Every finding on record at Newport Nursing and Rehabilitation Center

Based on interview, medical record review, and facility P&P review, the facility failed to protect the resident's right to be free from sexual abuse from other residents for one of three sampled residents (Resident 1) reviewed for abuse. * Resident 1 was standing by the nurses' station when Resident 2 approached and placed his left hand on Resident 1's left breast. This failure had the potential for psychosocial harm to Resident 1.Findings: Review of the facility's P&P titled Abuse Prohibition dated 4/2021 showed the facility prohibits abuse for all the residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is defined as abusive sexual behavior by one individual against another individual who is often a member of a vulnerable population. 1. a. Medical record review for Resident 1 was initiated on 8/10/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 7/2/26, showed the resident could make needs known but could not make medical decisions. Further review of Resident 1's medical record showed the resident suffered from paranoid schizophrenia. b. Medical record review for Resident 2 was initiated on 8/10/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 9/20/25, showed the resident could make needs known but could not make medical decisions. Further review of Resident 2's medical record showed the resident suffered from unspecified schizophrenia. Review of SOC 341 (document used to file a written report of suspected elder or dependent adult abuse) form dated 7/29/26, showed a Written Statement form attached to the SOC 341 form. The Written Statement form showed on 7/29/26 at approximately 0720 hours, Resident 2 was observed near the nursing station when the staff witnessed him intentionally placed his hand on Resident 1's breast and the hand stayed for three seconds. Resident 1 verbally responded by stating, Why are you touching me? Resident 2 released his hand as the staff verbally intervened as well. Resident 2 was immediately escorted to his room for assessment. Upon interview, and when asked if he had touched Resident 1's breast, Resident 2 responded, Because I liked it and wanted to. Resident 2 was educated regarding the facility's policy on appropriate interpersonal boundaries, including any non-consensual physical contact, particularly with private body areas was inappropriate and unacceptable. Resident 2 responded by saying he did not care. Review of Resident 2's IDT Note dated 7/29/26 at 1051 hours, showed Resident 2 had a history of having poor boundaries with residents and peers, requiring regular reminders and education about appropriate boundaries. The Progress Note further showed since admission, Resident 2 has touched several residents inappropriately, and had poor insight and high impulsivity and minimal concern about the consequences of his actions. The Progress Note also showed Resident 2 stated, I was horny. Resident 2 was unable to verbalize remorse about the situation or any insignt into why this behavior was inappropriate. Review of Resident 2's IDT Note dated 7/31/26 at 1157 hours, showed Resident 2 intentionally engaged in inappropriate physical contact with another resident by touching the resident's breast without consent. On 8/6/26 at 1030 hours, an interview for Resident 2 was conducted with the DON. The DON stated Resident 2 was counseled before about other people's personal space and this was the first time he crossed the line. According to the DON, before, Resident 2 would touch someone's arm or something, smal insignificant touches. The DON verified Resident 2 touched Resident 1's chest when there were a number of staff and resident around the nurse's station. The DON also verified the Activities Director saw the incident and told Resident 2 to stop, and Resident 2 removed his hand. When asked, Resident 2 informed RN 1 that he wanted to do it and he liked it. On 8/11/26 at 0815 hours, an interview was conducted with RN 1. RN 1 stated on 7/29/26 at approximately 0720 hours, Resident 1 was standing by the nurses' station waiting to color when Resident 2 approached Resident 1 and placed his left hand on Resident 1's left breast. RN 1 did not see the incident happen but the Activities Director witnessed the incident and immediately told Resident 2 to stop. According to the Activities Director, Resident 2's hand remained on Resident 1's breast for approximately 1-2 seconds then he removed his hand and walked away. RN 1 walked after Resident 2 who was walking in the direction of his room and RN 1 spoke with Resident 2 and informed him that the behavior was unacceptable and when asked why he did it, Resident 2 replied I wanted to and I liked it. On 8/11/26 at 1115 hours, an interview was conducted with the Activities Director. The Activities Director stated on 7/29/26 at approximately 0720 hours, Resident 1 was standing by the nurse's station waiting to color when Resident 2 approached Resident 1 and placed his left hand on the Resident 1's left breast. The Activities Director saw it happen and immediately told Resident 2 to stop and Resident 2's hand remained on Resident 1's breast for approximately 1-2 seconds then he removed his hand and walked away. The Activities Director stated that she remained with Resident 1 for safety while RN 1 walked after Resident 2. On 8/11/26 at 1315, an interview was conducted with the DON who verified Resident 2 did sexually abuse Resident 1 on 7/29/26 at approximately 0720 hours, when Resident 2 placed his left hand on the left breast of Resident 1. The DON verified that the facility failed to prevent the sexual abuse from happening and this had the potential to cause physical and emotional harm to Resident 1.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure one heavy-duty blender and one plastic blender used for the puree preparation was air dried and free of water residue prior to storing and stacking. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's kitchen.Findings: Review of the facility's Diet Type Report dated 12/4/25, showed 61 of 61 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Sanitization revised date 11/2022 showed all the utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. The seals, hinges and fasteners are kept in good repair. The plastic ware, China and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. The damaged or broken equipment that cannot be repaired is discarded. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 12/3/25 at 0927 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed:- four rubber spatulas with red handles were chipped, cracked at the edges and discolored;- one stainless steel whisk was deformed; and- one stainless steel whisk with purple-gray rubber handle was cracked and worn out. The DSS acknowledged the above findings and stated the spatulas should not be used because the chipped particles can get mixed with the resident's food. The DSS further stated the whisks should have been replaced and not used for infection control purposes. 2. Review of the facility's P&P titled Sanitization revised date 11/2022 showed all the equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 12/3/25 at 0927 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed:- two stainless steel scoops with black handles used for food portioning had dry, crusted residue and watermarks;- two stainless steel scoops with gray handles used for food portioning had dry, crusted residue and watermarks; and- one stainless steel scoop with a white handle used for food portioning had dry, crusted residue and watermarks. The DSS acknowledged the above findings and stated all the dirty and crusted scoops should have been washed for infection control purposes. 3. Review of the facility's P&P titled Sanitization revised date 11/2022 showed food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 12/3/25 at 0924 hours, during the initial kitchen tour, an observation, and concurrent interview was conducted with the DSS. One heavy-duty blender and one clear plastic blender used for puree preparation was still moist and wet with visible water inside and stored on top of the countertop shelf. The DSS verified the findings and stated all kitchen equipment should be air dried to prevent bacteria growth.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician's orders matched the medication label provided by the pharmacy for one of four nonsampled residents (Residents 58) reviewed for the medication administration. * The facility failed to ensure Resident 58's physician's order for haloperidol decanoate (antipsychotic medication) matched the instructions shown on the medication label provided by the pharmacy. This failure posed the risk for negative health outcome to the resident.Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. The medications are administered in accordance with prescriber orders, including any required time frame. Medical record review for Resident 58 was initiated on 12/4/25. Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's H&P examination dated 10/6/25, showed Resident 58 could make needs known, but could not make medical decisions. Review of Resident 58's Order Summary Report showed a physician's order dated 10/3/25, for Haldol decanoate intramuscular solution 100 mg/ml inject 2 ml (200 mg) intramuscularly one time a day every 14 days for schizophrenia. However, review of the medication label by the pharmacy showed instructions to administer Haldol decanoate 50 mg/ml inject 4 ml (200 mg) intramuscularly one time every 14 days. Review of Resident 58's admission MDS assessment dated [DATE], showed Resident 58 had a BIMS score of 13, meaning the resident's cognition was intact. On 12/4/25 at 1000 hours, a medication administration observation for Resident 58 was conducted with LVN 2 in the resident's room and with the IP present. LVN 2 verified she administered two syringes filled with 2 ml of Haldol decanoate 50mg/ml in each syringe. On 12/5/25 at 1445 hours, an observation, interview and concurrent medical record review for Resident 58 was conducted with LVN 2. LVN 2 verified Resident 58's physician's order for Haldol decanoate did not match the pharmacy label on the bottle. LVN 2 stated the physician's order and the pharmacy label should match to reduce the potential for medication errors. LVN 2 further stated the licensed nurses should have contacted the pharmacy or the physician for clarification. On 12/10/25 at 1425 hours, an interview was conducted with the Administrator, DON, and DSD. The Administrator, DON, and DSD were informed and acknowledged the above findings.

Based on observation, interview, and facility document review, the facility failed to ensure essential equipment were maintained in proper working condition. * The facility failed to ensure the serial number on the glucometer and the serial number on the Daily Quality Control Record for Medication Cart A was accurate. * The facility failed to ensure the glucometer for Medication Cart B was calibrated and quality control was performed. These failures had the potential for the residents requiring blood glucose checks to have inaccurate readings.Findings: Review of the facility's document Fora GD50 Glucose Monitoring System Manual, undated, showed blood glucose monitoring plays an important role in diabetes control. Long-term study showed that maintaining blood glucose levels close to normal can reduce risk of diabetes complications by up to 60%. The results provided by this system can help the healthcare professional monitor and adjust treatment plan to gain better control of diabetes. The meter provides you with plasma equivalent results. The manual further showed the control solution contains a knowns amount of glucose that reacts with the test strips and is used to ensure meter and test strips are working together correctly. 1. On 12/8/25 at 1030 hours, an inspection of Medication Cart A, interview and concurrent facility document review was conducted with LVN 1. Review of Medication Cart A's Daily Quality Control Record for December 2025 showed the glucometer serial number on the Daily Quality Control Record 428622027000812C, did not match the glucometer serial number 4286223230001023. LVN 1 verified the above findings and stated the license nurse changed the glucometer but did not update the Daily Quality Control Record. LVN 1 further stated glucometers and the Daily Quality Control Record should match to ensure the residents' blood glucose checks are accurate. 2. On 12/3/25 at 1147 hours, an inspection of Medication Cart B, interview and concurrent facility document review was conducted with LVN 2. LVN 2 stated the license nurses on night shift (2300 to 0700 hours shift) perform glucometer checks to ensure accurate blood glucose readings of the residents. Review of Medication Cart B's Daily Quality Control Record for December 2025 showed on 12/3/25 at 12 AM, the low control reading was 52 and high control reading was 295. The glucometer did not show a low control reading of 52 and high control reading of 295. LVN 2 verified the above findings. On 12/3/25 at 1215 hours, an inspection of Medication Cart B's glucometer, interview, and concurrent facility document review was conducted with RN 1. RN 1 verified the glucometer did not show the low control glucose reading of 52 and the high control glucose reading of 295. RN 1 stated glucometers were calibrated and quality control was completed to ensure the functionality of the glucometer device. On 12/10/25 at 1425 hours, an interview was conducted with the Administrator, DON, and DSD. The Administrator, DON, and DSD were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the refuse was stored in a sanitary manner. * The facility failed to ensure the garbage was properly stored in one of three garbage dumpsters. This failure had the potential to attract pest/rodents that carried diseases.Findings: According to the 2022 FDA (Food and Drug Administration) Food Code, the outside garbage 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. Review of the facility's P&P titled Sanitization revised date 11/2022 showed kitchen wastes that are not disposed of by mechanical means are kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/ compactors with lids (or otherwise covered). Areas used for garbage disposal are free from odors and waste fats and maintained to prevent pests. On 12/3/25 at 1501 hours, an observation and concurrent interview was conducted with the Environmental Services Director. One of three garbage dumpsters was observed with the lid partially propped open by the cardboard boxes, preventing the lid from fully closing. The Environmental Services Director verified the findings and stated the dumpster lids should be completely closed at all times for infection control purposes.

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the P&P for the Outside Food met the current federal regulation. This failure had the potential to cause foodborne illnesses to the medically vulnerable residents population who received food items from outside sources.Findings: Review of the CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from the visitors, family, friends, or other guests according to their rights to make choices. According to the Code of Federal Regulations, Section S483.60(i)(3) Food Safety Requirements, the facility must have a policy regarding use and storage of food brought to residents by family and other visitors to ensure safe and sanitary, handlings, and consumption. However, review of the facility's P&P titled Behavioral Health Outside Food revised 9/6/24, showed under Storage, the food brought into the facility cannot be stored or saved. The P&P further showed the food brought by the visitors must not be stored or kept in residents' personal areas. On 12/3/25 at 0945 hours, an interview with the DSS was conducted. The DSS stated the facility did not have a refrigerator to store the residents' food items brought in from outside sources. The DSS further stated the food items brought in from outside sources were for immediate consumption. On 12/10/25 at 1344 hours, an interview was conducted with RNA 1. RNA 1 stated the residents were not allowed to bring food from the outside sources and/or store them for later consumption. RNA 1 stated the families could order food from the outside sources for the residents for same day consumption. RNA 1 further stated the facility did not have a refrigerator to store the residents' food items brought in from outside sources. On 12/10/25 at 1525 hours, an interview was conducted with the RN 2. RN 2 acknowledged the above findings and stated the food items brought in for the residents from the outside sources had to be sealed and were for immediate consumption. RN 2 further stated the residents were not allowed to store food items brought in from outside sources for later consumption and the facility did not have a refrigerator designated for the residents to store these food items.

Based on observation, interview, and facility P&P review, the facility failed to store the drugs, biologicals, and medical supplies in a safe manner. * The facility failed to ensure LVN 2 did not leave two syringes filled with two ml Haldol decanoate (antipsychotic medication) unattended at Resident 58's bedside. * The facility failed to ensure the medications in the bin for the medication disposal in Medication Room A were properly stored and disposed of. These failures had the potential for the medications to be accidentally administered or used inappropriately.Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications should only be removed from the cart at the time of administration and must not be left unattended. Review of the facility's P&P tiled Discarding and Destroying Medications revised 6/2025 showed both controlled and non-controlled substances may be disposed of in the collection receptacle. The collector is responsible for managing the collection receptacles, including picking up and properly disposing of medications collected in the receptacles. For unused, non-hazardous controlled substances not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below:a. Take the medication out of the original containers.b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. 1. Medical record review for Resident 58 was initiated on 12/3/25. Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's H&P examination dated 10/6/25, showed Resident 58 could make needs known, but could not make medical decisions. Review of Resident 58's admission MDS assessment dated [DATE], showed Resident 58 had a BIMS score of 13, indicating intact cognition. Review of Resident 58's Order Summary Report for December 2025 showed the following a physician's order dated 10/3/25, to administer Haldol decanoate intramuscular (injecting medication or vaccine directly into the muscle tissue) solution 100 mg/ml, give two ml (200 mg) intramuscularly one time a day every 14 days for schizophrenia (a mental illness that affects how a person thinks, feels, and behaves). On 12/4/25 at 1000 hours, a medication administration observation was conducted with LVN 2 in Resident 58's room, with the IP present. LVN 2 was observed with two syringes filled with two ml of Haldol decanoate medication for Resident 58. While in Resident 58's room, LVN 2 drew the curtains for privacy and stated she was going to use the resident's bathroom to perform hand hygiene. The IP was observed standing next to the resident's bathroom door behind the curtains and Resident 58 was not within the eyesight of the IP. Upon returning from the resident's bathroom, LVN 2 was observed without the two syringes of the Haldol decanoate medication. The two medication filled syringes were observed on Resident 58's bed unattended. On 12/4/25 at 1017 hours, an interview was conducted with LVN 2. LVN 2 verified she returned from Resident 58's bathroom without the two medication filled syringes. LVN 2 stated she thought the IP would watch the medication when she left to perform hand hygiene. LVN 2 then stated, she should have brought both of the syringes with her and stated the medications were not to be left unattended at the resident's bedside. LVN 2 stated leaving the medications unattended at bedside had the risk of the residents administering the medications inappropriately. LVN 2 stated Resident 58 could not self-administer the medications and stated the resident would need assistance with medication administration. On 12/4/25 at 1019 hours, an interview was conducted with the IP, with LVN 2 present. When the IP was asked if he maintained observation of Resident 58's two medication filled syringes while LVN 2 left the room to perform hand hygiene, the IP stated he did not. The IP verified he was behind the curtains and not within the eyesight of the two medication filled syringes. The IP then asked LVN 2, you did not have the medications with you when you washed your hands? The IP verified the two syringes filled with the Haldol deanoate medication were left unattended at Resident 58's bedside. 2. On 12/3/25 at 1119 hours, an observation and concurrent interview was conducted with RN 1 in Medication Room A. Multiple, unidentified whole pills were observed in the medication disposal bin. Further observation showed the lid of the medication disposal bin was not secured. RN 1 verified the findings and stated the medications should be secured and diluted with fluids to ensure the medications were properly disposed of. On 12/3/25 at 1142 hours, an observation and concurrent interview was with the DON in Medication Room A. The DON verified the above findings. The DON stated she expected the licensed nurses to mix the disposed tablets with fluids to ensure the disposed medications were dissolved. On 12/10/25 at 1425 hours, an interview was conducted with the Administrator, DON, and DSD. The Administrator, DON, and DSD were informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by a resident for one nonsampled resident (Resident 31) investigated for abuse. * Resident 31 was hit on the left eyebrow by another resident (Resident 32), resulting in a small laceration with bleeding. Resident 32 was identified with a history of attacking others out of anger due to delusions. However, there were no specific interventions in the care plan regarding the attacking behavior. This failure had the potential for not protecting the resident and negatively impact the resident's well-being.Findings: 1. Review of the facility's P&P titled Abuse Prohibition and Prevention dated 11/2017 showed the facility strives to provide an environment which prohibits and prevents abuse, neglect, and exploitation of residents and misappropriation of resident property. The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self- injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 12/9/25, showed a resident to resident altercation between Residents 31 and 32 was reported by the Administrator. On 12/9/25 at around 0835 hours, Resident 32 was at the water station and was getting water while Resident 31 was behind him waiting to get water. Resident 31 was awaiting to take his supplement with water from LVN 2. Resident 31 asked LVN 2 if he could get some water and verbalized Resident 32 had five cups of water. Resident 32 turned and stated he had only two cups of water. Resident 31 replied to Resident 32 cool, and Resident 32 said we cool with a blank stare and closing the distance between them and then hit Resident 31 in the left eyebrow. Resident 31 sustained a slight cut. A code green (an emergency alert for behavioral issues) was initiated and both residents were immediately separated. Resident 32 was taken outside to cool off with the Administrator and the behavioral clinician while Resident 31 was taken to his room and was assessed by the nurses who immediately addressed his eyebrow cut. Review of the facility's Patient-to-Patient Aggression Five-Day Follow-Up Report dated 12/10/25, showed the facility had notified the conservators of Residents 31 and 32. Resident 32 had a diagnosis of Schizophrenia, with episodes of anger and striking out with delusions. Corrective actions and follow-up implemented were:- Immediate 1:1 observation was implemented for Resident 32 following the assault;- Both residents were put on every 15 minutes monitoring of behavior and location for 72 hours;- [NAME] Beach Police Department was engaged, and proper documentation was completed (case number was provided)- Post-incident monitoring for Resident 31 was implemented, and the resident remained stable; and- An additional water station was added for Cart 2 to separate the residents a little more. a. Medical record review for Resident 31 was initiated on 12/9/25. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's H&P examination dated 6/5/25, showed Resident 31 could make needs known but could not make medical decisions, and had a significant diagnosis of schizoaffective disorder with catatonia (a disorder which disrupts a person's awareness of the world around them). Review of Resident 31's MDS assessment dated [DATE], showed Resident 31 was cognitively intact. Further review of the MDS assessment showed Resident 31 had no behavioral symptoms exhibited such as physical behavioral symptoms directed toward others (for example-hitting, kicking, pushing, scratching, grabbing, or abusing others sexually) and verbal behavioral symptoms directed toward others (for example-threatening others, screaming at others, or cursing at others). Review of Resident 31's eInteract Change in Condition Evaluation dated 12/9/25, showed at 0845 hours, Resident 31 was punched by another resident. Resident 31 stated he needed to drink water to take his medications while another resident took his time to drink water. A body assessment of Resident 31 was performed by the nurse. Resident 31's vital signs were within normal limits. Resident 31 obtained laceration to left side of eyebrow with scant bleeding and was treated with triple antibiotic and icepack. Resident 31's nurse practitioner was notified and no new order given. A neurological assessment was initiated for 72 hours to assess delayed injury for Resident 31. b. Medical record review for Resident 32 was initiated on 12/9/25. Resident 32 was admitted to the facility on [DATE]. Review of Resident 32's H&P examination dated 9/20/25, showed Resident 32 could make needs known but could not make medical decisions, and had a significant diagnosis of schizoaffective disorder. Review of Resident 32's plan of care initiated on 9/24/25, showed a care plan problem addressing Resident 32's history of attacking people out of anger due to delusions. However, there were no specific interventions included in the care plan regarding the behavior of attacking other people. Review of Resident 32's MDS assessment dated [DATE], showed Resident 32 had moderate impaired cognition. Further review of the MDS assessment showed Resident 32 had no behavioral symptoms exhibited such as physical behavioral symptoms directed toward others (for example-hitting, kicking, pushing, scratching, grabbing, or abusing others sexually) and verbal behavioral symptoms directed toward others (for example-threatening others, screaming at others, or cursing at others). Review of Resident 32's eInteract Change in Condition Evaluation dated 12/9/25, showed at 0845 hours, Resident 32 was drinking water after taking morning medications when another resident came close to take water. Resident 31 was triggered due to another resident getting too close to him and punched the other resident on the left side of the eyebrow. Resident 31 was put on every 15 minutes monitoring. On 12/9/25 at 1130 hours, an observation and concurrent interview was conducted with Resident 31. Resident 31 was observed with band aid in his left eyebrow. Resident 31 stated it was his first time to be hit by another resident in the facility. Resident 31 stated he was waiting in line in the water station for Resident 32 to finish getting and drinking water because he had to take his medications. Resident 31 stated he asked LVN 2 if he could get water since Resident 32 had been drinking a lot of water from the water container. Resident 31 stated he told Resident 32 that there were also other residents who needed to drink water and then Resident 32 suddenly hit him on the left side of his face. Resident 31 stated he obtained a cut in his left eyebrow, and it was bleeding at that time. Resident 31 stated the facility staff separated them immediately. Resident 31 further stated he was feeling fine, and he just informed his nurse if possible, during mealtime in the dining area if he could be seated at a table far away from Resident 32. On 12/9/25 at 1408 hours, an observation and concurrent interview was conducted with Resident 32. Resident 32 stated he was getting water when resident 31 came to him and told him not to get water and to watch out. Resident 32 stated he drank some more water, filled up another cup of water then Resident 31 told him to hurry up. Resident 32 admitted he hit Resident 31 on his cheek, and he just backed away. Resident 32 stated the facility staff separated them immediately after the incident. Resident 32 stated it was his first incident of hitting someone in the facility and he had no thoughts of hurting others again. Resident 32 further stated he apologized to Resident 31 and told him it would never happen again. On 12/9/25 at 1426 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 32 was alert and oriented times 2-3 and able to make his needs known. LVN 2 stated it was the first time Resident 32 exhibited aggression in the facility. LVN 2 stated the resident to resident altercation between Residents 31 and 32 occurred this morning at around 0845 hours. LVN 2 stated she was in her medication cart when Resident 32 was getting water from the water station and Resident 31 was making multiple remarks regarding Resident 31's too much water drinking. LVN 2 stated she could not intervene on time. LVN 2 stated she tried to stop both residents from arguing and called for help, but unfortunately Resident 32 was quick and hit Resident 31 in the face. On 12/10/25 at 1100 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated Resident 32 was alert with confusion, delusions, and could be agitated. RN 2 stated Resident 32 apologized to Resident 31, was referred to the behavioral clinician for follow-up monitoring, was seen by the psychiatrist on 12/9/25, after the incident, was given a dose of prescribed anti-anxiety medication, and was placed on 1:1 monitoring to ensure his safety and other residents. RN 2 stated Resident 31 never had any argumentative issue with other residents. RN 2 stated Resident 31 was assessed immediately by the nurses after the incident and was on continuous monitoring for change in condition, was seen as well by the psychiatrist. RN 2 further stated both residents were being followed up by the social worker and were on every 15 minutes monitoring for their behavior and location to ensure safety.

Based on interview and facility P&P review, the facility failed to report an abuse allegation to the CDPH and law enforcement for an unidentified number of residents investigated for abuse. * The facility failed to report an allegation of excessively rough staff providing care to the residents. This failure of not reporting abuse allegation had the potential to put the residents at risk for further abuse. Findings: Review of the facility's P&P titled Abuse Prohibition and Prevention dated 11/2017, showed the facility has policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property. The purpose is to assure the facility is doing all that is within its control to prevent occurrences. The P&P further showed the facility personnel will investigate different types of incidents including:a. Identification of staff member(s) responsible for the initial reporting;b. Investigation of alleged violations; andc. Reporting of results to the proper authorities.The facility will provide protection of residents from harm during an investigation including, but not limited to:a. Suspension of facility personnel involved in the suspected or actual abuse allegation;b. Separation of residents involved in a resident to resident altercation(s);c. Interventions to calm the situation and support the involved resident(s); andd. Measures to protect the resident in the event the alleged or suspected abuser is a person other than facility staff. Additionally, the P&P showed the facility shall report all alleged violations and all substantiated incidents:a. To the state agency and to all other agencies as required;b. And take all necessary corrective actions depending on the results of the investigation;c. Report to the state nurse aide registry or licensing authorities any knowledge it has of any action s by a court of law which would indicate an employee is unfit for service; andd. Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. The P&P further showed the facility shall ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than two hours after the allegation is made. Review of the SOC 341 - Report of Suspected Dependent Adult and/or Elder Abuse form dated 2/2024 showed the purpose of the form is to document the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult. Information to complete the form showed if any item of information nis unknown, enter unknown. Furthermore, the form showed any mandated reporter, who in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be abuse or neglect, or is told by an elder or dependent adult that he or she has experienced behavior constituting abuse or neglect, or reasonably suspects that abuse or neglect has occurred, shall complete this form for each report of known or suspected instance of abuse (physical abuse, sexual abuse, financial abuse, abduction, neglect (self-neglect), isolation, and abandonment) involving an elder or dependent adult immediately or as soon as practicably possible. Lastly, the form further showed to report to the local law enforcement agency, Ombudsman, and the California Department of Public Health. On 12/3/25 at 0827 hours, a telephone interview was conducted with Ombudsman A. Ombudsman A stated there were anonymous reports of two staff who were excessively rough with residents and favoritism. Ombudsman A stated the name of one CNA; however, was unable to provide the name of the other CNA named in the allegation. Ombudsman A stated the DSD was notified of the allegations on 11/24/25. Ombudsman A stated per the DSD, the facility did not have a CNA by the name provided by Ombudsman A. Ombudsman A then stated the DSD acknowledged the facility had two staff with the first name of one CNA and the last name of another CNA. On 12/3/25 at 0900 hours, an interview was conducted with the Administrator. The Administrator stated although he was not at the facility on the day Ombudsman A informed the DSD of the abuse allegation, he was made aware. The Administrator further stated he did not have a CNA by the name provided by Ombudsman A; however, there were two CNAs (CNAs 2 and 3) who each had a same name identified by Ombudsman A. CNA 2 had the same first name, and CNA 3 had the same last name as the alleged CNA in the abuse allegation. The Administrator stated the facility was not provided with a definitive name of the CNAs involved in the abuse allegation and believed the complaint was due to workplace gossip. Moreover, the Administrator denied reporting the allegation to CDPH or law enforcement agencies and stated the facility did not submit a SOC 341. On 12/3/25 at 0922 hours, an interview was conducted with the DSD. The DSD verified Ombudsman A notified him of the abuse allegation on 11/24/25, and stated CNA 2 had the same first name and CNA 3 had the same last name as the alleged CNA involved in the abuse allegation. The DSD further stated the abuse allegations by Ombudsman A were favoritism and rough handling of residents, and he reported the information to the Administrator. The DSD stated he investigated the abuse allegation and closed out the investigation after interviews with the residents and staff. When asked if CNAs 2 and 3 were still on schedule during the investigation process, the DSD stated yes and denied removing them off the schedule. The DSD stated the abuse allegations were to be reported to the Administrator, law enforcement, CDPH, Ombudsman, and DON. The DSD further added the SOC 341 form must be completed. When asked if allegation of the staff being excessively rough with residents was considered abuse, the DSD stated yes and the investigation process should be initiated as everyone is a mandated reporter. Moreover, the DSD denied completing a SOC 341 form and verified the abuse allegation reported by Ombudsman A was not reported to CDPH and law enforcement as per the facility's P&P. On 12/9/25 at 1435 hours, an interview was conducted with LVN 2. LVN 2 stated abuse allegations are reported to the Administrator, DON, police, Ombudsman, and CDPH. LVN 2 stated if staff were part of the abuse allegations, they would be sent home pending the investigation. When asked if an allegation of excessive roughness would be considered abuse, LVN 2 stated yes and stated she would report the allegation immediately to the Administrator. On 12/10/25 at 1425 hours, an interview was conducted with the Administrator, DON, and DSD. The Administrator verbalized disagreements with findings and stated Ombudsman A did not provide the correct names of the CNAs involved in the abuse allegation and stated the complaint originated from a disgruntled employee. When asked if the process of investigating an abuse allegation was to report and then investigate or investigate and then report, the Administrator, DON, and DSD acknowledged the process of reporting abuse was to report to the agencies as per the facility's P&P and investigate. The DON stated she understood the concerns and the facility should have reported the abuse allegation despite incomplete information by Ombudsman A and the facility could have continued with their investigation process. The Administrator, DON, and DSD were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to ensure LVN 3 performed appropriate hand hygiene during a medication administration observation. This failure put the residents at risk for increased risk of infection and transmissions of diseases.Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed medications are administered in a safe and timely manner, and as prescribed. The P&P further showed the staff follows established facility infection control procedures including handwashing and antiseptic techniques for the administration of medications. On 12/5/25 at 1600 hours, a medication administration observation and concurrent interview was conducted with LVN 3 at Medication Cart B. During the medication administration, LVN 3 did not perform hand hygiene before and after administering oral medications to Resident 25. LVN 3 verified he did not perform hand hygiene before and after administrating the medications to Resident 25 and to two other residents. LVN 3 stated he should have performed hand hygiene to ensure infection control protocols were maintained. On 12/10/25 at 1425 hours, an interview was conducted with the Administrator, DON, and DSD. The Administrator, DON, and DSD were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to maintain a safe and secured environment for two of five sampled residents (Residents 1 and 2).* The facility failed to ensure there were systems in place to prevent Residents 1 and 2 from eloping. This failure placed the residents at risk for harm or injury. Findings:Review of the facility's P&P titled Behavioral Health Elopement revised on 5/1/24, showed the definition of elopement as a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning or being struck by a motor vehicle.Review of the incident report of the DON dated 6/23/25, showed at approximately 1950 hours on 6/20/25, Residents 1 and 2 had left the premises through the west exit door.1. Closed medical record review for Resident 1 was initiated on 7/8/25. Resident 1 was admitted to the facility on [DATE], and discharged on 6/20/25. Review of Resident 1's Elopement Risk dated 3/26/25, showed Resident 1 was placed in a locked/secured (egress) facility. Review of the Resident 1's Care Plan Report initiated on 4/21/25, showed a care plan problem addressing the resident's risk for elopement related to involuntary placement and history of elopement.Review of Resident 1's MDS assessment dated [DATE], showed the resident was independent in making decisions regarding tasks of daily life. Review of Resident 1's eINTERACT Change of Condition Evaluation dated 6/20/25, showed Resident 1 was observed leaving AMA through the back door during the smoke break. The resident left the facility by kicking the exit door. 2. Closed medical record review for Resident 2 was initiated on 7/8/25. Resident 2 was admitted to the facility on [DATE], and discharged on 6/20/25.Review of Resident 2's H&P examination dated 6/19/25, showed Resident 2 could make needs known but could not make medical decisions.Review of Resident 2's eINTERACT Change of Condition Evaluation dated 6/20/25, showed Resident 2 was observed leaving through the alarmed back door during the smoke break. Resident 2 had a history of leaving the previous facility with her partner.Review of Resident 2's Care Plan Report initiated on 6/19/25, showed a care plan problem addressing the resident's risk for elopement related to involuntary placement.On 7/8/25 at 0925 hours, a video of the elopement incident on 6/20/25 was shown by the Administrator. Resident 2 was seen trying to climb over the white fence and Resident 1 was kicking the exit door. Both Residents 1 and 2 were able to get out of the facility through the exit door. After a minute or two, two facility staff were observed running after the residents.On 7/8/25 at 1016 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director showed the two exit doors in the smoking area. The Maintenance Director stated an alarm could be heard if the door was forcefully opened and without a key. On 7/9/25 at 0924 hours, an interview was conducted with Resident 5. Resident 5 stated he saw Resident 1 kick the exit door and left the facility with Resident 2. Resident 5 stated there was no licensed nurse or facility staff by the exit door. Resident 5 stated the facility staff then ran after Residents 1 and 2 when they heard the banging of the exit door.On 7/9/25 at 1034 hours, a telephone interview was conducted with CNA 1. CNA 1 stated Residents 1 and 2 were observed walking around the courtyard until the facility staff heard a big bang towards the back gate/exit door. CNA 1 then observed Residents 1 and 2 running through the exit door. CNA 1 stated the exit door would make an alarm sound when someone tried to open, push, or touch it. However, at the time when Residents 1 and 2 left through the exit door, the facility staff just heard the banging of the exit door, but no alarm sound was heard.On 7/9/25 at 1136 hours, an interview was conducted with MHW 2. MHW 2 stated the elopement incident happened around 1950 hours on 6/20/25. MHW 2 stated he heard a door banging. MHW 2 then ran towards the exit door and saw Residents 1 and 2 running towards the street. MHW 2 stated if the exit door was pushed open, an alarm would sound. However, at the time of the incident, MHW 2 stated he just heard the banging of the door, and no alarm sound was heard.On 7/9/25 at 1627 hours, a telephone interview was conducted with the Maintenance Director. The Maintenance Director stated he checked all the doors everyday, especially the exit doors. When asked if there was a maintenance log to show when the exit doors were checked for proper function, the Maintenance Director stated no. On 7/9/25 at 1640 hours, an interview was conducted with the Administrator and DON. The Administer and DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse when Resident 4 was punched in the face and all over the body at two separate incidents by Resident 3. This failure caused Resident 4 to sustain bleeding from his nose, redness above his right eyebrow and on the bridge of his nose, and a bluish/purplish discoloration on his left eye extending to his left cheekbone.Findings:Review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised 4/2021 showed the residents have the rights to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse.Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 7/7/25, showed Resident 3 physically assaulted Resident 4 by striking Resident 4 in the face. Shortly thereafter, Resident 3 physically assaulted Resident 4 a second time, striking Resident 4 multiple times in the body. Resident 4 sustained a bloody nose. a. Closed medical record review for Resident 3 was initiated on 7/8/25. Resident 3 was admitted to the facility on [DATE], and discharged to the acute care hospital on 7/6/25.Review of Resident 3's H&P examination dated 3/27/25, showed Resident 3 had the capacity to understand and make decisions. Resident 3 had a diagnosis of schizophrenia (chronic brain disorder that affects a person's ability to think clearly, manage emotions, make decisions and relate to others).Review of Resident 3's Order Summary Report from 3/27 to 7/7/25, showed a physician's order dated 6/25/25, to administer clozapine (antipsychotic medication) 300 mg by mouth at bedtime for schizophrenia. Review of Resident 3's progress notes showed the following:- On 7/2/25 at 1823 hours, Resident 3 was observed pacing and appearing more anxious. Resident 3 reported to the staff he was hearing auditory hallucinations, commanding him to annihilate the people who want to harm you (meaning the staff). Resident 3 was able to communicate to the staff when he was hearing voices. Resident 3 was administered Zyprexa (antipsychotic medication) 10 mg by mouth one time for auditory hallucinations. - On 7/3/25 at 1043 hours, Resident 3 verbalized to the licensed nurse he was feeling paranoid and hearing voices a little.- On 7/6/25 at 1341 hours, Resident 3 remained on every 15 minutes checks for safety. Resident 3 denied hearing voices and remained quiet and self-guarded. - On 7/6/25 at 1640 hours, RN 2 observed Resident 4 sitting in a chair close to the medication cart and Resident 3 walking in the hallway close to the nurse's station when Resident 3 punched Resident 4 in the face. Both residents were separated right away by the staff, and Resident 3 was brought to the dining area. When Resident 3 was asked about the incident, Resident 3 stated he was feeling paranoia (mental state characterized by intense suspicion and distrust of others) for the past two weeks. Resident 3 informed the staff that Resident 4 touched him on the back, so when he saw Resident 4 in the hallway, he punched Resident 4 in the face. Resident 3 was currently on close monitoring for change of behavior/mood/feeling. - On 7/6/25 at 1640 hours, when RN 3 interviewed Resident 3, Resident 3 stated for the past one to two weeks, he had been feeling paranoid and increased the thought that people were trying to harm him and did not feel safe around the other residents. Resident 3 stated Resident 4 was outside with him earlier in the day and had touched him on his back. Resident 3 stated he felt threatened but did not share his feelings with the staff or other residents. Resident 3 stated when he saw Resident 4 sitting on the chair by the nurse's station, he decided to react and defend himself against Resident 4. Resident 3 stated he punched Resident 4 on the left side of his cheek and eye. Resident 3 was placed on the one-to-one care by the staff. - On 7/6/25 at 1730 hours, RN 3 observed Resident 3 running at a high rate of speed and jumping on Resident 4 who was still sitting in a chair by the nurses' station. Resident 3 began punching Resident 4 all over his body multiple times. The CNA who was providing the one-to-one care for Resident 3 in the dining room was running behind Resident 3 but could not catch up with Resident 3 before Resident 3 jumped on Resident 4.Review of Resident 3's plan of care dated 7/6/25, showed a care plan problem addressing Resident 3's two episodes of aggressive behaviors (punching Resident 4 multiple times on the face and body). The interventions included safeguarding the others by removing Resident 3 from the situation and/or providing the one-to-one supervision and for the staff to position themselves closely to supervise the resident and peers when in high traffic areas and allow space between peers. b. Medical record review for Resident 4 was initiated on 7/8/25. Resident 4 was admitted to the facility on [DATE].Review of Resident 4's H&P examination dated 4/3/25, showed Resident 4 could make needs known but could not make medical decisions. Review of Resident 4's eINTERACT Change of Condition dated 7/6/25 at 1640 hours, showed Resident 4 was punched with a closed fist on the face on the left eye and cheek by Resident 3. The documentation further showed Resident 4 complained of pain at the level of 5 (on the pain scale of 0 to 10 with 0 = no pain and 10 = most pain) to his left cheek and left eye, indicating moderate pain. Review of Resident 4's Hospital Transfer Form dated 7/6/25, showed Resident 4 was sent to the acute care hospital. The reason for the transfer showed another resident had punched him multiple times all over his body, including his head, which caused bleeding from the nose.Review of Resident 4's progress notes showed the following:- On 7/6/25 at 1640 hours, Resident 4 was observed sitting on a chair in the hallway near the medication cart next to the nurses' station. Resident 3 was observed pacing back and forth in the hallway near Resident 4 when suddenly Resident 3 punched Resident 4 with a closed fist on Resident 4's left eye and left cheek. The CNA and the staff were able to separate Residents 3 and 4, and Resident 3 was taken to the dining room. - On 7/6/25 at 1700 hours, Resident 4 complained of pain at the level of 5 to his left eye and left cheek. The PRN pain medication was administered to Resident 4.- On 7/6/25 at 1730 hours, RN 2 heard a loud sound and observed Resident 3 running towards Resident 4 who was sitting on a chair by the medication cart close to the nurse's station. Resident 3 then punched Resident 4 multiple times all over the body, including the resident's head. Resident 4 was observed with a bloody nose and increased redness and swelling to his face. Resident 4 complained of a headache and thought his nose might be broken. Resident 4's physician was notified, and Resident 4 was transferred to the acute care hospital for further evaluation. - On 7/6/25 at 2355 hours, showed Resident 4 returned from the acute care hospital at around 2300 hours. Resident 4 was observed with the redness above his right eyebrow and on the bridge of his nose, and a bluish/purplish discoloration below his left eye extending to his left cheekbone. The acute care hospital's diagnosis included facial contusion (injured tissue or skin) and right wrist pain. - On 7/7/25 at 1312 hours, Resident 4 emerged from his room and asked the staff if the resident (Resident 3) who attacked him was in the facility. Resident 4 was concerned about the resident who attacked him and wanted to stay away from him.On 7/9/25 at 1026 hours, an observation and concurrent interview was conducted with Resident 4. Resident 4 was observed with a reddish and bluish discoloration on the left eye. When asked if his left eye hurt, Resident 4 stated, it still burns. Resident 4 was asked how he sustained the discoloration on his left eye, Resident 4 stated someone punched him in the face but did not know why the other person punched him. Furthermore, Resident 4 stated the incident happened two times, one before dinner and the other was after dinner. On 7/9/25 at 1328, a telephone interview was conducted with CNA 2. CNA 2 stated Resident 3 punched Resident 4's left side of the face. CNA 2 stated the first incident happened before the dinner in front of the nurses' station. The second incident happened after the dinner when Resident 3 ran from the TV room and hit Resident 4 multiple times in the body and face. CNA 2 stated he did not know which staff was supervising Resident 3 in the TV room. On 7/9/25 at 1502 hours, an interview was conducted with CNA 5. CNA 5 stated he did not observe the first incident when Resident 3 punched Resident 4. However, CNA 5 stayed with Resident 3 while the resident was in the dining area after the first incident. CNA 5 stated he sat behind Resident 3 in the dining room with a round dining table in between them. Resident 3 stood up and started pacing. When Resident 3 was closed to the door, CNA 5 asked the resident what he was doing and where he was going. Resident 3 then sprinted out of the dining room door and CNA 5 ran after the resident. Resident 3 then started punching Resident 4 close to the nurse's station.On 7/9/25 at 1456, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to prevent the development and transmission of diseases and infections. * The facility failed to show documentation of the Legionella facility risk assessment and testing protocols for Legionella and other opportunistic waterborne pathogen. * CNA 1 failed to remove the gown and gloves and perform hand hygiene after touching Resident 498 and before touching Resident A's environment. * The facility failed to ensure a N95 respirator was stored in a sanitary manner, at the entrance to a resident COVID-19 isolation room. * CNA 6 placed Resident 298's shower bin (which contained a clean towel and bathrobe belt) on top of a soiled linen cart during Resident 298's shower. * The residents' clean linen cart was observed with several bath robe belts lying on top of the clean linen cart. These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility. Findings: 1. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17, the facilities must develop and adhere to the policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; - Develops and implements a water management program that considers the ASHRAE (American Society of Heating Refrigerating and Air-Conditioning Engineers) industry standards and the CDC (Centers for Disease Control and Prevention) toolkit; and - Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. Review of the facility's P&P titled Legionella Water Management Program revised 9/2022 showed as part of the infection prevention and control program, the facility has a water management program. The purposes of the water management program were to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. Further review of the facility's P&P showed the water management program includes the following elements: b. A detailed description and diagram of the water system in the facility, including the following: 1. Receiving; 2. Cold water distribution; 3. Heating; 4. Hot water distribution; and 5. Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: 1. Storage tanks; 2. Water heaters; 3. Filters; 4. Aerators; 5. Showerheads and hoses; 6. Misters, atomizers, air washers and humidifiers, 7. Hot tubs; 8. Fountains; and 9. Medical devices such as CPAP machines, hydrotherapy equipment, etc.; d. The identification of situations that can lead to Legionella growth; e. Specific measures used to control the introduction and/or spread of Legionella; f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program. The facility failed to show documentation a facility risk assessment was conducted to identify, test, and prevent Legionella and other opportunistic waterborne pathogens in the facility. On 12/5/24 at 1416 hours, the Administrator was asked about the facility's diagram of the water system entering the facility and identified areas of potential pathogen growth and spread. The Administrator stated the facility did not have a flow chart of the water system entering the facility and the water fountain located outside the facility was the only identified risk. On 12/5/24 at 1435 hours, an interview was conducted with the EVS Director. The EVS Director stated his role in the water management program was to check and clean the water fountain weekly. The EVS Director stated the facility had four water heaters, two shower rooms with two shower heads in each room, and an ice machine. The EVS Director stated an outside source comes to the facility to test the water fountain and stated the company did not test any other areas in the facility. The EVS Director was asked if he tested for Legionella or other potential pathogens in areas that are potential risks for standing water and the EVS Director stated he did not conduct any testing protocols. On 12/5/24 at 1612 hours, a follow-up interview was conducted with the Administrator. The Administrator stated the purpose of the water management program was to monitor for and check surfaces/areas in the facility that have the potential to have Legionella growth. The Administrator reviewed the facility's P&P and CDPH's AFL 18-39 and verified the above findings. On 12/5/24 at 1701 hours, the Administrator and DON were informed and acknowledged the above findings. 2. Medical record review for Resident 498 was initiated on 12/2/24. Resident 498 was admitted to the facility on [DATE]. Review of Resident 498's Order Summary Report showed a physician's order dated 11/26/24, to provide EBP for high contact resident care activities related to indwelling medical devices: g-tube; Foley catheter; to perform hand hygiene and apply PPE: gloves, gown and/or goggle/face shield worn if risk of splash or spray during high contact resident care activities; to remove PPE and perform hand hygiene prior to exiting the room to prevent the transmission of MDROs. On 12/2/24 at 0935 hours, a concurrent observation and interview was conducted with CNA 1 in Resident 498's room. CNA 1 was observed wearing a gown and gloves and touched Resident 498's arm to check for Resident 498's identification verification band. CNA 1 verified Resident 498 was not wearing an ID band and was observed placing the ID band on Resident 498. CNA 1 was then observed going to Resident A's bedside to remove the diaper from the diaper package and was observed touching Resident A's bed linen. CNA 1 was not observed removing her gown or gloves after contact with Resident 498 and before coming in contact with Residents A's environment. CNA 1 verified she did not change her gown and gloves and did not perform hand hygiene before assisting Resident A. CNA 1 stated she needed to change the PPEs and perform hand hygiene between the residents to avoid contamination. On 12/4/24 at 1517 hours, an interview was conducted with the IP. The IP stated for the residents placed on enhanced barrier precautions, the staff members were expected to perform hand hygiene and don gown and gloves for high contact activities, when changing linen/perineal care, transferring, or during contact with the resident, to prevent the transfer of MDROs. The IP stated the staff member were expected to change gown and gloves in between the residents and if the gown and gloves were not changed in between the residents, there may be the risk of transmission of infection. On 12/5/24 at 0947 hours, an interview was conducted with the DON. The DON stated for the residents on enhanced barrier precautions, gowns and gloves were needed when touching the resident or their linens. The DON stated staff members were expected to remove the gown and gloves before working with another resident to prevent the contamination from one resident to the next. On 12/5/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the above findings. 37726 3. On 12/2/24 at 0825 hours, a concurrent observation and interview was conducted with RN 2. Resident Room A was observed with a plastic container (which contained PPE) located at the entrance of the room. An N95 respirator was observed unpackaged lying on top of the plastic PPE container. RN 2 stated Resident Room A was currently being used to isolate residents who tested positive for COVID-19. RN 2 was asked to whom the N95 respirator belonged and if it was used or unused. RN 2 stated she did not know if the N95 respirator belonged to a resident, a resident family member, or a facility staff member. RN 2 stated she was uncertain as to whether the N95 respirator had been used or not. RN 2 stated if the N95 respirator had been used it should not be stored on top of the plastic PPE container and should have been discarded, to ensure infection control. Furthermore, RN 2 stated if the N95 respirator had not been used it needed to be stored in a clean package and should not be stored on top of the plastic PPE container, for infection control. On 12/5/24 at 1337 hours, an interview was conducted with the IP. The IP stated the used N95 respirators needed to be discarded. The IP stated clean N95 respirators needed to be stored in the original packaging or when distributed for staff use, the N95 respirator would be stored in a clean bag. The IP stated these facility practices were to avoid the transfer of pathogens. 4. On 12/2/24 at 0755 hours, a concurrent observation and interview was conducted with CNA 6. CNA 6 was observed inside the residents' shower room. CNA 6 stated she had just finished assisting Resident 298 take a shower. Resident 298's plastic bin was observed lying on top of the soiled linen cart. CNA 6 verified Resident 298's plastic bin contained a clean towel and a clean bathrobe belt. CNA 6 stated she had placed Resident 298's plastic bin on top of the soiled linen cart while assisting Resident 298 with his shower. CNA 6 stated the soiled linen cart was located close to the location where Resident 298 had showered, which allowed her access to the contents of Resident 298's bin throughout his shower. CNA 6 verified the soiled line cart contained soiled linen. On 12/5/24 at 1337 hours, an interview was conducted with the IP. The IP stated the resident's shower bins which contained clean linens (towels, resident bath robes, and bath robe belts) should not be stored on top of the soiled linen cart for infection control. 5. On 12/2/24 at 0755 hours, a concurrent observation and concurrent interview was conducted with CNA 6. A clean linen cart which contained clean resident towels, bathrobes, and bathrobe belts was observed inside of the shower room. Several bathrobe belts were observed lying on top of the clean linen cart. CNA 6 verified the findings and stated the resident bathrobe belts had yet to be used by the residents and should have been stored inside the clean linen cart for infection control. On 12/5/24 at 1337 hours, an interview was conducted with the IP. The IP stated the clean residents bathrobe belts should not be stored on top of the clean linen cart for infection control.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the microwave utilized to warm up the food was in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the countertop mounted can opener was in sanitary condition and free of residue. * The facility failed to ensure the heavy-duty blender used for puree preparation and the stainless-steel bucket were cleaned and air dried prior to storing. * The facility failed to ensure the expired foods were discarded. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Patient Diet List dated [DATE], showed 39 of 41 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Ice Machine and Storage Chests revised date ,d+[DATE] showed the ice machines and ice storage/ distribution chests will be used and maintained to assure a safe and sanitary supply of ice. Clean and sanitize the ice machine per manufacturer's guidelines. The Maintenance Director/ designee will maintain a copy of these procedures; including a cleaning log. According to the USDA Food Code 2017, Section ,d+[DATE].11, the equipment food-contact surfaces and utensils shall be clean to sight and touch. On [DATE] at 0850 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Environmental Services Director. The ice machine's interior top portion to the water curtain located directly above the ice bin, was observed with pinkish residue. The Environmental Services Director acknowledged the findings and stated was unknown what the pink residue from, and the ice would not be used because it was dirty and to prevent cross contamination. 2. Review of the facility's P&P titled Cleaning Instructions: Microwave Oven dated 2023 showed the microwave oven will be kept clean, sanitized, and odor free. The microwave oven interior should be cleaned after each use as needed, and at minimum, after each meal service. According to the USDA Food Code 2017, Section ,d+[DATE].11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On [DATE] at 0905 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The microwave on a stainless-steel shelf was observed dirty with dry, crusted food residue inside the microwave's door and had dry food residue inside the microwave. The Dietary Supervisor verified the findings and stated the microwave should have been clean daily after each used and deep cleaned weekly by the Dietary staff. 3. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed all food service equipment should be cleaned, sanitized, air-dried and reassembled after each use. According to the USDA Food Code 2022 Section ,d+[DATE].11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On [DATE] at 0905 hours, during the kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The kitchen hood over the stove had black, grease residue. The Dietary Supervisor acknowledged the findings and stated the dietary staff member cleaned the hood once a week to prevent grease residue from dropping into the food and cleaned every six months by an outside company and was last serviced on [DATE]. 4. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed the plastic-ware or dishware that has lost its glaze or is chipped or cracked must be disposed of. According to the USDA Food Code 2022 Section ,d+[DATE].11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts ,d+[DATE] and ,d+[DATE] or shall be discarded. According to the USDA Food Code 2022, Section ,d+[DATE].11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On [DATE] at 0752 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The following was observed and verified by the Dietary Supervisor: - Two stainless whisk with gray/ purple handles were worn out, rubber handles were chipped and cracked. - One white basting brush used for butter was worn out and bristles was frayed. - Three mesh strainers were deformed and worn out with rusty discoloration. - One black rolling pin used to make pizza had degraded coating, handles peeling and worn out. - One black egg slicer was worn out, discolored, dirty, and had dry crusted food residue. - Three rubber spatulas with red handles were dirty, discolored and had chipped edges. - One stainless steel spatula with black handle was partially burnt. - One stainless steel spatula with wooden handle discolored and partially burnt. - One dough cutter/ scraper with wooden handle was worn out, discolored and had uneven edges. The Dietary Supervisor acknowledged the above findings and stated all should not be use, will be discarded and replaced because it could get mix with the food and cause cross contamination. 5. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed all the food service equipment should be cleaned, sanitized, air-dried and reassembled after each use. Review of the facility's P&P titled Handling Clean Equipment and Utensils dated 2023 showed clean equipment and utensils will be handled properly to prevent contamination. According to the USDA Food Code 2022, ,d+[DATE].11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, ,d+[DATE].13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On [DATE] at 0905 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The following was observed and verified by the Dietary Supervisor: - One stainless whisk with gray/ purple handle had dry, crusted black residue. - Three rubber spatulas with red handles were dirty and had dry food residue. - Two stainless steel slotted spoons were dirty and had dry, crusted residue. - Two cutting knives with black handles were dirty, fuzzy with cloudy stains on the blades. - One stainless steel spatula with wooden handle was dirty and had dry water spots. - One black egg slicer was dirty and had dry food residue. - One small size stainless steel bucket was dirty and had dry water spots. The Dietary Supervisor acknowledged the above findings and stated it needed to be washed to prevent from residue getting mix with food, prevent food contamination and some needed to be discarded and replaced. 6. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed separate the cutting boards for raw and uncooked food and for raw fruits and vegetables will be used. The cutting boards should be of hard rubber construction (not wood) and must be dishwasher safe. The cutting boards should be cleaned and sanitized after each use, following the dish machine or three compartment sink method and will be air dried before storing. According to the USDA Food Code 2022, Section ,d+[DATE].12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On [DATE] at 0752 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The white and green cutting boards were observed discolored, fuzzy, heavily marred and had deep groves. The Dietary Supervisor verified the findings and stated the cutting boards were not acceptable and should have been discarded and replaced. 7. Review of the facility's P&P titled Cleaning Instructions: Can Opener dated 2023, showed the can opener will be cleaned after each use. According to the USDA Food Code 2017, Section ,d+[DATE].11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On [DATE] at 0905 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The countertop mounted can opener had rusty discoloration on the blade and peeled coating. The Dietary Supervisor verified the findings and stated the can opener would not be used to avoid food contamination. 8. Review of the facility's P&P titled General Food Preparation and Handling dated 2023 showed all food service equipment should be cleaned, sanitized, air-dried and reassembled after each use. According to the USDA Food Code 2022, ,d+[DATE].11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, ,d+[DATE].11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On [DATE] at 0905 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The following was observed and verified by the Dietary Supervisor: - One heavy-duty blender stored on the counter shelf was still wet with visible water inside and had white food residue inside. - One medium size stainless steel bucket stored wet. The Dietary Supervisor acknowledged the above findings and stated it needed to be washed and air dried to prevent bacteria growth and food contamination. 9. Review of the facility's P&P titled Food Storage dated 2023 showed all foods should be covered, labeled and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. According to the FDA Food Code 2017, Section ,d+[DATE].17 Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking: Marking the date or day the original container is opened with a procedure to discard the food on or before the last date by which the food must be consumed. On [DATE] at 0752 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Supervisor. The following was observed and verified by the Dietary Supervisor: - One small bowl of egg salad stored in the refrigerator dated [DATE]. - Multiple individual fruit cups covered w/ saran wrap all placed in a gray serving tray stored in the refrigerator with label showed, Item: Fruit, Prep date [DATE] and use by date [DATE]. - Multiple styrocups w/ prunes and apple sauce all placed in a gray serving tray stored in the refrigerator with label showed, Item: Prunes & Apple sauce, Prep date [DATE] and use by date [DATE]. - Multiple styrocups w/ pudding all placed in a gray serving tray stored in the refrigerator with label showed: Item: Reg pudding, Prep date [DATE] and use by date [DATE]. The Dietary Supervisor verified the above findings and stated above items should have been labeled accurately and expired items should have been discarded. On [DATE] at 1700 hours, the DON and the Administrator was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure LVN 1 informed the physician of a change in condition for one of three sampled residents (Resident 598) reviewed for falls. This failure had the potential for Resident 598 to have a delay in care and treatment. Findings: Review of the facility's P&P titled Neurological Assessment (Routine) revised 10/2023 showed a routine neurological assessment is conducted to evaluate the resident for small changes over time that may be indicative of neurological injury. Routine neurological exams include assessing the mental status and level of consciousness, pupillary response, motor strength, sensation, and gait. Under the section Pupillary Response, showed to test both the pupils to ensure they are equally round and reactive to light and accommodation. Under the section Reporting, showed to notify the physician of any change in a resident's neurological status and report other information in accordance with facility policy and professional standards of practice. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changed in the resident's medical/mental condition and/or status. The nurse would notify the resident's attending physician or physician on call when there has been a (an): accident or incident involving the resident, discovery of injuries of an unknown source, adverse reaction to medication, significant changes in the resident's physical/ emotional/mental condition, need to alter the resident's medical treatment significantly Medical record review for Resident 598 was initiated on 12/2/24. Resident 598 was admitted to the facility on [DATE]. Review of Resident 598's MDS assessment dated [DATE], showed Resident 598 had severely impaired cognition. Review of Resident 598's plan of care showed a care plan problem initiated on 11/30/24, addressing Resident 598's unwitnessed fall on 11/30/24. The interventions showed to initiate the neurological checks via neurological evaluations for 72 hours: every 15 minutes x 4 (four times), every 30 minutes x 4, every one hour x 4, and every eight hours x 8. Review of Resident 598's Neurological/Vital Sign Check- V 4 on 11/30/24 at 1400 hours, showed the nurse documented Resident 598's right and left pupils were equal. Review of Resident 598's Neurological/Vital Sign Check- V 4 on 11/30/24 at 1600 hours, showed the nurse documented Resident 598's right and left pupils were equal. Review of Resident 598's Neurological/Vital Sign Check- V 4 on 12/1/24 at 0600 hours, showed the nurse documented Resident 598's right and left pupils were equal. Review of Resident 598's Neurological/Vital Sign Check- V 4 on 12/1/24 at 1100 hours, showed the nurse documented Resident 598's right pupil was non-reactive and left pupil was equal and sluggish. Review of Resident 598's Progress Notes failed to show documentation the physician was notified of the change in Resident 598's pupillary responses for the neurological check on 12/1/24 at 1100 hours. Further review of the notes showed a Change in Condition Note dated on 12/1/24 at 1436 hours, documenting Resident 598 had another fall and was found on the floor with a left forehead skin laceration. On 12/4/24 at 1617 hours, a concurrent interview and medical record review for Resident 598 was conducted with LVN 1. LVN 1 stated the neurological checks and assessments were conducted and should be compared with the previous neurological assessment to check for any neurological impairments or changes related to the resident's fall. LVN 1 further stated upon comparison of the neurological assessments, if there were any changes in the pupillary response, motor function, or level of consciousness, the physician would be informed. LVN 1 reviewed Resident 598's neurological checks and verified she completed the neurological check for Resident 598 on 12/1/24 at 1100 hours. LVN 1 verified there was a change in Resident 598's pupillary responses for the neurological check on 12/1/24 at 1100 hours, compared to the neurological check on 12/1/24 at 0600 hours. When asked, LVN 1 stated she did not compare Resident 598's neurological check with the previous neurological assessment and should have compared the assessments and notified the physician of the change in the assessment findings. On 12/5/24 at 1511 hours, a concurrent interview and medical record review for Resident 598 was conducted with the DON. The DON stated when conducting neuro check assessments on the residents, she expected the nurse to compare the results of the neurological check with the previous neurological check assessment to determine if there was a change in the resident's neurological status. If there was a change in the assessments, the DON stated she expected the nurse to notify the physician and document the physician had been informed. The DON was informed and acknowledged the above findings. On 12/15/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plans were implemented for one of thirteen final sampled residents (Resident 298) and one nonsampled resident (Resident 301). * The facility failed to implement the bilateral floor mats in accordance with the Risk for Falls care plan for Resident 298. * The facility failed to administer Resident 301's Lidocaine 4% external patch for pain management in accordance with Resident 301's At Risk for Pain care plan. These failures placed the residents at risk of not being provided appropriate, consistent, and individualized care. Findings: 1. Medical record review for Resident 298 was initiated on 12/2/24. Resident 298 was admitted to the facility on [DATE]. Review of Resident 298's care plan titled At Risk for Falls initiated 11/30/24, showed Resident 298 was at risk for falls related to generalized weakness, and a history of CVA and TIA. The care plan approaches included the placement of floor pads (mats) next to Resident 298's bed, when Resident 298 was in his bed. On 12/2/24 at 0930 hours, during an observation, Resident 298 was observed lying in bed. Resident 298's bed was observed with a floor mat in place on one side of Resident 298's bed. The opposite side of Resident 298's bed was observed without a floor mat in place. On 12/2/24 at 1213 hours, a concurrent observation, interview, and medical record review was conducted with LVN 4. Resident 298 was observed lying in bed. Resident 298's bed was observed with a floor mat in place on one side of Resident 298's bed. The opposite side of Resident 298's bed was observed without a floor mat in place. LVN 4 verified the findings. LVN 4 stated in accordance with Resident 298's Risk for Falls care plan approaches, a fall mat should have been placed on both sides of Resident 298's bed. Cross reference to F689, example #2. 2. Medical record review for Resident 301 was initiated on 12/2/24. Resident 301 was admitted to the facility on [DATE]. Review of Resident 301's care plan titled At Risk for Pain initiated 11/20/24, showed Resident 301 was at risk for pain related to a history of peripheral vascular disease, osteoporosis, and generalized body pain. The care plan approaches included to administer analgesia medications as ordered by the physician. On 12/4/24 at 0821 hours, a medication administration observation for Resident 301 was conducted with LVN 4. LVN 4 prepared and administered Resident 301's medications. During the medication administration observation for Resident 301, LVN 4 was observed having applied one lidocaine 4% external patch to Resident 301's hip. However, Resident 301's order for the lidocaine 4% external patch showed to apply two patches one time a day at the same time to the right hip and right foot topically for pain management. LVN 4 verified she applied one lidocaine 4% external patch to Resident 301's hip. On 12/4/24 at 1108 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 verified she failed to administer Resident 301's lidocaine pain medication in accordance with Resident 301's At Risk for Pain care plan. Cross reference to F759, example #2.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of a new pressure ulcers and promote the healing of the existing pressure ulcers for two of two final sampled residents (Residents 598 and 599) reviewed for pressure ulcers. * The facility failed to ensure the LAL mattress setting was consistent with Resident 599's weight and failed to ensure the wound treatment was administered as per the physician's order for Resident 599. * The facility failed to ensure the LAL mattress setting was consistent with Resident 598's weight. These failures had the potential for Residents 598 and 599 to not benefit from the therapy provided by the LAL mattress, and potential for delayed wound healing or worsening of existing pressure ulcers for Resident 599. Findings: Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown- Clinical Protocol revised 3/2014 showed the physician will authorize pertinent orders related to the wound treatments, including the wound cleansing and debridement approaches, dressings, and application of topical agents if indicated for type of skin alteration. Review of the facility's document titled Power Pro Elite Alternating Pressure with Low Air Loss Mattress system User Manual undated, showed the Power Pro Elite Mattress System is an alternating mattress replacement system used in the prevention and relief for (residents) with, or vulnerable to, pressure ulcers. The Power Pro Elite Mattress System offers (residents) a comfortable and relaxing support surface by using the established principles of alternating therapy, which can both prevent skin breakdown and enhance healing. The comfort level controls the air pressure output level. Press the firm button and the output pressure will increase and higher pressure output will support heavier weight (resident) . According to the weight of the (resident) adjust the pressure setting to the most suitable level without bottoming-out . Please consult with your physician for a proper setting. Further review of the user manual showed Table 1 Weight and Comfort Level Reference for the LAL mattress setting. For a 36-inch mattress, Light 1: 90 to 120 pounds, Light 2: 115 to 145 pounds Light 3: 120 to 175 pounds, Light 4: 145 to 200 pounds, Light 5: 175 to 230 pounds, Light 6: 200 to 265 pounds, Light 7: 230 to 300 pounds, and Light 8: 265 to 330 pounds. 1a. On 12/2/24 at 0840 hours, during the initial tour of the facility, Resident 599 was observed in bed, with a LAL mattress. Staff member was not observed in the room providing care to Resident 599. The LAL mattress unit was observed with the firmness level set at the 8th light bar (setting levels for firmness, level one: soft, and level 8: firm), and the static light on. A sticker titled Patient Weight Sticker was observed on the LAL mattress unit and showed for the 8th light bar, the weight indicated on the sticker was 300 to 330 pounds. When asked, Resident 599 stated she had a bedsore on her butt that had developed during her stay at the facility. When asked about the LAL mattress, Resident 599 stated the LAL mattress was supposed to help redistribute the air, but she did not felt the air being redistributed. When asked if the facility discussed the settings of the LAL mattress unit with her, Resident 599 stated the facility did not. Medical record review for Resident 599 was initiated on 12/2/24. Resident 599 was admitted to the facility on [DATE]. Review of Resident 599's MDS dated [DATE], showed Resident 599 was cognitively intact, and was totally dependent on the staff members assistance for bed mobility, to roll from left and right, and from sit to lying, and lying to sitting on the side of the bed. Further review of Resident 599's MDS, showed Resident 599 weighed 230 pounds, was at risk for developing the pressure ulcers/injuries, and Resident 599 did not have one or more unhealed pressure ulcers/injuries; however, the MDS showed Resident 599 had moisture-associated skin damage. Review of Resident 599's Order Summary Report dated 12/3/24, showed the following physician's orders: - dated 11/8/24, the resident was incapable of understanding the rights, responsibilities, and informed consent, - dated 11/20/24, to apply the LAL mattress for wound management, and - dated 11/23/24, for the Stage 2 pressure ulcer at the coccyx, to wash with soap and water, pat dry, apply Triad cream (a sterile, zinc oxide-based wound dressing cream that can be applied directly to broken skin or wounds) and cover with foam dressing, every day shift for 14 days. Review of Resident 599's plan of care showed the following care plan problems: - dated 11/8/24, addressing Resident 599's risk for skin impairment and further decline of skin integrity related to decreased mobility with high risk for friction, thin fragile skin, head of bed elevated most of the time. The interventions showed to apply the pressure reduction mattress to the bed. - dated 11/23/24, addressing Resident 599's Stage 2 pressure ulcer on the coccyx. The interventions did not include the use of a LAL mattress. Further review of Resident 598's plan of care failed to show a care plan problem addressing the use of a LAL mattress or the specific LAL mattress setting specific to Resident 599. Review of Resident 599's TAR for November and December 2024 failed to show documentation the LAL mattress was monitored for functionality and appropriate setting for the resident. On 12/2/24 at 1013 hours, an interview was conducted with LVN 2. LVN 2 stated she was scheduled as the treatment nurse for the day. When asked, LVN 2 stated the treatment nurses and the Maintenance Department were responsible for the set up and initial settings on the LAL mattress when first applied. LVN 2 stated the treatment nurses were responsible for adjusting the level/settings on the LAL mattress unit and the CNAs do not adjust the settings on the LAL mattress unit. When asked about the settings on the LAL mattress unit, LVN 2 stated the settings on the LAL mattress unit would be based on the resident's weight and the setting selected after comparing the resident's weight to the Patient Weight Settings sticker located on the LAL mattress unit. LVN 2 stated the licensed nurses should check the LAL mattress unit every shift, to ensure the LAL mattress unit was on and the settings were correct. On 12/2/24 at 1030 hours, a concurrent observation, interview and medical record review for Resident 599 was conducted with LVN 2. LVN 2 reviewed Resident 599's medical record and stated on 11/25/24, Resident 599 weighed 222 pounds. Resident 599 was observed in bed, and staff was not observed in the room providing care to Resident 599. LVN 2 verified Resident 599's LAL mattress unit was set at the 8th light bar and the static setting was on. LVN 2 reviewed the Patient Weight Settings sticker located on Resident 599's LAL mattress unit and stated the current LAL mattress setting was not appropriate for Resident 599's weight. When asked, LVN 2 stated not having the appropriate LAL mattress setting for the resident would put the resident at risk of not receiving the full benefits of alternating pressure to the wound and may affect wound healing. When asked, LVN 2 stated the checking and monitoring of the appropriate settings on the LAL mattress unit should be done every shift and documented in the TAR. LVN 2 reviewed Resident 599's medical record and stated there was no documentation in Resident 599's medical record to indicate the appropriate LAL mattress setting for the resident and no documentation the LAL mattress settings were checked. On 12/3/24 at 0903 hours, Resident 599 was observed in bed with the LAL mattress unit set at the 5th light bar. On 12/3/24 at 1517 hours, an interview was conducted with LVN 3. LVN 3 stated initially the treatment nurses were responsible for setting the firmness level on the LAL mattress unit. LVN 3 further stated the firmness settings for the LAL mattress was based on the resident's weight and the treatment nurses are responsible for checking the LAL mattress unit daily. LVN 3 stated the CNAs and charge nurses did not touch the settings on the LAL mattress unit. LVN 3 was asked about the static setting on the LAL mattress. LVN 3 stated in static mode, the pressure of the mattress would be the same. LVN 3 further stated the pressure would be alternating and the LAL mattress should not be on static mode, and the static mode should only be used when transferring or changing the resident. On 12/4/24 at 1453 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 599 had a pressure ulcer on her coccyx and was receiving daily wound treatment by the nurse. CNA 6 stated Resident 599 had a LAL mattress, however CNA 6 stated he did not know what the setting should be set at and he did not touch the settings on the LAL mattress unit. On 12/5/24 at 0906 hours, a concurrent interview and observation was conducted of Resident 599. Resident 599 was observed lying in bed, with the LAL mattress unit set at the 5th light. Resident 599 stated since the settings on the LAL mattress was changed a few days ago, she did feel air in the mattress being circulated more. Resident 599 was asked if the facility discussed the settings of the LAL mattress with her and what settings she was comfortable with, since the application of the LAL mattress. Resident 599 stated no. On 12/5/24 at 1511 hours, an interview was conducted with the DON. The DON stated the licensed nurses should monitor the LAL mattress unit every shift, monitoring for functionality of the unit, and for any leaking, or service lights. The DON stated the monitoring of the LAL mattress unit should be documented on the TAR. When asked about the appropriate settings on the LAL mattress, the DON stated the LAL mattress unit had a sticker to show what the firmness level should be set at, and the setting should be based on the residents' weight. When asked about the potential risk of the LAL mattress setting being set at a level not appropriate for the resident's weight, the DON stated there was the potential to affect the wound healing. When asked about the LAL mattress settings specific to each resident, the DON stated the LAL mattress was an intervention for the residents with pressure injuries, or at risk for developing the pressure injuries, however if the resident had a LAL mattress, then there should be an individualized care plan for the use of the LAL mattress for the resident. 1b. Review of Resident 599's TAR for the month of November and December 2024 showed the wound care order dated 11/24/24, for the Stage 2 pressure ulcer on the coccyx, to wash with soap and water, pat dry, apply Triad cream, and cover with foam dressing, every day shift for 14 days. Further review of Resident 599's TAR for November and December 2024 showed the above wound treatment was administered to Resident 599's Stage 2 pressure ulcer on the coccyx from 11/24/24-12/3/24, during the day shift. Review of Resident 599's plan of care showed a care plan problem dated 11/23/24, addressing Resident 599's Stage 2 pressure ulcer on the coccyx. The care plan interventions showed to administer the medications as ordered, monitor and document for side effects/effectiveness, and for the Stage 2 pressure ulcer on the coccyx: to wash with soap and water, pat dry, apply Triad cream, and cover with foam dressing. On 12/3/24 at 1500 hours, a wound treatment observation for Resident 599 was conducted with LVN 3. LVN 3 was observed cleaning the coccyx wound bed with wipes saturated with water and chlorhexidine (antiseptic and disinfectant) solution. On 12/3/24 at 1517 hours, a concurrent interview and medical record review for Resident 599 was conducted with LVN 3. LVN 3 verified he used chlorhexidine to clean Resident 599's Stage 2 pressure wound on the coccyx. LVN 3 reviewed Resident 599's medical record and verified the physician's order was to clean the wound with soap and water. LVN 3 stated he had always used chlorhexidine to clean the wound instead of soap. LVN 3 was asked if the physician was aware he was using chlorhexidine instead of soap, as ordered. LVN 3 stated yes. However, when LVN 3 was asked to show the documentation the physician had been informed that the chlorhexidine was used instead of the soap to clean the wound, LVN 3 stated there were no documentation in the resident's medical record. LVN 3 stated if the physician was aware, then the order would have been clarified to accurately reflect the resident's current wound treatment. LVN 3 agreed the soap and chlorhexidine were not the same and stated the order would have been changed. On 12/5/24 at 1118 hours, a telephone interview was conducted with Physician 1. When asked if Physician 1 was aware the facility was using chlorhexidine instead of soap, as ordered to clean Resident 599's Stage 2 pressure ulcer on the coccyx, Physician 1 stated the facility may have mentioned to him. Physician 1 further stated chlorhexidine could be used to cleanse the wound, however if that was the case, the order should have been clarified to use the chlorhexidine instead of the soap. On 12/5/24 at 1511 hours, an interview was conducted with the DON. The DON stated when providing wound treatments, the DON expected the nurse to administer treatments as ordered by the physician. The DON further stated if the treatment nurse was not using what was ordered by the physician, then there should be a clarification of the order to ensure the treatment accurately reflected the physician's order. On 12/5/24 at 1701 hour, the Administrator and DON were informed and acknowledged the above findings. 2. During the initial tour of the facility on 12/2/24 at 0830 hours, Resident 598 was observed lying on a LAL mattress. The LAL mattress unit was observed with the firmness set at the 8th setting (level one: soft and level 8: firm). Resident 598's family member was observed at bedside. When asked about the LAL mattress, FM 1 stated the LAL mattress was for the prevention of the pressure ulcers. When asked, FM 1 stated she did not know what the settings should be set at and the facility did not discuss the settings of the LAL mattress with her. Staff member was not observed in the room providing care to Resident 598 at this time. Medical record review for Resident 598 was initiated on 12/2/24. Resident 598 was admitted to the facility on [DATE], with the diagnosis of hemiplegia (paralysis or weakness in one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (a stroke) affecting the right dominant side. Review of Resident 598's Order Summary Report dated 12/3/24, showed the following physician's orders: - dated 11/26/24, the resident was incapable of understanding the rights, responsibilities, and informed consent, and - dated 11/26/24, to apply the LAL mattress for skin maintenance. Review of Resident 598's MDS dated [DATE], showed Resident 598 weighed 121 pounds, had severely impaired cognition, and was at risk for developing pressure ulcers/injuries. Further review of Resident 598's MDS showed Resident 598 was totally dependent on the staff members assistance for bed mobility, for rolling from left to right, for sitting to lying, for lying to sitting on the side of the bed, and for chair/bed-to-chair transfers. Review of Resident 598's plan of care showed the following care plan problems: - dated 11/26/24, addressing Resident 598's ADL self-care performance deficits. The intervention dated on 12/3/24, showed to apply the LAL mattress for skin maintenance. - dated 11/26/24, addressing Resident 598's risk for skin impairment and further decline of skin integrity. The intervention dated on 11/26/24, showed to apply the pressure reduction mattress to the bed, and dated 12/3/24, showed to apply the LAL mattress for skin maintenance. Further review of Resident 598's plan of care failed to show a care plan problem addressing the use of a LAL mattress or the specific LAL mattress setting specific to the resident. Review of Resident 598's TARs for November and December 2024 failed to show the monitoring of the LAL mattress unit. On 12/2/24 at 1013 hours, an interview was conducted with LVN 2. LVN 2 stated she was scheduled as the treatment nurse for the day. When asked, LVN 2 stated the treatment nurses and the Maintenance Department were responsible for the set up and initial settings on the LAL mattress when first applied. LVN 2 stated the treatment nurses were responsible for adjusting the level/settings on the LAL mattress unit and the CNAs did not adjust the settings on the LAL mattress unit. When asked about the settings on the LAL mattress unit, LVN 2 stated the settings on the LAL mattress unit would be based on the resident's weight and the setting selected after comparing the resident's weight to the Patient Weight Settings sticker located on the LAL mattress unit. LVN 2 stated the licensed nurses should check the LAL mattress unit every shift, to ensure the LAL mattress unit was on and the settings were correct. On 12/2/24 at 1020 hours, a concurrent interview, observation, and medical record review for Resident 598 was conducted with LVN 2. LVN 2 reviewed Resident 598's medical record and stated on 11/27/24, Resident 598 weighed 122 pounds. Concurrent observation of Resident 598's LAL mattress unit was conducted with LVN 2, at Resident 598 bedside. Resident 598 was observed lying in bed and the LAL mattress setting was observed set at the 8th light bar. LVN 2 verified the findings. LVN 2 reviewed the Patient Weight Settings sticker located on Resident 598's LAL mattress unit, and stated per Resident 598's weight, the LAL mattress should be set at 2 light bars, for the weight between 120 to 145 pounds. LVN 2 reviewed Resident 598's medical record and stated there were no documentation of the specific LAL mattress setting for Resident 598. LVN 2 reviewed Resident 598's TAR for November and December 2024, and stated there were no documentation the LAL mattress unit was monitored and the settings were checked. On 12/3/24 at 0852 hours, Resident 598 was observed lying in bed with the LAL Mattress unit set at 2 light bars. On 12/4/24 at 1453 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 598 had a special mattress, and that he did not touch the settings on the LAL mattress unit. On 12/5/24 at 0944 hours, a follow-up interview was conducted with FM 1. FM 1 stated the facility had discussed the use of the LAL mattress; however the facility did not discuss the specific setting for the LAL mattress. FM 1 stated, since the facility changed the setting on the LAL mattress on Monday, FM 1 noticed her mother complained less of discomfort in her bottom and appeared less fidgety in bed. On 12/5/24 at 1511 hours, an interview was conducted with the DON. The DON stated the licensed nurses should monitor the LAL mattress unit every shift, monitoring for functionality of the unit, and for any leaking, or service lights. The DON stated the monitoring of the LAL mattress unit should be documented on the TAR. When asked about the appropriate settings on the LAL mattress, the DON stated the LAL mattress unit had a sticker to show what the firmness level should be set at, and the setting should be based on the residents' weight. When asked about the potential risk of the LAL mattress setting being set at a level not appropriate for the resident's weight, the DON stated there was the potential to affect the wound healing. When asked about the LAL mattress settings specific to each resident, the DON stated the LAL mattress was an intervention for the residents with pressure injuries, or at risk for developing the pressure injuries, however if the resident had a LAL mattress, then there would be an individualized care plan for the use of the LAL mattress for the resident. On 12/5/24 at 1701 hours, the Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 298 and 600) reviewed for accident hazards remained free from the accident hazards. * The facility failed to ensure CNAs 2 and 3 used a gait belt as per the fall risk evaluation and care plan when transferring Resident 600 to the commode. * The facility failed to implement the bilateral floor mats for safety and fall prevention in accordance with the physician's order for Resident 298. These failures have the potential to place Residents 298 and 600 at risk for serious injury. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed based on the previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. According to the MDS, a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person of if he or she had not caught him/herself, is considered a fall. Under the section Resident-Centered Approaches to Managing Falls and Fall Risk showed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 1. On 12/2/24 at 0939 hours, an interview was conducted with Resident 600. Resident 600 stated she had a fall on 11/28/24, during the transfer from her bed to the bedside commode. Medical record review for Resident 600 was initiated on 12/2/24. Resident 600 was admitted to the facility on [DATE]. Review of Resident 600's Fall Risk Evaluation dated 11/23/24, showed Resident 600 was at moderate risk for falls. Under the section Gait, showed Resident 600 had weak on walking and short, shuffle steps, lightly touching furniture for support. Under impaired gait, showed Resident 600 was at risk for falls related to generalized weakness. The approach selected showed Resident 600 had impaired gait/balance, to use the gait belt and the PT had recommended devices per the plan of care for the resident's transfers/ambulation. Review of Resident 600's IDT: Post Accident/Fall dated 11/28/24, showed Resident 600 had a fall on 11/28/24 at 0335 hours. The IDT determined the follow-up measures that were needed to reduce the risk of reoccurrence were to apply non-skid or appropriate footwear, room free of clutter and the use of the gait belt when transferring/ambulating. Review of Resident 600's Fall Risk Evaluation dated 11/28/24, showed Resident 600 was at moderate risk for falls. Under the section Gait, showed Resident 600 had weak in walking and short, shuffle steps, lightly touching furniture for support. Under impaired gait, showed Resident 600 was at risk for falls related to generalized weakness. The approach selected showed Resident 600 had impaired gait/balance, to use the gait belt and PT had recommended devices per the plan of care for the resident's transfers/ambulation. Review of Resident 600's plan of care showed the following care plan problems: - dated 11/26/24, addressing Resident 600's risk for falls related to her status post anterior and posterior lumbar fusion (a surgical procedure that joins two or more vertebrae in the lower back to relieve pain and restore function) on 11/19/24. The interventions showed Resident 600 had impaired gait/balance, to use the gait belt and PT had recommended devices per the plan of care for the resident's transfers/ambulation. - dated 11/28/24, addressing Resident 600's witnessed fall. The intervention initiated 12/2/24, showed to use the gait belt with resident's transfers and ambulation. Review of Resident 600's MDS dated [DATE], showed Resident 600 was cognitively intact and required substantial/maximal assistance to roll on the left and right, to move from sitting to standing, for chair/bed-to chair transfer, and for toilet transfers. On 12/4/24 at 1516 hours, a phone interview was conducted with CNA 2. CNA 2 stated she was Resident 600's CNA on 11/28/24, when Resident 600 had her fall. CNA 2 stated Resident 600 was alert and was able to verbalize her needs. CNA 2 stated she had previously assisted Resident 600 to the bedside commode prior to her fall. CNA 2 was asked about how she assisted Resident 600 to the bedside commode and CNA 2 stated she used Resident 600's walker. When asked about the use of the gait belt, CNA 2 denied using the gait belt. When asked if CNA 2 offered the use of the gait belt to Resident 600, CNA 2 stated she felt Resident 600 was steady for the use of the walker with the assistance from CNA 2. CNA 2 stated she assessed Resident 600 and the resident was stable and it did not occur to her to use the gait belt. CNA 2 was asked if she was informed by the nurse she needed to use the gait belt with Resident 600 during her transfers, CNA 2 stated no. CNA 2 stated the purpose of the use of the gait belt was to prevent falls. On 12/5/24 at 0914 hours, during an observation, Resident 600 was observed sitting in her wheelchair and informed CNA 3 she needed to use the bedside commode. CNA 3 was observed pulling the privacy curtain, donning gloves, and assisting Resident 600 to the bedside commode. CNA 3 was observed grabbing Resident 600's walker to use during the transfer to the bedside commode and assisted Resident 600 on to the bedside commode. The gait belt was observed on Resident 600's bed and was not observed used during the transfer. On 12/5/24 at 0927 hours, an interview was conducted with CNA 3. CNA 3 was asked if she was aware Resident 600 had a previous fall. CNA 3 stated she was informed Resident 600 had a previous fall during a transfer to the commode. CNA 3 stated Resident 600 was a fall risk and usually transferred with the gait belt. CNA 3 verified she did not use the gait belt when she transferred Resident 600 to the bedside commode. CNA 3 stated she was familiar with the resident and she felt confident in transferring Resident 600 without the use of the gait belt. When asked when the gait belt should be used, CNA 3 stated the gait belt should be used at all times when moving from one position to another, including from the bed to the wheelchair, and from the wheelchair to the commode. CNA 3 stated she was informed by the charge nurse to use the gait belt during transfers for Resident 600. CNA 3 stated she used the gait belt with Resident 600 in the past, however she was more comfortable with Resident 600 so she did not use the gait belt during the transfer. On 12/5/24 at 0935 hours, an interview was conducted with OT 1. OT 1 stated she was familiar with Resident 600 and was working with Resident 600 on transferring on and off of the toilet/commode, getting dressed and the use of adaptive equipment. OT 1 was asked about the protocol for transferring for Resident 600. OT 1 stated for Resident 600, the resident required partial to moderate assistance with one person assist during the transfers. OT 1 stated for the transferring for Resident 600 to the bedside commode, either from the bed or the wheelchair, Resident 600 must wear her back brace, non skid socks, and the staff assisting with the transfer should use a gait belt and the walker. On 12/5/24 at 1511 hours, a concurrent interview and medical record review for Resident 600 was conducted with the DON. The DON stated if the resident had a previous fall and the IDT recommended the use of the gait belt for transfers, she expected staff to transfer the resident using the gait belt. The DON reviewed Resident 600's fall risk evaluations and post fall IDT recommendations and verified the approaches and recommendations. The DON was asked and stated the use of the gait belt was for the safety of the resident and the CNA. On 12/5/24 at 1604 hours, an interview was conducted with Resident 600. Resident 600 stated staff were supposed to use the gait belt when they transfer her. When asked, Resident 600 denied refusing the use of the gait belt during her transfers. On 12/5/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the above findings. 37726 2. Medical record review for Resident 298 was initiated on 12/2/24. Resident 298 was admitted to the facility on [DATE]. Review of Resident 298's Order Summary Report showed a physician's order dated 11/30/24, for the bilateral floor mats for safety and fall prevention. Review of Resident 298's care plan titled At Risk for Falls initiated 11/30/24, showed Resident 298 was at risk for falls related to generalized weakness, and a history of CVA and TIA. The care plan approaches included the placement of floor pads (mats) next to Resident 298's bed when Resident 298 was in his bed. On 12/2/24 at 0930 hours, during an observation, Resident 298 was observed lying in bed. Resident 298's bed was observed with a floor mat in place on one side of Resident 298's bed. The opposite side of Resident 298's bed was observed without a floor mat in place. On 12/2/24 at 1213 hours, a concurrent observation, interview, and medical record review was conducted with LVN 4. Resident 298 was observed lying in bed. Resident 298's bed was observed with a floor mat in place on one side of Resident 298's bed. The opposite side of Resident 298's bed was observed without a floor mat in place. LVN 4 verified the findings. LVN 4 stated as per the physician's order, a fall mat should have been placed on both sides of Resident 298's bed to reduce the risk of injury as Resident 298 was at risk for falls. Cross reference to F656, example #1.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of 13 final sampled residents (Resident 398). * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the medical record for Resident 398. This failure had the potential to delay the identification of catheter related complications for the resident. Findings: Review of the facility's P&P titled Central Venous Catheter Care and Dressing Changes dated 2001 showed the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. For PICCs, measure arm circumference and compare to baseline when clinically indicated to assess for edema and possible deep-vein thrombosis. Medical record review for Resident 398 was initiated on 12/2/24. Resident 398 was admitted to the facility on [DATE]. Review of Resident 398's H&P examination dated 11/20/24 showed Resident 398 had the capacity to understand and make decisions but failed to show the information of the measurement and assessment of the PICC line was documented when the resident was admitted to the facility. Review of Resident 398's Order Summary Report for December 2024 showed a physician's order dated 11/25/24, for PICC line dressing and cap change every seven days and as needed with CVC dressing kit. Apply Biopatch (a chlorhexidine (CHG)-impregnated sponge that releases CHG continuously for up to seven days. It prevents skin organisms from entering the body at the insertion site and reduces the risk of catheter-related bloodstream infections) around catheter at insertion site. Transparent dressing placed over Biopatch dressing, no gauze over site. Measure the external length of the catheter and upper arm circumference (10 cm above insertion site) every day shift, every Sunday. Review of Resident 398's care plan dated 12/2/24, showed the resident had a PICC line on the right upper arm with two lumens. Under the section approaches/tasks showed to measure the external length of the catheter and upper arm circumference (10 cm above insertion site). Review of Resident 398's IV Administration Record dated 11/26/24, showed the measurements for the arm circumference of 32 cm and catheter was zero. Further review of Resident 398's medical record failed to show a documented evidence of the measurements of the length of the PICC line catheter above the insertion site and arm circumference were obtained upon admission. On 12/5/24 at 1327 hours, a concurrent interview and medical record review for Resident 398 was conducted with RN 1. RN 1 stated the dressing change for the PICC line was performed every seven days. RN 1 verified Resident 398's medical record did not show the PICC line external catheter and arm circumference measurements upon admission to the facility. RN 1 stated there should have been a measurement of the length of the catheter and arm circumference upon admission of the resident. In addition, RN 1 stated the arm circumference measurement would indicate signs and symptoms of infection such as swelling, and blood clots and the external catheter length would indicate dislodgement. On 12/5/24 at 1700 hours, the DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care for one of three final sampled residents (Resident 12) reviewed for respiratory care. * The facility failed to ensure Resident 12's CPAP machine was cleaned as per the manufacturer's user cleaning guidelines. This failure had the potential to adversely affect the health and well-being Resident 12 and posed the risk for equipment contamination and respiratory complications. Findings: Review of the facility's P&P titled CPAP/BiPAP Support revised 3/2015 showed the specific cleaning instruction guidelines are obtained from the manufacturer of the PAP device. For the machine cleaning, to wipe the machine with warm, soapy water and rinse at least once a weeks and as needed. For the humidifier (if used), to use clean, distilled water, to clean the humidifier weekly and air dry, to disinfect, place vinegar-water solution (1:3) in the clean humidifier, soak for 30 minutes and rinsed thoroughly. For the components of the machine such as the masks, nasal pillows, and tubing, to clean daily by placing in warm, soapy water and soak/agitating for five minutes. Mild dish detergent is recommended. To rinse with warm water and allow to air dry between uses. For the headgear, to wash with warm water and mild detergent as needed and allow to air dry. On 12/2/24 at 0900 hours, a concurrent observation and interview was conducted with Resident 12. Resident 12's bedside drawer was noted to have a CPAP (ResMed Air Sense 11) machine, which was observed off with the CPAP mask observed on top of the CPAP machine. The mask was not observed stored in a plastic bag. Resident 12 was asked about his CPAP machine and stated he used his CPAP machine every night. Resident 12 was asked if the staff cleaned the CPAP machine, tubing and mask. Resident 12 stated no, he had not seen staff member clean it since he started using the CPAP at the facility. Review of the ResMed Air Sense 11 (CPAP machine) user guide, undated showed under the section Cleaning and Caring For the Device, showed to clean the device and its components according to the schedules shown in this guide, to maintain the quality of the device and to prevent the growth of germs that can adversely affect your health. Medical record review for Resident 12 was initiated on 12/2/24. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 had moderately impaired cognition and was coded for the use of the CPAP machine. Review of Resident 12's Order Summary Report dated 12/3/24, showed the following physician orders: - dated 10/14/24, the resident was capable of understanding the rights, responsibilities, and informed consent - dated 10/14/24, to apply the CPAP at 5.5 cm H2O with the oxygen concentrator every evening and night shift. The Order Summary Report failed to show a physicians order for the cleaning of the CPAP machine and its components. Review of Resident 12's plan of care showed a care plan problem dated 10/27/24, addressing Resident 12's CPAP Therapy. The interventions showed to educate the resident on the importance of the CPAP therapy and to encourage the resident's use of the CPAP. The care plan problem failed to show the specific CPAP setting for Resident 12 and failed to show interventions for the maintenance and care of the CPAP machine and the components. On 12/3/24 at 0841 hours, a concurrent observation and interview was conducted with Resident 12. Resident 12's CPAP mask was observed on top of a pillow on the bedside drawer. The CPAP mask was not observed inside a storage bag. Resident 12 was asked if a staff member had cleaned his CPAP mask this morning, Resident 12 stated no. On 12/4/24 at 0826 hours, a concurrent observation and interview was conducted with CNA 4. Resident 12's CPAP mask was observed on Resident 12's bedside drawer. The CPAP mask was not observed inside a storage bag. The CPAP tubing was observed on top of the CPAP mask, and an ice bag inside of the sling was observed on top of the CPAP mask. Resident 12 stated at home, he cleaned his CPAP machine and mask once a week or as needed. CNA 4 stated he assisted Resident 12 to remove his CPAP mask in the mornings. CNA 4 stated he did not clean the CPAP mask and was not sure who was responsible for the cleaning of the CPAP mask, and how often it should be cleaned. On 12/4/24 at 0842 hours, a concurrent interview and medical record review for Resident 12 was conducted with the DSD. The DSD stated for the use of a CPAP machine, there should be a physician's order for how to clean and the frequency of the cleaning of the CPAP machine and its components. The DSD stated the cleaning of the CPAP masks are done by the licensed nurses after each use and upon removal of the CPAP mask in the morning. The DSD stated the CPAP masks should be rinsed with warm water and pat dry daily, after every use, for infection control purposes. The DSD stated the oxygen tubings should be changed and labeled every seven days and when not in use, the CPAP masks and tubing should be stored inside a storage bag for infection control. The DSD also stated, the cleaning of the CPAP machine and the CPAP mask should be documented in either the progress notes or the MAR. The DSD reviewed Resident 12's medical record and verified there were no orders for the cleaning of Resident 12's CPAP machine and its components, there were no documentation of the cleaning of Resident 12's CPAP machine and its components, and Resident 12's care plan addressing his CPAP therapy did not specify the CPAP settings, or did not include the interventions for the cleaning of the CPAP machine and its components. On 12/4/24 at 0900 hours, a concurrent interview and observation was conducted with the DSD at Resident 12's bedside. The DSD verified the above findings. When asked about the oxygen tubing connecting the oxygen concentrator to the CPAP mask, the DSD verified the oxygen tubing was not labeled and stated he did not know how long the oxygen tubing have been in use. The DSD stated the oxygen tubings should be changed and labeled every seven days. On 12/5/24 at 1511 hours, an interview was conducted with the DON. The DON stated both the CNAs and the LVNs could clean the CPAP mask, however, it should be documented on the MAR by the licensed nurses, to monitor the cleaning of the CPAP machine and its components. The DON stated the CPAP mask and machine should be cleaned routinely, and when not in use, the CPAP make should be stored in a storage bag for infection control purposes. On 12/5/24 at 1701 hours, the Administrator and the DON were informed and acknowledged the above findings.

Based on clinical record review, facility document review and interviews, the facility failed to provide adequate supervision, resulting in Resident 1 being left unattended in the bathroom. Resident 1 was found face down and unresponsive in the bathroom on [DATE] at 1058 hours, and died on [DATE] at 1507 hours, from a cervical spine fracture secondary to a fall. Findings: On [DATE], clinical record review was initiated for Resident 1. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1 was a [AGE] year old female who was living at home with family when she fell and broke her right hip. Resident 1 was admitted to the facility from an acute care hospital on [DATE], to recover and rehabilitate from the surgically repaired broken hip. On [DATE] at 1058 hours, Resident 1 was found by the maintenance director face down in the bathroom, nonresponsive and without a pulse. Resident 1 was transferred to the emergency department in full arrest (without a heart beat or breathing) and was pronounced dead at 1507 hours. Review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated [DATE], showed she required extensive assistance from two staff members to assist her for toileting, including transfers on and off the toilet and cleansing self after elimination. Resident 1's balance for moving on and off the toilet showed she was not steady and was only able to stabilize with human assistance. In addition, Resident 1 had a history of [REDACTED]. Review of Resident 1's Care Area Assessment (CAA) for "Falls" showed an analysis of her findings as being at risk for falls/injuries related to dementia, osteoporosis, impaired balance during transitions and an unsteady gait. Review of Resident 1's Fall Risk assessment dated [DATE], shows a score of 12 (a score of 10 or above represents a high risk for falls). Review of Resident 1's Licensed Nurse Weekly Summaries dated [DATE] and [DATE], showed Resident 1 had no behavioral problems and was at risk for falls. Her functional status for activities of daily living (ADL) showed she required extensive assistance with transfers and toileting. Review of Resident 1's Nurse's Notes dated [DATE] at 1840 hours, [DATE] at 1330 hours and 1800 hours, [DATE] at 1445 hours and 2000 hours, [DATE] at 1940 hours, [DATE] at 1400 hours, 1600 hours, [DATE] at 1030 hours and 1700 hours, [DATE] at 1400 hours and 1900 hours and [DATE] at 0100 hours, showed she required extensive assistance with her ADLs. An entry dated [DATE] at 1058 hours, showed Certified Nursing Assistant (CNA) 1 assisted Resident 1 to the bathroom, went to get another CNA, and Resident 1 had fallen and was unresponsive. Cardiopulmonary resuscitation (CPR) was initiated. Review of Resident 1's care plan problem dated [DATE], to address her alteration in thought process related to dementia showed an approach plan to anticipate her needs, while observing safety. Review of Resident 1's care plan problem dated [DATE], to address her risk for falls/injuries related to a recent decline in her functional status and history of falls, showed an approach plan to assist with ADLs, anticipate needs and observe safety precautions. Review of Resident 1's care plan problem dated [DATE], showed she required extensive assistance with toileting needs. Review of Resident 1's care plan problem dated [DATE], to address her risk for spontaneous fracture related to osteoporosis showed an approach plan to handle gently during transfers and mobility. Review of Resident 1's Physical Therapy Treatment Encounter Notes dated [DATE], showed she required stand by assistance with transfers, her standing balance was fair and had impaired safety awareness. Review of Resident 1's Physical Therapy Discharge Summary dated [DATE], showed Resident 1 required stand by assistance with transfers. Review of Resident 1's Occupational Therapy Treatment Encounter Notes dated [DATE], showed she required stand by assistance with toilet transfers, and needed stand by assistance with completing pericare (cleaning of the perineal area - urinary and rectal orifices) and putting her pants on and off. Resident 1's standing balance was fair. Review of Resident 1's Occupational Therapy Discharge Summary dated [DATE], showed Resident 1 continued to need stand by assistance with toileting and 20% verbal cues (verbal reminders 20% of the time) for safety awareness and for safety while turning. Review of the facility's Investigation Follow-Up dated [DATE], showed Resident 1 was assisted to the bathroom by CNA 1. Resident 1 had asked for privacy; CNA 1 closed the bathroom door. CNA 1 left Resident 1 in the bathroom to endorse to another CNA that Resident 1 was in the bathroom. A short time late, another staff member called for help and Resident 1 was assessed and found unresponsive. Review of the DON's written statement dated [DATE], showed CNA 1 took Resident 1 to the bathroom. CNA 1 left Resident 1 in the bathroom alone, to check on another resident, and returned to check on Resident 1 again. Resident 1 requested more time in the bathroom. CNA 1 went to the hallway to find another CNA to watch Resident 1 in the bathroom. While CNA 1 was asking the other CNA to watch the resident, another staff member was yelling for help when he found Resident 1 on the floor in the bathroom. Review of the maintenance director's written statement dated [DATE], showed he was performing monthly call light inspections. When he entered Resident 1's room, he did not see Resident 1 or a staff member. He knocked on Resident 1's bathroom door and nobody answered. He opened the door and found Resident 1 face down on the bathroom floor. Review of CNA 1's written statement dated [DATE], showed at 1045 hours, she assisted Resident 1 to the bathroom. She documented she had closed the door and stood in the hallway for Resident 1's privacy. CNA 1 documented, since her lunch was at 1100 hours, around 1057 hours, she went to tell another CNA to check on Resident 1. While she was telling the CNA about the situation, she saw a staff member running to the nurses' station to alert the nurses of the code. Resident 1 had fallen from the toilet and was lying on the floor. Review of CNA 1's Employee Warning/Discipline Memo dated [DATE], showed her performance problem was leaving Resident 1 unattended in the bathroom. The memorandum further showed the corrective action was to never leave the resident unattended, finish what you are currently doing with the resident, and call somebody to come to the room by using the call light, without leaving the resident. During an interview on [DATE] at 1015 hours, the DON stated Resident 1 was alert and forgetful. She stated on [DATE] at approximately 1045 hours, CNA 1 assisted Resident 1 to the bathroom, waited outside the bathroom door and left to get a replacement CNA. The DON stated, on [DATE] at 1058 hours, the maintenance director found Resident 1 face down on the bathroom floor, unresponsive. She stated CNA 1 is no longer employed at the facility. During an interview on [DATE] at 1115 hours, the maintenance director stated, on [DATE] at 1058 hours, he was doing his monthly inspection of the residents' call lights. He stated he knocked on Resident 1's bathroom door, got no response, so he opened the bathroom door and found Resident 1 face down in front of the toilet bowl. The maintenance director stated no staff members were present and he immediately called for help. He stated he did not see any movement from Resident 1 and she was not verbally responsive. Review of Resident 1's Prehospital Care Report dated [DATE] at 1110 hours, showed Resident 1 was found at the facility in cardiac arrest (no vital signs - pulse, respirations or blood pressure). She had a hematoma (bruise) to her forehead. CPR was started. Review of Resident 1's Emergency Physician Record dated [DATE] at 1131 hours, showed she was unresponsive, had no vital signs and had a frontal hematoma with an abrasion. CPR continued. At 1140 hours, Resident 1's heart rate was 138 beats per minute and a blood pressure of ,[DATE], CPR was stopped. Review of Resident 1's computed tomography (CT) scan of the brain without contrast dated [DATE] at 1301 hours, showed Resident 1 had a large area of soft tissue swelling/hematoma over the bifrontal region of her scalp (the area across the forehead at the hairline). In addition, a small, nondisplaced subtle fracture would be difficult to entirely exclude. Review of Resident 1's CT scan of her cervical spine without contrast dated [DATE] at 1302 hours, showed a minimally displaced type II dens fracture (the result of a severe force including rotation across the cervical spine), a nondisplaced right posterior C1 arch fracture (occurs when the head is hyperextended and the posterior neural arch of C1 is compressed between the occiput (back of the skull) and the strong, prominent spinous process of C2), and a mild posterior subluxation of the left C1-C2 facet (a partial or incomplete dislocation). Review of Resident 1's hospital physician progress notes [REDACTED]. She was found unresponsive and CPR was initiated. At the emergency room , her Glasgow Coma Scale (GCS - a scale for measuring level of consciousness, especially after a head injury, in which scoring is determined by three factors: amount of eye opening, verbal responsiveness, and motor responsiveness, a score of three is compatible with brain death) was a score of three post advanced cardiac life support measures. At 1325 hours, Resident 1 was placed on comfort care per the family's request, was taken off the ventilator at 1431 hours and expired at 1507 hours. Review of the Coroner's autopsy report showed Resident 1's cause of death as a cervical spine fracture due to a fall. The coroner ' s anatomic summary showed Resident 1 had epidural hematomas (traumatic accumulation of blood in the spinal canal) of T (thoracic vertebra) 1 through T10, a fracture of the right transverse process and the right lateral vertebral body of C4 and had hemorrhage (bleeding) of the spinal cord at the level of C1 through C4. During an interview on [DATE] at 1130 hours, CNA 2 stated Resident 1 had no behavioral problems. She stated, when she assisted Resident 1 to the bathroom, she stayed with her to prevent her from falling. CNA 2 stated she would not close the bathroom door completely, but she would leave the bathroom door open slightly so she could watch Resident 1 to make sure she was all right. During an interview on [DATE] at 1140 hours, CNA 3 stated Resident 1 had no behavioral problems. He stated Resident 1 was able to take a couple of steps, but required stand by or minimum assistance in ambulating. CNA 3 stated the facility's policy is to stay with the resident while they are in the bathroom. He stated, when he assisted Resident 1 to the bathroom, he would stand outside the bathroom door with the door slightly open to monitor Resident 1, and listen to make sure the resident was all right.