swell and narrow), according to the facility Face Sheet. Record review of Resident 3's MDS dated [DATE] indicated Resident 3 required extensive assistance of one staff for toilet use. Record review of a care plan last revised on 8/18/23 for Resident 3 indicated, [Resident 3] is at risk for UTI (Urinary tract infection-a bacterial infection of the bladder and associated structures), septicemia (A serious bloodstream infection) and skin breakdown r/t (Related to) extensive assistance required with toileting and episodes of bladder/bowel incontinence, One of the interventions for this condition included, Check [Resident 3] as required for incontinence. Wash, rinse and dry perineum (The region between the thighs). Change clothing PRN (As needed) after incontinence episodes. Record review of Resident 3's flowsheets from 8/10/23 through 8/23/23, indicated she was provided with bowel/bladder incontinence care only twice on 8/10/23, 8/12/23, 8/13/23/ 8/14/23, 8/15/23, 8/16/23, 8/17/23, 8/18/23, 8/20/23, 8/21/23 & 8/22/23, and only once on 8/11/23 & 8/23/23. The flowsheet indicated that on 8/11/23, she received the last incontinence care services at 8:59 p.m., and no further incontinence care services until the following day, on 8/12/23 at 7:26 a.m., which was a time period of more than 10 hours. Record review of the staffing timesheets for August 2023, indicated the Certified Nursing Assistant assigned to Resident 3 for night shift on 8/11/23 was assigned to 43 residents, which was confirmed by the Director of Staff Development (DSD) during an interview on 9/13/23 at 9:13 a.m. The DSD explained that another Certified Nursing Assistant scheduled to work night shift on 8/11/23 had called off, and the facility was unable to find a replacement, leaving one Certified Nursing Assistant assigned to 43 residents. The DSD stated there was not enough time for one Certified Nursing Assistant to provide ADL services required by 43 residents. During an interview with Resident 3 on 8/23/23 at 10:20 a.m., she confirmed there was one night when there was nobody to change her diaper for hours during the nighttime, until morning shift arrived. Resident 3 stated she was left wet for more than 2 hours. During an interview with the DSD on 8/23/23 at 9:57 a.m., she stated staff should be charting every time they provided incontinence care to a resident, but a minimum of once per shift. Record review of the facility policy titled, Incontinence, last revised in August of 2022, indicated, Residents must be cleaned after each episode of incontinence .As appropriate, based on an assessment of the category and causes of incontinence the staff will provide scheduled toileting. Record review of the facility policy titled, Repositioning, last revised in May of 2023, indicated, Residents who are in bed should be on at least every two hour (q2 hour) repositioning schedule.

Based on interviews and records review, the facility failed to complete a wandering (traveling aimlessly from place to place) risk assessment and failed to provide oversight supervision to one of two sampled residents (Resident 1) when Resident 1 left the facility unsupervised on three occasions. This failure resulted to Resident being found on the ground outside of the facility twice and sustained fracture (broken bone) of the left pinkie (fifth digit) finger to which Resident 1 experienced pain. Findings: During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Cervical spinal fusion (surgery that joins two or more of the vertebrae [series of small bones forming the backbone] in your neck); Alcohol Abuse; Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath); Muscle Weakness and Cognitive (involving conscious intellectual activity [such as thinking, reasoning, or remembering]) Communication Deficit (difficulty with thinking and how someone uses language). 8/14/22 Incident During a record review for Resident 1, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 7/10/22 indicated Resident 1 had a BIMS score of 9 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 1 required supervision with locomotion (how resident moves to and from distant areas on the floor). During a record review for Resident 1, the document titled Progress Note dated 8/14/22 at 9:30 p.m. indicated Licensed Staff B documented, [Resident 1] was found outside on the ground by a charge nurse, 2 men walking down the sidewalk helped pick him up and place back in the chair before charge nurse could assess [Resident 1]. The Progress Note indicated Resident 1 sustained minor redness to his forehead, left and right arm. The Progress Note indicated the Licensed Staff B notified the DON (Director of Nursing) with a request for wanderguard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time). During a record review for Resident 1, the Elopement Care Plan indicated, [Resident 1] was at risk for elopement related to [Resident 1] seen outside of the facility grounds (8/14/22). Care Plan interventions initiated on 8/16/22 indicated: - Distract resident from wandering by offering pleasant diversions, structured, activities, food, conversation, television, and books; - Interventions r/t (related to) elopement risk: redirection and [Resident 1] at times would be saying his daughter/family is here to pick him up and will do banking in Ukiah. [Resident 1] responds to reorientation though at times he would insist that family is in the facility to pick him up; - Monitor location. Document wandering behavior and attempted diversional interventions; During a record review for Resident 1, the document titled Progress Note dated 8/17/22 at 2:22 p.m. indicated, the IDT (Interdisciplinary Team - group of health care professionals who work together toward the goals of the resident) met to discuss whether Resident 1 would need a wanderguard. The Progress Note indicated the IDT deemed not necessary for a wanderguard. During an interview with the DON (Director of Nursing) on 10/13/22 at 2:59 p.m. when asked reason why the IDT decided not to apply a wanderguard to Resident 1 after the 8/14/22 elopement incident, the DON stated Resident 1 has not tried leaving the facility in the past. She stated Resident 1was not given a wanderguard because it was a dignity issue and did not want Resident 1 to be bothered with the alarm every time Resident 1 gets close to the door. The DON stated the staff were aware to keep an eye on Resident 1every time he was up and about. During an interview with the MDSC (MDS Coordinator (a nursing professional who helps manage a nursing team in a medical facility) regarding wandering risk assessment on 10/13/22 at 2:25 p.m., the MDSC stated Resident 1 had three incidents of leaving the facility unsupervised; however, the facility did not complete a Wandering Risk Observation/ Assessment. The MDSC stated initial assessment should have been done after the 8/14/22 elopement (to run away) incident. 9/16/22 Incident During a record review for Resident 1, the document titled Progress Note dated 9/16/22 at 3:22 p.m. indicated Resident 1 ' s granddaughter was notified about Resident 1 getting out of the building and tried to find a ride to Ukiah. The Progress Note indicated wanderguard was applied to Resident 1 ' s right wrist. 10/01/22 Incident During a record review for Resident 1, the document titled Progress Note dated 10/01/22 at 10:00 p.m. indicated around 9:45 p.m. on 10/01/22, the paramedics (a person trained to give emergency medical care to people who are injured or ill) found Resident 1 on the ground outside of the facility as they were coming out of the facility. The Progress Note indicated Resident 1 ' s left pinky finger was deformed. The Progress Note indicated Resident 1 was transferred to the hospital for evaluation. During a record review for Resident 1, the document titled Progress Note dated 10/01/22 at 11:39 p.m. indicated Resident 1 had history of falling and wandering around the facility. During a record review for Resident 1, the document titled Progress Note dated 10/2/22 at 9:51 a.m. indicated Resident 1 returned from hospital on 10/02/22 at 7:30 a.m. During a record review for Resident 1, the document titled Progress Note dated 10/03/22 at 12:38 a.m. indicated, Oxycodone HCI (a powerful pain reliever) Tablet 5 mg (milligram - one thousandth of a gram) give 1 tablet by mouth every 6 hours as needed for moderate (4-6) to severe (7-10) pain. The Progress Note indicated Resident 1 received one tablet of Oxycodone HCI 5 mg for 8 out 10 generalized body pain. During a record review for Resident 1, the document titled Progress Note 10/3/2022 at 12:24 p.m. indicated Resident 1 ' s diagnosis from the hospital indicated fracture of the left little finger. During a record review for Resident 1, the document titled Progress Note dated 10/04/22 at 12:38 a.m. indicated, Oxycodone HCI (a powerful pain reliever) Tablet 5 mg (milligram) give 1 tablet by mouth every 6 hours as needed for moderate (4-6) to severe (7-10) pain. The Progress Note indicated Resident 1 received one tablet of Oxycodone HCI 5 mg for 8 out 10 generalized body pain. During a record review for Resident 1, the document titled Progress Note dated 10/05/22 at 12:26 p.m. indicated Resident 1 received Oxycodone HCI 5 mg. During a record review for Resident 1, the document titled Progress Note dated 10/09/22 at 11:15 p.m. indicated Resident 1 received one tablet of Oxycodone HCI 5 mg for severe generalized body pain. During a record review for Resident 1, the document titled Progress Note dated 10/10/22 at 5:20 a.m. indicated Resident 1 received one tablet of Oxycodone HCI 5 mg for 8 out 10 generalize body pain. During an interview with Licensed Staff B on 10/13/22 at 11:18 a.m. Licensed Staff B stated Resident 1 wanders around the facility and likes to talk about going to Ukiah. Licensed Staff B stated Resident 1 could independently propel his wheelchair around the facility. When Licensed Staff B was asked about the Resident 1 ' s recent fall incident, Licensed Staff B stated Resident 1 rolled down the stair outside of the front lobby. Licensed Staff B stated EMTs found Resident 1 on the ground and reported to the nurse. During an interview with Unlicensed Staff C on 10/13/22 at 1:58 p.m., Unlicensed Staff C stated Resident 1 had the tendency to go outside of the building. Unlicensed Staff C stated if Resident 1 was not in his room and cannot be found inside the building, staff would search Resident 1 outside of the facility. Unlicensed Staff C stated Resident 1 goes outside at least two to three times a week. Unlicensed Staff C stated a wanderguard was applied to Resident 1 ' s wheelchair recently to alert staff when Resident 1 attempted to leave the facility. During an interview with Unlicensed Staff D on 10/13/22 at 2:08 p.m. Unlicensed Staff D stated he was not aware that Resident 1 had a tendency of going out of the facility unattended. Unlicensed Staff D stated there was no receptionist at the front desk after hours and no designated staff to watch the front door. During an interview with Unlicensed Staff E on 10/13/22 at 3:14 p.m., Unlicensed Staff E stated Resident 1 likes to wander and able to go out of the front door. He stated Resident 1 usually used wheelchair to move around the facility; however, he could also ambulate. Unlicensed Staff E stated Resident 1 was always on monitoring for his whereabout. When Unlicensed Staff E was asked how Resident 1 was monitored at night when he was up and about, Unlicensed Staff E stated staff took turn to watch the front door when the receptionist goes home at 8:00 p.m.; however, Unlicensed Staff E stated no one was watching the front door on the night of 10/01/22 when Resident 1 was found on the ground outside of the facility. Review of the Facility Policy titled Wandering and Elopements revised in March 2019 indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 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.

Based on observation, interview and record review, the facility failed to arrange a follow-up appointment for vision care for 1 of 20 sampled residents (Resident 60) when Resident 60 verbalized she could not see well and needed new eyeglass. This failure resulted to Resident 60's inability to pursue her interest to read, stopped Resident 60 from watching T.V., feeling sad and uncomfortable because of headaches. Findings: During a clinical record review for Resident 60, the Progress Notes dated 11/17/20 indicated, the Director of Staff Development (DSD) spoke to the Nurse Practitioner (NP) about Resident 60's need for a new eyeglass. The NP stated to make an appointment for Resident 60. DSD called the Optical office but there was no available appointment. The optical office would call the facility when appointment was available. During a clinical record review for Resident 60, the Vision Care Plan dated 02/12/21 indicated Resident 60 had altered visual ability related to: [CONDITION(S)] (a condition of increased pressure within the eyeball, causing gradual loss of sight), [CONDITION(S)] (a clouding of the normally clear lens of the eye), Diabetic Retinopathy (caused by damage to the blood vessels in the tissue at the back of the eye), [CONDITION(S)] (deterioration of the central portion of the retina, the inside back layer of the eye that records the images we see. The retina's central portion is responsible for focusing central vision in the eye, and it controls our ability to read, drive a car, recognize faces or colors, and see objects in fine detail). The facility indicated these visual problems could have an impact on Resident 60's ability to self-feed and participate in ADL (Activities of Daily Living - common ADLs include feeding oneself, bathing, dressing, grooming, transferring, walking). The interventions were for Resident 60 to use Eyeglasses and magnifying glass; and provide eye exam as applicable. The long-term goals included Resident 60 would maintain optimal quality of life within limitation imposed by disease process; would be able to participate self-performance of ADLs; and would be able to participate in pursue of activities of reading/ writing interest. During a clinical record review for Resident 60, the Physician's Order dated 03/09/21, indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a clinical record review for Resident 60, the Minimum Data Set (MDS - an assessment tool) dated 05/05/21, indicated Resident 60 had moderately impaired vison (limited vision, not able to see newspaper headlines but can identify objects). During a clinical record review for Resident 60, the NP's Progress Notes dated 07/13/21, indicated Resident 60 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NP notes indicated an assessment plan to monitor, consult with ophthalmology (the branch of medicine concerned with the study and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a clinical record review for Resident 60, the Hospice (a type of health care that focuses on easing the pain and symptoms of a terminally ill patient and attending to her emotional and spiritual needs at the end of life) Notes dated 07/13/21, indicated Resident 60 could get emotional and mentioned her eyeglasses were not working. During a Review of Resident 60's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] During a telephone interview with Resident 60's Responsible Party (RP)on 09/14/21 7:24 p.m., the RP stated, Resident 60 wears eyeglass but she probably needed a new one. The RP stated Resident 60 did not watch TV anymore because she could not see, and she was supposed to have an eye appointment last year, but it did not happen. During an interview with Unlicensed Staff F on 09/15/21 at 10:46 a.m. Unlicensed Staff F stated Resident 60 used to have eyeglasses but refuse to wear them because Resident 60 said they were not working, and she needed a new pair of eyeglasses. During an interview and concurrent record review with Unlicensed Staff O on 09/15/21 at 11:01 a.m., Unlicensed Staff O stated, We don't do ancillary services (services other than room, board, medical and nursing services that are provided to residents in the course of care) for hospice patients. Hospice Nurses and Doctors take care of this. Unlicensed Staff O provided a copy of Resident 60's Social Service progress note dated 11/17/2020, indicated for Licensed Staff D to schedule an appointment with the Optometrist (an eye doctor who provides primary eye and vision care, performs eye examinations to detect vision problems, and prescribes corrective lenses to correct those problems) because Resident 60 could not see well. During an interview with Unlicensed Staff P on 09/15/21 at 11:21 a.m. Unlicensed Staff P stated, Per Hospice, we may ask our in-house Ophthalmologist/ Optometrist if they can see (Resident 60) in the facility. Unlicensed Staff P reviewed Resident 60's clinical record and verified that no Ophthalmology/ Optometry appointment was scheduled for Resident 60 since 11/17/2020. During an interview with Licensed Staff D on 09/15/21 at 1:52 p.m., Licensed Staff D stated Resident 60 was last seen by the Optometrist in 2018. Licensed Staff D stated Social Service Assistants could also make follow-up appointments if needed. When asked how long it takes to make another appointment, Licensed Staff D stated, I don't think there is a policy on how long we have to wait before we can make a follow-up in setting an appointment. My rule is that I can give another 2 weeks before I make a follow-up, but it will not go over two weeks. During an interview with Licensed Staff W on 09/15/21 at 3:20 p.m., Licensed Staff W stated she spoke to the Social Worker and Licensed Staff D regarding Resident 60's complain about her eyeglasses. Licensed Staff W stated Licensed Staff D said he would put (Resident 60) on the list for the eye exam. During an observation with Unlicensed Staff G on 09/15/21 at 3:36 p.m. in Resident 60's room, Unlicensed Staff G asked Resident 60 how she felt not being able to see well without her eyeglasses. Resident 60 replied she felt sad and uncomfortable because it gave her headaches and the light also bothers her. During an interview with Unlicensed Staff F on 09/16/21 at 10:14 a.m. Unlicensed Staff F stated Resident 60 always complained about her eyeglass not working, and she said she could not read the paper unless she read it close to her face. During an interview with Unlicensed Staff O on 09/17/21 at 10:55 a.m., Unlicensed Staff O stated she did not offer Resident 60 a magnifying glass to aid Resident 60's vision. Unlicensed staff O stated she offered Resident 60 to try from their pile of donated eyeglasses but Resident 60 was unable to find one that worked for her. Review of the Facility policy and procedure titled Referrals and Appointments revised on 12/2008 indicated, Social Services Personnel shall coordinate most resident referrals and appointments. Social Services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. Review of the Facility policy and procedure titled Hospice Program revised on 7/2017 indicated, In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination of the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. Review of the Facility policy and procedure titled Care Plan revised on 10/2017 indicated, Care plans are developed to address and manage the resident overall health conditions and disease process.

Based on observation, interview, and facility record reviews, the facility failed to maintain an effective infection control program when: 1. 5 Staff (Licensed Nurse (LN) B, LN D, Registered Nurse (RN) C, RN G, and Certified Nursing Assistant (CNA) L) did not utilize N95 respirators (particulate-filtering face piece that meets U.S. National Standards for air filtration, filtering at least 95% of airborne particles) per CDC guidance (Center for Disease Control and Prevention). 2 Staff (RN C and RN G) were reusing their N95 respirators for 2-3 shifts (8-12 hours) when the facility had an adequate supply to allow staff to utilize extended-use of their N95, and 2 Staff (RN C and RN G) were taking contaminated respirators out of the facility (for later use). (Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters. Reuse refers to the practice of using the same N95 respirator for multiple encounters with patients but removing it after each encounter. The respirator is stored in between encounters to be put on again prior to the next encounter with a patient); and 2. The facility was conducting staff Covid-19 testing in the Conference room (a commonly used room) without ensuring adequate ventilation (Covid-19 is an infectious disease caused by the newly discovered coronavirus. Covid-19 can spread from person to person, was declared a global pandemic by the World Health Organization on 3/11/2020, and can be fatal). An IMMEDIATE JEOPARDY (IJ) was identified on 9/3/20 at 6:10 p.m., under §483.80 Infection Control: F880. Licensed Staff B and Unlicensed Staff K were present in the human resource's office, and Administrator A was present via telephone conference call when the IJ was identified. The IMMEDIATE JEOPARDY was abated on 9/11/2020 at 3:20 p.m. Administrator A was present in Administrator A's office when the IJ was abated. 3. 4 Staff (LN B, 2 Unidentified Social Service staff, and 1 Unidentified Activity Staff) were not wearing face coverings (face masks) in the building as required; 4. Transport personnel (EMT's - emergency medical technicians and ambulance drivers) were not screened prior to entering the PUI unit (a space where persons under investigation for Covid-19 were living), and did not wear appropriate PPE (personal protective equipment like N95's, masks, gowns and gloves) prior to entering the PUI unit; and 5. The document used to screen visitors who entered the facility did not reflect current CDC guidelines. These cumulative failures created potential for spread of Covid-19 to vulnerable residents, staff and visitors. Findings: 1. During an interview on 9/2/2020 at 11:50 a.m., RN C was asked to describe how she used N95 respirators at the facility. RN C stated she had the N95 on when entering the building, she kept it on the whole time (entire shift) and she used the N95 during resident care. RN C stated she used the N95 twice (for two, eight-hour shifts). She stated she took it off at the end of the day, put it into a paper bag, and stored it in her locker or car for the next use. During an interview on 9/2/2020 at 12:05 p.m., LN D stated she changed her N95 respirator every three days or as necessary (she wore the same N95 for three, eight-hour shifts). LN D stated she set the (used) N95 in the sun or sometimes in a bag, and ensured it was in a, special place. LN D stated at lunch, she placed her used (contaminated) N95 on a paper towel (for use after her meal). During an interview on 9/2/2020 at 12:10 p.m., CNA E stated staff could use their N95 respirators for two shifts (eight hour each) but she discarded hers at the end of the day. During an interview on 9/2/2020 at 1:30 p.m., LN B was asked about N95 use at the facility. LN B stated N95 respirators could be put in a brown bag at lunch and could go home in a bag (with staff at the end of the day). When asked how many times an N95 could be reused, LN B stated they should be discarded (not reused) on the Covid unit (unit with confirmed Covid-19 residents) and the PUI unit. LN B stated she would need to ask Administrator A about discarding N95's on the Green unit (unit without Covid patients). During an interview on 9/2/2020 at 1:40 p.m., Administrator A stated N95 respirators could be used up to three days (three full shifts) but two days was usual. During an interview on 9/3/2020 at 4:05 p.m., RN F was working on the PUI unit and stated she discarded her N95 at the end of her shift (and did not reuse for another shift). During an interview on 9/3/2020 at 4:10 p.m., RN G (who was working on the PUI unit) stated she used her N95 respirator for two days (two full shifts). RN G stated she put her used N95 into a paper bag and stored in in her car. On the following shift, RN G stated she put on the contaminated N95 and wore in into the facility lobby, where she was screened for Covid symptoms prior to beginning her shift. A review of the CDC website indicated the most significant risk of reusing an N95 respirator is contact transmission from touching the surface of the contaminated respirator. Respiratory pathogens on the respirator surface can potentially be transferred by touch to the wearer's hands and thus risk causing infection through subsequent touching of the mucous membranes of the face (i.e., self-inoculation). Other hazards associated with reusing respirators included the reduction in the respirator's ability to protect the wearer caused by .excessive reuse. (https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html) Review of the CDC website indicated when [MEDICATION NAME] extended use of N95 respirators, the maximum recommended extended use period is 8-12 hours. The CDC indicated respirators should not be worn for multiple work shifts and should not be reused after extended use. N95 respirators should be removed (doffed) and discarded before activities such as meals and restroom breaks. (https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html) Review of a CDC document (provided by Administrator A on 9/10/2020) titled, Respirator On/Respirator Off, subtitled, When you take off a disposable respirator (dated 6/9/2020) indicated, Remove by pulling the bottom strap over back of head, followed by the top strap, without touching the respirator. Discard in a waste container. 2. During an observation on 9/2/2020 at 11 a.m., LN B was in her office/the Conference room and was having a conversation with another staff member. During an interview (in the Conference room) with the DON, LN B, Manager H and Administrator A on 9/2/2020 at 1:45 p.m., LN B described the process she used for testing staff for Covid-19. LN B stated she performed the ongoing testing in the Conference room, usually between Tuesday and Friday. LN B stated she tested approximately thirty to forty staff per day and wore full PPE, including N95, gown and gloves. During the same interview on 9/2/2020 at 1:45 p.m., Manager H was asked if the window in the Conference room opened (was functional for ventilating the room during the testing). The Manager H stated the window did not open. When asked to identify the number of air exchanges per hour in the Conference room, the Manager H stated he did not know. (Air changes per hour (ACH) influences the time required for airborne-contaminant removal by efficiency. For example: If the Conference room had only two ACH, it would take approximately 138 minutes for removal at 99% efficiency of airborne contaminants). (https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1) During the same interview on 9/2/2020 at 1:45 p.m., the Director of Nursing (DON) was asked if the room was aired out during and after testing, and she stated the door was closed when the room was not in use. LN B stated she used the Conference room as a workspace (office) and she occupied the room after testing staff. During an observation and concurrent interview on 9/3/2020 at 5:30 p.m., the door to the reception office (off the lobby) was open. LN B stated the facility had a new process for staff Covid testing and it now occurred in the reception office. LN B stated she had tested approximately thirty staff that day in the reception office. She stated staff entered the office and were tested at fifteen-minute intervals. LN B stated she tested staff from 6:15 a.m. through 2:30 p.m. and stayed in the office during that timeframe. Due to the pattern of ineffective infection control precautions, an IMMEDIATE JEOPARDY (IJ) was identified on 9/3/20 at 6:10 p.m., under §483.80 Infection Control: F880. LN B and Unlicensed Staff K were present in the human resource's office, and Administrator A was present via telephone conference call when the IJ was identified. During an observation on 9/5/2020 at 3:25 p.m., multiple boxes of PPE were stored in the facility lobby and the dining room. The boxes in the lobby were stacked at a height of approximately six feet, or greater (pictures were taken). A review of the CDC website indicated as PPE availability returns to normal, healthcare facilities should promptly resume standard practices (rather than extended use and reuse). (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/general-optimization-strategies.html) During an interview on 9/5/2020 at 3:40 p.m., LN J was asked about PPE supplies at the facility. LN J stated the facility always had supplies and they always had new ones (PPE). During an interview on 9/5/2020 at 5:02 p.m., CNA L was asked about N95 training and use at the facility. CNA L stated at dinner, she put her N95 in her pocket (to reuse after her meal). During an observation (from the parking lot, prior to entering the building) on 9/8/2020 at 3:35 p.m., two unidentified staff exited the facility; one of the staff was wearing a mask. The masked staff member walked to a car and entered the vehicle, wearing the same mask she had been wearing when she exited the building. During an observation and interview on 9/8/2020 at 3:45 p.m., LN M was wearing a mask after leaving the building. LN M stated she was wearing the mask she had been wearing her entire shift. When asked if she had been educated on mask use at the facility, she stated she had received education that morning. When asked what was supposed to happen with her mask at the end of the day, LN M stated she usually threw it away (and pointed to a near-by trash can). After the interview, LN M walked to her car, still wearing her used/contaminated mask. A Plan of Action (POA) to abate the IJ was accepted on 9/9/2020 at 2:41 p.m. The POA was submitted and accepted via email communication and included the following actions: Issue 1. The facility would conduct response or surveillance testing in the Therapy business office. The Therapy office had a private entrance, private bathroom, window (for ventilation), and did not have an intake source into the ventilation system of the building. Directional signs would be posted to outside to direct the staff to the testing area. The room would be cleaned and disinfected after each test. The entrance door would be closed during testing. Testing Procedure would include: Licensed nurse (LN) shall wear full PPE to include N95 or equivalent or higher respirator, eye protection, gloves and a gown. Staff would be tested on e at a time, they will wear a face mask into the testing room, and they will leave the room and proceed to the facility's main entrance for screening and mask replacement. Symptomatic staff shall be tested out of the facility in a manner such as a drive by. Housekeeping would disinfect the area at the end of the day, allowing several hours to pass prior to the next day's testing. Issue 2. Staff would be educated regarding use of N95 as adequate supplies allow. The education included the CDC do's and don'ts of masking and OSHA compliance of N95 non-reuse. OSHA guidelines included, A surgical N95 mask or respirator is a single-use, disposable respiratory protective device used and worn by healthcare personnel (HCP) during procedures to protect HCP from transfer of microorganisms, body fluids, and particulate material. The POA indicated, Staff shall be (in) compliance with one time use of N95. N95 respirators would be worn (required) on Covid unit, PUI (unit containing residents suspected to be Covid infected or residents who's Covid status is unknown), or when a suspected resident is demonstrating signs of Covid-19 infection. Staff would be provided with New surgical masks/N95's at the beginning of their shifts. During mealtime, staff shall remove the surgical masks and discard, replaced with a new mask. Staff shall be provided replacement/clean masks. Staff would be in-serviced regarding mealtime disposal and replacement of surgical masks. Information regarding donning (putting on) and doffing (taking doff) of N95 in Covid or PUI unit would be provided to dedicated staff. Staff would remove face coverings at the end of the day and dispose of properly and not remove used coverings from the facility property. Facility would provide disposal receptacles for face coverings at front entrance and exit of facility, hand sanitizer dispenser would be installed in same area to sanitize hands after removing face covering. The lesson plan for staff education included, but was not limited to, Staff will not re-use any masks (N95 or surgical mask); surgical masks and N95's shall be replaced and considered contaminated following removal during meal time; dispose of all masks after every day and do not reuse .do no use paper bags to store any mask . During multiple staff interviews on 9/10/2020, staff indicated they would store their N95's during mealtimes for reuse afterwards. At 2:28 p.m., CNA M stated he would put his N95 into a paper bag at lunch. At 2:37 p.m., LN N stated she would put her N95 into a paper bag at lunch. At 3:12 p.m., CNA O stated she would put her N95 into a paper bag at lunch and discard it at the end of her shift. At 3:17 p.m., LN P stated she would use her N95 the whole shift and put it in a paper bag at lunchtime. During an interview at 3:50 p.m., Administrator A and Corporate Consultant (CC) stated it was acceptable to store N95 respirators during meals for use afterwards. The accepted POA indicated N95 would be discarded after meals; therefor, the IJ was not lifted. During an interview on 9/10/2020 at 4 p.m., Administrative A was asked how many N95 respirators the facility had for staff use. Administrator A stated they had, three thousand N95 respirators. After onsite verification (via observation, interview, and record review) that the POA was fully implemented and the immediacy of the IJ was no longer present, the IMMEDIATE JEOPARDY was abated on 9/11/2020 at 3:20 p.m. Administrator A was present in Administrator A's office when the IJ was abated. During a telephone interview on 9/14/2020 at 11:07 a.m., the Medical Director (MD) stated the facility did not have a lack of supplies and he was not aware staff were reusing and taking home used N95 respirators. He stated it was his understanding that the facility was not aware of the practice either. The MD stated staff were not supposed to reuse N95's or take used/contaminated respirators home. 3. During an observation and interview on 9/2/2020 at 11 a.m., LN B was in her office/the conference room and having a conversation with another staff member. LN B was not wearing a face mask. When asked why she was not wearing a facemask, LN B stated she did not usually wear one if she was in her office. During an interview on 9/2/2020 at 11:05 a.m., the DON was asked if LN B should be wearing a face mask at all times (while in the building) and she stated, yes. During an observation and concurrent interview on 9/2/2020 at 11:10 a.m., two Unidentified Social Service staff were in the social service's office. Neither staff member was wearing a face mask. When asked if these two staff should be wearing face mask's, the DON stated, They are six feet apart. (The distance generally considered a safe social distance). During a subsequent observation at 12:20 p.m. (over one hour later), the two staff in the social service office were not wearing face masks. During an observation and concurrent interview on 9/2/2020 at 12:40 p.m., an Unidentified Activity Staff member in the activity department was speaking with another staff member. One staff member was wearing a facemask and the other staff member was not wearing a facemask. The DON confirmed this observation. Review of facility document (provided by Administrator A on 9/11/2020) titled, Personal Protective Equipment - Non-Surgical Face Masks, subtitled, Policy Statement (revised 7/2020) indicated, Facility personnel must wear face masks during the COVID-19 Pandemic. Prior to entry of facility and while on duty in a non-contaminated area of office. 4) During an observation and concurrent interview on 9/5/2020 at 4:40 p.m., two EMT's entered the PUI unit from the back of the building (the PUI entrance). One EMT pushed a female resident in a wheel chair into the PUI unit. The EMT's were wearing gloves and masks (not N95's). LN F stated the two EMT's were taking the resident back from her [MEDICAL TREATMENT] appointment and they had not been screened prior to entering the PUI unit. At 4:44 p.m., two more EMT's entered the PUI unit and both were wearing gowns (in addition to masks and gloves). They were not screened prior to entering. During an interview on 9/5/2020 at 4:45 p.m., one unidentified EMT (who had arrived at 4:44 p.m. wearing a gown) was asked if he was screened at the facility prior to entering the PUI unit. The unidentified EMT stated he was screened at other skilled nursing facilities (prior to entrance) but was not screened at this facility prior to entrance. During an interview on 9/11/2020 at 4:40 p.m., the DON stated she was not aware transport personnel (EMT's) were entering the PUI unit without being screened. She stated they were supposed to wait outside (the PUI unit). Review of facility document titled, (Facility name) Covid 19 Mitigation Plan, subtitled, 2. Infection Prevention and Control (signed and dated by Administrator A on 8/24/2020) indicated, The SNF screens and documents every individual entering the facility (including staff) for COVID-19 symptoms screening includes temperature checks. Review of facility policy titled, Personal Protective Equipment- During COVID 19 Pandemic (containing a revision date of October 2018, a date prior to Covid-19's emergence) indicated, 4. Recommended PPE usage for different zones .b. Yellow Zone (PUI)- personnel must wear the following PPE (N95 .eye wear (goggle/face shield) prior to entering the unit . 5. Review of document titled, Respiratory Screening Questionnaire (Covid-19), (undated) on 9/5/2020 at 3:30 p.m., indicated employees and visitors that have a temperature in excess of 100.4 degrees Fahrenheit should, .self-quarantine for 5 days after the symptoms subside or until they receive a negative COVID-19 test result. A review of the CDC website indicated HCP (healthcare personnel) with symptoms of COVID-19 (including fever) should be prioritized for [MEDICAL CONDITION] testing. Return to Work Criteria for HCP with Covid-19 infection can be based on symptoms and include at least 10 days having passed since symptoms first appeared, at least 24 hours having passed since last fever without the use of fever-reducing medications, and symptoms having improved. These criteria can be altered based on the severity of the disease and/or immune status of the individual. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html) During an interview on 9/11/2020 at 4:40 p.m., the DON confirmed the visitor questionnaire did not reflect CDC guidelines or the facility policy. She stated staff with a fever should get a swab at the facility (Covid-19 test), go home, and quarantine for fourteen days.

Based on interviews and record reviews, the facility failed to provide necessary care and services to maintain Resident 1's highest physical level of well-being when a treatment was not done resulting in an infection of a wound. A wound V.A.C (Vacuum Assisted Closure) (a mechanical suctioning device (machine) used with a foam dressing for wound treatment and healing) treatment for one (Resident 1) of two residents receiving this treatment, was not changed according to physician orders. The treatment was signed by Licensed Staff A as completed. Licensed Staff A stated she had not actually completed the treatment. The failure to perform the ordered treatment resulted in an infection in Resident 1's wound. Resident 1 had to be readmitted to the local hospital due to the infection. This failed practice has the potential for other treatments not being performed as ordered and causing other residents in the facility harm. Findings: On 1/18/17, the Department received a complaint alleging the facility had not taken care of Resident 1's wound as prescribed by the Physician. This neglect had resulted in an infection in Resident 1's wound. The wound had been draining green purulent material, resulting in another hospitalization for Resident 1. Review of a document titled, Admission--Clinical Admission Combined, dated 12/8/16, revealed Resident 1 was a [AGE] year old male who was admitted to the facility on [DATE]. Resident 1 had abdominal surgery to repair a widening of the aorta (artery that carries blood to the stomach, pelvis, and legs). The surgery left Resident 1 with a wound in his right groin, which needed nursing care, and for which the wound V.A.C. treatment had been ordered. Resident 1's clinical record included a physician order in the Treatment Administration History: 12/8/16-1/4/17 to apply Santly ([MEDICATION NAME] ,[MEDICAL CONDITION]. histo.) (a medication) ointment; 250 units/gram; topical (onto the skin) once a day on Mon, Wed, Fri , with Special instructions white foam base, then black foam (used with the wound V.A.C.) continue to apply Santly to area of slough (whitish colored dead tissue) with dressing changes. The start date for the order was 12/28/16. The document revealed Licensed Staff A's initials on the page for 12/28/16 and 1/2/17. The document revealed a note by Licensed Staff A written on 1/2/17 at 18:33 (6:33 p.m.) Comment: Done on time at 15:30 (3:30 p.m.). During an interview and concurrent record review on 3/9/17 at 2:30 p.m., Licensed Staff A was asked about Resident 1's wound condition on 1/2/17 when she had changed the wound V.A.C. Licensed Staff A stated she remembered Resident 1 but had never changed his wound V.A.C. Licensed Staff A confirmed the initial on the record were her initials, but she had not changed the wound V.A.C. on that day or any other day. Licensed Staff A stated she did not feel comfortable changing a wound V.A.C. Licensed Staff A stated she had initialed the record indicating the treatment and wound V.A.C. change had been done, but she had not done them. Licensed Staff A stated she had signed it for other nurses who told her that they were going to change it, like (name), the treatment nurse, or support nurses. Licensed Staff A was asked who had changed the wound V.A.C. on 1/2/17 or 12/28/16, the two days she had initialed the wound V.A.C. change and treatment as being done. Licensed Staff A stated she was not sure. Licensed Staff A stated someone told me they would (change the wound V.A.C. and do the treatment) and I signed it. I'm not doing it any longer because I don't know if it gets done unless I put my hands on it or see it. Licensed Staff A stated she had learned her lesson. Licensed Staff A confirmed there was no nursing progress note written on 1/2/17. During an interview on 3/9/17 at 2:35 p.m., Management Staff B stated the facility did not have a policy regarding the wound V.A.C. Management Staff B stated the facility followed physician orders and manufacture's guidelines. Management Staff B stated the company who provided the wound V.A.C. machine also provided the training. Management Staff B stated the training was now a web based training. Management Staff B was asked for the documentation and attendance sheets for the training. Management Staff B provided documentation about training on the wound V.A.C. done in 3/17. No other training documentation about wound V.A.C. was provided. Management Staff B stated nurses would document the treatment and wound V.A.C. change on the treatment record. When asked about documentation in the nursing progress notes, Management Staff B stated nurses were expected to document in the progress notes if there was an issue with the wound, like drainage, infection, or other issue. Management Staff B was asked to provide documentation about which licensed staff had been competent to change a wound V.A.C. in January 2017. No documentation was provided. During an interview and concurrent record review on 3/16/17 at 1:20 p.m., Management Staff C was informed that Licensed Staff A had documented on the treatment record that the treatment and wound V.A.C. had been changed per MD order, but Licensed Staff A had admitted she had not done so. Management Staff C stated she did not know what happened, and that maybe the treatment had been performed by the treatment nurse. Management Staff C confirmed that there was no progress note written regarding a wound V.A.C. change. Management Staff C stated she would look into it. Management Staff C was informed Resident 1 had been readmitted to a local hospital with an infection in his wound. Review of a document titled Care Plan History dated Date Range:12/26/16-1/26/17 revealed no entry regarding a wound V.A.C. device. Review of a facility document titled Wound Care Progress Note dated 12/20/16 17:55 (5:55 p.m.) by Wound Consultant D revealed .wound bed 80% pink granular (new healthy) tissue/20% scattered loose slough (whitish dead tissue) .small amount of serous (clear, thin) drainage in canister (< (less than) 25 ml), no odor, periwound with mild [DIAGNOSES REDACTED]tous macropapular rash (red area with small bumps) with satelite [MEDICAL CONDITION] (injury)at inferior end of wound. Wound has improved. Review of a document titled [MEDICATION NAME] Surgery Office/Clinic Note dated 12/22/16 12:18 PST (12:18 p.m.) (Pacific Standard Time) by Clinic Licensed Staff E, who assessed Resident 1 in the Clinic, revealed under Physical Exam .Right groin incision clean, dry, intact. The document revealed under Assessment/Plan: .Wound vac intact at right groin site--still draining. Right groin clean and dry without sign of infection . Review of the facility policy and procedure provided on 1/26/17 titled Wound Care dated 2001 (Revised April 2009) revealed under section Preparation 2. Review the resident's care plan to assess for any special needs of the resident. The document revealed under section Documentation. The following documentation should be recorded in the resident's medical record: 1.The type of wound care given, 2. the date and time the wound care was given, 3. the position in which the resident was placed, 4. the name and title of the individual performing the wound care.5. Any changes in the resident's condition. 6. All assessment data (i.e. wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure.10. The signature and title of the person recording the data. Review of a document titled Charting and Documentation provided by the facility on 3/9/17 as facility Policy and Procedure, dated 2001 (Revised April 2008), revealed under Section Documentation Criteria .6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: . b. The name and title of the individual(s) who provided the care. Review of a local hospital document titled History and Physical dated 1/4/17 14:08 (2:08 p.m.) PST (Pacific Standard Time) revealed Resident 1's Chief Complaint I have an infection in my right groin. The document revealed under Review of Systems General: Depressed and does not want to return to that SNF (skilled nursing facility). Neuro: A/O (alert and oriented) X4 (knows name, time, place, and situation). Extremities: .Right groin wound vac not present, per patient not present for 2 days. Green purulent discharged (sic). Review of a local hospital document titled: Procedure Note dated 1/4/17 17:26 PST revealed under Indication for Procedure .The wound broke down requiring debridement and placement of wound VAC, patient was seen in the office today there was greenish drainage from the wound patient was admitted .

Based on interviews and record reviews, the facility failed to a) clarify incomplete physician orders for Resident 1's diabetic medication, b) follow nursing practice standards to not administer the diabetic medication and call the MD for further instructions, c) assess Resident 1's blood glucose when he acted irrational by attempting to stab himself. The facility therefore failed to provide the necessary care and services to maintain one (Resident 1) of 16 residents with diabetes (a chronic condition that affects the way the body uses sugar (glucose) highest level of well-being. This failed practice resulted in harm to Resident 1 and had the potential to cause harm and possible death to all residents diagnosed with [REDACTED]. Findings: On [DATE], the Department received a complaint alleging Resident 1 had been admitted to a local hospital on [DATE] after Resident 1 attempted to stab (him)self with a fork. Resident 1's blood sugar in the emergency roiagnom on [DATE] had been 14 mg/dL. Resident 1 died on [DATE]. Review of a document titled Resident Face Sheet revealed Resident 1 was a [AGE] year old male who had been admitted to the facility on [DATE]. Resident 1 had, among others, the [DIAGNOSES REDACTED]. enough insulin or does not correctly use the insulin it does make. When eating, the body breaks down all sugars and starches into glucose. The body needs insulin to use glucose for energy), long term and current use of insulin (hormone that is needed to allow the body to utilize glucose as a fuel for the body and the brain; occurs naturally in the body or is given in form of medication for persons with diabetes). Resident 1 did not have [DIAGNOSES REDACTED]. Review of a facility document titled Diabetic Management Administration History: [DATE]-[DATE] revealed under section Order on page 1 [MEDICATION NAME] ,[DATE] (insulin nph (Neutral Promanine Hagedorn) (70%) (intermediate acting (onset 1XXX,[DATE] hours) and regular (30%) (short acting (onset 30 min-1 hour) human) (OTC) (over the counter) suspension; 100 units/mL (milliliter) (,[DATE]); amount to administer: 25 units; subcutaneous (under the skin). The frequency indicated once per day before breakfast. The document revealed Resident 1's blood sugar on [DATE] at 07:30 (7:30 a.m.) was 71 mg/dL. Page 3 of the document revealed under Order [MEDICATION NAME] (insulin [MEDICATION NAME]) (a long acting (onset 0XXX,[DATE] hours) insulin) solution; 100 units/ml; Amount to Administer: 14 units; subcutaneous. The physician order did not contain parameters of when the insulin was to be held and Resident 1, with a blood sugar of 71mg (milligram) (a unit of measurement) was administered the insulins. Both insulins were signed as administered by Licensed Staff B on [DATE] at 7:30 a.m. Review of a facility document titled Diabetic Management Administration History revealed Resident 1 was given 25 units of one and 14 units of another type of insulin via injection before breakfast. (Insulin is given within ,[DATE] minutes before a meal. Insulin breaks down the food so it can be used as energy). Resident 1's blood sugar (level of sugar in the blood) was 71 mg/dL (milligram per deziLiter (tenth of a Liter)) (normal range for person with diabetes ,[DATE] mg/dL (recommendation by the American Diabetic Association) before the two types of insulin were administered. During an interview and concurrent record review on [DATE] at 2:05 p.m., Management Staff A (a licensed nurse in a management position) confirmed on [DATE] at 0750 (7:50 a.m.) Licensed Staff B had administered 2 types of insulin to Resident 1 according to the Medication Administration Record. Management Staff A stated according to the Medication Administration Record, [REDACTED]. Management Staff A confirmed the Medication Administration Record [REDACTED]. Management Staff A stated he would expect (nurses) to hold (not administer) (the insulin) and call the MD if the blood sugar was below 80 mg/dL. Management Staff A stated that nurses usually got the parameters (low blood sugar reading when to hold the insulin and notify the physician, and high blood sugar reading when to notify the physician) clarified by the physician. Management Staff A stated any nurse could clarify the parameters. Management Staff A stated anyone who had a sudden change in condition, like Resident 1, should have had their blood sugar checked, especially a resident diagnosed with [REDACTED]. During an interview on [DATE] at 2:22 p.m. Licensed Staff C stated she had been involved in sending Resident 1 to a local hospital on [DATE] due to Resident 1 attempting to stab himself with a fork. Licensed Staff C stated she had not been aware Resident 1 was diagnosed with [REDACTED]. Licensed Staff C confirmed the nurse's notes written by Licensed Staff C on [DATE] did not include a blood sugar check before Resident 1 was sent to a local hospital. During an interview on [DATE] at 2:45 p.m., Licensed Staff B confirmed administering two types of insulin via injection to Resident 1 in the morning of [DATE]. Licensed Staff B confirmed Resident 1's blood sugar had been 71 mg/dL. Licensed Staff B stated Resident 1 had acted loopy (confused) before receiving the insulin doses. Licensed Staff B stated there had been no parameter when to hold the insulins, and therefore she had given the insulins. Licensed Staff B stated the admission nurses, who clarified admission orders [REDACTED]. When asked who could clarify the orders or obtain the hold parameter, Licensed Staff B stated she did not know. Licensed Staff B stated she was not comfortable entering orders into the computer system. Licensed Staff B confirmed Resident 1's blood sugar was not checked prior to being sent to a local hospital on [DATE]. Licensed Staff B confirmed there was no progress note written by Licensed Staff B on [DATE] regarding Resident 1 attempting to stab himself with a fork and being sent to a local hospital. Review of a facility document titled Vitals Report dated [DATE] at 10:06 a.m., revealed two identical entries for Breakfast by Unlicensed Staff D Not taken: Refused. Resident 1 refused to eat his breakfast after receiving the two types of insulin. (Not eating a meal after receiving insulin could drop blood sugars to a critical level). Review of a facility document titled Event Report dated [DATE] at 11:46 a.m., revealed the Physician order: Transfer patient to ER (emergency room ) for psych. (psychiatric) Eval (Evaluation). The document revealed .patient's vital signs are currently stable the vital signs taken (,[DATE] (Blood pressure); 78 (Pulse); 19 (Respirations); 98.7 (Temperature); 93% (Oxygenation of the blood) RA (Room Air)). (The vital signs taken did not include Resident 1's blood sugar). Resident 1's Care Plans, provided by the facility on [DATE], did not include a Care Plan for Diabetes Mellitus. There were no goals or interventions listed for how to care for Resident 1 in regards to his [DIAGNOSES REDACTED]. Review of a hospital document titled History and Physical dated [DATE] at 18:30 PST (6:30 p.m. Pacific Standard Time) revealed under Chief Complaint Patient presents with [DIAGNOSES REDACTED] (low blood sugar). The document revealed under section History of Present Illness .In the ED (Emergency Department) he was found to be hypoglycemic to 14 (critical levels are < (less than)50 mg/dl (Lexicomp online). The document revealed under section Results Review: Lab results: Lab dated [DATE] at 12:23 PST POCT (Point of Care Testing) (a glucometer) -Glucose (Capillary) 14 mg/dL CRIT (critical), Interpretation Abnormal Results [DIAGNOSES REDACTED] The document revealed under section Reexamination/Reevaluation: Course: resolved. Altered mental status ,[DATE] (secondary to) (due to) [DIAGNOSES REDACTED], and under assessment Exam improved, patient no longer altered mental status after receiving IV (intravenous) D50 (liquid sugar solution) and he ate lunch to prevent relapse of [DIAGNOSES REDACTED]. Review of the facility Policy and Procedure titled Nursing Care of Resident with Diabetes Mellitus dated 2001, revised [DATE], revealed as Purpose .3. Prevent recurrent [MEDICAL CONDITION]/[DIAGNOSES REDACTED] 4. Recognize, manage, and document the treatment of [REDACTED].The document reveals under Glucose Monitoring .4. b. Normal Ranges are approximately ,[DATE] mg/dl before meals and <180 mg/dl after meals, . and 5.a. Mild [DIAGNOSES REDACTED] ,[DATE] mg/dl. The document reveals under section Conditions associated with Diabetes .3. [DIAGNOSES REDACTED] (blood sugar below reference range). Signs and Symptoms of [DIAGNOSES REDACTED] usually have a sudden onset and may include the following .f. irritability or bizarre changes in behavior Review of Lippincott Manual of Nursing Practice, 9th edition, published 2010 by Wolters Kluwer Health, Chapter 25 Diabetes Mellitus page 958 revealed under [DIAGNOSES REDACTED] Unawareness Patients may exhibit irrational thought, . Under the Section Standard of Care Guidelines the Manual reveals Assess for signs of [DIAGNOSES REDACTED]: .confusion. Review of Essentials of Medical-Surgical Nursing, Susan C. deWit, fourth edition, 1998, reveals in Chapter 25 Care of Patients with Endocrine Disorders: Diabetes Mellitus and [DIAGNOSES REDACTED] p.818 Nursing Assessment and Intervention: One of the most unfortunate consequences of [DIAGNOSES REDACTED] from any cause is that the physiological symptoms may be mistaken for indications of psychiatric illness. These symptoms include irritability, personality change .

Based on interviews, facility records and acute care hospital record, emergency medical services record, coroner's report, and death certificate review, the facility failed to provide the necessary care and services to maintain one of 130 (max capacity) resident's (Resident 1's) highest physical level of well-being. Despite knowledge of critical lab values, which alerted staff to a high possibility of bleeding, staff failed to follow policy and notify the physician of continued bloody stools in Resident 1. Resident 1 started bleeding 9 hours prior to being transferred to the hospital. Resident 1 passed away within 30 minutes of arriving at the local acute care hospital. Resident 1 was a Full Code (patient/family want everything possible done to keep patient alive). Findings: During a telephone interview on 11/30/16 at 3:32 p.m. Complainant X stated Resident 1 had been admitted to the facility for therapy. Complainant X stated Resident 1 had started bleeding from the rectum in the morning of 10/21/16, and continued bleeding throughout the day. Staff had repeatedly told the family, who had been present throughout the day, Resident 1 was fine. The family had not heard from Resident 1's attending physician. Complainant X stated the family had relied on the professionals to take care of Resident 1. Complainant X stated the emergency room was so close, and questioned why Resident 1 was not sent to the emergency room sooner. Complainant X stated licensed staff had not paid attention to Resident 1 until Resident 1 had become unconscious. Review of a document titled Resident Progress Notes dated 10/16/16 at 16:04 (4:04 p.m.) revealed an entry by Licensed Staff G which indicated Resident 1 had been admitted on [DATE]. The document identified Resident 1 as a [AGE] year old male with the diagnosis, among others, of Left Middle Cerebral Artery Embolism (blood clot on the brain) with Stroke, Hypertension, and CAD ([MEDICAL CONDITION]). The entry revealed Resident Code Status: Full Code. During an interview on 1/5/17 at 2:10 p.m., Unlicensed Staff A stated she had been taking care of Resident 1 during the day shift (6:30 am-2:30 pm) on 10/21/16 and noticed in the morning that something was wrong. Unlicensed Staff A stated Resident 1 had experienced 3-4 episodes of loose stools throughout the shift. The color of the stool had been brownish-reddish, and then changed to more reddish. Unlicensed Staff A stated she had notified Licensed Staff B. Licensed Staff B had witnessed the bloody stool in the morning. During an interview on 1/5/17 at 2:25 p.m., Licensed Staff B stated she had witnessed the bloody stool in the morning on 10/21/16. Licensed Staff B stated she had not spoken directly with Physician I regarding Resident 1's bloody stools. Licensed Staff B stated she had relied on Licensed Staff C (discharge nurse) to relay the information to Physician I. Review of a document titled Resident Progress Notes dated 10/21/16 at 13:22 (1:22 p.m.) by Licensed Staff B revealed .noted resident had large amounts of loose BM (bowel movement), color is red and dark brown, . notified .discharge nurse (Licensed Staff C) to notify MD .VS (vital signs) at 0815 (8:15 a.m.): 124/76 (blood pressure) . continues to have loose bloody stools, vs at 0945 (9:45 a.m.) 122/66 . During an interview on 1/5/17 at 10:45 a.m., Licensed Staff C (discharge nurse) stated she had spoken on 10/21/16 in the morning with Physician I regarding Resident 1's bloody stool. Licensed Staff C stated she had notified the physician about Resident 1's lab result in the early afternoon on 10/21/16. Licensed Staff C stated that was all the involvement she had regarding Resident 1 on 10/21/16. Review of a document titled Resident Progress Notes dated 10/21/16 at 8:06 a.m. revealed the following entry by Licensed Staff C .dark red blood in the stool. MD was notified and waiting for orders at this time. Patient did have a critical high (4.25 units) ( indicating high risk for bleeding) PT(Prothombin time)( measure of how quickly blood clots)/ INR( International normalized ratio) (standard unit used to report the result of a PT test) (lab test to determine the clotting time of blood; target range for patients on blood thinners is 2-3 units) noted yesterday . Review of a document titled Resident Progress Notes dated 10/21/16 at 8:16 a.m. revealed an entry by Licensed Staff C Received a TO (telephone order) from MD and continue to monitor for blood in the stool. Review of a document titled Resident Progress Notes dated 10/21/16 at 14:08 (2:08 p.m.) revealed an entry by Licensed Staff C indicating notification to physician regarding lab results. The entry did not mention continued bloody stools. During an interview on 1/18/17 at 1:45 p.m., Management Staff D stated he remembered Resident 1 had coded (experienced cardiopulmonary arrest) in the building. Management Staff D stated Licensed Staff C had been in contact with the physician and was asked to provide the documentation. During an interview 1/18/17 at 2:45 p.m., Management Staff E provided a copy of a lab result in response to a request for documentation showing staff had contacted the physician about Resident 1's continued bloody stools. The document titled Diagnostic Laboratories and Radiology dated 10/21/16 revealed results of a CBC (Complete Blood Count) (a laboratory test that measures several components of blood) laboratory report. The laboratory results indicated low RBC (Red Blood Count) ( a blood test to find out how many red blood cells a person has)3.79 (normal rage 4.63-6.08 X10^6/ul (microliter)), low Hemoglobin (red cells responsible for transporting oxygen in the blood) 10.0 (13.7-17.5 g/dL(gram per deciliter)) , and low Hematocrit (ratio of the volume of red blood cells in the total volume of blood) 32.7 (40.1-51.0 % (percent)) (all low values indicating possible [MEDICAL CONDITION] or lack of blood). The document indicated on the bottom of the page 10/21/16 at 1:50 p.m. TO (telephone order) Dr (Name) Re-check CBC in AM 10/22/16. The document was signed by Licensed Staff C. The document did not reveal any discussion about the Resident 1's continued episodes of bloody stools. No other documentation was provided indicating staff had contacted the physician regarding the continued bloody stool after the initial physician order to monitor for blood in the stool was received at 8:16 am on 10/21/16. Record review of a document titled Resident Progress Notes dated 10/21/16 at 11:26 a.m. revealed an IDT (Interdisciplinary Team) note written by Licensed Staff F. The category titled Events revealed 10/20/16 Critical Lab. The progress note revealed PT/INR with critical high result:4.25. MD notified . The note revealed .mont' (sic) (monitor) for s/s (signs and symptoms) of bleeding. Increased chance of bleeding, bruising, nose bleed, red or brown urine, black tarry stools . The IDT note did not address the episodes of bloody stools during the morning of 10/21/2016. Review of a document titled Event Report dated 10/21/16 at 21:21 (9:21 p.m.) written by Licensed Staff H revealed the Description Sudden Change in Condition The document revealed under Notes dated 10/21/16 at 19:31 (7:31 pm) Resident is Unresponsive to external stimuli (not responding to being touched or shaken) . Appears to be weak .Abnormal vs taken: weak pulse PR (pulse rate) of 16, temp of 99.2 F (Fahrenheit), RR (respiration rate) of 8cpm (bpm) (breath per minute), BP (blood pressure) of 90/8, O2 (oxygen) 88. Primary Physician on (sic) the building and notify (sic) with the current status of the patient and agreed to transfer on (sic) the ED thru 911 Resident leave (sic) the facility at 1730 (5:30 p.m.) . During an interview on 2/6/17 at 3:38 p.m., Licensed Staff H stated she had been taking care of Resident 1 during the pm shift (2:30pm-11pm) on 10/21/16. Licensed Staff H stated Resident 1 had been totally fine. Resident 1's wife had notified Licensed Staff H that something was wrong with Resident 1. Licensed Staff H had found Resident 1 unresponsive already. Review of a document titled Pre-Hospital Field Notes; Agency: (Local) Fire Department dated 10/21/16, and timed Pt (patient) contact time 16:58 (4:58 p.m.), revealed Chief Complaint: [MEDICAL CONDITION]. The document revealed Pt had a large amount of blood coming from rectum . Review of a document titled ED Summary Report dated 10/21/16 reveals under General Data Arrival Date/Time: 10/21/16 1735 (5:35 p.m.). Review of a document titled Emergency Department Report dated 10/21/16 1839 (6:39 p.m.), revealed When paramedics arrived the patient was nonresponsive and reportedly had a rapid pulse. Notably there was dark blood in the bed which appeared to be coming from the rectum. There is a copious amount of blood, as much as 1 liter according to the paramedics. The document revealed in the subtitle Physical Exam General Appearance: unresponsive Rectal: bloody stool noted. In the subtext of Medical Decision Making the text revealed . He (Resident 1) was pronounced dead at 6 PM. During a phone interview on 2/16/17 at 3:08 p.m., Physician I stated he did not recall Resident 1. Physician I stated he had not been the admitting physician, and had therefore not been familiar with Resident 1. Physician I stated he did not recall the conversation regarding bloody stool. Physician I stated brighter bloody stool would indicated there is a problem. Physician I stated he would have notified the facility to call 911 if there had been any changes like red blood. Review of the facility policy and procedure titled Acute Condition Changes dated 2001 (revised October 2010) revealed under section Assessment and Recognition .5.a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected pertinent information, including the resident's current symptoms and status. 6. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response. The document revealed under section Cause Identification 2. As needed, the Physician will discuss with the staff and the resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization .b. The discussion should consider the resident's overall condition, prognosis, and wishes. Review on 2/21/17 of the Local Law Enforcement's Coroner's report dated 10/21/16 at 18:21 (6:21 p.m.) revealed during an interview conducted by Local Law Enforcement on 10/21/16 at the local acute care hospital, Physician K stated he believed the decedent (Resident 1)possibly blead (sic) (bled) out. The document revealed an interview with family members who had been concerned due to the large amount of blood found in the decedents stool throughout the day .(Family member name) had brought it to the attention of care staff who stated it was ok. (Family member name) stated at some time during the morning (family name) had initially advised the care home staff of the blood. (Family name) had mentioned it twice more. The staff stated it was ok. The document revealed during an interview on 10/21/16 conducted by Local Law Enforcement, Licensed Staff B stated her main concern was the decedents frequent loose bowel movements containing blood throughout the day. Licensed Staff B stated the decedent needed to be changed at least 8 times that day and each time the stool was very dark and bloody. Review of Resident 1's Death Certificate on 2/23/17 at 8:30 am revealed in section Cause of death subsection: other significant conditions contributing to death acute gastrointestinal (stomach) hemorrhage (bleeding)

Based on observation, interview, review of clinical records, and review of facility documentation, the facility failed to maintain an effective infection prevention and control program designed to prevent the development and transmission of disease and infection for the residents in the facility, when: 1. Staff did not implement contact precautions correctly and did not follow infection control policy and procedures for 2 of 24 sampled residents (Residents 13 and 15) with Clostridium difficile (C diff, a bacteria in feces that causes watery diarrhea and is a frequent cause of antibiotic associated diarrhea), with the potential for widespread exposure of pathogenic organisms to all residents. (Contact precautions are rules and procedures that staff and visitors must follow when they are in the room of a resident who has been diagnosed with [REDACTED].) Immediate Jeopardy was identified on [DATE] at 4:05 p.m., under 483.65 Infection Control. The Administrator, Director of Nurses and two Nurse Quality Consultants were present. Immediate Jeopardy was abated on [DATE] at 2:50 p.m. The Administrator, Director of Nurses and two Nurse Quality Consultants and Dietary Consultant were present. 2. Staff failed to care plan, analyze, trend or report the recurrent urinary tract and[DIAGNOSES REDACTED] infections and failed to notify the Quality Improvement Committee of the recurrent infections for 4 of 24 sampled residents (13, 14, 15, and 20). There were 23 positive cultures for Clostridium difficile (C diff) between [DATE] and [DATE] and 1 of 24 sampled residents (Resident 20) had been treated for [REDACTED]. 3. Staff failed to disinfect rooms and surfaces contaminated by[DIAGNOSES REDACTED] with the appropriate bleach solution with the potential for widespread exposure of[DIAGNOSES REDACTED] to all residents. 4. Staff failed to keep the urinary catheter drainage bag off the floor for 1 of 24 sampled residents (Resident 15) with the potential for urinary tract infections. 5. Staff failed to maintain appropriate infection control when the urinary catheter tubing, urine collection bag and a urinal were left on the top of a toilet water tank for 1 of 24 sampled residents (Resident 20) who had 9 urinary tract infections between [DATE] and [DATE], with the potential for cross-contamination, recurrent urinary tract infections or sepsis (bacterial infection in the blood caused by a urinary tract infection) which could lead to organ failure and death. 6. Staff did not label Oxygen tubing to indicate the date the tubing was changed for one random resident (Random Resident 36), with the potential for not changing the oxygen tubing in a timely manner and causing respiratory tract infection. Findings: 1. During an observation during the initial tour on [DATE], at 9 a.m., there was a sign at Resident 13's door which indicated an infection control alert, and included a cart (isolation cart) outside the door that contained personal protective equipment (PPE) which included gowns, gloves and resident specific supplies for that room. On the top of the isolation cart was a container of disinfection wipes titled Super Sani Cloth, (a disinfectant which does not contain bleach). During a concurrent interview, when asked what type of precautions were in place for Resident 13, Administrative Staff E stated the precautions were for[DIAGNOSES REDACTED]. infection. During an observation on [DATE], at 12:25 p.m., Unlicensed Staff C was at the bedside assisting Resident 13 with care while wearing a gown and gloves. Unlicensed Staff C removed the gown and gloves and placed them in a plastic bag in the trash can in the room. Unlicensed Staff C went into the bathroom and returned to the room, moved the over-bed table over Resident 13 and handed Resident 13 items from the bedside table with bare hands, Unlicensed Staff C's clothing touched the bed and linens. Unlicensed Staff C then tied the plastic bag that contained contaminated items with bare hands and took another plastic bag from the pocket of the uniform, with bare hands, and placed that in the trash container. Unlicensed Staff C then picked up the trash in the plastic bag and the dirty laundry with bare hands and proceeded out of the room and walked down the hall and picked up the cover to the laundry container with a contaminated bare hand and dropped the laundry in and then proceeded to the trash bin by the nurses station desk and picked up the cover of the trash bin with a contaminated bare hand and disposed of the plastic bag. Unlicensed Staff C did not wash hands with soap and water and did not use a sanitizing hand product after disposing of the contaminated items. Unlicensed Staff C then proceeded into another resident ' s room without washing hands with soap and water. During an observation on [DATE], at 12:10 p.m., Resident 15's room had a sign indicating precautions and an isolation cart was beside the doorway. Unlicensed Staff D was observed opening the door with the gloved hand while wearing contaminated gown and gloves. Unlicensed Staff D picked up the cover to the laundry container outside the doorway with a contaminated glove and dropped the dirty linen inside and then shut the door to the room with the contaminated glove. At 12:25 p.m., Unlicensed Staff D opened the door with bare hands, without PPE, and carried the plastic bag containing contaminated trash and picked up the cover of the trash container with a contaminated bare hand and placed the trash inside. Unlicensed Staff D then used the sanitizing gel mounted on the wall outside the room and rubbed the gel over the bare hands and went into another residents room without washing hands with soap and water. When asked what type of isolation Resident 15 was on, Unlicensed Staff D stated contact precautions for[DIAGNOSES REDACTED]. Review of Resident 13's clinical record on [DATE] at 2 p.m., [DATE] at 10 a.m. and [DATE] at 9 a.m., revealed Resident 13 had [DIAGNOSES REDACTED]. Resident 13 had been admitted to the facility in December of 2014 following a hospital stay for urinary tract infection. Resident 13 was readmitted to an acute care hospital on [DATE] for altered mental status, diarrhea and a fever of 104.4 degrees Fahrenheit (F), with a final [DIAGNOSES REDACTED]. Resident 13 was readmitted to the facility on [DATE]. Laboratory reports included stool cultures positive for[DIAGNOSES REDACTED] on [DATE], [DATE] and [DATE]. There was a current physician order, dated [DATE], for contact isolation for[DIAGNOSES REDACTED] for continued loose stools. A repeated stool culture, for loose stools on [DATE] indicated[DIAGNOSES REDACTED]. On [DATE] at 4 a.m., Resident 13 developed a fever of 102 degrees F and dropped oxygen levels in the blood to 66 % (normal range is 92 - 100%) and was transferred to the acute care hospital. The emergency room report for this admission indicated recurrent[DIAGNOSES REDACTED] and recurrent urinary tract infection. Review of Resident 15's clinical record on [DATE] at 9:30 a.m., revealed Resident 15's [DIAGNOSES REDACTED]. Laboratory data revealed a urinary tract infection (UTI) on [DATE] and [DATE], and positive stool cultures for[DIAGNOSES REDACTED] on [DATE] (with contact precautions) which was clinically resolved on [DATE]. Resident 15 had a recurrence of diarrhea and a stool culture showed[DIAGNOSES REDACTED] on [DATE] with Resident 15 placed on contact precautions again. Resident 15 continued to have diarrhea. During an interview on [DATE], at 4 p.m., with Licensed Nurse (LN) B, the infection control nurse/educator for the facility, the facility infection control program was discussed. LN B stated culture reports were reviewed on a daily basis to determine if a resident required isolation precautions. LN B stated nursing staff could start isolation based upon symptoms, such as diarrhea, until the culture report came back. When asked about the infection control inservice education to staff, LN B reported providing the following inservices since [DATE]: A. Infection control and Clostridium difficile - [DATE]. This inservice included information that the bacteria spores were transferred to patients primarily via the hands of health care workers who have direct contact with infected patients or have touched a contaminated surface or item; B. Managing Infection control in utility rooms - [DATE]; C. Infection Control: Environmental and equipment protection and disinfection - [DATE]; D. Infection control: Norovirus planning, prevention, documentation, standard precautions and contact precautions, washing hands - [DATE]; and E. Infection Control - using PPE when working in isolation rooms - [DATE] When asked how monitoring was done to ensure staff knowledge, after the education sessions, LN B stated observations of care were done, such as hand washing and care of incontinent residents to ensure perineal care (washing of the genital and rectal areas) was done correctly and the staff did a return demonstration. These sessions were not documented, but staff was informed immediately if they did not follow the appropriate process. During a review on [DATE] at 3 p.m., the Infection Control Policies and Procedure Manual located at the nursing station included a policy, dated revised [DATE], titled: Isolation - Categories of Transmission Based Precautions, which included: .Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted by others.2. Based on CDC (Center for Disease Control) definitions, three types of Transmission-Based precautions (airborne, droplet and contact) have been established.Contact Precautions: In addition to standard precautions, implement Contact Precautions for residents with known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.(2) diarrhea associated with Clostridium difficile;.b. Resident placement:.(2) if a private room is not available, the Infection Control Coordinator will assess various risks associated with other resident placement options (e.g., cohorting).c. Gloves and Hand washing.(2) While caring for a resident, change gloves after having contact with infective material (for example, fecal material and wound drainage). (3) Remove gloves before leaving the room and wash hands with an antimicrobial agent or a waterless antiseptic agent. (4) After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces.Gown: (2) After removing the gown do not allow clothing to contact potentially contaminated environmental surfaces. The Center for Disease Control and Prevention: Frequently Asked Questions about Clostridium difficile for Healthcare Providers:. How is Clostridium difficile transmitted? Clostridium difficile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the Clostridium difficile spores. Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. How can Clostridium difficile infection be prevented in hospitals and other healthcare settings? Use antibiotics judiciously, Use Contact Precautions: for patients with known or suspected Clostridium difficile infection: Place these patients in private rooms. If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with Clostridium difficile infection. Use gloves when entering patients' rooms and during patient care. Perform Hand Hygiene after removing gloves. Because alcohol does not kill Clostridium difficile spores, use of soap and water is more efficacious than alcohol-based hand rubs. Preventing contamination of the hands via glove use remains the cornerstone for preventing Clostridium difficile transmission via the hands of healthcare workers; . If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with Clostridium difficile infection. Use gowns when entering patients' rooms and during patient care. Dedicate or perform cleaning of any shared medical equipment. Continue these precautions until diarrhea ceases. Because Clostridium difficile-infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay. Implement an environmental cleaning and disinfection strategy: Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Consider using an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g., household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants are not effective against Clostridium difficile spores.). Over the past several years nationwide, states have reported increased rates of [DIAGNOSES REDACTED]icile (C Diff) infection, noting more severe disease and an associated increase in mortality. [DIAGNOSES REDACTED] infection remains a disease mostly associated with healthcare (at least 80%) Patients most at risk remain the elderly, especially those using antibiotics. Immediate Jeopardy was identified on [DATE] at 4:05 p.m., under 483.65 Infection Control. The Administrator, Director of Nurses and two Nurse Quality Consultants were present. The facility Plan of Action was approved on [DATE] at 7 p.m. and included: Immediate disinfection with bleach solution to the facility - all surfaces; All staff were required to attend an inservice using the CDC[DIAGNOSES REDACTED] guidelines prior to starting their next shift of work; A post- test and direct observations of residents on contact precautions to validate education; and All staff and residents were observed for signs and symptoms of[DIAGNOSES REDACTED], staff were not to return to work if symptoms were present. The IJ for Infection Control was abated on [DATE] at 2:50 p.m., when monitoring for the plan of action indicated staff were compliant with Contact Precautions. 2. During an interview on [DATE] at 4 p.m. LN B, the facility infection control nurse provided an overview of the facility infection control report and data reported monthly to the Quality Improvement Committee. When asked if recurrent infections were reported, using Resident 20's 9 UTI's since [DATE] as an example, LN B stated the data reported did not include recurrent infections. LN B concurred that just infections per month, both acquired while a resident at the facility (facility acquired) and those where the residents were admitted with an infection were reported to the Quality Improvement Committee. LN B stated that in [DATE] the primary focus of infections for the Quality Improvement Committee were respiratory infections due to the increased number during the flu season. When asked if there was a report for total number of residents with recurring urinary tract infections and/or positive for[DIAGNOSES REDACTED], or recurring[DIAGNOSES REDACTED], LN B stated there was no report and this had not been evaluated. LN B agreed to provide this data the following day. The data run by the laboratory utilized by the facility indicated that for calendar year 2014 there were 9 positive cultures and 8 negative cultures for[DIAGNOSES REDACTED]. The 2015 data was run from [DATE] to [DATE] and indicated 23 positive cultures and 19 negative cultures for[DIAGNOSES REDACTED]. This data indicated: Resident's 13 and 14 had three positive cultures; 4 residents had two (included Resident 15); and 10 residents had one positive culture. Data by month: Residents with positive[DIAGNOSES REDACTED] cultures [DATE] - 10 residents (two residents on [DATE] and 2 residents on [DATE]); February 2015 - 2 residents; [DATE] - 4 residents; [DATE] - 6 residents; and [DATE] - 1 resident (Resident 13 had another positive culture for[DIAGNOSES REDACTED] was done during the hospital admission on [DATE] - per the emergency room report). People getting medical care can catch serious infections called healthcare-associated infections (HAIs). One type of HAI - caused by the germ[DIAGNOSES REDACTED]icile - was estimated to cause almost half a million infections in the United States in 2011, and 29,000 died within 30 days of the initial diagnosis. Those most at risk are people, especially older adults, who take antibiotics and also get medical care. The Center for Disease Control: Healthcare Associated Infections, Clostridium difficile. http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_infect.html Review of Resident 20's clinical record on [DATE], at 11:15 a.m., revealed that Resident 20 had a Foley catheter (tube into the bladder to empty urine) and the following laboratory reports: (cultures containing more than 100,000 colonies/ml (milliliter) are indicative of infection). 1). On [DATE], Urine culture, indicated > (greater then) 100,000 colonies/ml of Escherichia Coli (E Coli: bacteria in lower intestines), treated [MEDICATION NAME](an antibiotic) for 7 days; 2). On [DATE], Urine culture: >100,000 colonies/ml Providencia stuarti (bacteria in lower intestines) and treated with Bactrim (an antibiotic) for 10 days; 3). On [DATE], Urine culture: >100,000 colonies/ml E coli and treated with an antibiotic; 4). On [DATE], stool culture: positive for[DIAGNOSES REDACTED], treated with Deficid 200 mg twice a day for 10 days (antibiotic for[DIAGNOSES REDACTED] associated diarrhea); 5). On [DATE], Urine culture: >100,000 colonies/ml Providencia stuarti (bacteria in lower intestines) and treated with Bactrim (an antibiotic) for 10 days; 6). On [DATE], Urine culture: 2 bacteria present >100,000 colonies/ml Providencia stuarti and > 100,000 colonies/ml of E Coli which were treated [MEDICATION NAME](an antibiotic) for 10 days; 7). On [DATE], urine culture: 2 bacteria present with > 100,000 colonies/ml of E Coli and > 100,000 staphylococcus aureus which were treated with Bactrim (an antibiotic) for 10 days; (Staphylococcus aureus is frequently isolated from urine samples obtained from long-term care patients. S. aureus is a cause of urinary tract infection among patients with urinary tract catheterization. Clinical Infectious Disease. 2006 [DATE];42(1):,[DATE]. Epub (electronic publication) 2005 [DATE].) 8). On [DATE], stool culture: Positive for Norovirus (a very contagious virus, which causes the stomach or intestines or both to get inflamed - acute gastroenteritis - causes nausea, vomiting and diarrhea); 9). On [DATE], urine culture: > 100,000 colonies/ml [DIAGNOSES REDACTED] pneumoniae (bacteria normally found in the intestines) and treated [MEDICATION NAME] mg twice a day for 7 days; and 10). On [DATE], urine culture: > 100,000 colonies/ml of E Coli treated with Bactrim (an antibiotic) for 10 days During an interview on [DATE], at 4 p.m., when asked if the recurrent UTI's for Resident 20 had been evaluated, LN B, the facility infection control nurse, stated that Resident 20 was a very difficult and demanding resident and the family member demanded urine cultures stating that Resident 20 was agitated and confused which usually indicated an infection, but staff did not agree that this was a behavior or change in mental status and the physician was trying to appease the family member by ordering tests and antibiotics. When asked if the facility felt that the physician was ordering unnecessary antibiotics if this issue was referred to the Quality Improvement Committee or Medical Director, LN B stated it had not been discussed. Review of Resident 13's clinical record on [DATE], at 2 p.m., indicated that Resident 13 had been admitted to the facility in December of 2014 following a hospital stay for urinary tract infection. Resident 13 was readmitted to an acute care hospital on [DATE] for altered mental status, diarrhea and a fever of 104.4 degrees Fahrenheit (F), with a final [DIAGNOSES REDACTED]. Resident 13 was readmitted to the facility on [DATE]. Laboratory reports for Resident 13 included stool cultures which were positive for[DIAGNOSES REDACTED] on [DATE], [DATE] and [DATE]. On [DATE] at 4 a.m., Resident 13 developed a fever of 102 degrees F and dropped oxygen levels in the blood to 66 % (normal range is 92 - 100%) and was transferred again to the acute care hospital. The emergency room report for this admission indicated recurrent[DIAGNOSES REDACTED] (positive culture on [DATE]) with a positive culture for urinary tract infection. Review of Resident 15's clinical record on [DATE] at 9:30 a.m., revealed the following: On [DATE] the Nurse Practitioner ' s note included a small penile erosion (ulcer) and nursing staff were instructed to secure the catheter tubing to Resident 15 ' s leg and include a teaching plan directed to prevent further penile injury; On [DATE] the penile erosion had increased in size to 2.0 centimeters (cm) and the wife requested a suprapubic catheter (inserted through the abdominal wall into the bladder) so the penile erosion could heal; On [DATE] Urine culture: >100,000 colonies/ml E coli and > 50,000 colonies Methicillin Resistant Staphylococcus Aureus (MRSA) which was treated with Ertarpenem (an antibiotic for severe infections) via intramuscular injection for 7 days and a second antibiotic, Doxycillian twice a day for 10 days; On [DATE] Resident 15 was transferred to a hospital for insertion of the suprapubic catheter and received 5 days of antibiotics following the insertion to prevent post-operative infection; On [DATE] Urine Culture: > 100,000 colonies/ml Proteus Mirabilis, with a white blood cell count of 44.6 (normal 4.4 - 11.0, elevated levels are indicators of infection by bacteria) and the physician noted probable urosepsis; On [DATE] Stool culture: positive for[DIAGNOSES REDACTED] and treated with [MEDICATION NAME] (an antibiotic) 250 mg four times a day for 14 days, with notation that the[DIAGNOSES REDACTED] was clinically resolved on [DATE]; and On [DATE] Stool culture: positive for[DIAGNOSES REDACTED] and treated with [MEDICATION NAME] 250 mg four times a day for 14 days. Review of Resident 14's clinical record on [DATE], at 10 a.m., indicated that Resident 14 was admitted to the facility on [DATE], revealed the following laboratory data: On [DATE] stool culture: positive for[DIAGNOSES REDACTED] and treated with the antibiotic [MEDICATION NAME]; On [DATE] stool culture: positive for[DIAGNOSES REDACTED] and treated with the antibiotic [MEDICATION NAME]; and On [DATE] stool culture: positive for[DIAGNOSES REDACTED] and treated with the antibiotic [MEDICATION NAME]. Review of Resident 11's clinical record on [DATE], at 11 a.m., indicated that Resident 11 had a stool culture on [DATE] was positive for[DIAGNOSES REDACTED]. During an interview on [DATE], at 11:50 a.m., the facility Medical Director stated the facility staff provided infection control reports monthly to the Quality Improvement Committee. Staff had not provided information about recurrent infections; especially repeated[DIAGNOSES REDACTED] and UTI's and staff should have provided that data to the committee members. The Medical Director agreed that fluid intake and output and nutritional needs should be addressed in the care plans for residents with[DIAGNOSES REDACTED] and UTI's and that care planning should include the prevention of recurring infections. 3. During an interview on [DATE], at 9:15 a.m., Resident 14 recalled being sick and isolated for a long time. When asked if he knew what[DIAGNOSES REDACTED] was, Resident 14 became agitated, his voice went up an octave, and stated, I sure don't want any of that again! A review of Resident 14's admission record, dated [DATE], indicated that Resident 14 had been admitted from a hospital with[DIAGNOSES REDACTED]. A review of Resident 14's laboratory data on [DATE] at 11:50 a.m. indicated that Resident 14 had a recurrence of[DIAGNOSES REDACTED] on [DATE], [DATE] and [DATE]. During an interview on [DATE], at 10:14 a.m., Administrative Staff Q stated the facility trained housekeeping staff to use 1 part bleach to 9 parts water for cleaning isolation rooms contaminated by[DIAGNOSES REDACTED]. Administrative Staff Q stated they also used Microdot wipes that contained bleach and it was important to leave the bleach to air dry for 10 minutes. During an interview on [DATE], at 10:36 a.m., Unlicensed Staff P stated Clorox wipes could be used to clean surfaces had been infected by[DIAGNOSES REDACTED] and then wiped off with a clean blue cloth. When asked if bleach required to be air dried in order to kill[DIAGNOSES REDACTED] spores, Unlicensed Staff P stated, No. During a concurrent interview and demonstration on [DATE], at 6:04 a.m., Unlicensed Staff R demonstrated how she would clean a room infected with[DIAGNOSES REDACTED] by spraying a 1:9 bleach spray on a blue cloth and wipe surfaces, i.e. resident's bedside table, mattress, side rails, and then flip the cloth to a dry side and wipe the wet surface dry. Unlicensed Staff R did not allow the bleach spray to air dry. During an interview on [DATE] at 6:20 a.m., Unlicensed Staff S stated housekeeping were unavailable during nights to clean rooms and therefore it was the job of certified nursing assistants (CNAs) and nursing to clean up after residents with[DIAGNOSES REDACTED]. Unlicensed Staff S stated isolation carts, located outside isolation room doorways, had no bleach spray available or wipes available. Unlicensed Staff S stated there were wipes kept on the nursing carts that could be used for wiping surfaces, and paper towels and water for the floors. At 6:34 a.m., Unlicensed Staff T stated sometimes isolation carts had the bleach wipes, but not always. Unlicensed Staff T stated wipes could be found at the nursing carts. During an interview on [DATE], at 10:40 a.m. Unlicensed Staff W stated isolation carts did not have any cleaning supplies. Unlicensed Staff W stated they would wash up with soap and water and paper towels and then leave the room to get cleaning supplies. Unlicensed Staff W thought bleach was used for[DIAGNOSES REDACTED] but usually it was the housekeepers ' job to clean resident rooms and CNAs job to clean the resident using soap and water and wash towels. During a concurrent observation and interview on [DATE], at 9:55 a.m. Licensed Nurse X opened a bottom drawer of the nursing cart and displayed 2 round containers of wipes. One had a red top and indicated Sani-Cloth Plus, and the other had a green top and indicated Clorox wipes but was bleach free. Licensed Nurse X stated that she did not know if the Sani-Cloth Plus killed[DIAGNOSES REDACTED] without reading the label first. A review of the label indicated that Sani-Cloth Plus killed [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE), but not the Clostridium difficile (C diff) organism. During an interview on [DATE], at 2:30 p.m., Unlicensed Staff Y stated that there were no cleaning supplies kept on the isolation carts. Unlicensed Staff Y indicated that it was a housekeeping task to clean room surfaces and CNAs job to clean the resident. 4. During an observation on [DATE], at 3:30 p.m., Resident 15 was lying in bed, with the bed in the lowest position. Resident 15's suprapubic catheter urinary collection bag was lying on the floor. The tubing contained urine with white colored sediment. Review of the facility policy titled Catheter Care, Urinary, revised [DATE], indicated .Infection Control.2b. Be sure the catheter tubing and drainage bag are kept off the floor. 5. During an observation on [DATE], at 9:18 a.m., in a resident's bathroom, an unlabeled and unprotected urinary collection bag and tubing and a urinal were on top of the toilet water tank. During a concurrent observation and interview on [DATE], at 9:25 a.m., Unlicensed Staff L validated that the urinary catheter collection bag and tubing and the urinal were on top of the toilet water tank. Unlicensed Staff L stated that Resident 20 used the urinary catheter collection bag and tubing and the urinal to drain the urine. (Resident 20 had nine urinary tract infections since [DATE]) During an interview on [DATE], at 10 a.m., Licensed Nurse F stated the urinary collection bag and tubing and the urinal should not be placed on top of the toilet water tank. Licensed Nurse F stated We don't know if they (urinary bag, tubing, and urinal) were being used or not. If the resident used it to attach to the urinary catheter, it will cause urinary tract infection. Licensed Nurse F also stated the urinary collection bag and tubing and the urinal could contaminate the toilet. Licensed Nurse F further stated the CNA should drain the urine for the resident. The facility policy and procedure titled Catheter Care, Urinary, revised ,[DATE], indicated .Infection Control.1. Use standard precautions when handling or manipulating the drainage system.2c. Empty the drainage bag regularly using a separate, clean collection container for each resident. 6. During an observation on [DATE], at 8:55 a.m., the oxygen tubing for Random Resident 36 was not dated to indicate when it should be changed. During an interview on [DATE], at 9:20 a.m., Licensed Nurse H stated the oxygen tubing should have a date on it. Record review of the facility's policy and procedure titled Oxygen Administration, dated ,[DATE], indicated .23. Replace oxygen tubing ' s every 7 days; label with date when changed.

The facility failed to: 1. Ensure that the Licensed Staff provide continued nursing assessment, 2. Develop the resident's plan of care for treatment of [REDACTED]. Notify the attending physician promptly of changes to the skin, and 4. Document treatments and findings in the resident's medical record of the changes to Resident 1's cut on the head of his penis, resulting in a full erosion of the penile shaft down to the scrotal sack. Findings: Resident 1 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Physician orders, dated 4/11/13, "Please exchange Foley catheter every month. Last exchanged 3/28/13." During an interview on 11/6/13 at 11:30 a.m., Physician L stated that Resident 1's order was for the catheter to be changed on or around the 28th of each month. Physician L stated that the last catheter change was on 3/28/13 and the next catheter changes should have been on 4/28/13, 5/28/13, 6/28/13, 7/28/13,... Physician L also stated that the facility should have called the medical provider on 7/21/13 due to the cut. "The cut falls under wound care which takes everything to another level." During an interview on 8/20/13 at 10 a.m., Administrative Staff A stated that indwelling catheters are only changed out on as needed basis and not once a month. Administrative Staff A stated that Resident 1 was not taken to a higher level of care, by the facility, as his current medical provider would not cover the cost without a specific order. Nursing notes dated 7/19/13 at 5:30 a.m., indicated that License Staff F wrote "Spoke to previous Noc (night shift licensed nurse) nurse about the redness on penis, stated that AM's was aware and were addressing the issue. Will continue to monitor." Nursing notes dated 7/21/13 at 5:31 a.m., revealed, "Reported to AM's that get treatment nurse to evaluate redness and inflammation on penis, resident is combative and difficult to assess. No temps. vitals wnl (within normal limits), faxed MD and left in rounder (file)." On 7/22/13 at 5:40 a.m., "Redness on penis noted, inflammation, some drainage, Foley draining cloudy urine, no blood, resident combative, resistive to assessment, will have AM's follow up with FAX and visual inspection with MD today." During an interview on 8/26/13 at 2:50 p.m., Licensed Staff F stated that she first noticed the cut on the head of the penis on 7/21/13 and sent a fax to Resident 1's physician at 7:00 a.m. Licensed Staff F stated that she would have day shift nurses follow up with the fax, that she sent, as she was going off duty and would not be back until 7/28/13. During an interview on 8/20/13 at 2:45 p.m., Licensed Staff E stated that she noticed a cut on the head of the penis of Resident 1 on 7/21/13 at 7 a.m. but did not document anything. Licensed Staff E stated that she received a faxed order to change the Resident 1's indwelling catheter on 7/22/13. No notes were completed as she did not change the indwelling catheter, she had another nurse do it and she only assisted. Licensed Staff E stated that she relies upon the Certified Nursing Assistant (CNA) to tell her if there are any problems with the residents. During an interview on 8/23/13 at 1:30 p.m., Licensed Staff G stated that he was asked by Licensed Staff E to change Resident 1's indwelling catheter on 7/22/13. Licensed Staff G stated that he did not remember what Resident 1's penis looked like or what size catheter was placed. Licensed Staff G stated that he did not chart on Resident 1 as Licensed Staff E indicated that she would chart everything. Licensed Staff G also stated that he should have charted what he saw and what he did as that is a nursing requirement and facility policy. During an interview on 8/30/13 at 2:15 p.m., Nurse Practitioner D stated that she first observed the cut on the head of the penis of Resident 1 on 7/22/13. Nurse Practitioner D stated that she wrote orders for the care of Resident 1 on 7/22/13 and assumed that they would be carried out and if their was a problem that she would have received a report from the facilities licensed staff. A Nurse note indicated that on 7/22/13 at 2:12 p.m., that Licensed Staff E wrote, "Resident noted with redness and drainage from penis (Nurse Practitioner named) assessed and additional orders to change f/c (Foley catheter), collect UA (urinalysis) C & S (culture and sensitivity), clean penis daily with mild soap & water apply [MEDICATION NAME] to tip of penis, urine sample collected and placed in ref (refrigerator) for pickup." No documentation of assessments of Resident 1 were noted in the medical record concerning the cut or the redness on the head of the penis or that Licensed Staff E completed an assessment with the Foley catheter in place or that the Foley catheter had been changed. A fax was noted from Nurse Practitioner D dated 7/22/13 to "Change out F/C, send UA C&S per protocol, clean penis daily with mild soap and water, apply [MEDICATION NAME] ointment to outer tip of penis." Nursing plan of care for penile erosion, dated 8/2/13, a nursing plan of care was developed 5 days after staff identified the changes in Resident 1's skin. The plan of care indicated that staff were to change the foley catheter every month and as need if the foley was leaking, plugged or pulled out. During an interview on 8/26/13 at 3:45 p.m., Licensed Staff H stated that she was on duty for three days, 7/25/13, 7/26/13 and 7/27/13, during the day shift. Licensed Staff H stated that Resident 1 was not improving and the Resident 1's penis had started to split open but she did not document anything. Licensed Staff H stated that she was told by other staff that Nurse Practitioner D was taking care of it. The physician's orders to "Change out F/C (foley catheter), send UA (urinalysis), CS (culture and sensitivity) per protocol, clean penis daily with mild soap and water, apply [MEDICATION NAME] ointment to outer tip of penis" were not carried out from 7/22/13 to 7/28/13. During an interview on 9/3/13 at 2:10 p.m., Licensed Staff I stated that she was on duty during the night shift on 7/26/13 and 7/27/13. Licensed Staff I stated that she was not concerned about Resident 1 as Nurse Practitioner D and the other nursing staff knew about Resident 1. Licensed Staff I stated that she failed to chart assessments or observations of Resident 1. No physician orders were carried out. During a record review on 8/19/13, a nursing note made by Licensed Staff F, in Resident 1's medical record, indicated that on 7/28/13 at 6:28 a.m., "Foley draining well, clear yellow urine, cath intact protruding from penis. Penis is still red swollen with what appears to be a slit down the side with Foley cath protruding. The base of the penis has open area that was cleansed with warm soap and water, [MEDICATION NAME] applied, Resident complaining of pain." During an interview on 8/26/13 at 2:50 p.m., Licensed Staff F stated that upon her return on 7/28/13 she assessed the penis of Resident 1 and discovered that "His penis was spit open like a sausage." Licensed Staff F stated that she also relies on CNA's to inform her of resident problems. During an interview on 8/19/13 at 1 p.m., Family Member C stated that she was informed by the facility of a cut on the head of Resident 1's penis on 7/30/13. Family Member C stated that upon visiting Resident 1 on 7/31/13, she requested to see Resident 1's penis. Family Member C stated that the indwelling catheter was still inserted in the penis and Resident 1 had a cut on his penis the entire length of Resident 1's penile shaft. Family Member C stated that she confronted Administrative Staff A and Nurse Practitioner D who were both not aware that there was a cut the entire length of Resident 1's penile shaft. During an interview on 8/30/13 at 2:15 p.m., Nurse Practitioner D stated that I did not see Resident 1's penis again until 7/28/13 when she was informed of the cut on Resident 1's penis. During an interview on 10/22/13 at 2:55 p.m., Physician K stated that if the penile erosion were found sooner a suprapubic (A suprapubic catheter is a hollow flexible tube that is used to drain urine from the bladder. It is inserted into the bladder through a cut in the abdomen, a few inches below the navel in the abdomen) catheter could have been placed and the penile erosion could have been prevented. The facility's policy titled "Catheter Care, Urinary", dated October 2010, indicated that "The following information should be recorded in the resident's medical record: 1. The date and time that the catheter care was given. 2. The name and title of the individual (s) giving the catheter care. 3. All assessment data obtained when giving catheter care. 5. Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. 6. Any problems or complaints made by the resident related to the procedure. 7. How the resident tolerated the procedure. 9. The signature and title of the person recording the data". The facilities Policy and Procedure does not indicate how staff will follow up on conditions pertaining to drainage, redness, bleeding, irritation, crusting, or pain. During an interview on 10/9/13 at 1:30 p.m., Administrative Staff J stated that the facility does not have a policy for skin assessments or wound care but does have a policy for Pressure Ulcer Risk Assessment. The policy "Pressure Ulcer Risk Assessment", dated 10/2010, indicated that "Staff will maintain a "Skin alert", performing routine skin inspections daily or every other day as needed, Nurses are to be notified to inspect the skin if skin changes are identified", and "Once risk factors have been identified, proceed to the Care Area Assessment, care planning and interventions individualized for the resident and their particular risk factors."