Every finding on record at Ocean View Post Acute

Based on observation, interview and record review, the facility failed to ensure medications were safely secured when Resident 1's medications were left unattended by nursing staff and the medication cart was not locked for 1 of 3 medication carts observed. This failure had the potential to affect residents' safety and may lead to drug diversion (the illegal distribution, transfer, or use of a prescription medication outside its intended medical purpose). Findings:Per the Facility's admission Record, Resident 1 was admitted on [DATE] with diagnoses which included Quadriplegia (a medical condition involving the partial or total paralysis of all four limbs and the torso) and Generalized Anxiety Disorder (a mental health condition defined by constant , excessive worry about everyday things like work, health, or money). A review of Resident 1's Minimum Data Set (MDS- federally mandated assessment tool) dated 6/4/2026 indicated Resident 1's brief interview for mental status (BIMS) score was 13 which meant Resident 1's cognition (thought process) was intact. On 8/26/26 at 9:55 A.M., an observation during a complaint investigation was conducted. In front of Resident 1's room was observed an unlocked medication cart with no staff present and there were pills in a clear plastic cup sitting on top of the medication cart. On 8/26/26 at 10 A.M., an interview with licensed nurse (LN 1) was conducted. LN 1 stated she left the medication cart unattended with Resident 1's pills in a clear plastic cup on top of the medication cart because she had to check on a another resident's oxygen. LN 1 stated it was important not to leave the medications on top of the medication cart unattended, and to lock the medication cart. The concern is that the facility residents, staff and visitors might just pick them (the medications) up and a possible drug diversion might happen. LN 1 also stated safe storage of medications is important for residents' safety. A record review of Resident 1's Physician's orders were for the following unattended medications :Baclofen (skeletal muscle relaxant that acts on spinal cord nerves and decreases the number and severity of muscle spasms in patients) oral tablet 5 mg , give 1 tablet by mouth two times a day for muscle spasm start date 7/24/2023.Docusate sodium oral capsule 100 mg, give 1 capsule by mouth one time a day for constipation, hold for loose stool start date 6/09/2026.Gabapentin (used for seizures or for nerve pain and this medication may cause depressed respiratory rate -number of breaths per minute) 300 mg capsule, give 1 capsule by mouth three times a day for neuropathic pain. Hold the dose if lethargic or if RR (Respiratory Rate <12 (breaths decrease below 12 per minute) start date 5/25/2023.Levetiracetam (controls and prevents seizures) f/c (film coated tablet) 500 mg, give 1 tablet by mouth every 12 hours for seizure disorder start date 5/25/2023.Methenamine Hippurate (kills bacteria in the bladder) oral tablet 1 gm , give 1 tablet by mouth two times a day for prophylaxis (preventative care) UTI (Urinary Tract Infection) start dated 8/8/2025 On 8/26/26 at 10:30 A.M., an interview with LN 2 was conducted. LN 2 stated it was important not to leave medications on top of the cart unattended because anybody can take the medications, narcotics would not be safe, since the facility has residents with dementia and for their safety. On 8/26/26 at 12 noon, an interview with the Director of Nursing (DON) was conducted. The DON stated it was important not to leave medications or the medication cart unattended and unlocked because it could lead to drug diversion and affected resident safety. A review of the Facility's Policy on Medication Storage dated 12/19/2022 , Policy Explanation and Compliance Guidelines c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/ cart.

Based on interview, and record review, the facility failed to provide care and services to prevent accidents for one of five sampled residents (Resident 1) who has left sided hemiplegia (paralysis affecting one side of the body) and hemiparesis (one-sided weakness). Resident 1 was left unattended in bed while she was turned on her left side and the bed raised in a high position.As a result, Resident 1 fell off the bed and sustained a femoral neck fracture (fractured hip), which required surgical intervention.Findings:During a record review, the undated Facility admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia (a form of paralysis that causes loss of movement to one side of the body) following cerebral infarction (a stroke) affecting left non-dominant side, generalized muscle weakness, lumbago with sciatica on the right side (pain which radiates from the lower back and travels down the left buttock, thigh, leg and feet), and need for assistance with personal care.During a review of the Minimum Data Set (MDS- a federally mandated assessment tool), dated 2/10/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to measure cognition, or mental processes) of 13 which indicated Resident 1 was cognitively intact. The MDS section GG further indicated Resident 1 was fully dependent on staff for mobility, including the ability to roll from lying on her back to left and right side, and return to lying on the bed. According to section J of the MDS, Resident 1 did not have a history of falls prior to admission.During a record review of the facility's document titled eINTERACT Change in Condition Evaluation by Licensed Nurse (LN) 1, dated 4/24/26 at 8 A.M., the document indicated, Writer was notified by cna [Certified Nursing Assistant] that pt rolled off bed [sic]. Upon arrival RN [Registered Nurse] there for assessment [sic]. Pt stated that she was trying to turn on bedroom light while waiting for cna and her right leg slipped off the bed which cause her to roll off bed. pt was then assisted by 4 people back into bed with hoyer lift [a mechanical lift used to transfer patients]. pt stated her left knee hurt 5/10 [a pain rating of five out of ten, with ten being the most painful].During an interview with Certified Nursing Assistant (CNA) 1 on 5/1/26 at 9:55 A.M., CNA 1 stated she was Resident 1's assigned CNA on 4/24/26. CNA 1 stated, on 4/24/26, while assisting Resident 1 with getting changed and dressed, Resident 1 asked if the medication nurse could place a lidocaine patch (a medication used to relieve pain) on her back before she got fully dressed. CNA 1 stated she left Resident 1 in bed and positioned the resident on her left side. CNA 1 stated she did not position Resident 1 on her back before leaving to find the medication nurse. CNA 1 further stated the bed was in a raised high position, and that she did not lower the bed prior to leaving Resident 1's room. CNA 1 stated, I told [Resident 1] I'll be back to get the nurse so she can give you the [lidocaine] patch. CNA 1 stated a few minutes after she left the room; Resident 1 had fallen from the bed. CNA 1 stated, I should have asked her to lay on her back and lowered the bed and at least waited for another nurse to watch her while I got the nurse. CNA 1 stated Resident 1 would not have rolled off the bed if she had been laying on her back. CNA 1 stated it was unsafe to leave Resident 1 in a side lying position, with the bed raised in a high position.During an interview with Restorative Nursing Assistant (RNA) 1 on 5/1/26 at 10:29 A.M., RNA 1 stated she was walking down the hallway and heard Resident 1's roommate called out for help. RNA 1 stated she entered Resident 1's bedroom and observed Resident 1 on the floor, in a sitting position, facing the bed. RNA 1 stated, Resident 1's right leg was bent and the left leg was on top of the right leg. RNA 1 further stated she observed Resident 1's bed was at a raised/waist level at the time of the fall.During a telephone interview with Resident 1 on 5/8/26 at 4:17 P.M., Resident 1 stated, [CNA 1] was going to change my brief, but first she went to ask for my lidocaine patch. Resident 1 stated she was lying on her left side, close to the edge of the bed, and I changed my weight distribution. I don't remember how, but my weight shifted, I didn't intentionally roll. Resident 1 stated, they could've left me on my back when [CNA 1] left the room.they could have centered me in the bed so I couldn't roll off.During an interview with the Assistant Director of Nursing (ADON), on 5/12/26 at 9:30 A.M., the ADON stated she was responsible for investigating facility falls and led the Interdisciplinary Team Meeting (IDT- a group of individuals with different areas of expertise). The ADON stated Resident 1's fall was preventable if safety measures were provided prior to leaving Resident 1 without supervision. The ADON stated, a safe position would have been on her back, in the middle of the bed, and the bed was in a lower position.During an interview with the Director of Rehab (DOR) on 5/12/26 at 9:52 A.M., the DOR stated he was familiar with Resident 1 and had worked with her during her stay at the facility. The DOR stated Resident 1 was at risk for falls due to left side weakness, and having recently had surgery. The DOR stated he considered Resident 1's fall on 4/24/26 to be an avoidable fall. The DOR stated, I would have hit the resident's call light and waited for assistance , or get [Resident 1] in a supine position [lying flat on the back, facing upward] before leaving the room.A review of a hospital document titled Consultation Note dated 4/24/26 at 2:45 P.M., authored by Medical Doctor (MD) 1, indicated, The patient is a [AGE] year old who arrives by ambulance after falling out of bed. She states staff had rolled her onto her side.she excellently [sic] rolled off the bed.She was at her skilled nursing facility today when they went to go change her she was on her right side when she is not sure where the person went and then she fell rolled back off of the bed and onto her butt on the floor and had immediate pain in her hip. She was brought here and found to have a displaced femoral neck fracture [a broken hip].She was able to walk around Thanksgiving at rehab prior to her second surgery. The document further stated, Assessment/Plan.Discussed the severity of the injury with the patient and family. This is a particularly challenging injury in someone with her functional deficits.her options would be a hemi hip arthroplasty [joint replacement surgery] versus a [NAME] [a type of hip surgery done, without placing an artificial hip joint]. A [NAME] would [NAME] her of the ability to ambulate [walk]on this leg in the future but help with her significant pain. A hemi [hip arthroplasty] would carry significant risk of dislocation as well as periprosthetic fracture.but would give her the hope of potentially walking as accomplish goals of pain control. After a very long discussion with her and her husband they would like to proceed with a left hip hemiarthroplasty to hopefully allow for transfers or ambulation in the future.She understands if she dislocates she would likely require a [NAME] and this would not allow her to ambulate.Other risks [of surgical intervention] were reviewed including pain, bleeding, blood clots, anesthesia, medical complications, dislocation, periprosthetic fractures, loosening, infection requiring multiple procedures and unforeseen complications.During a review of the facility's policy titled Fall Prevention Program revised 4/20/26, the policy indicated, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.At risk protocols.Provide additional interventions as directed by the resident's assessment, including but not limited to.Assistive devices.increased frequency of rounds.low bed.

Based on interview and record review, the facility failed to allow one of three sampled residents (Resident 1) to return to the facility following a visit to the emergency department.This failure had the potential for Resident 1 to not receive continuity of care and violated his right to return to the facility per the facility's policy.Findings:According to the facility's admission Record, Resident 2 was admitted to the facility on [DATE] with diagnoses which included aphasia (a disorder which affects a person's ability to speak or understand speech) following cerebral infarction (a stroke).During a record review, the Minimum Data Set (MDS- a federally mandated assessment tool) dated 3/28/26 indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess thinking skills) of 12, which indicated moderate cognitive impairment.A review of the document titled Interdisciplinary Care Conference dated 3/31/26 indicated, Discharge plan.Patient is homeless, does [sic] not have a dc [discharge] plan.During an interview with the Administrator (ADMIN), on 4/29/26 at 9:35 A.M., the ADMIN stated on 4/14/26, Resident 2 was transferred to the hospital for evaluation related to unresolved headaches. The ADMIN stated a CT (computed tomography- a type of x-ray to create images of the body) scan was performed at the hospital. The ADMIN stated the CT scan was negative, and Resident 2 was not admitted to the hospital. The ADMIN further stated upon completion of the CT scan at the hospital, Resident 2 was not permitted to return to the facility because he was independent with ADL's, had altercations with other residents, and behaviors. Additionally, the facility had accommodated Resident 2 with a private room. The ADMIN stated, This is probably not the best place for him and the facility's admissions director was instructed to not to accept Resident 2 back to the facility.During a telephone interview with Resident 2 on 4/29/26 at 7:52 A.M., Resident 2 stated on 4/14/26, after he had completed the CT scan and was cleared to return to the facility, the hospital Case Manager informed him the facility would not allow him to return. Resident 2 stated, after the exam, I just sat there waiting to see if I would have a ride back to the facility. They told me, [the facility] doesn't want you back. Resident 2 stated since he was homeless, and could not return to the facility, he used a ride share service to drive him to a friend's office space. Resident 2 stated his personal belongings were still at the facility, and he did not have any medications with him, including Plavix, a medication to prevent blood clots.During a record review of the Emergency Department document titled Case Management Note, the document indicated, Cm [Case Management] spoke with [facility liaison].regarding pt's [patient's] return. Per [facility liaison] pt already hit one of his room mates, he is demanding private room which is not available at this time.An interview with the Social Services Director (SSD) was conducted on 4/29/26 at 10:02 A.M., The SSD stated Resident 2 was homeless, did not have any income, and did not have a specific discharge plan yet. The SSD stated when Resident 2 became ready to be discharged , she planned on assisting Resident 2 with applying for Social Security benefits. The SSD stated if or when Resident 2 was approved, she would have assisted Resident 2 with placement into either an Assisted Living Facility or an Independent Living Facility, depending on the amount of Social Security benefits. The SSD stated she would have coordinated with Home Health Agencies to provide services for Resident 2 after discharge. The SSD stated the plan was to assist Resident 2 with a safe discharge. During a telephone interview with Resident 2's primary care physician (PCP) 1 on 4/29/26 AT 10:50 A.M., PCP 1 stated Resident 2 was medically cleared to return to the facility after the Emergency Department visit on 4/14/29. PCP 1 stated, My presumption was that [Resident 2] was going to go back [to the facility].Why he couldn't return back, I don't know the answer. PCP 1 acknowledged Resident 2 did not have any orders for discharge from the facility as of 4/14/26.During a concurrent interview and record review with Licensed Nurse (LN) 1 on 4/29/26 at 11:45 A.M., LN 1 stated a safe discharge plan consisted of a physician's order, post-discharge education provided to the resident or their representative, and coordination with home health services. LN 1 acknowledged Resident 1 did not have documentation which indicated a physician's order for discharge and no education provided to Resident 1 regarding medications or discharge instructions. LN 1 further stated medications and their personal belongings would be provided to residents. LN 1 stated it was important to follow the facility's discharge process for continuity of care, and to ensure residents had a safe and coordinated discharge.During an interview with the Director of Nursing (DON) on 5/12/26 at 3:44 P.M., the DON stated her expectation was for a coordinated and planned discharge, to ensure residents' safety.During a review of the facility's policy titled Discharge Planning Process, revised 12/29/22, the policy indicated, It is the policy of this facility to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.The facility will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge.

Based on observations, interview, and record review the facility failed to ensure infection control procedures were followed when staff did not wear a gown for residents (47, 52 and 306) with enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds and medical devices and with history of multidrug-resistant organism- MDROs]). These failures had the potential for cross contamination, spread of infection and residents' decline of health. Findings: 1. Resident 47 was readmitted to the facility on [DATE], with diagnoses which included methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), per the facility's admission Record. On 6/2/25 at 10:05 A.M., an observation of Resident 47's room was conducted. A plastic sign indicating EBP was posted outside the entrance to the room. On 6/2/25 at 10:40 A.M., an observation was conducted as Certified Nursing Assistant (CNA) 1 transferred Resident 47 from the bed to the wheelchair. CNA 1 did not wear a gown during the transfer. On 6/3/25 at 10:39 A.M., an observation was conducted as two staff members transferred Resident 47 from the wheelchair to the bed. The two staff members did not wear gown during the transfer of Resident 47. A review of Resident 47's care plan related to EBP, dated 5/4/25, indicated an intervention of utilizing EBP to prevent the spread of infections. On 6/4/25 at 8:57 A.M., a joint review of Resident 47's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 47 was on EBP due to MRSA. The IP stated the staff were supposed to know which residents were on EBP and were expected to wear a gown and gloves when providing high contact activities like providing shower, providing hygiene and transferring. The IP stated the purpose of gowning and glove use for EBP was to help prevent the transmission of an infection from the resident to another resident through a caregiver's clothing. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to follow infection control practices related to EBP to prevent the spread of microorganisms from one resident to another. A review of the facility's policy titled, Enhanced Barrier Precautions, dated 12/19/22, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .c. The facility will have .to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .2.b. EBP are indicated for residents with any of the following .indwelling medical devices like central lines, hemodialysis catheters .feeding tubes .infection of colonization with any resistant organism .4. High-contact resident care activities include .c. Transferring . 2. Resident 52 was readmitted to the facility on [DATE] with diagnoses which included kidney disease, per the facility's admission Record. Resident 52's attending physician completed Resident 52's history and physical (H&P) dated 5/7/25. The H & P indicated Resident 52 had Extended Spectrum Beta-Lactamase (ESBL, enzymes produced by some bacteria that may make them resistant to some antibiotics). On 6/2/25 at 10:21 A.M., an observation of Resident 52's room was conducted. A plastic sign indicating EBP was posted outside the entrance to the room. On 6/3/25 at 10:11 A.M., a follow up observation and an interview was conducted of Resident 52 in his room. Resident laid in bed and stated he was scheduled to go to dialysis. Resident 52 pointed to his dialysis access on his right upper chest. On 6/3/25 at 10:13 A.M., an observation was conducted as CNA 1 transferred Resident 52 from one bed to another. CNA 1, without wearing a gown, lifted Resident 52 using a mechanical lift (a device used to safely transfer patients who cannot independently bear weight). CNA 1's clothing was in contact with Resident 52 while transferring him from the bed to the mechanical lift. On 6/3/25 at 10:30 A.M., an interview was conducted with CNA 1. CNA 1 stated she did not wear a gown because Resident 52 was not on EBP. CNA 1 stated the EBP sign by the resident's door was indicated for another resident. On 6/3/25 at 4:18 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 52. CNA 2 stated she was not aware Resident 52 was on EBP. A review of Resident 52's care plan related to EBP, dated 3/19/25, indicated an intervention of utilizing EBP to prevent the spread of infections. On 6/4/25 at 8:57 A.M., a joint review of Resident 52's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 52 was on EBP as he had a medical device in his right chest. The IP stated the staff were supposed to know which residents were on EBP and were expected to wear a gown and gloves when providing high contact activities like providing shower, providing hygiene and transferring. The IP stated the purpose of gowning and glove use for EBP was to help prevent the transmission of an infection from the resident to another resident through a caregiver's clothing. On 6/5/25 at 10:50 A.M., an interview was conducted with the DON. The DON stated the expectation was for the staff to follow infection control practices related to EBP to prevent the spread of microorganisms from one resident to another. A review of the facility's policy titled, Enhanced Barrier Precautions, dated 12/19/22, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .c. The facility will have .to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .2.b. EBP are indicated for residents with any of the following .indwelling medical devices like central lines, hemodialysis catheters .feeding tubes .infection of colonization with any resistant organism .4. High-contact resident care activities include .c. Transferring . 3. Per the facility's admission Record, Resident 306 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty of swallowing) and had a gastrostomy tube (g-tube, a medical device for medication administration and nutrition). On 6/5/25 at 7:30 A.M., an observation with Licensed Nurse (LN) 21 was conducted. LN 21 entered Resident 306's room. A plastic sign indicating EBP was posted outside the entrance to the room. LN 21 administered medications to Resident 306 through the g-tube. LN 21 did not wear a gown during medication administration. On 6/5/25 at 8:30 A.M., an interview with LN 21 was conducted. LN 21 stated he did not know he had to wear a gown in an EBP room. On 6/5/25 at 11 A.M., an interview with the DON was conducted. The DON stated gown and glove use were required when providing direct care to residents with medical devices to reduce the spread of organisms. A review of the facility's policy titled, Enhanced Barrier Precautions, dated 12/19/22, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .c. The facility will have .to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .2.b. EBP are indicated for residents with any of the following .indwelling medical devices like central lines, hemodialysis catheters .feeding tubes .infection of colonization with any resistant organism .

Based on observations, interviews and record review, the facility failed to implement a care plan (detailed plan with information about a patient's treatment, goal, and interventions) related to: A. Anticoagulant (blood thinner) therapy for Resident 47, B. Enhanced Barrier Precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with chronic wounds and medical devices]) practices when providing care to residents on EBP (Resident 47 and Resident 52), and, C. Dialysis (a process to remove waste from the blood for residents with kidney disease) access care of Resident 52. These failures had the potential to not meet the goals of treatment and needs of Resident 47 and Resident 52. Cross reference to F 757, F 880 and F 698. Findings: A. Resident 47 was readmitted to the facility on [DATE], with diagnoses which included contracture (stiffening/shortening at any joint, that reduces the joint's range of motion) of lower legs and on long term use of anticoagulant, per the facility's admission Record. A review of physician's order on 5/2/25 for Resident 47 indicated heparin (anticoagulant medication) to be administered to Resident 47 twice a day. A review of Resident 47's care plan related to heparin, dated 5/3/25, indicated one of the interventions was to, Monitor/ document/ report PRN (as needed) adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath (SOB), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs . On 6/4/25 at 11:03 A.M., a joint review of Resident 47's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident was on anticoagulant. LN 1 stated when residents were on anticoagulant, the residents were monitored for bleeding. LN 1 stated there was no documentation Resident 47 was monitored for bleeding. LN 1 stated the nurses should have monitored and implemented Resident 47's care plan. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the care plan should have been implemented related to monitoring adverse reactions to anticoagulants for early detection of bleeding and to ensure safety of the resident. Per facility's policy titled, Comprehensive Care Plans, revised 12/19/22, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .6. The comprehensive care plan will include measurable objectives .to meet the resident's need . B.1. Resident 47 was readmitted to the facility on [DATE], with diagnoses which included methicillin-resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics), per the facility's admission Record. On 6/2/25 at 10:05 A.M., an observation of Resident 47's room was conducted. A plastic sign indicating EBP was posted outside the entrance to the room. On 6/2/25 at 10:40 A.M., an observation was conducted as Certified Nursing Assistant (CNA) 1 transferred Resident 47 from the bed to the wheelchair. CNA 1 did not wear a gown during the transfer. On 6/3/25 at 10:39 A.M., an observation was conducted as two staff members transferred Resident 47 from the wheelchair to the bed. The two staff members did not wear gown during the transfer of Resident 47. A review of Resident 47's care plan related to EBP, dated 5/4/25, indicated an intervention of utilizing EBP to prevent the spread of infections. On 6/4/25 at 8:57 A.M., a joint review of Resident 47's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 47 was on EBP due to MRSA. The IP stated the staff were supposed to know which residents were on EBP and were expected to wear a gown and gloves when providing high contact activities like providing shower, providing hygiene and transferring. The IP stated the purpose of gowning and glove use for EBP was to help prevent the transmission of an infection from the resident to another resident through a caregiver's clothing. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the care plan should have been implemented related to EBP to prevent the spread of microorganisms from one resident to another. Per facility's policy tiled, Comprehensive Care Plans, revised 12/19/22, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .6. The comprehensive care plan will include measurable objectives .to meet the resident's needs . B.2. Resident 52 was readmitted to the facility on [DATE] with diagnoses which included kidney disease, per the facility's admission Record. Resident 52's attending physician completed Resident 52's history and physical (H&P) dated 5/7/25. The H & P indicated Resident 52 had Extended Spectrum Beta-Lactamase (ESBL, enzymes produced by some bacteria that may make them resistant to some antibiotics). On 6/2/25 at 10:21 A.M., an observation of Resident 52's room was conducted. A plastic sign indicating EBP was posted outside the entrance to the room. On 6/3/25 at 10:11 A.M., a follow up observation and an interview was conducted of Resident 52 in his room. Resident laid in bed and stated he was scheduled to go to dialysis. Resident 52 pointed to his dialysis access on his right upper chest. On 6/3/25 at 10:13 A.M., an observation was conducted as CNA 1 transferred Resident 52 from one bed to another. CNA 1, without wearing a gown, lifted Resident 52 using a mechanical lift (a device used to safely transfer patients who cannot independently bear weight). CNA 1's clothing was in contact with Resident 52 while transferring him from the bed to the mechanical lift. On 6/3/25 at 10:30 A.M., an interview was conducted with CNA 1. CNA 1 stated she did not wear a gown because Resident 52 was not on EBP. CNA 1 stated the EBP sign by the resident's door was indicated for another resident. On 6/3/25 at 4:18 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 52. CNA 2 stated she was not aware Resident 52 was on EBP. A review of Resident 52's care plan related to EBP, dated 3/19/25, indicated an intervention of utilizing EBP to prevent the spread of infections. On 6/4/25 at 8:57 A.M., a joint review of Resident 52's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 52 was on EBP as he had a medical device in his right chest. The IP stated the staff were supposed to know which residents were on EBP and were expected to wear a gown and gloves when providing high contact activities like providing shower, providing hygiene and transferring. The IP stated the purpose of gowning and glove use for EBP was to help prevent the transmission of an infection from the resident to another resident through a caregiver's clothing. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the care plan should have been implemented related to EBP to prevent the spread of microorganisms from one resident to another. Per facility's policy tiled, Comprehensive Care Plans, revised 12/19/22, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .6. The comprehensive care plan will include measurable objectives .to meet the resident's needs . C. Resident 52 was readmitted to the facility on [DATE] with diagnoses which included kidney disease and was dependent to dialysis, per the facility's admission Record. On 6/3/25 at 10:11 A.M., an observation and an interview was conducted of Resident 52 in his room. Resident laid in bed and stated he was scheduled to go to dialysis. Resident 52 pointed his dialysis access on his right upper chest. Resident 52 stated he did not have dialysis access in his arms. A review of Resident 52's dialysis communication form (communication record between the dialysis center and the facility indicating an assessment of the resident's type of dialysis access, vital signs like blood pressure, heart and respiratory rate and temperature) from April to June 2025 was conducted. There were missing documentation and information of Resident 52's vital signs and correct identification of his dialysis access type on the following dates: - 4/1/25, 5/20/25, and 5/27/25 - no post dialysis information - 4/10/25, and 4/19/25 - no pre dialysis information - 4/24/25, 4/26/25, 4/29/25 and 5/1/25 - no dialysis access type information - 5/17/25, 5/20/25, 5/24/25, 5/27/25, 5/29/25, 5/31/25, 6/3/25 dialysis access type indicated Resident 52 had right upper arm dialysis access. A review of Resident 52's care plan related to dialysis, dated 5/20/25, indicated interventions of, Monitor vital signs pre and post dialysis, and monitor/ document/ report any signs and symptoms of infection to access site . On 6/4/25 at 11:21 A.M., a joint review of Resident 52's clinical record and an interview was conducted with LN 1. LN 1 stated the dialysis communication forms were inaccurate and incomplete. LN 1 stated the facility should have followed Resident 52's care plan. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to implement the resident's care plan to ensure quality of care. Per facility's policy tiled, Comprehensive Care Plans, revised 12/19/22, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .6. The comprehensive care plan will include measurable objectives .to meet the resident's needs .

Based on observation, interview, and record review, the facility failed to follow nursing standards of practice when: 1) A Licensed Nurse (LN) did not provide instructions related to an inhaler medication usage. 2) A LN did not follow physician's orders related to an insulin time of administration. These failures had the potential to compromise the residents' medical status. Cross Reference to F 759. Findings: 1) A record review of the facility's admission Record indicated Resident 307 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). A record review of Resident 307's Minimum Data Set (MDS- a federally mandated assessment tool) dated 5/29/25, indicated a Brief Interview for Mental Status (BIMS) score of 9 which meant Resident 307's cognition (thought process) was moderately impaired. On 6/4/25 at 8:30 A.M., a medication administration observation was conducted with Licensed Nurse (LN) 21. LN 21 handed the Atrovent (medication for breathing) inhaler to Resident 307 without giving instructions for use. Resident 307 and was holding the inhaler and was looking at LN 21. LN 21 informed Resident 307 to take the medication. Resident 307 quickly placed the inhaler to his mouth and pressed the inhaler twice. No deep breaths were taken prior to use, and no time elapsed between inhaling the two doses. A record review of Resident 307's Physicians orders dated 5/24/25 indicated Atrovent inhaler two puffs four times a day. A review of the manufacturers' recommendation indicated instruction of use: - exhale, breathe out deeply through the mouth - slowly breathe in through the mouth and at the same time spray inhaler into the mouth - firmly press the canister against the mouthpiece one time - hold breath for 10 seconds - take the mouthpiece out of mouth and breathe out slowly - wait for 10 seconds and repeat previous steps. An interview on 6/5/25 at 8:35 A.M., with LN 21 was conducted. LN 21 stated he was too nervous that he forgot to give Resident 307 instructions on how to administer the inhaler. LN 21 stated Resident 307 can follow directions when instructed. LN 21 stated it was important to give instructions prior to the medication use so that it would be effective. 2) A record review of the facility's admission Record indicated Resident 154 was admitted to the facility on [DATE] with diagnoses that included diabetes (abnormal blood sugar). A review of Resident 154's Physician orders dated 5/20/25 indicated Resident 154 was to receive insulin (medication for diabetes) before meals. On 6/4/25 at 9 A.M., a medication administration observation for Resident 154 was conducted with LN 1. LN 1 administered insulin (medication for diabetes) to Resident 154. On 6/4/25 at 9:05 A.M., an interview was conducted with LN 1. LN 1 stated he had forgotten to administer Resident 154's insulin before breakfast. LN 1 stated it was important to follow the physician's orders to ensure Resident 154's safety and avoid possible complications or decline. An interview was conducted on 6/4/25 at 9:06 A.M. with Resident 154. Resident 154 stated he had eaten his breakfast around 8 A.M. An interview on 6/5/25 at 10:30 A.M., with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to implement the nursing standard of care.

Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 5.1 percent. Two medication errors out of 39 opportunities were observed during the medication administration process for two of five randomly observed Residents (154, 307) . These failures had the potential to compromise the residents' medical health and condition. Cross Reference F 658. Findings. 1) A record review of the facility's admission Record indicated Resident 307 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). A record review of Resident 307's Minimum Data Set (MDS- a federally mandated assessment tool) dated 5/29/25, indicated a Brief Interview for Mental Status (BIMS) score of 9 which meant Resident 307's cognition (thought process) was moderately impaired. On 6/4/25 at 8:30 A.M., a medication administration observation was conducted with Licensed Nurse (LN) 21. LN 21 handed the Atrovent (medication for breathing) inhaler to Resident 307 without giving instructions for use. Resident 307 and was holding the inhaler and was looking at LN 21. LN 21 informed Resident 307 to take the medication. Resident 307 quickly placed the inhaler to his mouth and pressed the inhaler twice. No deep breaths were taken prior to use, and no time elapsed between inhaling the two doses. A record review of Resident 307's Physicians orders dated 5/24/25 indicated Atrovent inahaler two puffs four times a day. A review of the manufacturers' recommendation indicated instruction of use: - exhale, breathe out deeply through the mouth - slowly breathe in through the mouth and at the same time spray inhaler into the mouth - firmly press the canister against the mouthpiece one time - hold breath for 10 seconds - take the mouthpiece out of mouth and breathe out slowly - wait for 10 seconds and repeat previous steps. An interview on 6/5/25 at 8:35 A.M., with LN 21 was conducted. LN 21 stated he was too nervous that he forgot to give Resident 307 instructions on how to administer the inhaler. LN 21 stated Resident 307 can follow directions when instructed. LN 21 stated it was important to give instructions prior to the medication use so that it would be effective. An interview on 6/5/25 at 10:30 A.M., with the Director of Nursing (DON ) was conducted. The DON stated it was important to give instructions with regard to specific medication use to provide a positive outcome for Resident 307. According to the facility's policy titled, Medication Administration, dated 12/19/22, .Guidelines .administer medication as ordered in accordance with manufacturer specifications . 2) A record review of the facility's admission Record indicated Resident 154 was admitted to the facility on [DATE] with diagnoses that included diabetes (abnormal blood sugar). A record review of Resident 154's Minimum Data Set (MDS-a federally mandated assessment tool) dated 5/26/25 indicated Resident 154's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition (thought process). A review of Resident 154's Physician orders dated 5/20/25 indicated Resident 154 was to receive insulin (medication for diabetes) before meals. On 6/4/25 at 9 A.M., a medication administration observation for Resident 154 was conducted with LN 1. LN 1 administered insulin (medication for diabetes) to Resident 154. On 6/4/25 at 9:05 A.M., an interview was conducted with LN 1. LN 1 stated he had forgotten to administer Resident 154's insulin before breakfast. LN 1 stated it was important to follow the Physician's orders to ensure Resident 154's safety and avoid possible complications or decline. An interview was conducted on 6/4/25 at 9:06 A.M. with Resident 154. Resident 154 stated he had eaten his breakfast around 8 A.M. An interview with the DON was conducted on 6/5/25 at 10:40 A.M. The DON stated it was important to follow the physician's orders to ensure safety. A review of the facility's policy titled, Nursing Care of the Resident with Diabetes Mellitus, dated 12/19/22 indicated, Medication management .assist the resident with his or her specific medication regimen, as ordered .

Based on interview and record review, the facility failed to ensure the flu vaccine (a vaccine which provides immunity to a variety of influenza viruses) was provided to one of five sampled residents (Resident 69). This had the potential for putting Resident 69 at risk for acquiring, transmitting or experiencing complications from influenza (an acute contagious viral infection characterized by inflammation of the respiratory tract). Findings: A review of Resident 69's admission Record indicated Resident 69 was readmitted to the facility on [DATE] with diagnoses which included immunodeficiency (decreased ability of the body to fight infections and other diseases). A review of Resident 69's attending physician completed Resident 69's history and physical (H&P) dated 10/26/24. The H&P indicated Resident 69 did not have the capacity to understand and make decisions. On 6/4/25 at 8:57 A.M., a joint review of Resident 69's clinical record and an interview was conducted with the Infection Preventionist (IP). The IP stated Resident 69 did not receive his flu vaccine from 10/1/24 to 3/31/25. The IP stated he did not see any electronic nor paper documentation flu vaccine was offered to Resident 69. On 6/4/25 at 2:23 P.M., a follow up review of Resident 69's clinical record and an interview was conducted with the IP. The IP stated he did not find documentation flu vaccine was offered to Resident 69. The IP stated the LNs were to offer flu vaccines to all residents on admission. The IP stated flu vaccine would help prevent the spread of flu among residents and staff. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the Licensed Nurses (LNs) to offer flu vaccine to all residents to prevent infection and spread of flu disease. Per the facility's policy titled, Influenza Vaccination, dated 12/19/22, It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents .annual immunizations against influenza .2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st .

Based on observation, interview and record review, the facility failed to dispose of an expired food product in a nursing unit refrigerator. This failure had the potential to place residents at risk for food borne illness. Findings: An observation of a nursing station refrigerator was conducted on 6/4/25 at 10:30 A.M. with Licensed Nurse (LN) 12. A prepackaged sandwich was in the refrigerator, with a label indicating it had been placed in the refrigerator on 5/31/25, and should be disposed of on 6/3/25. LN 12 stated a staff member should have thrown away the sandwich the previous day. Per LN 12, it was nursing staff responsibility to check all food items in the unit refrigerator to prevent food poisoning. An interview was conducted with Registered Dietitian (RD) 1 on 6/5/25 at 2 P.M. Per RD 1, nursing staff was responsible for checking the unit refrigerators for expiration dates. Per a facility policy, revised 9/13/25 and titled Food From Outside Sources, Food brought in by visitors, family, friends or other guests for residents is permitted allowing the resident the right to choose .Perishable food should be sealed and dated with a use-by-date and placed in refrigeration. The community will also designate who will .discard outdated or uneaten foods .Nursing staff will be trained also in Safe Food Handling Procedures .

Based on observation, interview and record review, the facility failed to provide alternate menu options of similar nutritional value to residents. This failure had the potential to result in meals not being equal in nutritive value, and may result in weight loss. Findings: A record review was conducted of the facility's menu and alternate items list. An Always Available Menu was posted outside of the dining room, and it included cheese quesadilla and a grilled cheese sandwich. An observation of the lunch trayline was conducted on 6/4/25, beginning at 11:45 A.M. 1. At approximately 12:20 P.M., Food Service worker (FSW) 1 stepped over to the stove and placed four small tortillas into a pan. FSW 1 added a small amount of shredded cheese to each tortilla and folded them in half. FSW 1 did not use a measuring cup or scale prior to adding the shredded cheese to the pan. FSW 1 stated two of the small quesadillas counted as a portion. 2. At approximately 12:40 P.M. FSW 1 stepped over to the stove, and placed four slices of white bread into an oiled pan. FSW 1 added two yellow, square cheese slices to two of the bread slices, then topped the cheese slices with another piece of bread. FSW 1 did not use a scale to weigh the cheese slices prior to making the grilled cheese sandwiches. A concurrent interview and record review was conducted with Registered Dietitian (RD) 1 on 6/4/25 at 2 P.M. RD 1 reviewed the recipe for quesadilla, and stated FSW 1 should have measured a half cup of shredded cheese prior to making the quesadilla. RD 1 stated it was important to match the amount of protein in the regular menu item for the day. RD 1 stated the recipe indicated an eight inch tortilla, and one quesadilla was a portion. RD 1 reviewed the grilled cheese recipe, and stated four slices of cheese should have been used for each sandwich to meet the protein requirement. RD 1 stated FSW 1 did not use enough cheese and did not follow the recipe. Per RD 1, the recipe was used to confirm the facility had provided an adequate amount of protein from the alternate menu items. An interview was conducted with the Administrator (ADM) on 6/5/25 at 3:30 P.M. Per the ADM, the alternate menu items were important to offer the residents choices and preferences. The ADM stated food service staff should follow recipes to ensure the nutritional adequacy of all food items served. Per a facility policy, revised 7/9/18 and titled Menu Alternatives, .If a food is disliked, an appropriate equivalent substitution must be made. Alternative meals should be available .and recipes that are of equivalent nutritional value to the meals on the menu .

Based on observation, interview and record review, the facility failed to ensure kitchen staff utilized recipes when preparing foods. This failure had the potential to place residents at risk for poor intake and weight loss. Findings: A review of the 6/4/25 lunch menu was conducted. The pureed lunch menu listed pureed pesto chicken pasta, pureed breadstick and chilled steamed vegetables. An observation of food production was conducted in the kitchen with [NAME] 1 (CK 1) on 6/4/25 starting at 10:30 A.M. 1. CK 1 stated she would make pureed bread. CK 1 placed approximately eight slices of white bread into a food processor, then poured an unmeasured amount of pale yellow liquid into the food processor. CK 1 stated the pale yellow liquid was chicken broth. When asked how much chicken broth she had added to the food processor, she stated, Enough to moisten the bread. When asked where the recipe was for pureed bread, CK 1 stated she would go ask for a recipe. CK 1 returned with a recipe for pureed bread. CK 1 continued processing the bread in the food processor. CK 1 stated she had not measured the amount of chicken broth used in the pureed bread recipe, or measured the chicken broth concentrate when making the chicken broth. An interview was conducted with the Registered Dietitian (RD 1) on 6/4/25 at 10:45 A.M. RD 1 stated CK 1 should always use a recipe when preparing foods. RD 1 stated it was important to measure the concentrated chicken broth so the pureed food would have an acceptable flavor. Per RD 1, the bread had little taste, so the chicken broth was used to enhance the flavors and encourage residents to eat and enjoy the foods. 2. CK 1 began adding pesto chicken pasta casserole to the food processor. After processing the casserole, CK 1 started to pour food thickener into the food processor. When asked how much thickener she planned to add, CK 1 stated, I don't have a recipe. I need to use the recipe. An interview was conducted with RD 1 on 6/4/25 at 11 A.M. RD 1 stated the recipe for the casserole needed to be available for CK 1 to use. RD 1 stated the recipe would indicate how much thickener should be added for the number of portions being made. RD 1 stated the recipes had not been available for CK 1. 3. CK 1 removed steamed green beans from the oven and placed them into the food processor. When asked to review the menu, CK 1 stated the green beans were to be chilled, but the green beans were hot. CK 1 continued to puree the hot green beans and placed the completed food onto the steam table. An interview was conducted with RD 1 on 6/4/25 at 11:45 A.M. RD 1 stated the chilled steamed vegetable was a new item, and CK 1 had not known to chill the green beans prior to preparing the recipe. Per RD 1, the item was a cold appetizer to be served similar to a salad. RD 1 stated the facility would need to find a recipe that included the chilling process, but they had not done so for the day's meal. An interview was conducted with the Administrator (ADM) on 6/5/25 at 2 P.M. Per the ADM, it was important to have recipes for all food items prepared. The ADM stated the menu was part of a new seasonal menu, but recipes should have been given to CK 1 to ensure she was able to produce the foods as written on the menu. Per a facility policy, revised 1/25/24 and titled Food Preparation Guidelines, .The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes .Food shall be prepared by methods that conserve nutritive value .this includes .Preparing foods as directed .Food .shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: .Serving hot foods .hot and cold foods .cold .

Based on observation, interview and record review, the facility failed to ensure menus and recipes were followed for pureed foods. This failure negatively affected the nutritional value of foods prepared in the kitchen, and had the potential for residents to receive the wrong caloric intake, further compromising their medical status. Findings: A review of the pureed lunch menu for 6/4/25 showed a serving of pureed breadstick was to be provided to residents on pureed diets. A concurrent observation and interview was conducted with [NAME] 1 (CK 1) in the kitchen on 6/4/25, starting at 11 A.M. CK 1 placed a loaf of white bread into the food processor, added chicken broth, and blenderized the bread. CK 1 stated the facility ran out of breadsticks, so she had substituted white bread. An interview was conducted with the Registered Dietitian (RD 1) on 6/4/25 at 11:30 A.M. RD 1 stated she had not authorized the substitution of white bread for the breadstick on the pureed diets. Per RD 1, it was important to provide the exact foods listed on the menu as the nutritional value of each item was different. RD 1 stated CK 1 had not informed her of the substitution. An interview was conducted with the Administrator (ADM) on 6/5/25 at 2 P.M. Per the ADM, CK 1 should have prepared the pureed breadsticks as it was listed on the menu. The ADM stated the RD reviewed the nutritional content of each menu, so it was important to use the foods listed. Per a facility policy, revised 1/25/24 and titled Food Preparation Guidelines, The cook, or designee, shall prepare menu items following the facility's written menus . Per a facility policy, revised 12/19/22 and titled Standardized Menus, .Menus should be approved and signed by the Registered Dietitian .Menus will be reviewed by the facility's dietitian .for nutritional adequacy .

Based on observation, interview, and record review, the facility failed to ensure dialysis (a process to remove waste from the blood for residents with kidney disease) assessments were consistently and accurately completed for one of three sampled dialysis residents (Resident 52). These failures had the potential for miscommunication between the facility and dialysis center and to affect the continuity and quality of care of Resident 52. Findings: A review of Resident 52's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses which included kidney disease, per the facility's admission Record. A review of Resident 52's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/15/25, Resident 52 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 5/15, (0 to 7 suggests severe impairment). The special procedures of the MDS indicated Resident 52 was on dialysis. A review of Resident 52's physician's orders, dated 3/31/25, indicated Resident 52 had a central venous catheter (CVC, flexible tube placed on the upper chest and is used for dialysis) located in his right chest and to be assessed every shift. On 6/3/25 at 10:11 A.M., an observation and an interview was conducted of Resident 52 in his room. Resident laid in bed and stated he was scheduled to go to dialysis. Resident 52 pointed his dialysis access on his right upper chest. Resident 52 stated he did not have dialysis access in his arms. A review of Resident 52's dialysis communication form (communication record between the dialysis center and the facility indicating an assessment of the resident's type of dialysis access, vital signs like blood pressure, heart and respiratory rate and temperature) from April to June 2025 was conducted. There were missing documentation and assessment of Resident 52's vital signs and correct identification of his dialysis access type on the following dates: - 4/1/25, 5/20/25, and 5/27/25 - no post dialysis assessment - 4/10/25, and 4/19/25 - no pre dialysis assessment - 4/24/25, 4/26/25, 4/29/25 and 5/1/25 - no dialysis access type assessment - 5/17/25, 5/20/25, 5/24/25, 5/27/25, 5/29/25, 5/31/25, 6/3/25 - dialysis access type indicated Resident 52 had right upper arm dialysis access. On 6/4/25 at 11:21 A.M., a joint review of Resident 52's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated when Resident 52 came back from dialysis, his vital signs were checked and ensure his dialysis access in his right upper arm was assessed by checking the bruit (an audible vascular sound heard using a stethoscope) and thrill (vibration felt by placing fingers over the dialysis access site). When asked how the LN assessed Resident 52's bruit and thrill for CVC (CVC did not require bruit and thrill checks), LN 1 responded by smiling. LN 1 stated Resident 52's access type was not assessed correctly and was documented inaccurately. LN 1 stated the staff were to check Resident 52's vital signs to monitor complications of dialysis like low blood pressure and bleeding. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the staff to know the type and location of the resident's dialysis access type for proper assessment. The DON stated the resident's vital signs should have been taken before and after dialysis to promote safety of the resident. A review of the facility's policy, titled Hemodialysis, dated 12/19/22, indicated, This facility will provide the necessary care and treatment .physicians orders .to meet the special medical, nursing .needs of residents receiving hemodialysis .This will include: The ongoing assessment of the resident's condition and monitoring of complications before and after dialysis treatments .Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .

Based on observation, interview and record review, the facility failed to ensure oxygen was administered per physician's order for one of two residents reviewed for oxygen use (Resident 28). This failure had the potential to worsen Resident 28's breathing and respiratory system (organs and tissues that enable breathing and gas exchange). Findings: Resident 28 was admitted to the facility on [DATE] with diagnosis to include pulmonary fibrosis (damaged lung tissue), pulmonary edema (fluid in the lung), and respiratory failure (when the respiratory system cannot provide adequate gas exchange), per the facility admission Record. A concurrent observation and interview with Resident 28 was conducted on 6/2/25 at 10:52 A.M. Resident 28 was in bed, with a nasal cannula (a hollow tubing for oxygen delivery) under her nose. The oxygen concentrator was set at three liters per minute (LPM). Resident 28 stated she did not use oxygen at home prior to arriving at the facility, and she planned to return to her home after discharge. An observation of Resident 28's oxygen concentrator was conducted on 6/3/25 at 3:45 P.M. The oxygen concentrator was set at three LPM. A record review was conducted on 6/4/25. Resident 28's Brief Interview for Mental Status (BIMS) score, dated 5/11/25, was 11, indicating moderately impaired cognition. Per Resident 28's physician orders, written 5/7/25, oxygen was to be administered at two LPM. A concurrent observation and interview was conducted with LN 11 on 6/4/25 at 4:37 P.M. at Resident 28's bedside. LN 11 observed the oxygen setting on the concentrator and stated the setting was incorrectly set at three LPM, but should be set at two LPM. LN 11 stated, Having the wrong amount of oxygen might make her breathing worse. It should be set to the amount the doctor ordered. An interview was conducted with the Director of Nursing (DON) on 6/12/25 at 3:30 P.M. The DON stated her expectation was for nursing staff to set the oxygen carefully and according to the physician's orders. Per a facility policy, revised 12/19/22 and titled Oxygen Administration, Oxygen is administered .Oxygen is administered under orders of a physician .

Based on observation, interview and record review, the facility failed to ensure two persons assist when safely transferring a resident using a mechanical lift (a device used to safely transfer residents who cannot independently bear weight), for one of three sampled residents reviewed for accidents (Resident 52). This failure had the potential for Resident 52 to have accident and fall that could lead to injury. Findings: A review of Resident 52's admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). A review of Resident 52's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/15/25, Resident 52 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 5/15, (0 to 7 suggests severe impairment). Resident 52's functional abilities of the MDS indicated Resident 52 required maximum assists for transfer. On 6/3/25 at 10:13 A.M., an observation was conducted as CNA 1 transferred Resident 52 from one bed to another. CNA 1 lifted Resident 52 using a mechanical lift by herself. Resident 52 held to the bar of the mechanical lift and appeared uncomfortable as evidenced by his feet were hanging and dangling in the air. On 6/3/25 at 10:30 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she used the mechanical lift by herself while transferring Resident 52. CNA 1 stated with the use of mechanical lift, it required two persons, one to hold the resident and one controlled the mechanical lift for resident safety. CNA 1 stated she did not ask help, Because all were busy. On 6/3/25 at 4:18 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 52. CNA 2 stated when transferring a resident with the use of the mechanical lift, it required two persons for the safety of the resident and the staff. On 6/4/25 at 11:21 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated two persons were required to transfer a resident using the mechanical lift for resident safety. On 6/4/25 at 3:08 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated a minimum of two persons were required to transfer a resident using the mechanical lift for resident safety. The DSD stated one staff was to hold the resident and one had to control the mechanical lift. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation for the staff was to follow the mechanical lift's manufacturers' instructions. The DON stated two persons were required to transfer a resident using the mechanical lift to promote safety of the resident. A review of the facility's policy, titled Safe Resident Handling/ Transfers, dated 12/19/22, indicated, .It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidelines .9. Two staff members must be utilized when transferring residents with a mechanical lift .

Based on observation, interview and record review, the facility failed to ensure monitoring of medication management was conducted when: 1. A consent for a medication was not updated with the current dosage, and all behaviors were not being monitored for medication effectiveness (Resident 22), and 2. Potential adverse effects of an anticoagulant (a medication which prevents blood clots) were not evaluated (Resident 47). These failures had the potential for the residents to experience adverse effects or receive unnecessary medication. Findings: 1. Resident 22 was readmitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior), per the facility admission Record. An interview was conducted with Resident 22 and a family member (FM 1) on 6/2/25 at 12:15 P.M. FM 1 answered questions for Resident 22, and stated he made decisions on her behalf. FM 1 stated he was having trouble getting the nurses to provide a medication at the best times to control Resident 22's behaviors. FM 1 stated when Resident 22 was at home, he preferred to give the medications at exact times in order to control her anxiety, agitation, and sleep patterns. FM 1 stated if Resident 22 did not sleep well due to her anxiety, she was prone to getting urinary tract infections. FM 1 stated if Resident 22 did not sleep, she became restless and more confused, believing she would be taken away by military police. A record review was conducted on 6/5/25. A consent for the medication was signed by FM 1 on 5/10/25, indicating four doses of the medication was to be given. A physician's order, dated 5/27/25, indicated Resident 22 was to receive five doses of the medication over a 24-hour period. The Medication Administration Record (MAR) was reviewed for May and June 2025. The MAR indicated five doses of the medication to be administered within a 24-hour period. The MAR, dated 5/9/25, indicated the rationale for the medication was to monitor Resident 22 for episodes of auditory hallucinations. An interview was conducted on 6/5/25 at 9 A.M. with Licensed Nurse (LN) 12. LN 12 stated she was assigned as the medication nurse for Resident 22. LN 12 stated she had spoken to the Nurse Practitioner (NP) working with Resident 22's physician about the additional dose of medication. LN 12 stated the NP advised her he had added the dose of medication per FM 1's request. LN 12 stated FM 1 told her he wanted the medications administered at the facility exactly like he did it at home to control her anxiety and to help her sleep. A concurrent interview and record review was conducted with LN 13 on 6/5/25 at 9:30 A.M. LN 13 reviewed the consent for four doses of the medication, as well as the order for five doses. LN 13 stated the consent should have been updated to match the order. LN 13 stated the consent was important because FM 1 wanted Resident 22 to receive the medications exactly as it was administered at home, and FM 1 had the authority to make decisions for Resident 22. LN 13 stated the nurse who obtained the order from the NP or physician for the additional dose should have obtained an updated consent. LN 13 stated the behavioral monitoring for auditory hallucinations was not thorough and should have included monitoring for anxiety, agitation, and sleeplessness. LN 13 stated, We should be monitoring more than we are to ensure the medication is working to control the symptoms. A concurrent interview and record review was conducted with LN 14 on 6/5/25 at 9:50 A.M. LN 14 stated the facility should be monitoring more behavioral symptoms than auditory hallucinations. LN 14 stated Resident 22's behavioral symptoms had worsened, and she had been hospitalized for it. LN 14 stated the behavioral monitoring should include paranoia and agitation as well as auditory hallucinations. Per LN 14, it was not acceptable to administer more doses of the medication than the consent indicated. LN 14 stated the nurse should have obtained a new consent when the additional dose of medication was added. LN 14 stated, The consent is important and it should match the order to ensure safety, and that everyone is in agreement with the dosage. A telephone interview was conducted with NP 1 on 6/5/25 at 10:30 A.M. NP 1 stated he had adjusted the dosage of medication for Resident 22 based on input from FM 1. NP 1 stated the dose was within a safe range, and FM 1 was satisfied with how the facility was giving the medication. NP 1 stated he was not aware the consent for the medication did not match the physician's order. An interview was conducted with the Director of Nursing (DON) on 6/5/25 at 3:32 P.M. Per the DON, it was important to ensure the consent matched the medication order. Per the DON, her expectation was nursing staff who took the medication order also obtained a new consent. The DON stated the nurses had the responsibility of ensuring the behavioral monitoring was comprehensive, and included all behaviors the staff should watch for. Per a facility policy, revised 3/17/25 and titled Use of Psychotropic Medications, .medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication .The facility will document that the resident or resident representative was informed in advance .(e.g. written consent form .) . 2. Resident 47 was readmitted to the facility on [DATE], with diagnoses which contracture (stiffening/shortening at any joint, that reduces the joint's range of motion) of lower legs and that she was on long term use of anticoagulant, per the facility's admission Record. Resident 47's attending physician completed Resident 47's history and physical (H&P) dated 5/23/25. The H&P indicated Resident 47 did not have the capacity to understand and make decisions. A review of physician's order on 5/2/25 for Resident 47 indicated heparin (anticoagulant medication) to be injected to Resident 47 twice a day. A review of Resident 47's care plan related to heparin, dated 5/3/25, indicated one of the interventions was to, Monitor/ document/ report PRN (as needed) adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath (SOB), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs . On 6/4/25 at 11:03 A.M., a joint review of Resident 47's clinical record and an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 47 was on anticoagulant. LN 1 stated when residents were on anticoagulant, the residents were monitored for bleeding. LN 1 stated there was no documentation Resident 47 was monitored for bleeding. On 6/5/25 at 10:50 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was for the LNs to monitor adverse reactions to anticoagulants for early detection of bleeding and to ensure safety of the resident. Per facility's policy titled, High Risk Medications - Anticoagulants, revised 12/19/22, This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety .4 .Risks associated with anticoagulants include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool), b. Fall in .blood pressure .

Based on interview and record review, the facility failed to respond to a medical records request for one of two sampled patients (1). As a result, the requester did not know if the records were made available to her. Findings: Per the facility's Admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include dementia (a mental and physical decline). On 2/20/25 at 2:19 P.M., an interview was conducted with the Social Worker (SW). The SW stated Resident 1's Responsible Party (RP 1) emailed her a request for medical records on 2/17/25. The SW further stated, they planned on having the medical records ready by 2/21/25 per RP 1's request. On 2/28/25 at 9:28 A.M., an interview was conducted with the SW. The SW stated, the medical records were ready to be picked up on 2/21/25, but she did not respond to RP 1's record request or notify RP 1 that the medical records were ready to be picked up. The SW stated, they received an additional medical records request on 2/24/25, and delivered the records to RP 1 on that day (seven days after the initial medical records request). On 3/6/25 at 2:45 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, when someone made a medical records request to the facility, the person who was fulfilling the request should have responded to the request to notify them of when the records would have been ready for pickup. Per the facility's policy, titled Release of Medical Records, revised 12/19/22, .Upon receipt of a request for medical record copies, the facility should notify the requesting party, in writing, of the cost for obtaining records and that the records are available 2 days after receipt of payment for copies .

Based on interview and record review, the facility failed to prevent a hazardous situation when supervision was not provided for one resident (1) during an outpatient appointment and his whereabouts were unknown. This deficient practice placed Resident 1 at increased risk of injury when Resident 1 was found, sitting in the sun, outside the outpatient appointment location by a bystander and sent to the hospital. Findings: Resident 1 was admitted to the facility on [DATE] with a diagnosis of a fracture of the right femur (broken right upper leg bone) and unspecified dementia (a loss of mental functioning including, remembering and reasoning) per the facility's admission record. A review of Resident 1's physicians orders indicated, Resident 1 had an outpatient follow-up appointment with an orthopedist ( a medical specialist who focuses on injuries and diseases affecting the musculoskeletal system (bones, muscles, joints and soft tissues), on 9/5/24 at 10:45 A.M. On 9/23/24 at 2:45 P.M., an interview was conducted with the social services director (SSD) at the facility. The SSD stated social services oversaw setting up transportation and escorts for residents who needed to attend outside appointments at the facility. The SSD stated social services fills out a paper document that indicates the following: the reason for the appointment, where the resident will be going, who is transporting the resident, if the resident needs a companion and who that companion will be, and a pickup and return time. The SSD stated the social services assistant (SSA) was contacted on 9/5/24 by the transportation company who stated they could not find Resident 1 at the orthopedist office when they went to pick up the resident. The SSD stated he spoke with the orthopedist office who reported Resident 1 left the facility, and was described as upset, after the appointment was over. On 9/23/24 at 3:01 P.M a concurrent interview and record review of the facility's transportation record for Resident 1 was conducted with the SSD and the SSA. The SSA stated he was responsible for filling out the paper transportation document for Resident 1's appointment at the orthopedist on 9/5/24. The SSA stated he assumed Resident 1's responsible party (RP) was going to accompany Resident 1 to the orthopedist appointment on 9/5/24. The SSA stated he did not confirm the plan for the RP to accompany the Resident the morning of the appointment. The SSA stated the transportation company picked up Resident 1 for the orthopedist appointment on 9/5/24. The SSA stated the transportation company returned to the facility without Resident 1 and stated the Resident could not be located at the orthopedist ' s office. A review of the document titled, Transportation, dated 9/5/24, indicated, the resident required a companion for the appointment but the section that indicated where the RP would meet the resident at the destination was left blank. The SSA stated they were notified by the RP and the orthopedist office the resident was found lying in his wheelchair in the sun by someone outside the building and the resident was sent to the hospital. The SSD and SSA acknowledged not confirming the Resident 1 ' s RP as an escort to the appointment increased the risk of Resident 1 being placed in an unsafe situation. On 9/23/24 at 3:22 P.M., an interview and record review were conducted with licensed nurse (LN) 1 at the facility. LN 1 stated it was the expectation that nursing document transportation to and from outside appointments in the progress notes. LN 1 stated the following should be documented in the progress notes: pickup time, type of appointment, type of transportation, if traveling with a wheelchair or gurney and if an escort was needed. LN 1 stated a second progress note indicating the time of the resident ' s return to the facility and any new orders should be documented in the electronic health record. A review of Resident 1's progress notes was conducted with LN 1. LN 1 acknowledged there was no progress note indicating how, when or who accompanied Resident 1 to his orthopedic appointment on 9/5/24. LN 1 stated residents who are not independent or need assistance should have supervision at an outside appointment to ensure they don ' t' get lost and wander or experience an accident or injury. On 9/23//24 at 3:59 P.M., a concurrent interview with the director of nursing (DON) and the administrator (ADMIN) was conducted. The DON stated social services was responsible for setting up transportation and escorts to appointments. The DON stated if a resident has an outside appointment and has dementia or other dependent needs, social services should confirm that a family will accompany the resident to the appointment. The DON stated if family is not available to accompany the resident to the appointment, the facility will provide an escort. The ADMIN and DON acknowledged that Resident 1 was not accompanied to his orthopedic appointment on 9/5/24 by the RP or a facility escort. The ADMIN and DON acknowledged the facility did not confirm and documented who was attending the appointment with Resident 1. A review of Resident 1's care plan, dated 8/30/24, indicated, The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t physical limitations . A review of Resident 1's nursing progress note, dated 9/5/24 at 12:20 P.M., indicated, Transportation driver came back with packets and telling she cannot find resident in the building where resident went for appt . Social Service called the clinic that the driver cannot find resident in the building . A review of Resident 1's nurses progress note, dated 9/5/24 at 1:35 P.M., indicated, Social service called . found that resident was sent to ER (emergency room ) . A review of Resident 1 ' s interdisciplinary progress note, dated 9/5/24 at 2:20 P.M., indicated, .Resident family came into facility. Son and wife told SSD father [Resident 1] was taken to emergency room (ER) from Doctors appointment. After sitting outside in the sun, 911 was called. SSD called Doctor office that stated resident became combative after appointment and wheeled himself outside before transportation had arrived. Grievance process started . A review of the facility ' s policy, revised 1/22/24, titled Transportation, did not address how the facility provided escorts or accompanying residents to outside appointments. A review of the facility ' s policy, revised 12/9/22, titled Accidents and Supervision, indicated, Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents .

Based on interview and record review, the facility failed to appropriately discharge one of one resident (Resident 3) with elopement risk reviewed for discharge planning when; 1. There was no documentation regarding Resident 3's elopement risk and the appropriateness of a discharge to an independent living facility and, 2. A discharge care plan was not developed. As a result, Resident 3 was readmitted to the hospital. Findings: Resident 3 was admitted to the facility on [DATE] with the diagnoses including dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) and repeated falls according to the facility's Admission Record. During a review of the physician's history and physical (H&P) admission note dated 2/7/24, the H&P indicated .patient resides at Board and Care (place to live that provides food and personal care). Patient was wandering and went missing for several days. He was found by local police and brought in the hospital and placed on 5150 hold (when a person is a danger to self or others is detained for 72 hours in a psychiatric hospital) . A review of Nurses Progress Note (NPN), dated 3/9/24, at 4:30 P.M. indicated, The resident was observed by staff ambulating on the walkway near Felicita Road close to traffic. Staff feared he may inadvertently wander into traffic . Further review of NPN dated 3/21/24, 12:10 P.M. indicated Resident 3 was discharged to an independent living facility (ILF-place to live for people who do not need assistance with walking or personal care). During an interview on 4/17/24, at 10:15 A.M. with the facility administrator (ADMIN), the ADMIN stated the interdisciplinary team (IDT-team members with various areas of expertise who work together toward the goals of their residents) discussed residents' discharge plans with social services to assist with home health needs. An interview and concurrent record review on 4/17/24, at 11:44 A.M. with the assistant director of nurses (ADON) was conducted. The ADON stated the IDT included discharge planner, social services, case manager, minimum data set nurse (MDS- nurse who assessed and evaluated the quality of care being given to long-term care residents), ADON or director of nurses, administrator, and rehab staff. The ADON reviewed Resident 3's progress notes (PN). The ADON stated there was no IDT documentation regarding the decision for Resident 3 to be discharged to an ILF. The ADON further stated the case manager, social services or nursing staff should have documented if Resident 3 was appropriate for an ILF. After the ADON's record review on 4/17/24, at 12:18 P.M., the ADON stated she did not attend the IDT meeting regarding Resident 3. The ADON stated if she attended, she would have questioned if the ILF was safe for the resident because Resident 3 had histories of elopements. An interview and concurrent record review was conducted on 4/17/24, at 12:31 P.M. with the social service director (SSD). The SSD reviewed Resident 3's records and stated he did not find IDT notes regarding decision for Resident 3 to be discharged to an ILF. The SSD further stated he should have documented the IDT's decision, family discussion and the income criteria for an ILF. During an interview and concurrent record review on 4/17/24, at 12:41 P.M. with the ADON, the ADON reviewed care plans for Resident 3. The ADON stated there was no care plan regarding Resident 3's discharge planning. The ADON further stated there should have been a care plan to know the plan for Resident 3's discharge. An interview on 5/7/24, at 1:08 P.M. with the ADON was conducted. The ADON stated it was important to document discharge plans for a resident to ensure everyone was aware of discharge and a care plan was expected to be completed for everyone to be aware of the details of discharge planning. A review of the facility's policy and procedure (P&P) titled, Discharge Planning Process, dated 12/19/22 was conducted. The P&P indicated, .5. If discharge to community is a goal, an active discharge care plan will be implemented and will involve the interdisciplinary team, including the resident and/or resident representative .An active individualized discharge care plan will address .discharge destination, with assurances the destination meets the resident's health/safety needs .caregiver/support person availability .The facility will document any referrals .The evaluation of the resident's discharge needs and discharge plan will be completely documented on a timely basis in the clinical record .

Based on observation, interview, and record review the facility failed to provide a plan of care and adequate supervision to prevent one of three residents reviewed for elopements from leaving the facility (Resident 1). As a result, Resident 1 went missing from the facility without staff ' s knowledge and placed Resident 1 at risk for harm. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) according to the facility ' Admission Record. During an interview on 3/15/24, at 9:46 A.M. with Resident 1, Resident 1 stated a week ago on Monday, 3/4/24 he walked out of the facility to look for a house for sale then came back. Resident 1 stated this past Monday, 3/11/24 he left the facility again when it was still dark outside and staff from the facility found him outside during the day. An interview was conducted on 3/15/24, at 10:22 A.M. with Resident 1 ' s assigned certified nurse assistant (CNA) 1. CNA 1 stated he was assigned to Resident 1 on 3/9/24 when Resident 1 eloped from the facility. CNA 1 stated resident ate breakfast on 3/9/24 and assumed Resident 1 ate lunch in the dining room. CNA 1stated Resident 1usually attended activity programs then ate lunch in the dining room. CNA 1stated meal trays for Resident 1 were delivered to his room unless he was in the dining room. CNA 1 stated at around 2-2:30 P.M. on 3/9/24, another CNA notified him that Resident 1was found outside the facility by the street. CNA 1 stated he then saw Resident 1 walking towards his room at that time and did not know that Resident 1 was not in the facility. During a concurrent review and interview on 3/15/24, at 12:15 P.M. with the activity director (AD), the AD reviewed the activity log for 3/9/24 and stated Resident 1 attended the morning activity but did not attend the afternoon activity. The AD further stated Resident 1did not have lunch in the dining room because there were no dining room meals served on the weekends, and 3/9/24 was a Saturday. During a review of the facility ' s progress note (PN) dated 3/9/24 written at 4:30 P.M., the PN indicated, The resident was observed by staff ambulating on the walkway near Felicita Road close to traffic. Staff feared he may inadvertently wander into traffic . An elopement risk assessment for Resident 1 dated 2/5/24 was reviewed. The assessment indicated, SC1. Score >1-At Risk for Elopement. During an interview on 3/15/24, at 12:21 P.M. with licensed nurse (LN) 3, LN 3 stated she created an at risk for elopement care plan for Resident 1 on 3/9/24. LN 3 stated there was no plan of care to address Resident 1 ' s elopement risk upon admission. The attending physician ' s history and physical (H&P) dated 2/7/24 was reviewed. The H&P indicated, .patient resides at Board and Care. Patient was wandering and went missing for several days. He was found by local police and brought in the hospital and placed on 5150 hold (involuntarily committing someone to a mental health facility) . A review of the facility ' s policy and procedure (P&P) titled, Elopements and Wandering Residents, dated 12/19/22 was reviewed. The P&P indicated, .This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accident, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so . An interview was conducted with the Director of Nurses (DON) on 3/22/24, at 11:25 a.m. The DON stated there should have been a plan of care for Resident 1upon admission to the facility because Resident 1 had a history of elopement.

Based on interview, and record review, the facility failed to maintain an infection control program to: 1. Identify staff and residents who were exposed to [DIAGNOSES REDACTED] (TB) (a bacterial infection that usually attack the lungs which is a communicable and reportable disease), 2. When they did not test the staff and residents, within the specified time frame, as required by the San Diego County [DIAGNOSES REDACTED] unit, and 3. Provide information to the TB unit, after the unit made over 3 attempts to obtain information from the facility. As a result, the failed practices of the facility, had the potential to expose 112 residents and an undetermined number of resident discharges, visitors,and staff to TB, due to the facility's lack of identification, tracking of information, and testing for an infectious disease. An Immediate Jeopardy was called on 2/24/16 at 2:10 P.M., the Administrator (ADM)Director of Staff Development (DSD) 2, Assistant Director of Nurses (ADON), the Regional Director of Clinical Services, and Vice President of Operations were present. The facility did not comply in identifying, testing, and providing information to the TB Unit. Findings: On 1/27/16 at 9 A.M. the Department received a phone call from the TB unit that an employee of the facility had tested positive for TB and the facility was not cooperating with the TB unit's instructions. The TB Health Investigator (HI) said she had spoken to the ADON three times and had not been able to set up an appointment to determine how many staff, or residents may have been exposed. On 1/28/16 at 9:15 A.M., a phone interview was conducted with the ADM in regard to the TB exposure at the facility. The ADM said he was not sure when he knew about the incident of exposure, but would comply with the TB unit's directives. On 2/3/16, the HI said she made a visit to the facility and spoke directly with the ADON, DSD 1 and the ADM. The HI said she gave the facility education about TB, and a spreadsheet, with instructions on how to complete it. The spreadsheet was to be completed by 2/6/16. The spreadsheet (a specially designed line listing created by the TB unit) was to contain tracking information for past TB test dates, results, and future test dates for staff and residents who had 8 or more hours of exposure to the infected staff member. On 2/8/16, the TB unit emailed the facility a letter to send to the discharged residents and staff who had left employment at the facility, which provided information about possible exposure and testing. On 2/23/16 at 9 A.M., the Department conducted a phone interview with the facility and the facility had not completed the spreadsheet as requested by the TB unit. On 2/23/16 at 9:15 A.M., the Department conducted a phone interview with the assigned HI. The HI said she had not received the spreadsheet as she requested by 2/6/16. On 2/23/16 at 9:40 A.M., the Department conducted a phone interview with the facility ADM and again requested the spreadsheet be completed by close of business on 2/23/16. The ADM assured the Department he would have his staff complete the spreadsheet by close of business. The ADM said he felt this was all, precautionary, and did not understand the urgency. On 2/23/16 at 4:30 P.M. the Department received the spreadsheet; however, the spreadsheet had many blank areas and was incomplete. On 2/24/16 at 7:45 A.M., the Health Facility Evaluator Nurse (HFEN) and Health Facility Supervisor (HFES) entered the facility. During a concurrent interview, Licensed Nurse (LN) 1 said she was the day unit manager. LN 1 said she became aware a staff person had a positive TB test last week and LN 1 said she was tested on [DATE]. LN 1 said she obtained this information from DSD 2 (a different Director of Staff Development, as DSD 1 had left the employment of the facility). On 2/24/16 at 8:45 A.M., during and interview, the ADM said DSD 1 left over a week ago. The ADM said, the DSD was responsible for the Infection Control program. The ADM said some of the residents had been skin tested and the facility had not yet determined if they had identified and tested all the exposed residents. The ADM said the staff testing had not been done as required by the TB unit. On 2/24/16 at 9 A.M., during an interview, DSD 2 said he had been assigned to cover the facility after DSD 1 left. DSD 2 said he just began the staff TB testing. The ADM and DSD 2 produced the census sheets and staff sheets. The ADM said he thought only those residents with greater than 24 hours of exposure needed to be tested . The ADM said no letters had been sent to the discharged residents or staff who were no longer employed in the facility as requested by the HI at the TB unit. On 2/24/16 at 10:10 A.M., a joint call was made to the HI at the TB unit, with DSD 2. The HI stated she gave instructions to the facility staff for completion of the spreadsheet on 2/3/16. The facility was to identify staff and residents exposed to Staff Member (SM) 1 for 8 hours or more. All staff and residents exposed were to be recorded on the spreadsheet. On 2/24/16 at 10:45 A.M., SM 1 came to the facility for an interview. SM 1 provided a list of both residents (from the census period), and staff that he worked with during the exposure period as determined by the TB unit, of 10/1/15 through 11/24/15. The list did not match the spreadsheet provided by the facility on 2/23/16. On 2/24/16 at 12:10 P.M., a review done by DSD 2 of the staff members who worked with SM 1 during the exposure period. During this review, it was determined that 8 staff members were directly identified as exposed to TB for greater than 8 hours; 6 had been tested on [DATE]. DSD 2 said the facility decided all staff were to be tested as they were unable to determine which staff were exposed for 8 hours or more, and some of the personnel records had incomplete documentation related to the dates staff had initial and annual TB testing. On 2/24/16 at 2 P.M., the facility had counted 60 to 80 residents with possible exposure, 21 had been tested during the week of 1/30/16, an additional 39 were identified who had not been tested , and 2 residents had refused testing. On the resident spreadsheet, 7 of 21 residents did not have an admission or annual skin test status listed. Per the facility policy, [DIAGNOSES REDACTED] Control Plan, dated 4/1/15, 9-5, .9. Repeat skin tests will be provided for PPD (a skin test for TB) negative resident after any suspected exposure to a documented case of active [DIAGNOSES REDACTED]. Per the facility policy, Associate Health, dated 5/26/10, 5-25, Exposure Incidents: all associates having occupation exposure will undergo the following: 1. PPD skin test, if previously PPD negative. 2. Follow-up PPD skin test in 10-12 weeks. If associate develops a positive test, a chest x-ray will be obtained. 3. All PPD converts, will be referred to the local Health Department for follow-up. 4. Documentation will be obtained from the public Health Department to direct the facility as to any additional actions needed. On 2/24/16 at 2:10 P.M., an Immediate Jeopardy (IJ) was called for infection control. The ADM, DSD 2, ADON, the Regional Director of Clinical Services, and Vice President of Operations were present. At the time of the IJ the facility had not complied with the required information and testing as set by the TB control unit. The facility did not identify current residents, discharged residents, current or former staff who were exposed to TB as requested by the TB unit. The facility also failed to take action and did not use preventative measures through identification of exposed staff and residents in order to protect residents and staff from a communicable disease, TB. On 2/24/16 at 6:40 P.M., the Immediate jeopardy was removed related to [DIAGNOSES REDACTED], infection control, after the Department received a written, acceptable Plan of Correction.