Every finding on record at North Starr Postacute Care

Based on observation, interview and record review the facility failed to revise Resident 11's comprehensive care plan to address a significant change in condition following hospitalization for suspected infected dialysis access (the site used to connect the resident to dialysis, a treatment that cleaned the blood when the kidneys could not do so), treatment with intravenous (IV) antibiotics (medicine given through a vein directly into the blood stream to treat infection), and replacement of the dialysis catheter (a flexible tube placed into a large vein to allow dialysis treatments). This failure had the potential to result in the residents' care needs not being identified, communicated and addressed through coordinated interdisciplinary care planning upon the residents' return to the facility. Findings:During an observation on 5/5/26 at 12:02 p.m., Resident 11 was observed in the dining room eating lunch. No issues or concerns were observed at that time. During a review of Resident 11's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 11 was admitted to the facility on [DATE] with a diagnosis which included end stage renal disease, stage 5 (the kidneys had almost completely stopped working and could no longer clean the blood or remove extra fluid from the body, so dialysis was needed to do the job the kidneys could no longer do) and type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control). During a review of Resident 11's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 11's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 12 indicated Resident 11 was moderately cognitively impairedDuring a concurrent interview and review of Resident 11's electronic health record on 5/7/26 at 1:33p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 11 was initially admitted to the facility on [DATE] and was hospitalized from [DATE] through 4/28/26 after being sent from dialysis for a possible dialysis catheter infection. LVN 1 stated Resident 11's dialysis catheter was removed during the hospitalization, and a new dialysis catheter was placed, and Resident 11 received intravenous (IV) antibiotics (medication given directly into the bloodstream through a vein to treat infection) while hospitalized . During a concurrent interview and review of Resident 11's electronic health record on 5/8/26 at 9:41 a.m. with LVN 2, LVN 2 stated when a resident experienced a change in condition, staff were expected to assess the resident, notify the physician, follow physician recommendations, notify the responsible party (RP), document the event in a progress note, initiate or create a care plan, follow up with the hospital and discuss the residents status in an interdisciplinary team (IDT) meeting with interventions added as needed. Review of Resident 11's progress notes revealed documentation that Resident 11's RP notified the facility Resident 11 had been sent to the hospital by dialysis facility staff due to drainage from the dialysis catheter site. Further review of Resident 11's electronic health record did not reveal a care plan addressing the hospitalization, physician notification, follow up care, or discharge planning after his return to the facility. No documentation was identified indicating physician notification or an IDT meeting related to Resident 11's change in condition. LVN 2 stated No, this is not the way the process should have gone, and stated the process was important to ensure the resident's condition was tracked and the physician remained informed of the resident's status. During a review of Resident 11's Patient Discharge Instructions, dated 4/28/26, the Patient Discharge Instructions indicated the reason for the hospital visit was cutaneous hypersensitivity (skin sensitivity or skin reaction), cellulitis (a bacteria skin infection that can cause redness, swelling, warmth and pain) at the port site, and a diagnosis of portacath line problem ( an issue with the implanted tube used to give medications or treatments directly into a large vein, such as infection, blockage, damage or improper function). During an interview on 5/8/26 at 12:10p.m. with the Director of Nursing (DON), the DON stated her expectation when a resident experienced a change in condition was for nursing staff to follow up with the hospital to obtain information, document the event, notify the physician, and for the social worker to follow up as needed. The DON stated if a change in condition occurred within the facility, nursing staff were expected to document the change in condition and notify the physician. The DON stated the expectation was to care plan the resident's hospitalization to support care planning upon the residents return and provide the resident with the best care. When asked whether a hospitalization related to suspected infection dialysis access represented a significant change in condition, the DON stated nursing staff should have had a care plan in place, as this was important for planning the residents care upon return to the facility. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated January 2018 the P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change.the nurse and/or the interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's conditionDuring a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated January 2026 the P&P indicated, 1. the nurse will notify the resident's attending physician or physician on all when there has been a (an): d. significant change in the resident's physical/emotional/mental condition, g. need to transfer the resident to a hospital/treatment center.2. A significant change of condition is a major decline or improvement in the resident's status that: c. requires interdisciplinary review and / or revision to the care plan.8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI instruction manual.During a review of the facility's policy and procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident With, dated January 2018 the P&P indicated, 5. The residents comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.

Based on interview, and record review the facility failed to ensure one (Resident 3) out of ten residents received a level II Pre-admission Screening and Resident Review (PASRR- evaluation for individuals suspected of having a Serious Mental Illness (SMI) or Intellectual/Developmental Disability (I/DD)/Related Condition (RC), triggered by a positive Level I screen, to determine if they need specialized services, ensuring placement in the least restrictive setting) evaluation by the designated entity to determine if SMI, ID/DD/RC conditions were present when Resident 3 had a PASSRR level I screening result positive for SMI and the facility did not ensure a PASRR level II screening was completed.This failure resulted in Resident 3 not receiving a required PASRR level II screening which could result in delayed treatment, identification of care or services.During a concurrent interview and record review on 5/6/26 at 2:48 p.m. with the Director of Nursing (DON), Resident 3's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 9/16/26, and Notice of Attempted Evaluation, dated 9/19/26, was reviewed. The DON stated she was responsible for completing, reviewing and following up on all PASRR's. The DON stated when residents were admitted or had a significant change in condition a PASRR level I was completed. The DON stated all positive level I PASRR's required a level II PASRR evaluation. The DON stated on 9/16/26 Resident 3 had a significant change in condition when she transferred to hospice services and a level I PASRR was completed. The DON stated Resident 3's level I PASRR, on 9/16/26, was positive for SMI. The DON stated on 9/19/26 the facility received a PASRR level II letter, Notice of Attempted Evaluation, which stated the designated state agency could not reach the facility on two or more attempts to complete Resident 3's PASRR level II evaluation. The DON stated a level II PASRR was not completed.During an interview on 5/8/26 at 12:06 p.m. with the DON, the DON stated facility policy and procedure was not followed when Resident 3 had a positive level I PASRR and the facility did not ensure a level II PASRR was completed. The DON stated Resident 3 should have had a level II PASRR completed following a positive level II PASRR result on 9/16/26. The DON stated it was important to complete level II PASRR's in a timely manner to ensure the facility could meet the needs of residents with a positive level I PASRR. The DON stated Resident 3 was placed at risk for delayed treatment, identification of care or services.During a record review of Resident 3's document titled, Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 9/16/26, the document indicated on 9/16/26 Resident 3 had a change in condition and the DON completed a PASRR level I evaluation. The document indicated Resident 3 was positive for SMI and required a PASRR level II screening evaluation by the designated state agency.During a record review of Resident 3's document titled, admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 5/7/26, the AR indicated Resident 3 was admitted on [DATE] with diagnoses of end stage renal disorder (kidney function decline requiring life-sustaining medical treatment), bipolar disorder (mental health condition resulting in mood swings) anxiety disorder (mental health condition resulting in persistent fear and worry), and schizophrenia (mental health condition affecting ability to think, feel and act).During a record review of Resident 3's document titled, Notice of PASRR Level I Screening Results, dated 9/16/26, the document indicated, .your facility will be contacted within two to four days to set up an appointment for an evaluator to conduct a Level II Mental Health Evaluation.During a record review of Resident 3's document titled, Notice of Attempted Evaluation, dated 9/19/26, the document indicated, .facility staff were unresponsive to two or more sperate attempts of communication within 48 hours of the Level I Screening.the case is now closed. To reopen, the facility must resubmit a new Level I Screening.please note this letter is a courtesy notice for administrative purposes only and does not comprise a completed individualized determination.During a record review of the facility's policy and procedure (P&P) titled, Preadmission Screening and Resident Review, dated 1/2018, the P&P indicted, .it is the policy of this facility to comply with federal and state regulations regarding the Preadmission Screening and Resident Review (PASRR) process. PASRR ensures that individuals with serious mental illness (SMI), intellectual disabilities (ID), or related conditions are appropriately placed in a skilled nursing facility (SNF) and receive necessary services.If the level I screening indicates a potential SMI, ID, or related condition, the resident must be referred for a level II PASRR evaluation conducted by the designated state agency.must follow up to ensure timely completion of the level II evaluation.the facility must receive written confirmation of level II results.if a significant change occurs, a new level I screening must be completed, and if necessary, a level II referral must be initiated.

Based on observation, interview, and record review the facility failed to ensure oxygen therapy (a colorless, tasteless gas essential to living organisms) professional standards of practice were followed for one (Resident 20) of ten residents when Resident 20 did not have oxygen therapy signage posted.This failure resulted in Resident 20's oxygen concentrator (medical device that helps residents breathe) being on with no oxygen therapy signage posted in or outside her room which could result in fire, hazards or injuries.During an observation on 5/5/26 at 10:01 a.m. in Resident 20's room, Resident 20 was observed lying in bed. Resident 20's oxygen concentrator was observed on at 5 LPM (liter per minute-a unit of measurement for the flow rate of oxygen). Resident 20's nasal cannula (a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen) was on the floor.During a concurrent observation and interview on 5/5/26 at 10:30 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 20's room, Resident 20 was observed lying in bed. Resident 20's oxygen concentrator was observed on at 5 LPM (liter per minute-a unit of measurement for the flow rate of oxygen). Resident 20's nasal cannula was on the floor. LVN 1 stated Resident 20 had an order for oxygen therapy and the oxygen concentrator was on. LVN 1 stated Resident 20 did not have any signage indicating oxygen therapy was in use. LVN 1 stated all residents on oxygen therapy required oxygen therapy signage for safety. LVN 1 stated oxygen therapy safety signage notified residents, staff, and visitors to avoid flames and flammable material for risk of fire, injury and hazard.During an interview with the Director of Nursing (DON) on 5/8/26 at 12:06 p.m., the DON stated when oxygen therapy was ordered or an oxygen concentrator was turned on, oxygen therapy signage was required to be posted. The DON stated oxygen therapy signage alerted residents, staff and visitors to the use of oxygen and safety requirements to avoid smoking and open flames to prevent fire. The DON stated facility policy and procedure, as well as, oxygen therapy professional safety standards of practice were not followed when Resident 20 had an order for oxygen therapy and an oxygen concentrator tuned on with no oxygen therapy signage posted. The DON stated Resident 20, other residents, visitors and staff were placed at risk of fire, hazards or injuries.During a record review of Resident 20's Order Summary Report (OSR), dated 5/6/26, the OSR indicated Resident 20 had an order for nasal cannula oxygen therapy since 4/22/26.During a record review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 1/2018, the P&P indicated, .the purpose of this procedure is to provide guidelines for safe oxygen administration.the following equipment and supplies will be necessary when performing this procedure. No Smoking/Oxygen in Use signs.place an Oxygen in Use sign on the outside of the room entrance door.Place an Oxygen in Use sign in a designated place on or over the resident's bed.remove all potentially flammable items.in accordance with facility policy and professional standards of practice.During a professional reference review retrieved from https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/oxygen-therapy/using-oxygen-safely , Oxygen Therapy: Using Oxygen Safely, dated 1/28/26, the professional reference review indicated, . post No Smoking and No Open Flames signs.turn off your oxygen when you're not using it.

Based on observation, interview and record review the facility failed to ensure care and services were provided to maintain the highest practicable physical well-being for one of seven sampled residents (Resident 4) by failing to ensure an order for monitoring Resident 4's anticoagulant (a medication that helped prevent blood from clotting too easily, which could increase the risk of bleeding) adverse effects (unwanted or harmful side effects from a medication) was in place following readmission to the facility. This failure had the potential to delay identification of signs and symptoms of bleeding, placing Resident 4 at risk for adverse outcomes related to anticoagulant therapy. Findings:During an observation on 5/6/26 at 11:29 a.m. Resident 4 was observed asleep in bed with the bed in the lowest position. No obvious bruising was observed on the face or upper body. During a review of Resident 4's admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 4 was initially admitted to the facility on [DATE] with a diagnosis which included embolism and thrombosis of an unspecified artery (a condition where a clump of blood blocked a blood vessel that carried blood away from the heart) and venous thrombosis and embolism (a condition where a clump of blood formed in a blood vessel that carried blood back to the heart and could move to another part of the body). During a review of Resident 4's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 4's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 5 indicating Resident 4 was severely cognitively impaired.During a concurrent interview and review of Resident 4's electronic health record with the Infection Preventionist (IP) on 5/6/26 at 2:49p.m., it was discovered Resident 4 had no current monitoring in place for anticoagulant adverse effects despite an active physician order for rivaroxaban ( a medication used to help prevent harmful clumps of blood from forming, but it could also increase the risk of bleeding) 20 mg (milligram a way to measure the amount of medication in a dose) by mouth once daily and the care plan indicating monitoring for medication side effects. The IP stateed Resident 4 had been hospitalized from [DATE] through 5/4/26 and upon readmission, the anticoagulant side effect monitoring order was discontinued on 5/4/26 and not renewed or reordered. The IP stated it was important to monitor the Resident 4 for side effects associated with the medication. During a concurrent interview and review of Resident 4's electronic health record with LVN 2 on 5/8/26 at 9:34 a.m., LVN 2 stated if a resident was out of the facility for more than three days, new orders were obtained upon readmission. Review of Resident 4's electronic health record revealed monitoring for anticoagulant adverse effects was discontinued on 5/4/26 and not reordered until 5/6/26. LVN 2 stated it was the nurse's responsibility to ensure required monitoring orders were in place, as the purpose of monitoring was to assess signs and symptoms of bleeding. LVN 2 stated without monitoring in place, signs and symptoms of bleeding may not be identified. During a review of Resident 4's Medication Administration Record (MAR) from April 2026 through May 2026 it was indicated rivaroxaban 20 mg once daily was discontinued on 5/4/26 at 2:52p.m. and restarted on 5/5/26 at 9:00a.m. Review further indicated monitoring for signs and symptoms of bleeding related to anticoagulant therapy was discontinued on 5/4/26 at 2:52 p.m. and was not restarted until 5/6/26 at 11:00p.m. During a review of Resident 4's Care Plan Report dated 5/4/26, the Care Plan Report indicated Resident 4 was receiving anticoagulant therapy with rivaroxaban and included interventions to monitor for adverse reactions and effectiveness each shift. Interventions included daily skin inspection, monitoring for signs and symptoms of bleeding, including blood in urine, black tarry stools and red blood in stools, bruising, blurred vision, shortness of breath, changes in appetite and sudden changes in vital signs or mental status with instructions to report abnormalities to nursing staff. During an interview on 5/8/26 at 12:06p.m. with the Director of Nursing (DON), the DON stated it was her expectation nursing staff follow all hospital discharge orders upon resident readmission. The DON stated it was her expectation Resident 4's anticoagulant monitoring remained in place following readmission. When asked if residents receiving anticoagulant therapy should be monitored the DON stated yes, as monitoring was important to identify signs of bleeding. During a review of the facility's policy and procedure (P&P) titled, Anticoagulation-Clinical Protocol, dated January 2018 the P&P indicated, .assess for any signs or symptoms related to adverse drug reactions due to the medication alone.staff and physician will monitor for possible complications in individuals who are being anticoagulated.

Based on observation, interview and record review, the facility failed to post actual direct care staffing hours worked for public review for 21 of 21 residents in the facility, as required, by posting projected DHPPD (Direct Hours Per Patient Day) staffing information instead of actual hours worked for the prior day.This failure had the potential to prevent residents' family members and visitors from having accurate information regarding the actual nursing staffing levels providing care in the facility. Findings:During an observation on 5/6/26 at 10:05 a.m. in the facility lobby, the publicly posted Daily, Nursing Shift Staffing sheet dated 5/6/26, was reviewed. The document identified Projected DHPPD: 4.2 at the bottom of the posting. During an interview on 5/8/26 at 11:56a.m. with the Director of Nursing (DON), the DON stated she was responsible for posting the daily DHPPD staffing sheet each day. During a concurrent interview and review of the facility's Daily Nurse Shift Staffing sheet dated 5/6/26 and Appendix PP tag F732, dated 2/3/23, on 5/8/26 at 12:23p.m. with the DON, the DON stated the facility used the staff schedule and daily census to determine staffing needs and that she completed the staffing posting in the morning and again before leaving for the day. When asked whether a resident, family member or visitor reviewing the posted staffing sheet would be able to determine the actual hours worked for prior day, the DON stated no, as the facility did not post the actual hours worked. The DON stated the posted staffing sheet reflected projected staffing rather than actual hours worked. The DON stated residents, family members and visitors had the right to know who cared for their loved ones. During the interview, the DON reviewed Appendix PP, Tag F732, dated 2/3/23, and verbalized understanding that the regulation required posting actual hours worked rather than projected staffing hours. During a review of facilities policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, dated January 2018, the P&P indicated, 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The Information recorded on the form shall include the following: g. the actual time worked during that shift for each category and type of nursing staff

Based on observation, interview, and record review, the facility failed to ensure food was stored, handled, and served in accordance with professional standards for food service safety when the ice machine was not secured and accessible to all residents, visitors, and staff.This failure resulted in the ice machine being improperly accessed and handled by Family Member (FM) 1 resulting in the contamination of ice which could lead to food borne illness for 22 out of 22 residents receiving food from the facility.During an observation on 5/5/26 at 9:19 a.m. the ice machine was observed at the end of the hall, near the kitchen and room [ROOM NUMBER]. The ice machine was observed in a closet with no door. The ice machine was observed with no lock. The ice machine was observed with no signage posted. The ice machine was observed with a designated ice scoop on the right side of the wall.During a concurrent observation and interview on 5/6/26 at 9:33 a.m. at the ice machine, Family Member (FM) 1 was observed exiting Resident 20's room carrying an empty water pitcher. FM 1 then opened the ice machine lid, placed the empty pitcher inside the ice machine, and scooped ice directly from the interior of the ice machine into the pitcher.FM 1 then closed the ice machine lid and returned to Resident 20's room. FM 1 stated he always obtained ice for his mother in this manner and staff had never instructed him not to.During an observation on 5/6/26 at 9:40 a.m. at the ice machine, Dietary Aide (DA) 1 was observed collecting ice with the ice scoop. DA 1 was observed returning to the kitchen with the collected ice.During an interview on 5/6/26 at 9:47 a.m. with DA 1, DA 1 stated she collected ice from the ice machine for kitchen preparation tasks. DA 1 stated there was no lock or door to the ice machine. DA 1 stated all residents, visitors, and staff could potentially access the ice machine at any time. DA 1 stated she had been at the facility for approximately one year and the ice machine had always been in the closet at the end of the hall, near the kitchen and room [ROOM NUMBER], with no door to the closet or lock on the ice machine.During a concurrent observation and interview on 5/6/26 at 10:42 a.m. with the Kitchen Supervisor (KS) at the ice machine, the KS stated the ice machine was accessible to all residents, visitors, and staff. The KS stated the ice machine had always been accessible to all with no doors or locks. The KS stated she had previously observed family members accessing the ice machine improperly. The KS stated she frequently observed FM 1 accessing the ice machine improperly. The KS stated she provided education to family members when she observed improper accessing of the ice machine. The KS stated only facility staff were expected and allowed to access the ice machine to ensure professional standards for food service safety were followed. The KS stated ice should only be scooped with the designated ice scoop and only after hand hygiene was performed to prevent contamination of ice. The KS stated ice would be considered contaminated if ice was scooped with any other object than the ice scoop. The KS stated ice was food and residents were at risk of food borne illness if they encountered contaminated ice. The KS stated the facility did not have any cross-contamination guard rails in place to ensure the ice machine was not contaminated when it was left accessible to all. The KS stated it could not be guaranteed the ice machine was clean and free from contamination at any given time since there was no door or lock to the ice machine to prevent unauthorized access.During an interview with the Director of Nursing (DON) on 5/8/26 at 12:06 p.m. the DON stated ice was food. The DON stated the expectation was for all food items to be stored, handled and served in accordance with standards for food service safety and facility policy for the prevention of foodborne illnesses. The DON stated only staff were allowed to access the ice machine. The DON stated the facility had no barriers in place to prevent unauthorized access to the ice machine to ensure ice was not contaminated by unauthorized users. The DON stated residents were placed at risk for infection and foodborne illness when the ice machine was not secured and was accessible to all.During a record review of the facility's policy and procedure (P&P) titled, Ice Procedures, dated 2023, the P&P indicated, .ice is to be handled properly to prevent infection.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program to help prevent the development and transmission of infections for one of ten sampled residents (Resident 30) when Resident 30 had a midline catheter (thin, flexible tube inserted into a vein in the upper arm used for intravenous treatments) dressing that was not changed for 8 days and then was not labeled or recorded in the medical record accurately after a dressing change.This failure resulted in Resident 30's midline catheter dressing not being changed per provider orders or facility policy and procedures which had the potential to result in catheter-related infections and illness.During an observation on 5/5/26 at 9:53 a.m. with Resident 30, in Resident 30's room, Resident 30's midline catheter dressing was observed dated 4/27/26. Resident 30's midline catheter dressing indicated it had not been changed in eight days.During a record review on 5/5/26 at 4:00 p.m. Resident 30's Treatment Administration Record (TAR), dated 5/5/26, was reviewed. The TAR indicated there were no documented midline catheter dressing changes since admission on [DATE].During an observation on 5/6/26 at 9:20 a.m. with Resident 30, in Resident 30's room, Resident 30's midline catheter dressing was observed dated 5/4/26.During a record review on 5/6/26 at 10:20 a.m. Resident 30's TAR, dated 5/6/26, was reviewed. The TAR indicated the Director of Nursing (DON) documented a midline catheter dressing change on 5/4/26.During a concurrent interview and record review on 5/6/26 at 11:25 a.m. with the Director of Nursing (DON), Resident 30's TAR, dated 5/6/26 was reviewed. The DON stated only Registered Nurses (RN) changed midline catheter dressings within the facility. The DON stated she changed Resident 30's midline catheter dressing on 5/5/26, eight days after the last dressing change on 4/27/26. The DON stated she then documented the incorrect date, 5/4/26, on the midline catheter dressing and TAR. The DON stated Resident 30's midline catheter dressing was required to be changed every 7 days, per physician orders and facility policy. The DON stated it was important to change midline catheter dressings every 7 days, per physician orders and facility policy, to prevent infection. The DON stated it was important to accurately label midline dressings and the TAR to indicate when the next dressing change was due.During an interview on 5/8/26 at 9:54 a.m. with the Infection Preventionist (IP), the IP stated midline catheters were at risk for infections and required weekly dressing changes to maintain the site and prevent catheter related infections associated. The IP stated it was important to accurately document and label midline catheter dressings to maintain weekly dressing change schedules. The IP stated Licensed Vocational Nurses (LVN) were responsible for daily midline catheter dressing assessments. The IP stated LVNs were expected to report if midline catheter dressing changes were due or past due. The IP stated RNs were responsible to change midline catheter dressings and accurately document and label dressing changes.During an interview on 5/8/26 at 12:06 p.m. with the DON, the DON stated facility policy and procedure was not followed when Resident 30's midline catheter dressing was not changed for eight days and then was inaccurately labeled and documented. The DON stated all midline catheter dressings were required to be changed every 7 days to prevent infection and maintain the site.During a record review of Resident 30's document titled, Order Summary Report (OSR), dated 5/6/26, the OSR indicated, .order start date 4/27/26.midline dressing change.every day shift every 7 day(s) and as needed soiled or dislodged.During a record review of the facility's policy and procedure (P&P) titled, Midline Dressing Changes, dated 1/2018, the P&P indicated, .the purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings.change midline catheter dressing 24 hours after catheter insertions, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.the following information should be recorded in the resident's medical record.date and time dressing was changed.

Based on observation, interview, and record review, the facility failed to ensure that residents skin assessments were completed to prevent pressure injuries (a wound or sore that develops from prolonged pressure on the skin, usually over a bony prominence such as heels, knees, elbows, hips, shoulders, and tailbone) for one of four sampled residents (Resident 1) when Resident 1's stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) pressure injury was identified on 6/3/25, 31 days after being admitted to the facility. This failure resulted in Resident 1 developing a stage 3 pressure injury, which prolonged his stay in the facility because the facility he was to be discharged to would not accept him with a pressure injury. During a review of Resident 1's admission Record (a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 8/19/25 , the admission record indicated Resident 1 was admitted to the facility on [DATE] for rehabilitation due to a fall that resulted in a left partial hip replacement (a surgical procedure where only the damaged part of the hip joint is replaced with an artificial implant). Resident 1 had a history that included type 2 diabetes mellitus (DM - high levels of sugar in the blood).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 8/15/2025, Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating no cognitive impairment. During a concurrent observation and interview on 8/19/25 at 11:08 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed with his left leg elevated on a pillow. Resident 1 stated his left foot was elevated on a pillow due to an injury on his left heel. Resident 1 stated he got an injury to his left heel while at the facility and did not have the injury prior to admission. Resident 1 stated he was not as mobile as he was prior to coming to the facility due to his fall and subsequent hip surgery. Resident 1 stated he needed assistance from facility staff with repositioning himself in bed and showering. During an interview on 8/19/25 at 1:15 p.m. with the Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1's skin was assessed for redness, bruises, or skin tears during showers, while changing his clothes, and during positioning. The CNA stated they used a shower assessment (a process of closely observing a resident's skin and overall condition during bathing to identify any abnormalities or changes that require further attention) to help identify skin issues during Resident 1's shower times. CNA 1 stated Resident 1's bony prominences (a part of the skeleton where a bone is close to the surface of the skin) were assessed for redness or signs of pressure injury during shower times. CNA 1 stated any changes found on Resident 1's skin during shower times would have been recorded on the shower assessment form, reported to the nurse for further assessment, and turned into the Director of Nursing (DON). During an interview on 8/19/25 at 2:34 p.m. with the DON, the DON stated Resident 1's left heel pressure injury was acquired at the facility. The DON stated on 6/3/25, when staff noticed Resident 1's pressure injury, it was a dark black color. The DON stated it was not typical for a resident to develop a pressure injury 31 days after admission. During a concurrent interview and record review on 8/20/25 at 10:42 a.m. with the Licensed Vocational Nurse (LVN) 1, Resident 1's Nurse's Note (NN), dated 5/3/25, was reviewed. The NN indicated Resident 1 was admitted to the facility on [DATE] from an acute care hospital for a left femur (the bone of thethigh) fracture. LVN 1 stated Resident 1 was pretty immobile (not able to move) at the time of his admission. LVN 1 stated Resident 1, stayed in bed, afraid to get up due to his fall at home.During a concurrent interview and record review on 8/20/25 at 10:45 a.m. with LVN 1, Resident 1's Advanced Skilled Evaluation (ASE), dated 5/4/25, was reviewed. The Advanced Skilled Evaluation indicated Resident 1's skin was .warm and dry, skin color WNL (within normal limits) . LVN 1 stated Resident 1 had no issues noted with his skin on admission other than his surgical site. LVN 1 stated the ASE's were done daily and were a head-to-toe assessment. During a concurrent interview and record review on 8/20/25 at 10:50 a.m. with LVN 1, Resident 1's ASE, dated 6/1/25, was reviewed. The (ASE) indicated Resident 1's skin was . warm and dry, skin color WNL . LVN 1 stated Resident 1 had no issues noted with his skin on 6/1/25.During a concurrent interview and record review on 8/20/25 at 10:55 a.m. with LVN 1, Resident 1's Nurse's Note, dated 6/3/25, was reviewed. The Nurse's Note indicated, Note Text: writer was notified that resident had a sore on his left heel . writer assessed . noted a large dark red sore to left heel measuring 5cm x 5cm (centimeters - a metric unit of length) . open area around the edges of the sore and clear drainage. LVN 1 stated she was the writer of the Nurse's note. LVN 1 stated she was notified of Resident 1's pressure injury by a CNA. LVN 1 stated she thought that a CNA noticed Resident 1's pressure injury while they were changing his socks.During a concurrent interview and record review on 8/20/25 at 11 a.m. with LVN 1, Resident 1's Initial Wound Evaluation & Management Summary, dated 6/5/25, was reviewed. The Initial Wound Evaluation & Management Summary indicated, Stage: Unstageable DTI (deep tissue injury - damage to the muscles, fat, or other underlying tissues that occurs while the outer skin still looks intact, often appearing as a bruise-like discoloration) with intact skin . Skin: intact with purple/ maroon discoloration . Electronically signed by: [Wound Doctor]. LVN 1 stated a DTI is a pressure injury that starts underneath the skin. LVN 1 stated a DTI develops over time, because of pressure. LVN 1 stated Resident 1 would not have developed a DTI between his last Advanced Skilled Evaluation on 6/1/25 and 6/3/25 when the pressure injury was noticed by a CNA. LVN 1 stated Resident 1's pressure injury should have been evident prior to 6/3/25. LVN 1 stated she looks at residents' bony prominences when doing the Advanced Skilled Evaluations. LVN 1 stated the heel is considered a bony prominence and should be checked for redness or other signs of a pressure injury LVN 1 stated it was difficult to observe and complete an assessment of Resident 1's heels due to his hip surgery. LVN 1 stated Resident 1's heels should have been checked during repositioning and showers. LVN 1 stated it is important to check bony prominences to prevent pressure injury. LVN 1 stated Resident 1 could have experienced a prolonged rehabilitation due to his pressure injury. LVN 1 stated that she expected CNAs to look thoroughly at residents' skin during repositioning and shower times and notify the nurse of any skin changes. During an interview on 8/20/25 at 11:21 a.m. with CNA 1, CNA 1 stated the shower assessment form was called a Skin Monitoring: Comprehensive CNA Shower Review. CNA 1 stated the Skin Monitoring: Comprehensive CNA Shower Review form prompted the CNAs to look at residents' heels and other bony prominences. CNA 1 stated these areas are looked at to identify any pressure injuries. During an interview on 8/20/25 at 11:45 a.m. with the DON, the DON stated the nurse should have looked for redness and changes in skin color, or texture, when doing Resident 1's skin assessments. The DON stated the nurse should have looked at areas more prone to pressure during their assessments, which included Resident 1's heels. The DON stated a DTI occurs over time and is the result of prolonged pressure. The DON stated a DTI would not develop overnight. The DON stated the CNAs and nurses should have noticed Resident 1's pressure injury prior to 6/3/25. The DON stated CNAs should have noticed any skin changes for Resident 1 during shower times or repositioning. The DON stated nurses should have identified skin changes for Resident 1 during assessments. The DON stated she expected the CNAs and nurses to look at bony prominences for signs of pressure injury. The DON stated Resident 1's pressure injury could take a long time to heal due to his medical history of type 2 DM which causes wounds to heal slowly. The DON stated the facility should have identified the pressure injury sooner, before it progressed. The DON stated Resident 1 was not admitted to the assistive living facility due to his stage 3 pressure injury. During an interview on 8/20/25 at 12:33 p.m. with the Administrator (ADM), the ADM stated pressure injuries should be prevented in the facility. The ADM stated staff should have assessed residents' skin before a pressure injury developed. The ADM stated that staff should have been more careful in identifying pressure injuries for Resident 1 since he was immobile due to hip surgery and because of his type 2 DM. During a review of Resident 1's Skin Monitoring: Comprehensive CNA Shower Review (CSR), dated 6/2/25, the CSR indicated, .Resident: Resident 1 . Perform a visual assessment of a resident's skin when giving the resident a shower . Use this form to show the exact location and description of the abnormality . The CSR indicated Resident 1's heels had no redness or discoloration. During a review of the facility's policy and procedure (P&P) titled, Pressure Injuries Overview, dated January 2018, the P&P indicated, This injury results from intense and/or prolonged (continuing for a long time) pressure . at the bone-muscle interface (junction where muscle tissue connects to bone). During a review of the facility's P&P titled, Repositioning, dated January 2018, the P&P indicated, General Guidelines: Evaluation of a resident's skin integrity after pressure has been reduced (lower pressure on specific body areas) or redistributed (more evenly spread pressure across a larger surface area) should give the development and implementation of repositioning plans . Evaluation: Evaluate the resident for an existing pressure ulcer. During a review of the facility's P&P titled, Shower, dated January 2018, the P&P indicated, Observe the resident's skin for any redness . reddish or blue-gray area of skin over a pressure point .

Based on observation, interview, and record review, the facility failed to follow their policy and procedure titled Medication Storage in the Facility when the medication room and medication refrigerator temperature which stored drugs and biologicals were not monitored and documented on 9/8/24 and 9/9/24. This failure had the potential for drugs and biologicals stored inside the medication room and medication refrigerator to decrease their effectiveness. Findings: During a concurrent observation and interview, on 9/10/24, at 11:52 a.m., with the Director of Nursing (DON), inside the medication room, the DON was observed reviewing the temperature log of the medication room and the medication refrigerator. The DON stated the medication room and the medication refrigerator temperature were not documented from 9/8/24 to 9/9/24. The medication room stored over-the-counter medications such as Multivitamins (supplement), Vitamin C (use for wound healing), Vitamin B-12 (use to prevent anemia), Zinc (use for wound healing), Ferrous Gluconate (iron supplement), Ibuprofen (use to relieve pain or fever), Acetaminophen (use to relieve pain or fever), Docusate Sodium (stool softener), Sennosides (stool softener), Milk of Magnesia (use to relieve constipation), and Melatonin (use to relieve sleeplessness). The medication refrigerator contained one vial of pneumovax vaccine (fights bacteria against pneumonia, blood infections, and bacterial meningitis-infection in the brain), two Tuberculin test (a tool for screening tuberculosis), two vials of regular insulin (a short acting insulin used to lower blood sugar level), two insulin glargine pen (a long acting insulin used to lower blood sugar) and the emergency kit which contained insulins (e-kit - emergency medications supplied by pharmacy that was stocked with 4-10-day supply of the most common medications used). During an interview on 9/10/24, at 12:28 p.m., with the DON, the DON stated the medications can go bad if the temperature of the medication room and medication refrigerator gets too hot or too cold. The DON stated Licensed Nurses (LNs) were responsible for checking the medication room and medication refrigerator temperature and document on the temperature log right away. During a review of a facility's document titled, Medication Storage Room Temperature Log, undated, the log indicated, . Month: September . Year: 2024 . 9/7/24 Temperature 78 degrees F . 9/8/24 Temperature [blank] . 9/9/24 Temperature [blank] . During a review of a facility's document titled, Refrigerator Temperature Log, undated, the log indicated, . Month: September . Year: 2024 . 9/7/24 Temperature 38 degrees F . 9/8/24 Temperature [blank] . 9/9/24 Temperature [blank] . During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, undated, the P&P indicated, . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . J. Medications requiring storage at room temperature are kept at temperatures ranging from 59 degrees Fahrenheit (F - unit of measurement) to 86 F degrees . K. Medication requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring .

Based on interview and record review, the facility failed to follow the policy and procedure titled Staff Development Program to ensure Licensed Nurses (LNs), Certified Nursing Assistants (CNAs) and ancillary (additional) support staff received and demonstrated competency to prevent and recognize resident abuse and had the necessary skills and techniques necessary to care for residents who were identified as high risk for fall when: 1. 11 of 28 facility staff had not attended and completed the 2024 annual mandatory in-service training for Abuse Prevention. 2. 16 of 28 facility staff had not attended and completed the 2024 annual mandatory in-service training for Fall Prevention. These failures had the potential to place residents at risk for care not being provided in a safe and competent manner. Findings: During a concurrent interview and record review on 9/12/24, at 10:41 a.m., with the Director of Staff Development (DSD), the in-service training titled Abuse Prevention, dated 3/20/24 was reviewed. The DSD stated they have 28 employees providing direct and indirect care to facility residents. The document indicated 11 of 28 facility staff had not attended the mandatory training. The DSD stated she did not offer a remedial class for staff who was not present on 3/20/24 mandatory in-service. The DSD stated without the training, staff would not have the proper knowledge on recognizing and preventing resident abuse. During a concurrent interview and record review on 9/12/24 at 2:57 p.m. with the DSD, the in-service training for Fall Prevention dated 6/21/24 was reviewed. The DSD stated, they have 28 employees providing direct and indirect care to facility residents. The document indicated 16 of 28 facility staff had not attended the mandatory training. The DSD stated she did not offer a remedial class for staff who was not present on 6/21/24 mandatory in-service. The DSD stated, without the training, staff would not have the proper knowledge on preventing residents from falling. During a concurrent interview and record review on 9/12/24 at 3:15 p.m. with the Director of Nursing (DON), the 2024 In-service Training Calendar was reviewed. The DON stated, the trainings for Abuse Prevention and Fall Prevention were mandatory trainings and should be completed annually. The DON stated, in-service training should be attended by Licensed Nurses, Certified Nurse Aides, and support staff to provide proper care to facility residents. During a review of the facility's policy and procedure (P&P) titled, Staff Development Program, dated 1/18, the P&P indicated, . All personnel must participate in initial orientation and regularly scheduled in-service training classes . 10. The following in-service training classes are mandatory . e. Resident Rights; f. Resident Abuse . During a review of the facility's P&P titled, Abuse Prevention Program, dated 1/18, the P&P indicated, . Our residents have the right to be free from abuse, neglect . 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse . During a professional reference of document titled Center for Clinical Standards and Quality/Survey & Certification Group, dated 9/14/12, indicated The Affordable Care Act: Section 6121 requires the Centers for Medicare & Medicaid Services (CMS) to ensure that nurse aides receive regular training on caring for residents with dementia and on preventing abuse. CMS created this training program to address the requirement for annual nurse aides training on these important topics. During a professional reference review retrieved from https://www.nursinghomeabuse.org/articles/nursing-home-abuse-training/ titled, Abuse and Neglect Training in Nursing Homes, dated 3/31/21, the professional reference indicated, .Nursing home abuse and neglect is unfortunately still a problem in nursing homes across the country. Nursing homes can significantly reduce the incidence of abuse and neglect in their facilities by investing in training and prevention. Nursing home facilities that do offer training have shown to have fewer cases of abuse and neglect . During a review of the facility's document titled, Licensed Vocational Nurse (LVN) Job Description, dated 10/15, the document indicated, . delivers efficient and effective nursing care . 11. Enhances nursing practice by attending all mandated in-service programs . During a review of the facility's document titled, Certified Nurse Aide Job Description, dated 10/15, the document indicated, . 1. Provides patient care in a manner conducive to safety and comfort . Must attend a minimum of 12 hours continuing education programs provided by the center in order to maintain certification . During a review of the facility's document titled, Maintenance Director Job Description, dated 10/15, the document indicated, . 2. Maintains the building in good repair and free of hazards . 9. Participates in and plans in-service programs . During a review of the facility's document titled, Staff Developer Job Description, dated 10/15, the document indicated, . the LVN Staff Developer functions as a practioner, consultant, educator and facilitator for all nursing staff focusing on the following areas . Nurse Education and in-service training . 2.6 Develops an annual nursing education calendar to include State/Federal Mandatory in-services .

Based on observation, interview, and record review the facility failed to provide a clean, safe, and sanitary homelike environment for two of five sampled residents (Residents 16 and 22) when the west hall shower room remained accessible for use with missing floor tiles, and the existing floor tiles were black with yellow areas in the tile grout. This failure resulted in an unclean, unsafe, unsanitary and non-homelike environment for Residents 16 and 22. Findings: During a concurrent observation and interview on 9/12/24 at 9:15 a.m. with Resident 16 in Resident 16's room, Resident 16 was observed dressed, sitting in her wheelchair next to her roommate's bed. Resident 16 complained of the shower in her hallway of being dirty. Resident 16 stated she did not want to use the shower in the west hall. Resident 16 stated she had requested to go to another shower in the next hallway. During a review of Resident 16's Admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 9/12/24, the AR indicated Resident 16 was admitted from the acute care hospital on 7/31/24. Resident 16 was admitted with diagnoses of metabolic encephalopathy (a brain dysfunction caused by an underlying condition), severe sepsis (a serious condition in which the body responds improperly to an infection) with septic shock (a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs), Fournier disease (Fournier's gangrene, a very serious, sometimes fatal infection in the genital or anal area. It's a type of necrotizing fasciitis [flesh-eating disease] that develops quickly, and is often associated with general signs of sepsis, rapid tissue destruction, and a high fatality rate) of vagina and vulva, abnormalities of gait (walking) and mobility and generalized muscle weakness. During a review of Resident 16's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 8/5/24, the MDS section C indicated Resident 16 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 16 was cognitively intact. During a concurrent observation and interview on 9/12/24 at 9:16 a.m. with Resident 22 in Resident 22's room, Resident 22 was observed dressed in bed speaking with her roommate. Resident 22 stated the shower in her hallway (west hall) was always dirty. Resident 22 stated she did not want to use the shower in her hallway and had to request to use another shower in the next hallway. During a review of Resident 22's AR, dated, 9/12/24, the AR indicated Resident 22 was admitted from an acute care hospital on 12/7/22, with diagnoses of fracture of left femur (thigh bone), shortness of breath, muscle weakness, difficulty in walking and essential hypertension (high blood pressure). During a review of Resident 22's MDS, dated , 6/13/24, the MDS section C indicated Resident 22 had a BIMS score of 15, which indicated Resident 22 was cognitively intact. During a concurrent observation and interview on 9/12/24 at 11:18 a.m. with the Maintenance Staff (MAINS) in the west hallway shower room, black colored shower tile, missing shower tile and yellow shower tile grout were observed. The MAINS stated the tile in the shower was old. The MAINS stated the shower should not have missing tile. The MAINS stated the areas in the shower with missing tile could not be cleaned appropriately and could be a source of infection to the residents who used the shower. During a concurrent observation and interview on 9/12/24 at 4:15 p.m. with the Housekeeping Supervisor (HS) in the west hallway shower room, black colored shower tile, missing shower tile, and yellow shower tile grout were observed. The HS stated the shower tiles were stained. The HS stated she had asked MAINS to replace and repair the stained, broken, and missing tiles a while ago. The HS stated the stained and missing tiles in the west hallway shower were not a homelike environment for the residents. During an interview on 9/13/24 at 10:54 a.m. with the Director of Nursing (DON), the DON stated all the shower rooms should be clean. The DON stated the west hall shower should not have had missing tile. The DON stated the shower floor with the missing tile could cause injury to the residents who use the shower. The DON stated the stained tile and missing tiles on the west hall shower floor were not considered a homelike environment for the residents. During a review of the facility document titled, Job Description: Housekeeping Supervisor, dated, 10/19/15, the document indicated, . manages the Housekeeping Department to ensure the provision of a clean and safe environment for customers, visitors and staff . inspects the center on a regular basis to determine the effectiveness of the housekeeping function . takes immediate action on any observed deficiencies . During a review of the facility document titled, Job Description: Maintenance Director, dated 10/19/15, the document indicated, . the Maintenance Director . is responsible for performing repairs . performing regular daily, weekly and monthly maintenance checks . performs overall supervision of the Maintenance Department including hands-on performance of maintenance and repair work . maintains the building in good repair and free of hazards . maintains the building and grounds in compliance with Federal, State, and local laws . During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated, [DATE], indicated, . residents are provided with a safe, lean, comfortable and homelike environment . facility staff and management maximized, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting . clean, sanitary and orderly environment .

Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for three of 16 sampled residents (Residents 1, 6, 10 ) when: 1. Resident 1's care plan was not developed to reflect interventions to address her use of a left shoulder sling after an unwitnessed fall with injury. This failure had the potential for Resident 1's left upper arm's injury to worsen. 2. Resident 10's care plan was not developed to reflect interventions to address her refusal of medications. This failure had the potential for Resident 10's medical needs to not be met. 3. Facility failed to implement the care plan for monitoring and assisting Resident 6 during meals. This failure resulted in Resident 6's monitoring and assessment needs to not be met and had the potential for aspiration. Findings: 1. During a review of Resident 1's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 9/11/24, the AR indicated, Resident 1 was admitted from the acute hospital on 4/16/24 to the facility with diagnoses including Displaced Fracture of Surgical Neck of Left Humerus (bone in the upper arm, between elbow and shoulder), Pneumonia (lung infection caused by bacteria), Chronic Obstructive Pulmonary Disease (COPD - is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), Hypertension (high blood pressure), and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 8/8/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 8 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent observation and interview on 9/11/24, at 10:57 a.m., with Resident 1 in the activity room, Resident 1 was observed sitting in her wheelchair and wearing a black shoulder sling on her left arm. Resident 1 stated she was pushed by someone several days ago, which resulted to an injury on her left arm and shoulder. Resident 1 was unable to give further details about the incident. Resident 1 reported having pain on her left arm and the pain level was between 6 and 8, on a scale of 0 to 10 (0 = no pain, 10 = severe pain). During a concurrent interview and record review on 9/13/24, at 9:40 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 1's Nursing Progress Note (PN), Physician Order Summary (POS), and Care Plan (CP) were reviewed. LVN 2 confirmed that she worked on 8/13/24, from 11:00 p.m. to 7:00 a.m. and was the Charge Nurse when Resident 1 had an unwitnessed fall. The PN indicated, . Resident had an unwitnessed fall. Certified Nurse Assistant notified [Charge] Nurse that resident [Resident 1] was on the floor in the bathroom . Nurse assessed resident and during assessment resident stated she was having pain to her left arm . when nurse asked resident to move the left upper extremity [arm] resident was unable to move it without assistance . [Ambulance] arrived at 0422 [4:22 a.m.] and left the building with resident at 0435 [4:35 a.m.] . Resident came from [Acute Hospital] at 10:40 a.m. [8/13/24] . came back with diagnosis of humeral fracture of left arm . Resident has swelling and discoloration on left upper arm. Resident has sling on her left arm . LVN 2 reviewed Resident 1's POS and stated she was unable to find a Physician Order written for the use of left shoulder sling. LVN 2 reviewed Resident 1's care plan and stated there was no care plan intervention created for Resident 1's use of shoulder sling. LVN 2 stated nurses were supposed to create a Resident specific care plan interventions and it was not done. LVN 2 stated Resident 1's left shoulder fracture could worsen if the sling was improperly use or not assess every shift. During a concurrent interview and record review on 9/13/24, at 12:30 p.m., with the Director of Nursing (DON), Residents 1's nursing care plan was reviewed. The DON stated Residents 1's care plan should have been resident-specific and it was not. The DON stated the care plan drove resident care to ensure resident's care and wishes were being met. The DON stated the facility failed to follow its policy and procedures related to care planning process. The DON stated the failure could potentially result to Resident 1's left upper arm bone fracture to worsen and limit her mobility. During a review of the facility's document titled, Job Description: Licensed Vocational Nurse (LVN), dated 10/15, the document indicated, . The LVN contributes to the nursing assessments and care planning, provides direct patient care . 3.1 Administers medications and performs treatment per physician orders . During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 1/18, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for reach resident . The comprehensive, person-centered care plan will: a. include measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being . 2. During a review of Resident 10's AR, dated 9/13/24, the AR indicated, Resident 10 was admitted from the acute hospital on 7/22/24 to the facility, with diagnoses including COPD, Hypertension, Muscle Weakness, and Congestive Heart Failure (CHF - weakness in the heart where fluid accumulates in the lungs). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 1'0s Brief Interview for Mental Status (BIMS) score was 15 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent observation and interview, on 9/10/24, at 2:30 p.m., with Licensed Vocational Nurse (LVN) 1, in front of the nurse station, LVN 1 was observed holding Resident 10's Fluticasone-Salmeterol inhaler. LVN 1 stated the inhaler opened date was 7/31/24 with 18 doses left in the container. LVN 1 stated the physician order was to administer twice a day and if given as ordered, there should be no remaining doses left in the inhaler that was opened on 7/31/24. During a concurrent interview and record review on 9/10/24, at 2:41 p.m., with LVN 1, Resident 10's August 2024 and September 2024 Medication Administration Record (MAR), Nursing Progress Note, and Nursing Care Plan were reviewed. LVN 1 stated Resident 10 has a history of refusing her Fluticasone-Salmeterol inhaler. LVN 1 stated she was unable to find any nursing documentation that Resident 10's attending physician was notified of multiple refusals. LVN 1 stated licensed nurses were supposed to notify the physician after multiple episodes of medication refusal and it was not done. LVN 1 stated licensed nurses were supposed to document medication refusals and it was not done. LVN 1 reviewed Resident 1's care plan and stated there was no care plan developed and no interventions were implemented to address Resident 10's medication refusal. LVN 1 stated nurses were supposed to create a care plan for medication refusal and it was not done. LVN 1 stated Resident 10's Chronic Obstructive Pulmonary Disease could worsen and potentially result to hospitalization . During a concurrent interview and record review on 9/13/24, at 12:15 p.m., with the DON, Residents 10's nursing care plan was reviewed. The DON stated she was unable to find a nursing care plan related to Resident 10's medication refusal. The DON stated Residents 10's care plan should have been resident-specific and it was not. The DON stated the care plan drove resident care to ensure resident's care and wishes were being met. The DON stated the facility failed to follow its policy and procedures related to care planning process. The DON stated the failure could potentially result to Resident 10's COPD to worsen. During a review of the facility's document titled, Job Description: Licensed Vocational Nurse (LVN), dated 10/15, the document indicated, . The LVN contributes to the nursing assessments and care planning, provides direct patient care . 3.1 Administers medications and performs treatment per physician orders . During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 1/18, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for reach resident . The comprehensive, person-centered care plan will: a. include measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being . 48739 3. Facility failed to implement the care plan for monitoring and assisting Resident 6 during meals. This failure resulted in Resident 6's monitoring and assessment needs to not be met and had the potential for aspiration. Findings: 3. During a review of Resident 6's AR, dated 9/12/24, the AR indicated, Resident 6 was admitted from the acute hospital on 6/22/20, with the diagnoses of dysphagia (difficulty swallowing), and gastro-esophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach called the esophagus), and heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath). During a review of Resident 6's MDS, dated , 6/17/24, the MDS section C indicated, Resident 6 had a BIMS score of six, which indicated Resident 6 had severe cognitive impairment. During a concurrent observation and interview on 9/10/24 at 12:07 p.m. with Resident 6 in Resident 6's room, Resident 6 was observed sitting up in her bed reading. Resident 6 stated she had not received her lunch tray. Observed the meal tray cart in the hallway with no staff nearby. Observed residents in the next room eating their meal. During an interview on 9/10/24 at 12:10 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated Resident 6's meal tray was not in the meal tray cart. CNA 6 stated she would ask the kitchen staff for Resident 6's meal tray. During a concurrent observation and interview on 9/10/24 at 12:15 p.m. with LVN 1 in Resident 6's room, LVN 1 was observed setting Resident 6's meal tray on the bedside table. LVN 1 stated Resident 6 had a pureed texture diet and required supervision during meals. LVN 1 was observed leaving Resident 6's room after setting up Resident 6's meal tray. Resident 6 was observed eating her pureed meal without supervision from staff. During a concurrent interview and record review on 9/11/24 at 4:35 p.m. with the Infection Preventionist (IP), Resident 6's CP, undated was reviewed. The CP indicated, . on 6/23/24, RD (Registered Dietician) recommended nursing to provide 1:1 feeding assistance to promote max PO intake . monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals . The IP stated Resident 6 had a CP for assistance with feeding 1:1. The IP stated somebody should have been with Resident 6 while she ate. The IP stated if Resident 6 was left alone with no assistance while eating, Resident 6's CP was not being followed. The IP stated if Resident 6 was not receiving assistance during mealtime, Resident 6 could have lost weight and Resident 6 could have declined. The IP stated Resident 6 had dysphasia and could have choked or aspirated food if Resident 6 was not being assisted or supervised while she ate. During a concurrent interview and record review on 9/13/24 at 10:36 a.m. with LVN 1, Resident 6's Nursing Progress Notes and CP, undated were reviewed. LVN 1 stated Resident 6 had some episodes of choking during her meals when she was admitted in June 2022. LVN 1 reviewed Resident 6's CP with the RD's recommendation for assistance and monitoring of Resident 6 during meals. LVN 1 stated if Resident 6's care plan was not followed, Resident 6 was at risk for choking. LVN 1 stated staff were to follow resident's care plans to prevent things from happening and to meet the resident's needs. LVN 1 stated Resident 6's care plans should have been followed by the staff to meet Resident 6's needs. During an interview on 9/13/24 at 10:54 a.m. with the DON, the DON stated staff should have been following Resident 6's CP. The DON stated if resident's CPs were not followed, staff could miss providing appropriate resident care. The DON stated her expectation was that the CP should have been completed and followed. The DON stated the CP should be individualized to each resident. During a review of the facility's document titled, Job description: Certified Nursing Assistant (CNA), dated 10/19/2015, the document indicated, . under the direction of a licensed nurse, the CNA . participates in the care planning process and implements care according to care plan . feeds or assists patients with meals and provides additional nourishment and hydration per care plan . During a review of the facility's P&P titled, Assisting the Impaired Resident with In-Room Meals, dated 1/2018, the P&P indicated . the purpose of this procedure is to provide appropriate support for residents who need assistance with eating . review the resident's care plan and provide for any special needs of the resident . During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 1/2018, indicated, . a comprehensive, person-centered care plan . is developed and implemented for each resident . the comprehensive, person-centered care plan will . describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . incorporate risk factors associated with identified problems . developing interventions that are targeted and meaningful to the resident .

Based on observation, interview, and record review, the facility failed to maintain a safe environment for two of nine sampled residents (Residents 20 and 22) when Residents 20 and 22's wheelchairs wheel locks were loose and not locking properly. This failure had the potential to put Resident 20 and Resident 22's safety at risk. Findings: During a review of Resident 20's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 9/11/24, the AR indicated, Resident 20 was admitted from the acute hospital on 8/5/24 to the facility with diagnoses including , Aftercare Following Joint Replacement surgery (a procedure that replaces a damaged joint with an artificial part, such as plastic, metal or ceramic), Morbid Obesity (overweight), Hypertension (high blood pressure), Muscle Weakness and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness). During a review of Resident 20's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 8/10/24, the MDS indicated Resident 20's Brief Interview for Mental Status (BIMS) score was 15 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of the Resident 20's document titled, History and Physical, dated 8/5/24, the document indicated, . DATE OF SURGERY: 7/31/24 . PROCEDURE: Right knee robotic-assisted total knee arthroplasty (a procedure that replaces a damaged joint with an artificial part) . During a concurrent observation and interview on 9/10/24, at 10:51 a.m., with Resident 20 in the activity room, Resident 20 was observed sitting in her wheelchair and trying to lock the wheel lock on the right side of her wheelchair. Resident 20 stated the wheel lock was loose for two weeks and she wanted it [wheel lock] to be fixed as soon as possible. Resident 20 stated the wheelchair was not safe to use. Resident 20 stated she recently had a knee surgery, requiring the use of wheelchair for mobility. During a review of Resident 22's AR, dated 9/11/24, the AR indicated, Resident 22 was admitted from the acute hospital on 12/7/22 to the facility with diagnoses including Fracture of Left Femur (thigh bone), Hypertension, Muscle Weakness, Difficulty Walking, and Unspecified Pain. During a review of Resident 22's MDS, dated [DATE], the MDS indicated Resident 22's Brief Interview for Mental Status (BIMS) score was 15 out of 15. During a review of the Resident 20's document titled, History and Physical, dated 12/8/22, the document indicated, . DISCHARGE DIAGNOSES AND PLAN . 2. Intertrochanteric Fracture (fracture that occurs in the upper part of the thigh bone) of left hip . During a concurrent observation and interview on 9/10/24, at 10:57 a.m., with Resident 22 in the activity room, Resident 22 was observed sitting in her wheelchair, next to Resident 20. Resident 22 stated the left wheel lock of her wheelchair was loose for several weeks and she wanted it [wheel lock] to be fixed as soon as possible. Resident 22 stated the staff knew that her wheelchair was not working but they did not do anything about it. Resident 22 stated she had a hip surgery couple of years ago, was unable to ambulate on her own, and used her wheelchair to go places. During a concurrent observation and interview on 9/10/24, at 10:59 a.m., with Certified Nurse Assistant (CNA) 1 in the activity room, CNA 1 checked Resident 20's wheelchair and stated Resident 20's right wheel lock was loosed and not locking properly. CNA 1 checked Resident 22's wheelchair and stated Resident 22's left wheel lock was loose. CNA 1 stated staff should report any equipment issues to the maintenance staff. CNA 1 stated loose wheel locks can allow the wheelchair to move, which can increase the risk of injury to Resident 20 and Resident 22. During a concurrent observation and interview on 9/10/24, at 11:06 a.m., with the Maintenance Supervisor (MAINS) in the activity room, MAINS checked Resident 20's wheelchair and stated Resident 20's right wheel lock was loosed and not locking properly. MAINS checked Resident 22's wheelchair and stated Resident 22's left wheel lock was loose. MAINS stated staff should report any equipment issue by completing the maintenance log. MAINS stated staff could also call him for issues requiring immediate attention such as wheel locks malfunction. MAINS stated loose wheel locks could cause fall or injury to Resident 20 and Resident 22. During a concurrent interview and record review on 9/10/24, at 4:00 p.m., with the MAINS, the facility's document titled Maintenance Log, undated, was reviewed. The log indicated, . Maintenance Needs . 9/3/24 . room [ROOM NUMBER]A . Bed remote not work [working] . MAINS stated the most recent maintenance request was related to bed remote not working. MAINS stated there were no documented request related to Resident 20 and Resident 22's loose wheelchair wheel locks. MAINS stated he cleans and inspects wheelchair once a month for any issues and perform repairs as needed. MAINS stated all staff were responsible in reporting any issues related to equipment malfunctions. MAINS stated loose wheel locks might result to a fall or injury to facility residents. During an interview on 9/13/24, at 12:49 p.m., with the Director of Nursing (DON), the DON stated licensed and unlicensed staff were responsible for reporting non-emergent equipment issues by completing the maintenance log. The DON stated for issues requiring immediate attention, staff should call the maintenance supervisor. The DON stated loose wheelchair wheel locks could cause injury to facility residents. The DON stated staff failed to follow the policy and procedure related to reporting equipment malfunction. During a review of the facility's document titled, Certified Nurse Aide (CNA) Job Description, dated 10/15, the document indicated, . 1. Provides patient care in a manner conducive to safety and comfort . 1.3 Assists patients with ambulation and transfers . 15. Reports changes in patient's condition, patient/family concerns or complaints to charge nurse/or supervisor . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse (LVN), dated 10/15, the document indicated, . the Licensed Vocational Nurse delivers efficient and effective nursing care . He/she operates within the scope of practice defined by the State Nurse Practice Act . 13. Promotes a culture of safety to ensure a healthy practice and living environment . During a review of the facility's document titled, Maintenance Director Job Description, dated 10/15, the document indicated, . The Maintenance Director is responsible for the overall maintenance operation of the center, and he/she is responsible for performing repairs and maintenance on equipment . 2. Maintains the building in good repair and free of hazards . During a review of the facility's policy and procedure (P&P) titled Assisted Devices and Equipment, dated 1/18, the P&P indicated, . Our facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents . Devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include, but are not limited to: a. Wheelchairs .

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse as per the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting policy for one resident (Resident 1), when Resident 1 had an unwitnessed fall with injury. In addition, the facility failed to report the results of the facility's investigation to the State Survey Agency within five working days of the alleged incident. This failure had the potential to place Resident 1 and other vulnerable residents at increased risk of abuse. Findings: During a review of Resident 1's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 9/11/24, the AR indicated, Resident 1 was admitted from the acute hospital on 4/16/24 to the facility with diagnoses including Displaced Fracture of Surgical Neck of Left Humerus (bone in the upper arm, between elbow and shoulder), Pneumonia (lung infection caused by bacteria), Chronic Obstructive Pulmonary Disease (COPD - is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), Hypertension (high blood pressure), and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical, and cognitive abilities), dated 8/8/24, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 8 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent observation and interview on 9/11/24, at 10:57 a.m., with Resident 1 in the activity room, Resident 1 was observed sitting in her wheelchair and wearing a black shoulder sling on her left arm. Resident 1 stated she was pushed by someone several days ago, which resulted to an injury on her left arm and shoulder. Resident 1 was unable to give further details about the incident. Resident 1 reported having pain on her left arm and the pain level was between 6 and 8, on a scale of 0 to 10 (0 = no pain, 10 = severe pain). During a concurrent interview and record review on 9/13/24, at 9:40 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 1's Nursing Progress Note (PN) was reviewed. LVN 2 confirmed that she worked on 8/13/24, from 11:00 p.m. to 7:00 a.m. and was the Charge Nurse when Resident 1 had an unwitnessed fall. The PN indicated, . Resident had an unwitnessed fall. Certified Nurse Assistant notified [Charge] Nurse that resident [Resident 1] was on the floor in the bathroom . Nurse assessed resident and during assessment resident stated she was having pain to her left arm . when nurse asked resident to move the left upper extremity [arm] resident was unable to move it without assistance . [Ambulance] arrived at 0422 [4:22 a.m.] and left the building with resident at 0435 [4:35 a.m.] . Resident came from [Acute Hospital] at 10:40 a.m. [8/13/24] . came back with diagnosis of humeral fracture of left arm . Resident has swelling and discoloration on left upper arm. Resident has sling on her left arm . LVN 2 stated she does not recall completing an incident report and submitting the report to the California Department of Public Health (CDPH - State survey agency) and the Ombudsman office (assist residents in long-term care facilities with issues related to resident's safety such as resident rights, physical, verbal, mental, or financial abuse). LVN 2 stated she did not complete the SOC 341 form (a form used to report a suspected dependent adult/elder abuse to the Ombudsman and State survey agency). During a concurrent interview and record review on 9/13/24, at 11:42 a.m., with LVN 1, Resident 1's PN and Interdisciplinary Team (IDT - staff members from various disciplines and responsible for the assessment, development, implementation, and evaluation of the treatment plan for facility residents) note were reviewed. LVN 1 stated she was unable to find documentation that the unwitnessed fall with injury was reported to CDPH and the Ombudsman office. LVN 1 stated Licensed Nurses were supposed to prepare an incident report and submit a copy to CDPH and to the Ombudsman office. LVN 1 stated, If we don't submit a copy of the incident report, it looks like were hiding something. Our Director of Nursing (DON) is pretty good about reporting incident to CDPH and to the Ombudsman office. During a concurrent interview and record review on 9/13/24, at 12:34 p.m., with the DON, Residents 1's IDT note was reviewed. The IDT note indicated, . Interventions . Resident was assessed by the charge nurse, vital signs were taken, neuro checks were started. [Attending] was notified via phone and the resident was sent out to ER [emergency room ] as MD [Physician] order for further evaluation. RP [Responsible Party] was also called but was unable to reach . The DON stated there was no record of the fall incident being reported to CDPH and to the Ombudsman office. The DON stated she does not think Resident 1's unwitnessed fall with injury was a reportable incident to CDPH and to the Ombudsman office. The DON stated there was no investigation report prepared and submitted to CDPH within five working days after the alleged incident. During a review of Resident 1's emergency room Record, dated 8/13/24, the record indicated, . brought in by ambulance from [Facility Name] for an unwitnessed ground-level fall .Findings: Left shoulder humeral fracture . Patient placed on sling . Hydrocodone for pain . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse (LVN), dated 10/15, the document indicated, . the Licensed Vocational Nurse delivers efficient and effective nursing care . He/she operates within the scope of practice defined by the State Nurse Practice Act . During a review of the facility's document titled, Job Description: Director of Nursing, dated 10/15, the document indicated, . The Director of Nursing has 24-hour accountability and is responsible for the delivery of high-quality and cost-effective health care while achieving positive clinical outcomes . 5.5 Ensures that patient's accidents/incident, adverse event and grievances/concerns are fully documented, investigated, reported and addressed in accordance with [Facility Name] policies and procedures and the Federal/State rules and regulations . During a review of the facility's policy and procedure (P&P) titled Abuse Investigation and Reporting dated 2/24, the P&P indicated, . All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknow source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . 5. The administrator, or his/her designee, will provide the appropriate agencies or individual listed above with written report of the findings of the investigation withing five (5) working days of the occurrence of the incident .

Based on interview and record review, the facility failed to provide services which met professional standards of practice for one of 16 sampled residents (Residents 10) when the facility failed to notify the Attending Physician of Resident 10's ongoing refusal of Fluticasone-Salmeterol (medication to prevent inflammation and narrowing of airway) inhaler. This failure had the potential to place Resident 10 at risk of not receive appropriate care and attain her highest well-being. Findings: During a review of Resident 10's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 9/13/24, the AR indicated, Resident 10 was admitted from the acute hospital on 7/22/24 to the facility, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), Hypertension (high blood pressure), Muscle Weakness, and Congestive Heart Failure (CHF - weakness in the heart where fluid accumulates in the lungs). During a concurrent observation and interview, on 9/10/24, at 2:30 p.m., with Licensed Vocational Nurse (LVN) 1, in front of the nurse station, LVN 1 was observed holding Resident 10's Fluticasone-Salmeterol inhaler. LVN 1 stated the inhaler opened date was 7/31/24 with 18 doses left in the container. LVN 1 stated the physician order was to administer twice a day and if given as ordered, there should be no remaining doses left in the inhaler that was opened on 7/31/24. During a concurrent interview and record review on 9/10/24, at 2:41 p.m., with LVN 1, Resident 10's August 2024 and September 2024 Medication Administration Record (MAR) and Nursing Progress Note were reviewed. LVN 1 stated Resident 10 has a history of refusing her Fluticasone-Salmeterol inhaler. The MAR indicated Resident 10 received her inhaler twice a day from 7/31/24 to 9/19/24 and there was no record of refusal. LVN 1 stated she was unable to find any nursing documentation that Resident 10 refused her inhaler and her attending physician was not notified of refusals. LVN 1 stated licensed nurses were supposed to document medication refusals and it was not done. LVN 1 stated licensed nurses were supposed to notify the physician after multiple episodes of medication refusal and it was not done. LVN 1 stated Resident 10's Chronic Obstructive Pulmonary Disease could worsen and potentially result to hospitalization . During an interview on 9/13/24, at 12:15 a.m. with the Director of Nursing (DON), the DON stated licensed nurses were supposed to notify the Attending Physician after three or more episodes of medication refusal. The DON stated her expectation was for the licensed nurses to document any refusal of medications and to report multiple episodes of medication refusal to the attending physician for further guidance. The DON stated licensed nurses failed to follow the facility's P&P related to refusing and/or discontinuing care or treatment. The DON stated the lack of follow-up and communication between the licensed nurses and the attending physician could result to Resident 10's COPD to worsen. During a review of Resident 10's Physician Order Summary(POS), dated 9/13/24, the POS indicated, . Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 Micro Grams Actuator (MCG/ACT - unit of measurement) . Order date 7/29/24 . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse (LVN), dated 10/15, the document indicated, . The LVN contributes to the nursing assessments and care planning, provides direct patient care . 3.1 Administers medications and performs treatment per physician orders . During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 1/18, the P&P indicated . Medications shall be administered in a safe and timely manner, and as prescribed . 19. The individual administering the medication must initial the resident's MAR after giving each medication .

Based on observation during the survey period of 9/10/24 to 9/13/24, the facility failed to provide the minimum of at least 80 square feet per resident in 15 out of 16 rooms (Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16). This failure had the potential for residents in Rooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 to not have reasonable privacy or adequate space. Findings: During an observation on 9/12/24, at 4:33 p.m., an environment tour was conducted with the maintenance supervisor, the inspection indicated the following rooms did not meet the minimum square footage as required by regulation. These rooms were as follows: Room Number Square Feet Number of Residents room [ROOM NUMBER] 144 2 room [ROOM NUMBER] 144 2 room [ROOM NUMBER] 144 2 room [ROOM NUMBER] 144 2 room [ROOM NUMBER] 144 2 room [ROOM NUMBER] 144 2 room [ROOM NUMBER] 144 2 room [ROOM NUMBER] 143 2 room [ROOM NUMBER] 143 2 room [ROOM NUMBER] 143 2 room [ROOM NUMBER] 143 2 room [ROOM NUMBER] 144 2 room [ROOM NUMBER] 144 2 room [ROOM NUMBER] 143 2 room [ROOM NUMBER] 143 2 However, variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Recommend waiver be continue in effect.

Based on interview, and record review, the facility failed to ensure a resident ' s right of being fully informed of care being furnished for one of three sampled residents (Resident 1), when the facility did not notify Resident 1 ' s representative party (RP) of an ophthalmology (branch of medicine concerned with the diagnosis and treatment of disorders of the eye) procedure that involved removing Resident 1 ' s eyelashes on 10/25/22. This failure had the potential to result in Resident 1 having feelings of anguish and depression from moving eyelashes without her knowledge and consent from the RP. Findings: During a review of Resident 1 ' s Admission Record (AR), dated 4/25/23, the AR indicated, .Original admitted [DATE] .Diagnosis Information .Chronic Obstructive Pulmonary Disease (refers to a group of diseases that cause airflow blockage and breathing-related problems) . During review of Resident 1 ' s Minimum Data Set Section C Cognitive Patterns (MDS-comprehensive, standardized assessment of residents' functional capabilities and health needs), dated 1/31/23, the MDS indicated, .BIMS (Brief Interview for Mental Status) Summary Score .7 (indicating impaired cognition) . During a review of Resident 1 ' s Progress Note (PN), dated 10/25/22, the PN indicated, Resident [1] was seen by Ophthalmologist (specialist in the branch of medicine concerned with the study and treatment of disorders and diseases of the eye) .Physician Notes: PCO trichiasis (Posterior capsule opacification, often referred to as secondary cataract, is the most common postoperative complication of cataract extraction resulting from eyelashes that are misdirected against the ocular surface) . During a review of Resident 1 ' s Ophthalmology Consultation (OC), dated 10/25/22, the OC indicated, .Procedure: Epilation Lashes (eyelash removal) .E1 left upper lid E2 left lower lid E3 right upper lid E4 right lower lid . During an interview on 5/17/23, at 10:20 a.m., with the Director of Nursing (DON), the DON stated on 10/25/22 Resident 1 had an Ophthalmologist appointment that included removal of eyelashes due to a condition where Resident 1 ' s eyelashes were growing inward. The DON stated she thought Resident 1 ' s RP knew of the need for follow up with the Ophthalmologist. The DON stated there was no indication in Resident 1 ' s records of notification of the ophthalmologist procedure to the RP. The DON stated she had spoken to the RP during a care conference meeting on 4/18/23, and RP stated she wanted to be notified of any procedure for Resident 1. The DON stated Resident 1 ' s ophthalmology procedures for removing eyelashes should have been discussed with the RP to give consent to treat. The DON stated the facility should have informed the RP of the eyelash removal for Resident 1. During an interview on 5/17/23, at 12:40 p.m., with the RP, the RP stated she had not approved the procedure to remove Resident 1 ' s eyelashes. The RP stated she did not know about the procedure until she was sent a Medicare Summary Notice EOB (explanation of benefits is statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf) that indicated an ophthalmology procedure had been done to remove Resident 1 ' s eyelashes. The RP stated because Resident 1 did not have the capacity to make those informed decisions, the facility should have communicated to consent to the procedure. During a review of Resident 1 ' s Admission Agreement (AA), dated 3/13/19, the AA indicated, .III. Consent to Treatment .you have the right, to the extent permitted by law, to refuse any treatment and the right to be informed of potential medical consequences should you refuse treatment. We will keep you informed about the routine nursing and emergency care we provide to you, and we will answer your questions about the care and services we provide you. If you are, or become, incapable of making your own medical decisions, we will follow the direction of a person with legal authority to make medical treatment on your behalf, such as a guardian, conservator, next of kin, or a person designated in an Advance Health Care Directive or Power of Attorney for Health Care . During a review of the facility policy and procedure (P&P) titled, Health, Medical Condition and Treatment Options, Informing Residents of, dated January 2018, the P&P indicated, .1. Every Resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance treatment and on an on-going basis. If a resident has an appointed representative, the representative is also informed . During a review of the facility P&P titled, Resident Rights, dated January 2018, the P&P indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to .o. be notified of his or her medical condition and of any changes in his or her condition: P. be informed of and participate in, his or her care planning and treatment .

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent when 10 medication errors were observed during 35 medication administration opportunities, which resulted in an error rate of 28.57 percent. These failures resulted in Resident 21 not being informed of the medications being administered and had the potential for unsafe medication administration. Findings: During a review of Resident 21's Admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/4/22, the AR indicated, Resident 21 was readmitted from an acute care hospital on 3/18/22 to the facility, whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 21's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact). During a concurrent observation and interview on 5/14/22, at 8:42 a.m., with Licensed Vocational Nurse (LVN) 1, outside Resident 21's room, LVN 1 stated she was giving Resident 21 the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 1 entered Resident 21's room, Resident 21 was lying in bed with the head of the bed approximately 35-40 degrees elevated. LVN 1 asked Resident 21 if she was ready for her medication and Resident 21 replied yes. LVN 1 gave the medications from the medication cup to Resident 21. Resident 21 was observed swallowing all her medications and drank 8 oz (ounce - unit of measurement) of water. LVN 1 did not inform Resident 21 of what medications were administered to her. LVN 1 validated the observation. LVN 1 stated she forgot to explain Resident 21's medications. LVN 1 stated Resident 21 has the right to know the medications that she was about to take. LVN 1 stated she failed to follow the facility's policy on medication administration. During an interview with the Director of Nursing (DON), on 5/6/22, at 12:58 p.m., DON stated LVN 1 should have stated the name and indication of each medication prior to handing the medication to Resident 21. DON stated LVN 1 did not follow the facility's policy on medication administration. DON stated giving the medication without stating the medication name and indication was a medication error. During a review of the facility's Licensed Vocational Nurse (LVN) Job Description (JD), dated 10/2015, the JD indicated . The LVN contributes to nursing assessments and care planning, provides direct patient care . 3. Provision of Direct Patient Care: 3.1 Administers medications and performs treatments per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, undated, the P&P indicated, . Policy: Medications are administered as prescribed in accordance with good nursing principles and practices . During a review of a professional reference titled, Involve Patients in Medication Checks, 2022, from the Institute for Healthcare Improvement retrieved from: http://www.ihi.org/resources/Pages/Changes/InvolvePatientsin MedicationChecks.aspx indicated, Patients have an important role in the medication administration process . Before administering any medications, clinicians should review the medication, its purpose, and the dose with the patient and ask him to verify that all are correct. The clinician should offer an opportunity for the patient to ask questions or raise concerns, and if anything is unclear the administration should be delayed until everything is resolved. This extra line of defense before the last step can be crucial in preventing adverse drug events .

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety when: 1. Two of two five-pound packs of ground beef were placed in the kitchen refrigerator to thaw without a documented pulled date (the date the frozen meat was removed from the freezer and placed in the refrigerator) or use-by date (the date the meat should be discarded); 2. The temperature of the water for the hand-washing sink in the kitchen was measured at 84 degrees Fahrenheit (F), below the expected temperature range of 100 to 108 degrees F per the facility policy and procedure. 3. The green salad on the kitchen assembly line on 5/4/22 had an internal temperature of 50 degrees F, rather than the expected temperature of 41 degrees or less per the Food Code. These failures had the potential to place residents at risk for serious complications from foodborne illness (disease or period of sickness caused by food contamination). Findings: 1. During a concurrent observation and interview on 5/3/22 at 10:15 a.m., with Cook 1, in the facility's kitchen, two thawed five-pound packs of ground beef were in a bin placed on the bottom rack of the kitchen's refrigerator. Cook 1 stated, the ground beef was place in the refrigerator to thaw but they did not know when the ground beef had been placed in the refrigerator since there was no label on the bin or on the meat packages. Cook 1 stated a label was required to indicate a pull date and used by date. During an interview on 5/3/22 at 11:52 a.m., with the Dietary Supervisors (DS) 1 and DS 2, DS 2 stated the ground beef was pulled on 5/2/22 by a kitchen staff. DS 1 stated, the kitchen staff should have labeled the ground beef with a pull date and used by date. DS 2 stated, the used by date was three days from the pull date to minimize foodborne illness. During an interview on 5/5/22 at 11:54 a.m., with Cook 2, Cook 2 stated Cook 2 removed the two five-pound packs of ground beef from the freezer on 5/2/22 and placed it in the refrigerator to thaw. Cook 2 stated a label was required to indicate when the ground beef should be used by. Cook 2 stated it was important to label the ground beef, so staff knew when to discard the meat. Cook 2 stated consuming meat passed the used by date can cause foodborne illness. Cook 2 stated, they should have labeled the ground beef. During a review of the facility's policy and procedure (P&P) titled, Food Preparation. Policy: Thawing of Meats, dated 2018, the P&P indicated, Procedure: Thawing meat properly can be done in these four ways: 1. In a refrigerator at 41 degrees F or colder. Allow 2 to 3 days to defrost, depending on quantity and total weight of meat. Labeling meat with pull and used by date. During a review of the professional reference retrieved from https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/big-thaw-safe-defrosting-methods, titled, The Big Thaw - Safe Defrosting Methods, dated 6/15/13, indicated, After thawing in the refrigerator, items such as ground meat, stew meat, poultry, seafood, should remain safe and good quality for an additional day or two before cooking; red meat cuts (such as beef, pork or lamb roasts, chops and steaks) 3 to 5 days. 2. During a concurrent observation and interview on 5/4/22 at 10:06 a.m., with Cook 1, in the facility's kitchen, the hand washing sink's hot water temperature was 84 degrees F when measured with a thermometer. Cook 1 used the facility's kitchen thermometer and validated the temperature was 84 degrees F. Cook 1 stated, the hot water should have been between 100 and 108 degrees F. During a concurrent observation and interview on 5/4/22 at 10:38 a.m., with the Maintenance staff (MS), in the facility's kitchen, the hand washing sink's hot water was measured with the MS's thermometer while the hot water was running. The hot water's temperature was 84 degrees F. MS stated the temperature should have been over 100 degrees F. During a concurrent interview and record review on 5/5/22 at 12:30 p.m., with the Regional Maintenance Supervisor (RMS), the facility's policy and procedure (P&P) titled, Hand Washing Procedure, dated 2020, was reviewed. The P&P indicated, Hand washing is important to prevent the spread of infection. Procedure: 1. Use warm running water (100 - 108 degrees F) and soap, preferably from a dispenser. RMS stated water temperature between 100 and 108 degrees F was required for effective handwashing to minimize spread of infection. 3. During a concurrent observation and interview on 5/4/22 at 11:51 a.m., with Cook 1 and DS 1, in the facility's kitchen, the tray line assembly for lunch preparation was measured with a food thermometer. The green salad's internal temperature was measured with the food thermometer, and thermometer indicated 50 degrees F. Cook 1 and DS 1 stated, the serving temperature of the green salad should have been 41 degrees or less to minimize foodborne illness. During an interview on 5/5/22 at 3:40 p.m., with the Registered Dietician (RD) and Administrator (ADM), RD stated, cold food should be stored at the proper temperature (below 41 degrees F) to prevent foodborne illness. The RD stated the elderly were at risk for foodborne illness. During a professional reference review of the Food Code - U.S. (United States) Food & Drug Administration 2017, dated 2017, the professional referenced indicated, .Historical Record of Cold Holding Temperature Provisions .41°F became the standard for cold holding . During a review of the professional reference retrieved from https://www.fda.gov/regulatory-information/search-fda-guidance-documents/guidance-industry-guide-minimize-microbial-food-safety-hazards-fresh-cut-fruits-and-vegetables, titled, Guidance for Industry: Guide to Minimize Microbial Food Safety Hazards of Fresh-cut Fruits and Vegetables, dated February 2008, the professional reference indicated, Processing fresh produce into fresh-cut products increases the risk of bacterial growth and contamination by breaking the natural exterior barrier of the produce (Ref. 6).The release of plant cellular fluids when produce is chopped or shredded provides a nutritive medium in which pathogens, if present, can survive or grow (Ref. 6). Thus, if pathogens are present when the surface integrity of the fruit or vegetable is broken, pathogen growth can occur and contamination may spread. The processing of fresh produce without proper sanitation procedures in the processing environment increases the potential for contamination by pathogens (see Appendix B, Foodborne Pathogens Associated with Fresh Fruits and Vegetables.) .The potential for pathogens to survive or grow is increased by the high moisture and nutrient content of fresh-cut fruits and vegetables, the absence of a lethal process (e.g., heat) during production to eliminate pathogens, and the potential for temperature abuse during processing, storage, transport, and retail display (Ref. 6). Importantly, however, fresh-cut produce processing has the capability to reduce the risk of contamination by placing the preparation of fresh-cut produce in a controlled, sanitary facility .

Based on observation, interview, and record review, the facility failed to maintain an effective infection control and prevention program when: 1. One of four staff (Certified Nurse Assistant [CNA] 2) failed to follow the facility's policy titled, Scope of Infection Control Program, when CNA 2 did not wear a face mask before entering the facility's screening area and main lobby. This failure had the potential to place residents, visitors, and staff at increased risk for transmission (a process on how an infectious agent can be transferred from one person to another) of [CONDITION(S)]-CoV-2 (the virus that causes a respiratory disease called Coronavirus disease 19 [COVID-19]. The virus is spread from person to person through droplets released when an infected person coughs, sneezes, or talks). 2. Licensed Nurses (LNs) and CNAs failed to ensure one of 12 sampled residents' (Resident 19) personal hygiene care plan was implemented when Resident 19's fingernails were untrimmed and covered with black and brown matter. This failure had the potential to result in Resident 19 developing skin infection and or stomach problems such as nausea, vomiting, diarrhea or stomach infection and the potential for cross contamination of any surfaces or objects that Resident 19 touches. Findings: 1. During a concurrent observation and interview on 5/4/22, at 5:45 p.m., with CNA 2, in the facility lobby, CNA 2 was observed entering the facility's screening area and main lobby without a face mask. CNA 2 validated the observation that she entered the facility's screening area and main lobby without a face mask. A posted sign on the facility's entry door indicated, Please wear a mask before entering . You are required to wear a face mask while in the building at all times . During an interview on 5/5/22, at 5:39 p.m., CNA 2 stated it was important to wear a face mask when entering the facility to prevent the spread of coronavirus. CNA 2 stated wearing a face mask was important to protect facility residents and staff from COVID-19 virus (Coronavirus disease, an infectious disease caused by the [CONDITION(S)]-CoV-2 virus). During an interview on 5/5/22, at 5:44 p.m., with Infection Preventionist (IP), IP stated staff must wear a face mask before entering the facility to protect residents and staff from COVID-19 virus. IP stated source control (use of well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory discharges when they are breathing, talking, sneezing, or coughing) was important to minimize the spread of COVID-19 virus. During an interview on 5/6/22, at 9:15 a.m., with Screener Receptionist (SR), SR stated staff and visitors must wear a face mask when entering the facility. Screener stated wearing a face mask would protect the residents, visitors, and staff from COVID-19 virus. During an interview on 5/6/22, at 9:26 a.m., with the Director of Staff Development (DSD), DSD stated staff and visitors must wear a face mask prior to entering the facility. DSD stated wearing a face mask would protect everyone in the facility from COVID-19 virus. During an interview on 5/6/22, at 1:20 p.m., with the Director of Nursing (DON), DON stated CNA 2 did not follow the facility's infection control policy. DON stated staff should wear a face mask before entering the facility to protect residents and staff from COVID-19. DON stated source control was important to minimize the spread of COVID-19 virus. During a review of the facility's policy and procedure (P&P) titled, Scope of Infection Control Program, dated 8/2016, the P&P indicated, . The scope of the program includes prevention, detection, management and control of spread of infection . 3. Infection control precautions and measures - includes safeguard and provision of personnel protective equipment as well as the use of transmission-based precautions, also known in California as enhanced standard precautions . During a professional reference review of the CDC, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 2/2/22, the professional reference indicated, . Health Care Provider (HCP) who are up to date with all recommended COVID-19 vaccine doses . They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors) . 2. During a review of Resident 19's Admission Record (AR, a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/4/22, the AR indicated, Resident 19 was admitted from an acute care hospital on 9/20/19 to the facility, whose diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 19's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 19's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 7 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact). During a review of Resident 19's Care Plan (CP), dated 10/3/19, the CP indicated, . The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] confusion and dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) . Interventions . PERSONAL HYGIENE/ORAL CARE: The resident requires extensive assistance from one person . During a concurrent observation and interview on 5/3/22, at 4:58 p.m., with CNA 1, in Resident 19's room. CNA 1 stated, Resident 19's fingernails on both hands were untrimmed and dirty, covered by brown and black substance. CNA 1 stated Resident 19's fingernails should be kept clean at all times. CNA 1 stated she and other nursing staff were responsible in maintaining Resident 19's fingernails were clean at all times. CNA 1 stated Resident 19 could develop skin or stomach infection because of her dirty fingernails. CNA 1 stated Resident 19 used her hands to eat her meals. During a concurrent observation and interview on 5/3/22, at 5:05 p.m., with LVN 2, in Resident 19's room. LVN 2 stated, Resident 19's fingernails on both hands were untrimmed and covered by a black and brown substance. LVN 2 stated Resident 19's fingernails should be kept clean at all times. LVN 2 stated facility staff did not follow Resident 19's personal hygiene care plan. LVN 2 stated Resident 19 used her hands to eat her meals, and the dirty fingernails could cause stomach problems such as nausea, vomiting, and diarrhea. LVN 2 stated Resident 19 could potentially have skin infection due to dirty fingernails. During an interview on 5/5/22, at 5:44 p.m., with the Infection Preventionist (IP), IP stated Resident 19's untrimmed and dirty fingernails was unacceptable and an infection control issue. During an interview on 5/6/22, at 12:43 p.m., with the Director of Nursing (DON), DON stated Resident 19's untrimmed and dirty fingernails were an infection control and dignity issue. DON stated Resident 19's personal hygiene care plan was not followed. DON stated staff should have cleaned Resident 19's hands and fingernails before and after meals, and as needed. DON stated the untrimmed and dirty fingernails could cause skin infection and stomach problems such as diarrhea, nausea, abdominal pain, and vomiting. During a review of the facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, dated 2/2018, the P&P indicated . The purpose of this procedure is to clean the nail bed, to keep nails trimmed . 10. Gently remove the dirt from around and under each nail with an orange stick. 11. Wipe the dirt from the orange stick with a paper towel . 22. Make the resident comfortable .