Every finding on record at Oxnard Manor Healthcare Center

Based on interview and record review, the facility failed to verify a physician's order to hold blood pressure medications or to include fluid restrictions in the diet order in one of two sampled dialysis residents, resident 1 (R1). These failures resulted in R1's inability to have a complete dialysis procedure (a process to remove extra fluid and clean the blood through an artificial filter in the machine, from toxic product of food metabolism to maintain health and sustain life) due to having too low of blood pressure or have extra fluid removal with a potential for R1 to have excess fluid in her body that can result in complications. During a review of R1's admission record, the record indicated R1 was admitted in the facility on 3/26/26 with diagnoses that included end stage renal disease (chronic kidney failure) and on dialysis. During a review of R1's History and Physical (H&P) dated 3/27/26, the H&P indicated, R1 did not have the capacity to understand and make her own decisions. During a review of R1's physician order dated 3/26/26, the order indicated R1 to have nothing by mouth (NPO) only, no other order specific for renal (kidney) diet such as fluid restrictions was observed, another physician order dated 3/27/26, the order indicated, may hold medications when resident is at dialysis and had no clarification of the order by staff of which medications were to be held. During a review of R1's dialysis communication record dated 7/10/26, the record indicated a note from dialysis nurse, arrived hypotensive (having low blood pressure) and unable to remove fluid due to low blood pressure and to observe for signs and symptoms of fluid overloading and if symptomatic, to send R1 to emergency room. During a review of R1's Medication Administration Record (MAR) dated 7/10/26, the MAR revealed that Losartan Potassium 100 mg, and Metoprolol Tartrate 12.5 mg (both anti-high blood pressure medications) were administered at 9:00 a.m. During an interview on 7/22/26 at 1:00 p.m. with the dialysis nurse (DLN1), the DLN1 stated that R1 came to the unit for dialysis on 7/10/26 with low blood pressure around 96/35, and the attending physician ordered to just clean the blood without removing fluid. DLN1 confirmed that R1 is usually able to have fluid removal between 1.5 to 2.4 liters per treatment but only removed 0.4 liter and was at risk of fluid overloading that weekend. During an interview on 7/27/26 at 3:35 p.m. with the dialysis nurse (DLN2), the DLN2 stated that on 6/1/26 dialysis, R1 came to their clinic with puffy face and legs and was unable to pull out fluid because of low blood pressure during treatment. The DLN2 further confirmed R1 went home weighing 1 kg. above her target and ideal weight of 58.5 kg. During an interview on 7/27/26 at 3:25 p.m. with a licensed nurse (LN2), the LN2 stated she received a call from the dialysis unit for R1 to have extra treatment on 6/2/26 to remove excess fluid in the body. During a concurrent interview and record review on 7/22/26 at 1:30 p.m., with the Director of Nursing (DON), sampled resident (R2)'s medication order was reviewed. The order indicated that R2's order was verified and specific to hold blood pressure pills on dialysis days while R1's order was not clarified with the physician. The DON agreed that the orders for all dialysis residents' orders need to be verified. The DON stated that a change in condition (COC) for R1 was made on 7/10/26 when reports from dialysis unit indicated that R1 did not have a complete dialysis due to low blood pressure while on treatment. During an interview on 7/27/26 at 3:45 p.m., with the Director of Nursing (DON), the DON verified that the specific renal diet order should have been ordered to communicate the fluid and diet restrictions to the staff. During a review of facility's Policy and Procedure (P&P), titled Physician Order, dated 12/28/22, the P&P indicated, orders will include a clear and complete description to provide clarity on the physician's plan of care. During a review of facility's Policy and Procedure (P&P), titled Dialysis Management, dated 3/27/24, the P&P indicated Diet and fluid restrictions will be followed as ordered.

Based on interview, record review, and Policy and Procedure (P/P)facility failed to ensure a resident receiving Hemodialysis ( (HD-procedure done by a trained professional to remove waste and excess fluids from the body when the kidneys stop working properly) received care and services consistent with professional standards of practice for one of three sampled residents (Resident 1)when:1. Pre and post dialysis evaluation was not completed2. A total inspection of an arteriovenous (AV) shunt (fistula, is a surgically created direct connection between an artery and a vein, typically in the arm, for long-term hemodialysis access) site area for color, warmth, redness, edema, and drainage was not done and documented. This failure resulted in Resident 1 developing a severe infection that required interventions. According to the American Nurses Association (ANA). (2021). Standards of practice. Nursing: Scope and Standards of Practice (3rd ed.) (pp. 53 - 66). First principle of documentation: 1. Documentation Characteristics: Accessible, Accurate and relevant, Auditable, Clear, concise, comprehensive, and thoughtful. Accuracy in nursing assessments is the collection of reliable and precise data that reflects the patient's true health status. During a review of Resident 1's admission Record (AR), dated 1/29/26 the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD - final stage of permanent kidney failure whereby requiring regular dialysis or a transplant for survival) and dependence on renal dialysis. During a review of Resident 1's Order Summary (OS) dated 2/12/25, the OS indicated Resident 1 had hemodialysis on Mondays, Wednesdays, and Fridays.During a review of Resident 1's OS dated for 1/29/2026 with a start order date of 3/24/24, the OS indicated, If bleeding occurs at AV shunt RUA (Right Upper Arm) any time after dialysis, apply pressure with clean gauze for 5-10 minutes.repeat until bleeding stops. If this intervention does not control the bleeding, notify MD.During a review of Resident 1's medical records titled, Pre-Dialysis Evaluation, B. Dialysis Unit to Complete, comments were written by the dialysis nurses on the access site assessment for the following dates of treatment:12/23/25 Dressing left on HD access.12/28/25 Dressing left on HD access since 12/26.must be removed to prevent clotting/damage to the access.1/5/26 Remove HD dressings tonight! Dressings from 12/26 were left on.1/12/26 Please remove fistula dressing 1 to 2 hours post HD to avoid problems with fistula site.1/16/26 Dressing left on from last treatment. Must be removed before bed.1/19/26 'Swabbed wound on access. Dressing left on since 1/16/26 and dressing damp left raw skin & sore.1/23/26 .Swabs done on access on 1/19 growth for staph aureus and pseudomonas aeruginosa (both bacteria that can cause an infection).During a review of Resident 1's medical records titled, Post Dialysis Evaluation, dated 12/23/25, 12/28/25, 1/5/26, 1/12/26, 1/16/26, and 1/23/26, there was no documentation to show dressings applied at the dialysis center after Resident 1's treatments were removed by the facility's receiving nurses.During a review of Resident 1's medical record titled Microbiology Report ( A report that help identify bacteria, fungi, or viruses from clinical specimens to diagnose infections and guide treatment) result date of 1/24/26 indicated, Culture Wound.Access Site.Collected 1/19/26.Organism Pseudomonas aeruginosa ( a major opportunistic pathogen, frequently causing severe, antibiotic-resistant), heavy growth and Staphylococcus aureus (a germ found on people's skin), moderate growth. In addition, the physician ordered Vancomycin and Ceftazidime (both antibiotics). During a review of Resident 1's Order Summary Report dated 1/21/26 the OS indicated Resident 1 had a physician appointment on 1/26/26 for possible infection R (right) upper AV shunt.During review of Resident 1's Care Plan (CP), dated 3/26/24, the CP indicated The resident needs hemodialysis related to End Stage Renal Disease. Nursing interventions included: Check and change dressing daily at access site. Document.Monitor/document/report PRN (as needed) any signs/symptoms (s/sx) of infection to access site: Redness, swelling, warmth, or drainage.Monitor /document/report PRN for s/sx of the following: Bleeding, hemorrhage, bacteremia, septic shock.During a review of Resident 1's medical record, there was no documentation to show Resident 1's dialysis access site had been monitored for infection since a growth result of bacteria was detected and was started on new antibiotic therapy.During a concurrent interview and record review on 1/29/26 at 1:46 p.m. with Licensed Nurse (LN 1), LN 1 stated being assigned familiar with Resident 1. LN 1 stated the process for post dialysis included entering notes in the medical record, if there were any, and to remove the dialysis dressing 1 hour after the resident arrives. LN1 acknowledged the Post Dialysis Evaluations dated 12/28/25, 1/7/26, 1/19/26, and 1/26/26 were signed by LN 1 and that there was no documentation to show the dressings applied at the dialysis center after Resident 1's treatments were removed.During a concurrent phone interview and record review on 2/3/26 at 3:34 p.m. with Licensed Nurse (LN 3), LN 3 confirmed to have been assigned and being familiar with Resident 1. Resident 1's pre-dialysis assessments dated 1/5/26, 1/19/26, and 1/26/26 were reviewed. LN 3 acknowledged the access site assessments performed by staff were discrepant from the dialysis center and that the resident's access site could not change so drastically during transport from the facility to dialysis. LN 3 stated the access site was assessed as being within normal limits (WNL) when there were other options in the electronic health record to better describe Resident 1's AVF site such as redness, swelling, pain, bleeding, or skin discoloration but those options were not selected. And LN 3 acknowledged, not to be aware the dressing on Resident 1's AVF site was the dressing from the previous dialysis session and confirmed there were no observations done to monitor for signs of inflammation, infection and or inspection of the shunt site area for color, warmth, redness, edema, and drainage.During a concurrent phone interview and record review on 2/3/26 at 4:03 p.m. with Licensed Nurse (LN 4), Resident 1's Pre-dialysis records dated 12/25 through 01/26 were reviewed. LN 4 confirmed to have been assigned and involved in the care of Resident 1 during when the resident had pre and post dialysis appointments. However, pre or post dialysis assessments were not performed on the days she was assigned to Resident 1 on 12/21/25, 12/28/25, 1/7/26, and 1/16/26, and 1/23/26 for Resident 1. Further interview with LN 4 revealed that dialysis dressing must be removed by the receiving nurse after 2 hours from arrival and LN 4 claimed to have assumed the dressings found on Resident 1's AVF site were for treatment provided by the facility. LN 4 state she was not aware the dressing on Resident 1's AVF site was the dressing from the previous dialysis session and acknowledged, there were no observations done to monitor for signs of inflammation, infection and or inspection of the shunt site area for color, warmth, redness, edema, and drainage,During a concurrent interview and record review on 2/19/26 at 10:21 a.m. with Director of Nursing (DON), Resident 1's Pre-dialysis records dated 12/25 through 01/26 were reviewed. DON confirmed the post dialysis dressing should be removed 4 - 6 hours after dialysis. DON confirmed dialysis center communicated to the facility on multiple occasions when Resident 1 had returned to dialysis with the dressing from the previous dialysis treatment and the risks it can cause to the AVF site.During a review of the facility's policies and procedures (P&P) titled, Dialysis Management, dated 3/24, the P&P indicated, The facility should assure that each resident receives care and services consistent with professional standards of practice. 3. A pre and post dialysis evaluation will be completed by the licensed nurse. 4. Vascular Access Site.b. Assessing, observing and documenting care of access sites daily, as applicable, such as.iii. Skin integrity (waxy skin, ulcerations, drainage from incisions) .vii. Evidence of infection at the surgical site, such as drainage, redness, tenderness at incision site, fever.During a review of the facility's P&P titled Arteriovenous Shunt Care, revised 01/12, indicated, . I. Observe for signs of inflammation, infection and obstruction.Inspect total shunt site area for color, warmth, redness, edema and drainage, once per shift

Based on record review, interview, and facility policy and procedure, the facility staff failed to obtain and clarify Oxygen administration orders from the physician for one of three sampled resident (Resident 1) when supplemental oxygen was administered without a physician order.This failure creates a risk for the mismanagement of respiratory distress and potential oxygen toxicity (lung damage that happens from breathing in too much extra (supplemental) oxygen). During review of Resident 1's admission Record (AR), dated 10/15/25, the AR indicated Resident 1 was initially admitted to the facility on [DATE], and then re-admitted on [DATE] with diagnoses that include hepatic encephalopathy (a decline in brain function occurring when a damaged liver cannot properly filter toxins), alcoholic cirrhosis of the liver without ascites (an advanced stage of alcohol-related liver disease where healthy liver tissue is replaced by scar tissue; the liver still performs basic functions without causing abdominal fluid buildup (ascites) or major complications), and acute respiratory failure with hypoxia (inability of the lungs to provide enough oxygen to the blood to preserve normal organ function). During review of Resident 1's hospital Discharge Summary, dated 11/13/25, indicates the patient uses oxygen at care facility at 1 to 2 liters. Review of Resident 1's Vitals and Pain Only progress note, dated 11/17/2025 at 22:59 p.m. indicates oxygen saturation was 95% at room air. The admission Summary Assessment progress note dated 11/17/25 at 23:13 indicates the resident's breathing was even and unlabored on room air. During a review of Resident 1's Weights and Vitals Summary (WVS) report for oxygen saturations, dated 1/20/26, the WVS indicate the oxygen saturation reading was obtained while the resident was on oxygen via nasal cannula on 11/19/25 through 11/24/25, 12/04/25, and 12/05/25. Review of Resident 1's Order Summary (OS), dated 11/17/26, had no physician order for oxygen. During an interview on 1/29/26 at 12:28 p.m. with Certified Nursing Assistant (NA 1), NA 1 stated that Resident 1 used oxygen via nasal cannula. In a separate interview on 1/29/26 at 1:28 p.m. with Certified Nursing Assistant (NA 2), NA 2 stated Resident 1 used oxygen via nasal cannula all the time. During a concurrent interview and review on 2/19/26 at 10:21 a.m. with the Director of Nursing (DON), Resident 1's Order Summary (OS) and Weights and Vitals Summary (WVS) report for oxygen saturations (O2 sats) were reviewed. DON acknowledged the WVS report indicated oxygen saturation results were taken on numerous occasions while Resident 1 was on oxygen via nasal cannula and the OS did not indicate there was a physician order for oxygen administration. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 10/31/2025, indicates in part, .Purpose: To ensure the safe administration of oxygen in the Facility.Policy: Oxygen will be initiated with a provider order.

Based on interview, record review, and facility Policy and Procedure (P/P) the facility failed to accurately assess for a change in condition (CIC) for one of three sampled residents ( Resident 1) when a ssessment relevant to the change in condition to determine what nursing interventions are appropriate with the overall condition utilizing a physical assessment was done. This failure created a situation whereby the resident treatment and care were not recieved in accordance to medical needs. During review of Resident 1's admission Record (AR), dated 10/15/25, the AR indicated Resident 1 was initially admitted to the facility on [DATE], and then re-admitted on [DATE] with diagnoses that include hepatic encephalopathy (a decline in brain function occurring when a damaged liver cannot properly filter toxins), alcoholic cirrhosis of the liver without ascites (an advanced stage of alcohol-related liver disease where healthy liver tissue is replaced by scar tissue; the liver still performs basic functions without causing abdominal fluid buildup [ascites] or major complications), fluid overload (excessive water accumulates in the body's bloodstream and tissues), and acute respiratory failure with hypoxia (inability of the lungs to provide enough oxygen to the blood to preserve normal organ function).During review of Resident 1's weekly Advance Long Term Care Evaluations (ALTCE) dated 11/21/25, 12/3/25, 12/11/25, and 12/18/25 indicate the resident's abdomen was flat and non-tender. The ALTCE dated 11/26/25 indicates the abdomen was non-tender.During a review of Resident 1's Changes in Condition (CIC), dated 12/22/25 at 6:55 a.m., the CIC indicated Resident 1 had a sudden onset of chest congestion and low oxygen saturation (O2 sat - the amount of oxygen being carried by red blood cells in the body with a normal range of 95%-100%) trending around 75%. Question 4 of the CIC was marked yes on whether an abdominal/GI (gastrointestinal - relating to the stomach and the intestines). The follow-up question (4a) had multiple boxes to choose from such as abdominal pain, distended abdomen, or abdominal tenderness to describe the abdominal/GI changes. The only box selected was no changes observed. Review of records titled Progress Notes (PN) dated 12/22/26 indicated, the nursing observations, evaluation, and recommendations made were at around 6:45 a.m., resident had sudden onset of low O2 (Oxygen) trending around 75% and noted with chest congestion. Resident appearing anxious and having and dyspnea And further reviews did not show Resident 1's abdomen was assessed for change in condition prior to sending Resident 1 out to the ER (emergency) per resident request and recommendation by MD (physician).During review of Resident 1's hospital record, dated 12/23/25, the record indicates the resident was admitted to the hospital on [DATE] at 7:20 a.m., for acute shortness of breath. The hospital staff's physical examination revealed the resident had a painful abdomen and significant abdominal distention. Diagnostic imaging confirmed the resident had large volume ascites and laboratory results indicate 4600 mL (milliliters- measurement of volume) of ascites was removed via paracentesis (procedure where a needle is inserted through the abdominal wall into the space between the abdominal wall and organs to remove ascites).During a concurrent phone interview and record review on 2/4/26 at11:51 a.m. with Licensed Nurse (LN 2), Resident 1's CIC dated 12/22/25 was reviewed. LN 2 acknowledged Resident 1's abdomen was not assessed or evaluated for abdominal pain or distention.During a review of the facility's policies and procedures (P&P) titled, Change in Condition, dated 08/25/2022, the P&P indicates in part, The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate. a. Before notifying the Physician/ APP (attending primary physician), the Licensed Nurse must observe and assess the overall condition utilizing a physical assessment and chart review.

Based on interview and record review, the facility failed to ensure licensed nurses (LNs) were competent in providing quality of care for one of three sampled residents (Resident 1) when a comprehensive assessment and individualized care plan was not completed related to Resident 1's change of condition (new onset of infection).This failure had resulted in Resident 1's signs and symptoms of infection not monitored by staff and had the potential to develop complications. During a review of Resident 1's admission Record (AR), dated 1/29/26 the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD - final stage of permanent kidney failure whereby requiring regular dialysis or a transplant for survival) and dependence on renal dialysis (procedure done by a trained professional to remove waste and excess fluids from the body when the kidneys stop working properly). During a review of Resident 1's Order Summary (OS) dated 2/12/25, the OS indicated Resident 1 had hemodialysis on Mondays, Wednesdays, and Fridays. During a review of Resident 1's OS dated 3/24/24, the OS indicated, If bleeding occurs at AV shunt arteriovenous fistula (AVF- a surgical connection between an artery and a vein used for dialysis) RUA (Right Upper Arm) any time after dialysis, apply pressure with clean gauze for 5-10 minutes.repeat until bleeding stops. If this intervention does not control the bleeding, notify MD.During a review of Resident 1's medical record titled Microbiology Report (a report that help identify bacteria, fungi, or viruses from clinical specimens to diagnose infections and guide treatment) result date of 1/24/26 indicated, Culture Wound.Access Site.Collected 1/19/26.Organism Pseudomonas aeruginosa (a major opportunistic pathogen, frequently causing severe, antibiotic-resistant), heavy growth and Staphylococcus aureus (a germ found on people's skin), moderate growth. In addition, the physician ordered Vancomycin and Ceftazidime (both antibiotics). During a review of Resident 1's medical record, there was no documentation to show a comprehensive assessment and an individualized care plan with interventions was done for Resident 1's new onset of infection on the dialysis access site and that it had been monitored for signs and symptoms of infection/complication since the start of a new antibiotic therapy. In addition, there was no documentation on Resident 1's change of condition related to the infection. During a concurrent phone interview and record review on 2/3/26 at 2:19 p.m. with Licensed Nurse (LN 2), LN 2 confirmed there was no change of condition in the Resident 1's medical record for the positive growth result and antibiotic therapy. LN 2 stated a change of condition should have been initiated but was not. During a concurrent phone interview and record review on 2/3/26 at 3:34 p.m. with Licensed Nurse (LN 3), LN 3 confirmed to have been assigned and was familiar with Resident 1. LN 3 acknowledged that the receiving nurse did not initiate a change of condition when dialysis staff communicated that the resident had positive bacterial cultures and was receiving antibiotics. During a review of the facility's policy and procedure titled, Change in Condition, dated 08/22, indicated, .2. The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate. a.i Notification to the Physician/APP will include a summary of the condition change and an assessment of the resident's vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required utilizing a SBAR format (situation, background, assessment, recommendation) .4. Reporting Information to the Physician/APP.b. Reporting Laboratory and Diagnostic results .

Based on interview, record review, and facility Policy and Procedures (P/P) the facility failed to ensure that one of three sampled residents (Resident 1) received timely and appropriate medical care under the supervision of a licensed physician when laboratory results were communicated to the attending physician timely.This failure has the potential to delay/miss treatment and care for the residentDuring review of Resident 1's admission Record (AR), dated 10/15/25, the AR indicated Resident 1 was initially admitted to the facility on [DATE], and then re-admitted on [DATE] with diagnoses that include hepatic encephalopathy (a decline in brain function occurring when a damaged liver cannot properly filter toxins), alcoholic cirrhosis of the liver without ascites (an advanced stage of alcohol-related liver disease where healthy liver tissue is replaced by scar tissue; the liver still performs basic functions without causing abdominal fluid buildup (ascites) or major complications), fluid overload (excessive water accumulates in the body's bloodstream and tissues), and acute respiratory failure with hypoxia (inability of the lungs to provide enough oxygen to the blood to preserve normal organ function). During review of Resident 1's Progress Note (PN), dated 11/25/25 at 17:43, the PN indicates an order was received for an x-ray of sacrum/coccyx to evaluate for evidence of osteomyelitis (bacterial infection of the bone that causes inflammation, severe pain and swelling) and for laboratory testing of white blood count (WBC - blood cells that fight infection), sedimentation rate (ESR- blood test that serves as an indicator of inflammation, infection, or cancer in the body), 25-hydroxy Vitamin D (measures Vitamin D levels stored in the body, which helps regulate calcium and phosphorus levels for bone health), comprehensive metabolic panel (CMP - blood test that measures different substances to evaluate organ function, metabolism, and electrolyte balance), C-reactive protein (CRP - measures protein levels produced by the liver, which rise significantly when there is inflammation, infection, or tissue damage in the body), and prealbumin (protein produced by the liver that transports thyroid hormones and Vitamin A; a rapid, sensitive marker for nutritional status and protein intake). Progress note dated 11/26/25 at 23:56 p.m. indicates a change of condition was initiated because the facility received a call from the lab to communicate that Resident 1 had a critical low calcium level of 6. The physician's recommendation was to continue to monitor. Further review of the progress notes showed no evidence that the x-ray of was reviewed by the attending physician. During review of Resident 1s PN dated 11/26/25 at 14:16 p.m. the PN indicates an order was received for a complete blood count with differential (CBC - blood test that measures the different type of blood cells to assess overall health), pro-time (PT - measures how many seconds it takes for the liquid portion [plasma] of blood to clot), International Normalized Ratio/partial thromboplastin time (INR/PTT - measure how long it takes for blood to clot), CMP, alpha-fetoprotein (AFP - protein primarily produced by the liver that acts as a tumor marker in adults), ammonia (toxic waste product filtered by the liver; high levels indicate liver or kidney problems), antimitochondrial antibodies (AMA - test used to diagnose chronic liver disease or autoimmune disorder) and anti-smooth muscle antibody ([NAME] - a key marker for diagnosing autoimmune inflammation of the liver with high levels indicating the immune system is attacking liver cells). PN dated 11/28/25 at 19:09 p.m. indicates the results were sent to the physician. The physician recommendation was to increase the calcium supplement to be given twice a day versus once a day. Further review of the PN's indicate the laboratory results were faxed to the gastroenterologist on 12/1/25 at 18:58. A PN dated 12/2/25 at 8:34 a.m., indicates the facility received a call from the gastroenterologist requesting to transfer resident to the hospital for further evaluation related to the low hemoglobin (a protein inside red blood cells that transports oxygen from the lungs to the body's tissues and organs, while carrying carbon dioxide back to the lungs) level. PN dated 12/2/25 indicates the resident was transferred to the hospital at 14:45 p.m. and returned to the facility same day at around 21:15 p.m. with a diagnosis of hypocalcemia (low calcium). During review of Resident 1's PN dated 11/26/25 at 14:16 p.m. the PN indicates an abdominal ultrasound for liver cirrhosis was ordered on 11/26/25. Review of Resident 1's abdominal radiology report indicates findings of cholelithiasis (the presence of hardened deposits [gallstones] in the gallbladder) and mild ascites in the right upper area of the abdomen. Further review of the PN's showed no evidence that the attending physician was notified or had reviewed the ultrasound results. During review of Resident 1's PN dated 12/8/25, the PN indicates a laboratory test for CRP and ESR was ordered. Progress notes dated 12/8/25 and 12/10/25 indicate physician was notified of ESR and CRP results but were awaiting response back. Progress note dated 12/10/25 at 3:52 a.m. indicates no new order at this time per physician. During review of Resident 1's PN dated 12/10/25 a hemoglobin and hematocrit test (measures the percentage of total blood volume made up of red blood cells to assess oxygen carrying capacity) was ordered. Review of PN's showed no evidence the attending physician was notified or had reviewed the hemoglobin and hematocrit results which indicated the hematocrit level was 24.9 (normal range is 42.0 - 52.0) and a hemoglobin was 8.0 (normal range is 12.0 - 18.0). During review of Resident 1's PN dated 12/15/25, the PN indicates an order was placed to repeat the CRP and ESR. Further review of the PN's showed no evidence that the attending physician was notified or had reviewed the laboratory test results. The results indicated the CRP was abnormal at 12.05 with a reference range of 0.00-0.80. During a concurrent interview and review on 1/29/26 at 4:30 p.m. with the Director of Nursing (DON), Resident 1's laboratory results dated [DATE] were reviewed. The DON was asked for evidence indicating the physician had been notified of the test results. The DON provided a faxed coversheet with attached laboratory results of several residents at the facility. One of the laboratory results included the hemoglobin and hematocrit ordered on 12/10/25 for Resident 1. DON stated the fax was the only record available to show the physician had been notified of the lab results. The faxed cover sheet document has the date and time stamped indicating the time the records were faxed but it does not indicate or show the physician received the fax and reviewed the results. DON acknowledged there was no record to show receipt confirmation, or any follow-up with the physician to verify if there were any new orders.During a follow up interview on 1/29/26 at 4:59 p.m. with the DON, the DON was asked for physician notification of Resident 1's abdominal radiology report dated 11/26/25. DON stated that there were no records to show the physician was notified. During an interview on 2/12/26 at 3:42 p.m. with Medical Director (MD), MD acknowledged not recalling being informed about Resident 1's abnormal radiology and laboratory results. During review of the facility's policy and procedure (P&P) titled, Physician Services and Visits, dated 8/28/25, indicates Policy: The physician is responsible for evaluating, managing, and coordinating the resident's overall care in accordance with the resident's condition, applicable laws, and this facility's interdisciplinary approach to care. Purpose: To ensure that residents receive timely and appropriate medical care under the supervision of a licensed physician, in compliance with federal and state regulations.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had an accurate medical record when a diagnosis of decompensated liver cirrhosis with ascites (an advanced stage of liver scarring where the liver can no longer function properly, leading to significant complications, most notably the accumulation of fluid in the abdomen [ascites] causing abdominal distension, discomfort, and potential breathing issues) was not listed as a diagnosis on the admission record. This failure had the potential for Resident 1 not to receive adequate care and have unmet medical needs.According to ANA's (American Nurses' Association) book titled, Principles for Nursing Documentation (Guidance for Registered Nurses), copyright 2010, the guidance indicated, in part, Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice .to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care. During review of Resident 1's admission Record (AR), dated 10/15/25, the AR indicated Resident 1 was initially admitted to the facility on [DATE], and then re-admitted on [DATE] with diagnoses that include hepatic encephalopathy (a decline in brain function occurring when a damaged liver cannot properly filter toxins) and alcoholic cirrhosis of the liver without ascites (an advanced stage of alcohol-related liver disease where healthy liver tissue is replaced by scar tissue; the liver still performs basic functions without causing abdominal fluid buildup (ascites) or major complications. During review of Resident 1's Hospital Discharge (HD), record dated 10/27/25, indicates Resident 1 had a past medical history of decompensated liver cirrhosis with ascites and fluid volume overload. Review of the AR dated 10/15/25 does not list the diagnosis of decompensated liver cirrhosis with ascites. Review of Resident 1's care plan also did not contain any nursing interventions for decompensated liver cirrhosis with ascites. During a concurrent interview and record review on 1/29/26 at 2:00 p.m. with Licensed Nurse 1 (LN 1), Resident 1's AR and HD records were reviewed. LN 1 acknowledged the diagnosis on the AR indicates alcoholic cirrhosis of liver without ascites and the HD record lists the diagnosis as decompensated cirrhosis with ascites. LN 1 stated that both diagnoses should be aligned to ensure appropriate care. During a concurrent interview and record review on 1/29/26 at 4:34 p.m. with Minimum Data Set Coordinator (MDS), Resident 1's AR was reviewed. MDS stated not knowing where the term without ascites was obtained that was entered in Resident 1's medical record for liver cirrhosis. MDS acknowledged the diagnosis of alcoholic cirrhosis of liver without ascites on the AR was incorrect. During an interview on 2/19/26 at 10:21 with DON, the DON acknowledged Resident 1's AR did not list the diagnosis of decompensated liver cirrhosis with ascites included in the medical records the facility received from the hospital prior to the resident's re-admission on [DATE].

Based on interview and record review, the facility failed to accurately assess one out of five sampled residents (Resident 6) skin integrity for pressure ulcers (PU - injury to skin and tissue resulting from prolonged pressure). This failure resulted in inaccurate assessment documentation and had the potential for Resident 6's identified care needs to go unmet.During review of the facility's policy and procedure (P&P) titled, Skin Integrity Management, dated 6/27/24, the P&P indicated in part, 1. Assessments a. A Licensed Nurse will complete a skin evaluation when there is a change in skin integrity. b. A Licensed Nurse will complete the skin evaluation weekly.2. Skin Integrity Treatments c. The physician and responsible party will be notified when there is a change in the condition of the pressure injury or skin integrity condition.3. Licensed Nurses will document the effectiveness of current treatment for skin integrity problems in the resident's medical record on a weekly basis . During review of Resident 6's admission Record (AR) dated 12/19/25, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy (brain dysfunction caused by a chemical imbalance where the brain struggles to work), speech and language deficits following cerebral infarction (the death of brain tissue from a lack of blood flow, oxygen, and nutrients due to a blocked artery in the brain, often from a blood clot), and sepsis (an overactive response to an infection that damages its own tissues, organs, and systems, leading to potential organ failure and death if not treated rapidly). During review of Resident 6's medical records, the admission skin assessment dated [DATE] indicated resident was admitted with a PU on the coccyx (small triangular bone on the base of the spinal column) stage 2 (a shallow open ulcer, with partial-thickness skin loss, and a red/pink base or intact/ruptured blister). The minimum data set (MDS - a comprehensive assessment that helps nursing home staff identify health problems and track the improvement or decline of those problems) dated 11/17/25 indicated Resident 6 had unhealed PU's but section M0300 (current number of unhealed PU's/injuries at each stage) indicated 0 for all PU stages. The interdisciplinary team (IDT - a group of professionals from different fields who collaborate closely, share knowledge, and work interdependently to create a unified, patient-focused care plan) note dated 11/13/25 indicates the PU on the coccyx was evaluated by the facility's wound physician and reclassified as unstageable (full-thickness skin loss where the wound bed is covered by yellow, tan, green, or gray dead tissue and debris or a brown/black scab falling away of dead skin hiding the true depth of the wound) and then reclassified again on 11/26/25 as stage 4 (full-thickness tissue loss where skin, fat, and underlying muscle, tendon, or bone are exposed, creating a deep, open wound and high risk of infection). Further review of Resident 6's following medical records indicate the PU on the coccyx was categorized as stage 2: on Nursing long-term care nursing evaluations dated 11/14/25, 11/21/25, 11/28/25, 12/5/25,12/12/25; on Nursing skin assessments dated 11/14/25, 11/18/25, 11/19/25, 11/21/25, 11/25/25, 11/28/25, 12/4/25, 12/5/25, 12/8/25; on SBAR (Situation, Background, Assessment, Recommendations - a communication tool used to concisely convey an individual's current problem, relevant history, evaluation, and what needs to be done) dated 11/18/25, 11/19/25, and on 11/25/25.During a concurrent interview and record review on 12/18/25 at 3:45 p.m. with the Director of Nursing (DON), Resident 6's progress notes were reviewed. The DON acknowledged there was a discrepancy in the pressure ulcer staging between the admission skin assessment, the IDT notes, the weekly nursing skin assessments, NLTCE's, and SBAR's. DON further stated that the electronic medical system carries over the initial skin assessment performed on the date of admission to future nursing skin assessments which may be a contributing factor to the discrepancies in the PU staging assessments.

Based on observation, interview, and record review, the facility failed to provide respiratory care services consistent with professional standards of practice for one of five sampled residents (Resident 52) when the oxygen order was not implemented as ordered by the physician. This failure had the potential to place Resident 52 at risk for difficulty breathing. Review of [NAME] and [NAME], Tenth Edition, Elsevier, Fundamentals of Nursing, page 609 in the section titled, Medication Administration, indicated, If there is any question about a medication order because it is incomplete, illegible, vague, or not understood, contact the health care provider before administering the medication. During review of Resident 52's admission Record (AR) dated 12/18/25, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that include acute and chronic respiratory failure with hypoxia (low oxygen) and hypercapnia (high carbon dioxide) (lungs can't oxygenate blood or remove carbon dioxide effectively), chronic obstructive pulmonary disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), and dependence on supplemental oxygen. During an observation inside Resident 52's room on 12/16/25 at 2:30 p.m., Resident 52 was in bed without a nasal cannula (a device used to administer oxygen). On 12/17/25 at 12:30 p.m. the resident was observed in the dining room not wearing a nasal cannula or on oxygen therapy while waiting for lunch to be served. During an interview on 12/18/25 3:20 p.m. with Resident 52, the resident stated oxygen is not used when the resident is out of bed. Resident 52 stated the nasal cannula was placed over the resident's head at night. During a concurrent interview and record review on 12/18/25 at 3:30 p.m. with Licensed Vocational Nurse (LN 1) and Registered Nurse (LN 2), Resident 52's oxygen order was reviewed. The physician's oxygen order read Oxygen at 2L/min (liters - a metric unit of capacity or volume per minute) via NC (nasal cannula) to keep O2 (oxygen) Sat (saturation) at/above 92% for COPD. LN 1 said the resident is ok without oxygen, only needs it at night but acknowledged the oxygen order did not specify if O2 should be continuous or PRN. LN 2 acknowledged the oxygen order was inadequate and stated it should be clarified with the physician. During a concurrent interview and review on 12/18/25 3:35 p.m. with the Director of Nursing (DON), Resident 52's oxygen order was reviewed. DON acknowledged the order should specify if PRN (as needed) or continuous and in lieu of that information missing the resident should always be on continuous oxygen via nasal cannula unless PRN is specified in the order. The facility policy and procedure titled Oxygen Procedure undated indicated, Patients that require oxygen as ordered by a physician will be placed on an oxygen concentrator or oxygen tank. Oxygen therapy will be administered as ordered. During review of the facility's policy and procedure (P&P) titled, Physician Orders, dated 12/28/22, the P&P indicates in part, 4. Treatment orders will include the following: a. A description of the treatment - including the treatment site (if applicable). B. The frequency of the treatment and duration of order (when appropriate). C. The condition or diagnosis for which the treatment is ordered.Other orders will include clear and complete description to provide clarity on the physician's plan of care.

Based on interview and record review, the facility failed to ensure two of eleven sampled residents (Resident 10 and Resident 52) received the necessary treatment and monitoring for pressure ulcers (PU - damage to the area of the skin caused by pressure) when: 1. A PU was not measured or documented in Resident 10's medical record after the resident was re-admitted to the facility.2a. A wound consultation and physician treatment orders were not requested for the care of bilateral stage 2 PU's (shallow, open ulcers, with partial-thickness skin loss, and a red/pink base or intact/ruptured blisters) on the right and left buttocks of Resident 52.2b. The admission skin assessment, nursing long-term care evaluations (NLTCE - assessments to determine an individual's need for assistance with daily activities, assessing their physical, cognitive, and psychosocial health to plan care), and weekly skin assessments had inconsistent and discrepant documentation of Resident 52's PU's and/or skin integrity issues that ranged from having no PU's, to PU's on bilateral buttocks stage 2, moisture associated skin damage (MASD), or an open area to coccyx. During review of the facility's policy and procedure (P&P) titled, Skin Integrity Management, dated 7/231/25, the P&P indicated in part, , A Licensed Nurse will complete a skin evaluation when there is a change in skin integrity.2. Skin Integrity Treatments a. Treatments to pressure injuries or other skin integrity conditions will be ordered by the physician. b. Consultation from a wound care physician may be obtained upon an order from the attending physician.e. Treatments administered will be documented in the resident medical record.3. Licensed Nurses will document the effectiveness of current treatment for skin integrity problems in the resident's medical record on a weekly basis. 1. During record review, Resident 10 was re-admitted to the facility on [DATE], with a Stage 3 (full thickness skin loss where the wound extends through the skin into the fatty [subcutaneous] tissue) coccyx (small triangular bone at the base of the spinal column) pressure ulcer. Admitting records revealed no wound measurements was done by the admitting nurse on the day of re-admission or the wound treatment nurse the next day as per facility practice for admissions and re-admissions of Resident 10's Stage 3 coccyx pressure ulcer. During an interview, on 11/19/25, at 9:52 a.m., with the Director of Nursing (DON), in the DON's office, the DON searched the medical records for wound measurements for the re-admission on [DATE]. The DON said she cannot locate any wound measurements for the re-admission on [DATE] nor any wound measurements completed after 24 hours. The DON stated, There were no wound measurements done. 2a. During review of Resident 52's admission Record (AR) dated 12/18/25, the AR indicated the resident was admitted to the facility on [DATE] with a Braden Score (clinical tool used to assess the risk of developing pressure ulcers [bedsores], based on six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear, with scores of 18 or less typically signaling at-risk status, prompting interventions) of 16 and later changed to 14. During review of Resident #52's admission skin assessment (ASA) dated 11/04/25, the ASA indicated the resident was admitted with bilateral buttock stage 2 PU's. The PU on the right buttock measured 2.5 centimeters (cm - a metric unit of length equal to one hundredth of a meter) length, 3 cm wide, 0.1 cm depth with no undermining or tunneling and the second PU on the left buttock measured 2 m length, 3 cm wide, and 0.02 cm depth with no undermining or tunneling. Further review of the following progress notes also indicated Resident 52 had bilateral buttock stage 2 PU's:Nursing Long-Term Care Evaluations (LTCNE - assessments to determine an individual's need for assistance with daily activities, and their physical, cognitive, and psychosocial health to plan care) dated 11/18/25, 11/25/25 12/1/25, 12/9/25, and 12/16/25.Skin Assessments dated 11/11/25 12/1/25, 12/8/25, and 12/9/25. During a concurrent interview and review on 12/18/2025 at 3:35 p.m. with DON, Resident 52's admission skin assessment, order summary, and nursing progress notes were reviewed. DON acknowledged Resident 52 had a stage 2 pressure ulcer on the right and left buttock on admission and that no wound consultation and physician treatment orders were in the resident's medical record for the bilateral stage 2 PU's on the buttocks. 2b. During review of Resident 52's NLTCE's dated 11/18/25, 11/25/25 12/1/25, 12/9/25, and 12/16/25 and weekly skin assessments dated 11/11/25 12/1/25, 12/8/25, and 12/9/25 indicate Resident 52 has bilateral stage 2 PU's on bilateral buttocks. Further review of Resident 52's following medical records indicate different skin assessment information with no mention of the bilateral buttock stage 2 PU's:Nursing progress notes dated 11/07/25, 11/08/25, 11/09/25, 11/11/25, and 11/12/25 indicate the resident is on monitoring for moisture associated skin damage (MASD) on bilateral buttocksChange in Condition (CIC) dated 11/23/25, nursing progress notes dated 11/24/25 11/25/25, 11/26/25, 11/27/25, and weekly skin assessments dated 11/18/25 and 11/25/25 indicate resident was noted with open area/lesion to coccyx. During a concurrent interview and review on 12/19/25 at 10:32 a.m. with the Director of Nursing (DON), Resident 52's progress notes were reviewed. DON acknowledged there was a discrepancy in the pressure ulcer staging between the various types of skin assessments.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 108), reviewed for arbitration (a contract in which two or more parties agree to resolve disputes through a private arbitration process instead of pursuing litigation in court) agreement, understood the documents signed during admission to the facility.This failure resulted in Resident 108 signing a facility agreement without a full understanding of resident rights and options.During a review of the facility's admission Record this indicated, Resident 108 was admitted to the facility on [DATE] with diagnoses that included infection following a procedure. Another document titled Social Services Assessment dated 12/11/25 indicated Resident 108 had a BIMS (Brief Interview for Mental Status) score of 15 which indicated Resident 108 had no cognitive (pertaining to memory, judgement and reasoning ability) deficits. During a concurrent observation and interview on 12/18/25 at 11 a.m., with Resident 108, Resident 108 was observed in his room, lying in bed, and was talking to a family member on the phone. When asked about documents signed upon admission, Resident 108 stated being not fully aware of what was signed, unaware of what an Arbitration Agreement was, there was no copy of the agreement to thoroughly read it, and no knowledge that the agreement can be canceled within 30 days after signing it. The family member on the phone also confirmed to not have information and knowledge of documents signed by Resident 108 on admission. Resident 108 further stated it was presented to him at a time when he was incoherent (confused, not fully aware, or unable to think clearly) from medications when he transferred to the facility. Resident 108 expressed wishes to talk to the Admissions person again to have a better understanding of the arbitration agreement.During an interview on 12/19/25 at 1:05 p.m., with the Director of Admissions (DOA), DOA stated as the one in charge of presenting the Arbitration Agreement; and that Resident 108's arbitration agreement was signed electronically on 12/08/25. The DOA was not able to provide documented evidence that showed the arbitration agreement was explained to Resident 108 and that a copy of the agreement was provided to Resident 108. The DOA further stated it was important to fully explain the details of any contracts/agreements to the residents and to provide copies of what they signed.A review of the facility's policy titled Arbitration Agreements dated 05/26/23, this indicated in part, 3. If the facility presents an arbitration agreement to a Resident, the person presenting the arbitration agreement will: a. Explain the agreement in a form and manner that they understand; and b. Confirm that the Resident understands the agreement.

Based on interview and record review, the facility failed to ensure the electrical outlet was in good repair and was safe for use in one of the resident's rooms (room [ROOM NUMBER]), when the socket was left opened without a protective plate.This failure had the potential to affect resident safety and increase the risk of injury. During the observation on 7/8/25 inside room [ROOM NUMBER], the wall electrical outlet outside of the bathroom in room [ROOM NUMBER] did not have a cover plate exposing some electrical wiring inside the socket. The maintenance logbook did not have the requisition for the repair of the open electrical outlet. During the interview on 7/8/25 at 3:00 p.m. with the maintenance supervisor (MS), MS stated that the matter was not brought to his attention neither it was entered in the maintenance logbook by any staff, so no repair was done on the issue.During the review of facility's policy and procedure (P&P), titled Maintenance Service, dated 1/1/2012, P&P indicated, The Maintenance Department is responsible for maintaining the buildings, grounds, andequipment in a safe and operable manner at all times, and functions of the maintenance department include maintaining the building in good repair and free from hazards.

Based on interview and record review, the facility failed to ensure staff accurately documented why a medication dose was not given, or that the physician was notified of the missed dose for one of two sampled residents (Resident 1) per their policy and procedure. This failure resulted in an incomplete medical record and had the potential for inaccurrate and delayed medical interventions for Resident 1. Findings: During a review of the Admission Record for Resident 1, dated 2/4/25, the Admission Record indicated Resident 1 was admitted on [DATE] and had a diagnosis including but not limited to Type 2 Diabetes Mellitus (a chronic disease that causes high blood sugar levels when the body doesn't produce enough insulin, or when the body cannot use insulin properly). During a review of the Medication Administration Record (MAR) for Resident 1, dated 1/1/25-1/31/25, the MAR indicated an order by the physician for Insulin Glargine Solution 100 UNIT/ML Inject subcutaneously two times a day for diabetes. The MAR further indicates on 1/19/25 at 5:00 PM the medication was not given, hold, see progress note is coded on the MAR. During review of the facility's policy and procedure titled, Medication Administration, revised January 01, 2012, indicates in part . III. Holding Medications . B. The licensed Nurse will document on the back of the MAR, noting the time and the reason the medication was held. During a concurrent interview and record review on 2/4/25 at 12:03 PM with the Director of Nursing (DON), the medical record for Resident 1 was reviewed and the DON was unable to locate any documentation of why the medication for Resident 1 was held on 1/19/25, or that the physician was notified. The DON agreed that documentation and notification should have been done and were not.

Based on record review and interview, the facility failed to follow physician orders and adhere to its medication administration policy and procedures for one of two sampled residents (Resident 1) when: 1. Staff did not seek physician clarification for a potential frequency change for a Lactulose (a medication which can be used to reduce the amount of ammonia in the blood of residents with liver disease) order when Resident 1 did not have four bowel movements in a day. 2. Staff did not notify Resident 1's physician of their continued inability to obtain an ordered medication of Rifaximin (An antibiotic that is used to treat and prevent complications in patients with cirrhosis). 3. Staff did not check Resident 1's blood pressure or heartrate prior to the administration of Propranolol (a medication used to treat high blood pressure). These failures had the potential to lead to negative outcomes for Resident 1. Findings: 1.During a review of Resident 1's Admission Record undated, indicated in part, Resident 1 had diagnoses including cirrhosis of the liver (a chronic liver disease characterized by the formation of scar tissue that replaces healthy liver tissue), hepatic encephalopathy (a brain dysfunction that occurs when a damaged liver fails to filter toxins from the blood), ascites (a condition where excess fluid accumulates in the abdominal cavity), and hypertension (a condition where the blood vessels have consistently elevated blood pressure). During a concurrent record review and interview, on 1/24/25, starting at 2:12 p.m., with Certified Nursing Assistant (CNA 1) and the Director of Nursing (DON 1), Resident 1's medical record was reviewed. Resident 1 had a physician order for Lactulose Oral Solution 10 GM (grams)/15ML (milliliters) (Lactulose) give 30 ml by mouth every four hours for liver disease increase or decrease frequency toward goal of four bowel movements per day. The CNA 1 confirmed Resident 1 had two bowel movements on 12/22/24, two bowel movements on 12/23/24, and two bowel movements on 12/24/24. The DON 1 verbalized Resident 1's physician should have been notified on those dates when Resident 1 had less than 4 bowel movements a day to inquire if a frequency change in the order was needed. The DON 1 could not provide documentation indicting this was done. 2. During a concurrent record review and interview, on 1/24/25, with Licensed nurse (LN 1) and DON 1, Resident 1's Medication Administration Record (MAR) was reviewed. Resident 1's MAR indicated in part, a physician order for Rifaximin Oral Tablet 200 MG (Rifaximin) Give two tablet by mouth three times a day for Cirrhosis of Liver. The medication start date was 12/20/24. The LN 1 verbalized that this medication was placed on hold due to the pharmacy not having the medication and that Resident 1's physician was notified of it on 12/20/24. The LN 1 verbalzied the oncoming nurses should have followed up with the pharmacy and kept Resident 1's physician informed of the continued unavailability of the medication. The DON 1 confirmed there was no documentation indicating from 12/21/24 through 12/25/24, staff had informed Resident 1's physician of the continued absence of the Rifaximin or had followed up with the pharmacy about obtaining the Rifaximin for Resident 1. 3. During a concurrent record review and interview, on 1/24/25, at 2:56 p.m., with the DON 1, Resident 1's MAR was reviewed. Resident 1 had a physician order for Propranolol HCL Oral Tablet 10MG (Propranolol HCL) Give one tablet by mouth two times a day for HTN (Hypertension) hold for SBP (Systolic Blood Pressure) less than 110mmhg (millimeters of mercury) or HR (Heart rate) less than 60 (60 beats per minute). The medication start date was 12/20/24. On eight occasions from 12/20/24 to 12/24/24, facility records indicated the medication was administered without checking Resident 1's heartrate or blood pressure prior to the administration of the medication. The DON 1 verbalzied there was no documentation on those occasions indicating Resident 1's blood pressure or heartrate was checked shortly before the administration of the medication as was ordered by the physician. During a review of the facility's policy and procedure titled Medication-Administration dated 1/12, indicated its purpose was To ensure the accurate administration of medications for residents in the facility. The policy further indicated,Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines .Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded .When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record.

Based on observation, interview and record review, the facility failed to label and discard perishable food items, from the resident refrigerator, per policy and procedure. This facility failure had the potential for residents to experience negative outcomes, including foodborne illness. Findings: During a review of the facility's policy and procedure titled Food Brought in by Visitors dated 6/18, indicated in part When food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose. The policy further indicated Perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours. During a concurrent observation and interview, on 1/21/25, starting at 1:44 p.m., with the Director of Nursing (DON 1) and Administrator (Admin 1), the resident refrigerator was inspected. Inside the resident refrigerator was one undated container of frozen stew and one undated plastic bag containing three rolls. Both Admin 1 and DON 1 verbalized the container of stew and the plastic bag containing the rolls should have been dated when put in the resident refrigerator but were not.

Based on record review and interview, the facility failed to capture/be aware of, a resident diagnosis of cataracts (a clouding of the lens of the eye) for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to experience negative outcomes in care. Findings: During a concurrent interview and record review, on 1/23/25, at 11:28 a.m., with the Director of Nursing (DON 1), the DON 1 was asked if facility records indicated Resident 1 had a diagnosis of Cataracts. The DON 1 verbalized Resident 1 did not have a diagnosis of Cataracts after examining Resident 1's medical records including but not limited to, the current list of Resident 1's diagnoses, care plan and physician orders. During a review of Resident 1's Eye Health Consult form dated 2/5/24, indicated in part, Resident 1 had a diagnosis of cataracts to both eyes. During a review of Resident 1's Complete Exam/Visit-Office form, dated 7/3/24, from an offsite eye specialty clinic, indicated in part, Resident 1 had an ocular history of OU (oculus uterque [both eyes]) Cataract. The form indicated in part Resident 1's medical doctor at the clinic Discussed indications for cataract surgery. Monitoring recommended. During a concurrent interview and record review, on 1/23/25, at 12:07 p.m., with the Director of Nursing (DON 1) and Administrator (Admin 1), the Admin 1 and DON 1 could not confirm how long Resident 1 had been at the facility with the diagnosis of cataracts. The DON 1 verbalized facility records should have indicated Resident 1 had a diagnosis of cataracts and that should have been reflected in Resident 1's care plan but was not.

Based on record review and interview, the facility failed to implement fall care planned interventions for one of two sampled Residents (Resident 1). This failure had the potential to lead to negative outcomes for Resident 1. Findings: During a review of Resident 1's Change in Condition Evaluation form, dated 12/2/24, indicated in part on 12/2/24, Resident 1 sustained a fall. The form indicated in part Heard loud noise in [Resident 1's] room. And nurse went to check, [Resident 1] was found lying on the floor, head by the door of the bathroom. During a review of Resident 1's Care Plan undated, indicated in part, Resident 1 was At risk for further falls due to decreased physical mobility, decreased endurance and weakness. Resident 1's Care Plan further indicated an intervention chosen for Q1H (Every one hour) rounding for anticipation of needs. During a concurrent interview and record review on 1/16/25, at 3:51 p.m., with the Director of Nursing (DON 1) and the Administrator (Admin 1), both the DON 1 and the Admin 1 were asked if the facility could provide documentation indicating staff were performing Q1H rounding for anticipation of needs for Resident 1 throughout 12/24. Both the DON 1 and Admin 1 verbalized the facility was unable to provide documentation indicating this care planned intervention was carried out for the entire month of 12/24. During a review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning dated 11/18, indicated in part It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. Based on record review and interview, the facility failed to implement fall care planned interventions for one of two sampled Residents (Resident 1). This failure had the potential to lead to negative outcomes for Resident 1. Findings: During a review of Resident 1's Change in Condition Evaluation form, dated 12/2/24, indicated in part on 12/2/24, Resident 1 sustained a fall. The form indicated in part Heard loud noise in [Resident 1's] room. And nurse went to check, [Resident 1] was found lying on the floor, head by the door of the bathroom. During a review of Resident 1's Care Plan undated, indicated in part, Resident 1 was At risk for further falls due to decreased physical mobility, decreased endurance and weakness. Resident 1's Care Plan further indicated an intervention chosen for Q1H (Every one hour) rounding for anticipation of needs. During a concurrent interview and record review on 1/16/25, at 3:51 p.m., with the Director of Nursing (DON 1) and the Administrator (Admin 1), both the DON 1 and the Admin 1 were asked if the facility could provide documentation indicating staff were performing Q1H rounding for anticipation of needs for Resident 1 throughout 12/24. Both the DON 1 and Admin 1 verbalzied the facility was unable to provide documentation indicating this care planned intervention was carried out for the entire month of 12/24. During a review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning dated 11/18, indicated in part It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the Registered Dietitian (RD) failed to ensure her skill set related to nutrition assessments was current when standards of practice were not implemented as follows: 1. The RD utilized a method to assess the nutritional needs for elderly residents classified as obese that had the potential to promote weight loss, and was not in accordance with professional standards of practice, without obtaining and/or discussing Resident 53's and/or responsible party (RP) weight goal or preference and potential risks of weight loss for informed decision making for one of one sampled residents (Resident 53). 2. The RD was unaware an unstageable (a full-thickness skin and tissue loss where the extent of damage is not clear because the wound is covered by eschar [a hardened, dead tissue that forms a scab-like covering over wounds] or slough [yellow/white material in the wound bed] pressure injury (a localized area of skin and tissue damage caused by prolonged or severe pressure) was treated as a Stage 3 (Stage 3 pressure injuries extend through the skin into deeper tissue and fat ) or Stage 4 pressure injury (A full-thickness tissue loss that exposes bone, tendon, or muscle) per professional standards of which had the potential for a delay in an accurate nutrition assessment and timely nutrition interventions to meet the increased nutritional needs for residents referred to her as an unstageable pressure injury, in general. 3. The RD did not inform the RD at the dialysis center that one of one sampled resident's (Resident 40) did not have a diet order for a renal diet (for kidney disease). As a result, the RD failed to ensure the development of resident care policies and procedures to ensure that the facility provides care and services in accordance with current standards of practice that provide clinical and technical direction to meet the nutritional needs of residents for quality of care. Lack of implementing standards of practice for nutritional assessments for residents categorized as obese, and for those presenting with an unstageable pressure injury had the potential to impact a pattern of residents residing at the facility. Findings: 1. During a review of Resident 53's Admission Record (AR), the AR indicated an original admitted [DATE] and a re-admitted [DATE], and Resident 53 was [AGE] years old. During an interview on 10/31/24 at 10:27 a.m., with RD, RD stated it was her usual practice to assess the daily calorie needs for obese residents based off of an adjusted body weight for resident's with a BMI (Body Mass Index -a calculated value that estimates body fat based on a person's height and weight.) greater than 30 and who were 150% (percent) of their ideal body weight (IBW), including for elderly residents with limited mobility. RD stated, otherwise she used a resident's actual body weight with a predictive equation titled The Mifflin-St Jeor equation to assess daily energy (calorie) needs for residents, including for elderly residents. During a concurrent interview and record review on 10/31/24 at 11:10 a.m. with RD, Resident 53's Nutritional Risk Assessment (NA), dated 9/30/24 was reviewed. The NA indicated, on 9/5/24, Resident 53 weighed 181.2 pounds (lbs.), BMI was 34.2, Goal Weight was listed as N/A, and Usual Weight was listed as unknown. RD stated she does not typically put a goal weight thus N/A meant not available, and Usual Weight was typically based on the resident's history of weights at the facility but was left blank. The NA indicated Estimated Nutritional Needs Weight - AdjBW [adjusted body weight] 136 lbs. obese BMI above IBWR (ideal body weight range) 90-132 lbs. 172.6% IBW AdjBW 136 lbs. used for needs r/t [related to] obesity and >150% IBW. Rt [resident] unable to report UBW [usual body weight] and trends since admit are inconsistent. RD noted the resident had recent weight gain as compared to Resident 53's previous admission, however RD stated her goal for Resident 53 was to maintain weight. The NA indicated Nutritional Goal: No significant, unplanned weight changes and maintain.for weight maintenance. RD stated she assessed Resident 53's calorie needs based on 136 lbs., which was 45 lbs. less than her actual body weight (a 25% significantly less difference than her current body weight), and that had the potential to promote unplanned weight loss. RD confirmed assessing nutritional needs based on a weight that was 45 lbs less than Resident 53's actual weight could be contradictory to Resident 53's nutrition plan of care to promote weight maintenance. RD stated that was her usual practice for performing nutrition assessments for residents who were 150% of their IBW without considering the residents goals and preferences, and without discussing with the MD in which it could promote weight loss. During a review of American Academy of Nutrition And Dietetics, Nutrition Care Manual 2023, under category of, Unintended Weight Loss for the Older Adult, the reference indicated, Unintended weight loss often results in protein-energy undernutrition as the older adult loses critical lean body mass and is more prone to pressure ulcers, infections, immune dysfunction, anemia, falls resulting in hip fractures, and other conditions . During an interview on 10/31/24 at 11:20 a.m. with RD, RD stated that if she had a consult referral for an elderly resident who had a 5% weight loss in one month, 7.5% weight loss in 7 months or 10% weight loss in 6 months for unplanned weight loss she would be concerned. RD stated it was standards of practice for geriatric nutrition to strive to prevent unplanned weight loss to prevent a loss of lean body mass that could lead to functional decline, and increased risk for pressure injuries, for example. During a review of AND's Nutrition Care Manual (NCM), dated 2024, under the heading of Determination of Energy Needs in Obese Individuals indicated the Mifflin-St Jeor equation was found to be the most reliable, predicting equation for both nonobese and obese individuals when used with a person's actual body weight [not adjusted body weight]. During a review of AND's NCM, dated 2024, under the heading What body weight is the proper one to use in resting metabolic rate equations?, indicated, When calculating resting metabolic rate in overweight or obese people, actual body weight should be used.Use of adjusted body weight will result in underestimation [of energy needs]. During an interview on 10/31/24 at 11:10 a.m. with the RD, RD verified standards of practice was not implemented when performing nutrition assessments for the obese elderly which could affect the accuracy of assessments and had the potential to promote unintended weight loss for elderly resident's residing at the facility who were nutritionally assessed based on an adjusted body weight when considered obese. During a review of the facility's policy and procedure (P&P) titled, Evaluation of Weight Nutritional Status, dated 11/16/22, the P&P indicated, The facility will work to maintain an acceptable nutritional status for residents by: a. Assessing the resident's nutritional status and the factors that put the resident at risk of not maintaining acceptable parameters of nutritional status.c. Defining and implementing interventions for maintaining, or improving nutritional status that are consistent with resident needs, goals, and recognized standards of practice.Significant weight loss (2% in one week, 5% &/or 5 lb. in one month, 7.5% in three months, or 10% in six months).Weight Variance Committee will: 1. Identify and implement appropriate interventions. During a review of the facility's policy and procedure (P&P) titled, Nutritional Evaluation, dated 5/19/22, the P&P indicated, Purpose: To assess a Resident's food and nutritional needs.The registered dietitian will provide recommendations in narrative and identify any risk factors for weight loss. The P&P lacked adequate directives and criteria based on professional standards of quality to ensure nutrition assessments were performed within accepted standards of clinical practice and regulations. During a review of the contract between the contracted RD and the facility, dated 9/20/16, the contract indicated, Appendix A: Dietary Consultant Services, 1. Assess dietary policies and procedures and assist in the development and/or revision of such policies and procedures as needed. 2. During a review of Resident 28's Admission record (AR), the AR indicated Resident 28 was admitted to the facility on [DATE], after a stroke (blood vessel ruptured in the brain) and had a diagnosis of type 2 Diabetes (a chronic disease that occurs when the body does not produce enough insulin or does not use insulin properly). During an interview on 10/31/24 at 9:48 a.m. with RD, RD stated the facility refers all pressure ulcers Stage 1 through Stage 4 including unstageable pressure injuries to the RD. RD stated it was her usual practice to perform a nutrition assessment for an unstageable pressure injury the same way she would for a Stage 1 pressure injury. RD stated Resident 28 was already assessed for daily protein needs at 1 - 1.2 g per kg of body weight for her multiple small diabetic ulcers and therefore she did not need to-reassess her daily protein needs at that time, after a unstageable pressure injury was referred to her. During a concurrent interview and record review on 10/31/24 at 9:52 a.m. with RD, Resident 28's Note Text: Skin review (NSR), dated 8/7/22 was reviewed. The NSR indicated Right ischium [large bone in the lower part of the hip] stage 4.Rt's [resident's] average po intake > [greater than] 75% [consumption of meals], likely meeting estimated needs for wound healing (140 [error noted]-1715 kcals/day (30-35 kcals [calories]/kg) and 60-73 g PRO [protein]/ [per] day (1.25-1.5 g/kg) and 1225-1470 cc/day [water needs for hydration] (25-30 cc/kg)). During an interview on 10/31/24 at 9:54 a.m. with RD, RD stated that her practice for a nutrition assessment, and nutrition plan of care, would differ from an unstageable pressure ulcer that she considers the same as a Stage 1 pressure injury in terms of assessing daily calories and protein needs from a Stage 3 or 4 pressure injury which she would assess daily calorie needs at 35 kcal/kg and protein usually at 1.5 g protein/kg or more, dependent on a resident's condition/labs/diagnosis that may dictate otherwise. During a review of professional standards of practice according to the American Academy of Nutrition & Dietetics's (AND) Nutrition Care Manual (NCM), the NCM indicated .the provision of medical nutrition therapy with the goal of optimizing nutritional intakes and preventing or correcting malnutrition is an important role of the RDN [registered dietitian nutritionist/interchangeable with RD].The EPUAP/NPIAP/PPPIA [The European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance] (EPUAP/NPIAP/PPPIA) Clinical Practice Guideline [CPG] recommends the completion of a comprehensive nutrition assessment for adults at risk of pressure injuries and malnutrition, as well as for all adults with a pressure injury. These professional standards of practice organization's defines unstageable pressure injury as a pressure ulcer [injury] with a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. During a review of the facility's policy and procedure (P&P) titled, Skin Integrity Management, dated 6/27/24, the P&P indicated, 2. Skin Integrity Treatments: d. The dietary needs of the Resident will be evaluated by the registered dietitian upon any significant change in skin condition and any recommendations will be reviewed by the physician and orders obtained if appropriate. During a review of the facility's job description (JD) for Registered Dietitian, dated 10/9/23, the JD indicated, Summary: Provide Medical Nutrition Therapy.to ensure.that quality food service and nutritional care are being provided to residents by performing the following duties. Essential Duties and Responsibilities: Evaluates the Medical Nutrition Therapy needs of the residents and implements appropriate interventions to improve their nutritional status. During a review of the facility's policy and procedure (P&P) titled, Nutritional Evaluation, dated 5/19/22, the P&P indicated, Purpose: To assess a Resident's food and nutritional needs.The Dietitian will use information from the Resident's medical record to complete the nutritional evaluation upon admission, readmission, annually and upon significant change of condition, including but not limited to: E. Skin condition.O. Estimated nutritional needs range.Q. Any other information that will help to address the nutritional concerns of the resident. The P&P lacked adequate directives and criteria based on professional standards of quality to ensure nutrition assessments related to unstageable pressure injuries were performed within accepted standards of clinical practice and regulations in a timely manner, as evidenced by RD was unaware an unstageable pressure injury should be nutritionally assessed with a nutrition plan of care as if it was a Stage 3 or Stage 4 pressure injury, until the specific stage of pressure injury could be established by the wound nurse. During a review of the contract between the contracted RD and the facility, dated 9/20/16, the contract indicated, Appendix A: Dietary Consultant Services, 1. Assess dietary policies and procedures and assist in the development and/or revision of such policies and procedures as needed. 3. During a concurrent interview and record review on 10/31/24 at 10:23 a.m. with RD, Resident 40's Nutrition Review (NR), dated 10/11/23 was reviewed. The NR indicated, .Her diet was liberalized to CCHO mech [mechanical] soft due to her preference and refusal to follow more restrictive diet. Risks have been explained but she prefers to continue current plan. Dx [diagnosis] moderate dementia but she states that she understands risks. Therapeutic diet (CCHO mech soft) . RD reviewed her notes she conducted for Resident 40 related to Resident 40's attendance at the dialysis center, and RD stated she did not see any documentation in her notes with the Dialysis center RD (RD 2) of notification that Resident 40 was not on a renal diet (for kidney disease). During a telephone interview on 10/31/24 at 10:28 a.m. with RD 2, in presence of RD, RD 2 stated she was not aware that Resident 40 was not receiving a renal diet at the facility she resides. RD 2 stated it was important for the collaboration of nutrition care plan so dialysis center could ensure diet orders were followed, and so the resident was receiving the same coordinated plan of care for clear, and consistent direction to the resident and/or RP (responsible party), as at times RD 2 would provide renal diet instruction to the residents who attend the dialysis center, when appropriate. Facility RD reviewed documentation that reflected RD had ongoing communication with RD 2 but stated, I missed that. RD stated she should have communicated Resident 40's diet order did not include a renal diet, per resident preference, to RD 2 to promote continuity of care. During a review of the facility's policy and procedure (P&P) titled, Dialysis Management, dated 1/25/24, the P&P indicated, The facility will arrange.a method of communication between the dialysis provider and the Facility.a. Diet and fluid restrictions will be followed as ordered.

Based on observation, interview, and record review, the facility failed to follow the planned menu for therapeutic diets (part of the treatment for a disease or clinical condition, to eliminate, decrease, or increase certain substances in the diet or to provide mechanically altered food) when: 1. Resident 9, Resident 40 and Resident 26 received salad when prescribed a mechanical soft diet (to make it easier to chew and swallow foods, reducing the risk of choking) that was not on the mechanical soft diet menu. The Dietary Supervisor (DS) 1 confirmed the error had the potential to affect the following resident's prescribed a mechanical soft diet: Resident's 378, 54, 233, 4, 67, 21, 53, 14, 52, 42, 70, 129, 41, 127, 60, 49, 24, 349, 10, 27, 28, 30). 2. Resident 59's meal tray card (MTC) (MTC provided resident specific menu directions to staff on what to serve for a meal) was not followed for a lunch meal related to Resident 59's therapeutic renal diet (for kidney disease). These facility failures had the potential to place the resident's at increased risk of choking and or diminished nutrient intake for those on a mechanical soft diet, and to impede the health status of Resident 59. There were a total of 75 residents receiving meals from the main kitchen. Findings: 1. During an observation on 10/28/24 at 12:30 p.m. in Resident 40's room, Resident 40's MTC was located on her meal tray that was on her bedside table positioned in front of her. Resident 40's MTC indicated her diet order was CCHO (consistent carbohydrate diet for diabetes) mechanical soft (to make it easier to chew and swallow foods, reducing the risk of choking). Resident 40 lunch meal tray contained a bowl of salad (not finely chopped). During a review of the facility's planned menu for mechanical soft diet (MSD), the MSD indicated soft chopped vegetables. During a concurrent observation and interview on 10/28/24 at 12:47 p.m. with DS 1 in the dining room, Resident 9's lunch meal tray was located on the meal delivery cart for distribution. DS 1 was asked to check Resident 9's lunch meal tray for accuracy after LN 3 and LN 1 had checked Resident 9's lunch meal tray with no concerns. DS 1 removed the lid to the bowl that contained intact salad, and DS 1 stated the salad should not have been served and returned it to the kitchen. During a concurrent observation and interview on 10/28/24 at 12:50 p.m. DS 1 had a dietary aide go to the dining room to place a bowl of finely chopped salad onto Resident 9's meal tray. Concurrently, DS 1 was located in the kitchen and he was asked what soft chopped vegetables meant that was listed on the facility's planned menu under mechanical soft diet for lunch on 10/28/24. DS 1 stated the soft chopped vegetables for the mechanical soft diet meant finely chopped salad. During an observation on 10/28/24 at 12:52 p.m. in the dining room, Resident 26 MTC indicated mechanical soft diet. Resident 26 had a bowl of intact salad (not finely chopped) on her lunch meal tray. During an interview on 10/28/24 at 3:55 p.m., with DS 1, in the presence of corporate Certified Dietary Manager (CDM), DS 1 stated he called the company who wrote the facility's menus to ask what should have been served for the mechanical soft diet when the menu indicated soft chopped vegetables. DS 1 stated he was informed the planned menu for mechanical soft diet should have been cooked chopped carrots cooked so it's soft, and not raw lettuce salad even if finely chopped. During a review of the facility's dining manager menu (DMM), provided by DS 1, titled, Soft Chopped Vegetables, dated 2024, the DMM indicated, Ingredients, carrots .variations: may substitute other soft, chopped, cooked vegetables for carrots. During a review of the facility's diet manual (DM) titled, Dental Soft (Mechanical Soft) Diet, dated 2022, the DM indicated, The Dental Soft (Mechanical Soft) Diet is for individuals with limited or difficulty in chewing regular consistency foods .Food Guide: Not allowed raw or cooked vegetables difficult to chew. During a review of The International Dysphagia Diet Standardization Initiative (IDDSI), IDDSI diets are the only texture-modified diets professionally recognized such as with the American Academy of Nutrition and Dietetics and the American Speech-Language & Hearing Association ([NAME]). (https://cms.iddsi.org/media/aroundtheworld/usa/what-every-administrator-should-know-about-iddsi.pdf). These professional standards of practice organizations indicate the National Dysphagia Diet (NDD) which had the mechanical soft diets utilized at the facility are now obsolete. IDDSI Level 6 Soft & Bite Sized (SB6) diet is the current standards of practice for the no longer professionally recognized NDD mechanical soft diet (IDDSI (https://www.dysphagia-diet.com/Images/ComparisonChart-NDD_IDDSI.pdf). During a review of SB6 diet, SB6 diet included Soft, tender and moist.Bite-sized ' pieces no bigger than 1.5cm [centimeter] x [by] 1.5cm in size,.Vegetables steamed or boiled with final cooked size no bigger than 1.5cm x 1.5cm.Examples of foods to avoid.lettuce. (https://cms.iddsi.org/media/publications-iddsi/patienthandouts/english/adults/6_soft_bite_sized_adult_consumer_handout_30jan2019.pdf) 2. During a concurrent observation and interview on 10/28/24, at 12:10 p.m., with Licensed Nurse (LN), in the main dining, Resident 59's lunch meal tray was observed by the LN 1 on the meal delivery cart. LN 1 observed a carton of milk on Resident 59's meal tray. Resident 59's meal ticket indicated, Renal diet: wants 4oz regular Milk for breakfast only. LN 1 further verbalized that the carton of regular milk should not have been in Resident 59's meal tray. During a concurrent observation and interview on 10/28/24, at 12:12 p.m., with Dietary Supervisor (DS) 1, DS 1 reviewed the meal ticket in Resident 59's lunch meal tray. DS 1 removed the regular milk and replaced it with fruit drinks. DS 1 stated that the milk should not have been in Resident 59's lunch tray. During a review of the facility's menu, [NAME] Diet Spreadsheet (DS) the menu for renal diet indicated fruit drink. During a review of the facility's policy and procedure (P&P) titled, Menu, 4/1/2014, the P&P indicated, To ensure that the Facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Science .Food served should adhere to the written menu.

Based on observation, interview, and record review, the facility failed to maintain a homelike environment in one resident room and two shower rooms. This failure had the potential to negatively impact residents. Findings: During an interview 10/30/24, at 10:40 a.m., with the maintenance assistant (MS 1), the MS 1 was asked if the facility was up to date with repairs. The MS 1 verbalzied yes. During an observation on 10/30/24, starting at 10:45 a.m., the facility was toured. During the tour one unoccupied room (room [ROOM NUMBER]) had wall damage with peeling paint and a damaged bathroom door frame. During an interview on 10/30/24, at 10:50 a.m., with MS 1, the MS 1 confirmed the wall damage and door frame damage in room [ROOM NUMBER]. During a concurrent observation and interview, on 10/30/24, starting at 4:09 p.m., with Environmental Services Director (ES 1), the facility's two shower rooms were toured. The east side shower room had a door frame in disrepair while the west side shower room had broken tiles along the wall's baseboards. The ES 1 confirmed the items in disrepair for both shower rooms and verbalzied they would need to be fixed. During a review of the facility policy titled Resident Rooms and Environment dated 1/1/12, indicated in part The facility provides residents with a safe, clean, comfortable, and homelike environment.

Based on interview and record review, the facility failed to ensure twice weekly testing for COVID-19 was completed for all staff. This failure created the likelihood for any resident who had not had COVID-19 within the past 90 days to contract and spread [MEDICAL CONDITION] and experience symptoms such as decreased oxygen saturations, fever, cough, [MEDICAL CONDITION], and death. On 01/12/21 at 3:35 PM, the Administrator and Director of Nursing were notified that an immediate jeopardy was identified at F886 for failure to ensure staff were tested for the COVID-19 virus twice weekly as required by county positivity rates with nine staff who missed this requirement subsequently testing positive. The facility provided an acceptable plan for removal of the immediate jeopardy on 01/13/21 at 12:15 PM. The survey team validated the immediate jeopardy was removed on 01/13/21 at 1:13 PM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at an E (pattern for more than minimal harm) scope and severity following the removal of the immediate jeopardy. Findings include: Review of Ventura County positivity rates revealed a positivity rate of 17.0 % for the week ending 01/06/21, which was considered red requiring staff testing twice a week. Review of the facility's Mitigation Plan, revised 11/4/20, revealed, . If an employee undergoes testing outside the facility, they will be required to provide a copy of the test results within 48 hours of submitting a sample . Routine testing intervals vary by community COVID-19 activity level . county positivity rate of (greater than) 10 % . minimum testing frequency twice a week . During an interview on 01/11/21 at 9:30 AM with the Director of Nursing (DON) and Infection Prevention (IP) Nurse, the IP nurse verified staff were required to be tested twice weekly at the current positivity rate. The IP nurse stated that staff were asked to complete their testing requirements at one of a variety of community testing centers and bring their results to the facility. The IP nurse stated she tracked the results for nursing staff and the Administrator tracked the results for all other staff. During an interview on 01/11/21 at 1:15 PM, Registered Nurse (RN) 4 revealed she was aware of the twice weekly testing requirement and that the facility's expectation was for her to go to a community testing center. RN4 stated she sometimes had difficulty getting an appointment with a testing center or the lines at the drive through centers were too long so she would wait until her next scheduled workday to see if she could get tested there. RN4 stated, I haven't been tested since the fourth (01/04/21), so I guess I'm overdue now. RN4 stated no one at the facility reminded her or prompted her to get tested . RN4 stated no one at the facility had reminded her that she was overdue for her test. During an interview on 01/11/21 at 2:15 PM, the IP nurse stated when a staff member brought in their results, she entered the result into a spreadsheet. The IP nurse stated she had no way of knowing for sure when a staff member had been tested , but sometimes they would send her a text with their appointment time or sometimes they would tell her verbally. The IP nurse stated it was her expectation that staff would be tested either Monday or Tuesday of each week and again either Friday or Saturday. The IP nurse stated she did not track to see that everyone had their test on those days specifically. The IP nurse said to the best of her knowledge, everyone was getting tested per the requirement. During this interview, the DON and IP nurse stated they were not aware RN4 was overdue for testing. Review of the facility's Blueprint for a Safer Economy document, identified as their notification from Ventura County of positivity rates, revealed the county positivity rate increased to 10.5% on 12/18/20. During an interview on 01/11/21 at 2:45 PM, the DON revealed the facility received that document on Friday 12/18/20, and was instructed to start testing staff twice weekly the following Monday, 12/21/20. During an interview on 01/12/21 at 9:05 AM, the Administrator revealed the facility implemented the practice of encouraging staff to get tested in the community, rather than at the facility, beginning in June sometime because there had become a slight delay in getting lab results quickly. The Administrator stated it was his expectation that each department head would track compliance with his or her own staff, and report discrepancies to the Administrator, DON, or IP nurse. The Administrator stated that it was his expectation that all staff would have started testing twice weekly beginning the week of 12/21/20, per the county positivity rate and direction of the county health department. The Administrator stated he had not been aware of widespread difficulties with staff compliance with testing. The Administrator stated the facility had no policy and procedure to address community testing of staff, who was responsible to track staff compliance, or how compliance was tracked. During an interview on 01/12/21 at 10:00 AM, the Medical Director revealed it was his expectation and understanding that the facility was testing all staff twice weekly, and he presumed the facility was collecting staff specimens at the facility. The Medical Director stated he was not aware that the facility was relying on the honor system for staff to obtain their own test results in the community. The Medical Director stated that if staff were not being tested twice weekly at this time, it increased the risk of COVID-19 infections amongst the residents, which was unacceptable and dangerous. Review of the facility's untitled spreadsheets for staff testing and a separate line listing spreadsheet for positive staff revealed nine staff who had missed at least one test after 12/21/20 and whose following test was positive. Further review of the spreadsheet revealed the facility had no evidence of testing for the Housekeeping Supervisor between 12/15/10 (negative) and 12/27/20 (positive); the Social Services Supervisor between 12/14/20 (negative) and 12/28/20 (positive); Certified Nursing Assistant (CNA)12 between 12/21/20 (negative) and 12/28/20 (positive); CNA13 between 12/24/20 (negative) and 12/31/20 (positive), the Dietary Supervisor between 12/14/20 (negative) and 12/30 20 (positive); CNA15 between 12/21/20 (negative) and 12/28/20 (positive); Physical Therapist (PT)16 between 12/21/20 (negative) and 12/28/20 (positive); Licensed Vocational Nurse (LVN)17 between 12/21/20 (negative) and 12/31/20 (positive); and CNA18 between 12/24/20 (negative) and 01/01/21 (positive). During an interview on 01/13/21 at 09:15 AM, the DON confirmed verbally that all nine identified staff had worked in the interim between their tests. The facility census at the time of survey was 53. The facility had 64 residents test positive for COVID-19 between 12/13/20 and 12/26/20 and 51 staff test positive between 11/9/20 and 01/11/21.

Based on record review and interview, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical and emotional abuse. Based on a previous encounter with a certified nursing assistant (CNA 1) Resident 1 asked the facility that CNA 1 not be her caregiver. The facility failed to ensure CNA 1 did not take care of Resident 1 unsupervised. On 6/23/15 CNA 1 provided personal care to Resident 1 amidst Resident 1's refusal and protest. As a result, Resident 1 suffered bruising to her wrist and arms. Secondary to the encounter with CNA 1 the resident required psychological counseling for emotional distress. Findings: Record review on 6/30/15, of the facility's undated policy titled, Reporting Abuse revealed the definition of abuse stated as, .the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Record review, on 6/30/15, revealed Resident 1's [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE], revealed Resident 1 was able to make herself understood and clearly understood others. The resident was independent in her decision making and was without any memory impairment. Resident 1 required extensive assistance of one staff for transferring, personal hygiene and turning side to side in bed. Plans of care, dated 5/15/15 and 5/16/15, related to Resident 1's [MEDICAL CONDITION], and risk for injury secondary to [MEDICAL CONDITION] (weak, brittle bones), indicated the resident was to be handled gently during care and while assisting to turn, transfer or walk. A weekly nursing assessment, dated 6/20/15, indicated the resident showed no new skin issues. A nursing note, dated 6/23/15 at 7 a.m., indicated prior to leaving for [MEDICAL TREATMENT] at 5:30 a.m., Resident 1 complained CNA 1 attacked her. A call from the [MEDICAL TREATMENT] center's social worker (SW 1) informed the facility's staff that upon arrival at the [MEDICAL TREATMENT] center, Resident 1 appeared shaken up and said she (Resident 1) was physically abused by a CNA who pinned her against the bed rail, was on top of her and took the call light away when she (Resident 1) tried to call for help. The facility's nursing notes indicated on 6/23/15 at 11 a.m., Resident 1 returned from [MEDICAL TREATMENT] complaining of generalized body pain and had a sad affect. On 6/24/15 at 11:15 a.m., the resident was seen by a nurse practitioner for complaints of pain in her left wrist and mid-back. At 7 p.m. on 6/24/15, the nurse practitioner was contacted regarding Resident 1's continued complain of pain. At 8:30 p.m. on 6/24/15, the facility noted and documented Resident 1 had multiple bruises to her upper extremities and left shoulder. Resident 1 was taken by ambulance to the emergency room for further evaluation. Review on 6/30/15, of a facility document titled, interview record, dated 6/23/14, revealed Resident 1 stated CNA 1 was aggressive and came into her room upset. CNA 1 told the resident, Turn that way so I can put lotion on your ass. The resident responded, You again? I told you not to come in here before. CNA 1 pushed Resident 1 onto her left side into the side rail and took away the call light. Resident 1 managed to pull away from CNA 1 and sat on the edge of the bed crying. Review of a psychologist note, dated 6/24/15 at 11:40 a.m., revealed Resident 1 was seen by the psychologist because the resident reported being handled in a rough manner by a CNA who pushed her into the side rail and used inappropriate language, have to turn over so I can clean your ass. The psychologist's note indicated Resident 1 was crying throughout the session and became increasingly distressed while relaying the events. During an interview, on 7/7/15 at 11:30 a.m., utilizing CNA 4 as a Spanish speaking interpreter, Resident 1 indicated two weeks ago, before [MEDICAL TREATMENT], CNA 1 came into her room mad. CNA 1 told the resident to turn over so she (CNA 1) could clean her (Resident 1's) ass. Resident 1 indicated CNA 1 was on top of her and caused Resident 1 to hit her right arm against the siderail causing bruises. Resident 1 indicated she used to like the door to her room closed at night, but after the incident with CNA 1 she's now afraid to have the door closed at night. During an interview, on 6/30/15 at 9:15 a.m., SW 1 indicated Resident 1 arrived at the [MEDICAL TREATMENT] center the morning of 6/23/15, upset, tearful, and shaky. SW 1 described the resident as alert and oriented, with a good memory and was typically calm and cooperative. Resident 1 told SW 1 on 6/23/15 a new night shift staff came to help her (Resident 1) get ready for [MEDICAL TREATMENT] and the staff pinned the resident to the bed and snatched the call button away telling the resident no one was going to help her. SW 1 indicated Resident 1 had visible red bruising on her left forearm and right hand. During an interview, on 6/30/15 at 5 p.m., CNA 1 indicated she was not assigned to Resident 1, but was helping another CNA by getting the resident ready for [MEDICAL TREATMENT]. CNA 1 further indicated she assisted Resident 1 to turn over and the resident started screaming and calling for the nurse. Resident 1 sat up on the edge of the bed and told CNA 1 she'd bruised her arms. CNA 1 stated, Before I touched the resident she said she didn't want to see me. During an interview, on 6/30/15 at 5:15 p.m., the director of staff development (DSD) indicated CNA 1 cared for Resident 1 once previously and the resident reported she didn't like CNA 1. Based on this the DSD decided CNA 1 needed more training. The DSD stated, CNA 1 was not supposed to be in the resident's room without additional staff. During an interview, on 7/2/15 at 7 a.m., CNA 3 indicated she was asked to help Resident 1 because the resident was mad with CNA 1. CNA 3 further indicated when entering Resident 1's room the resident was mad and screaming to fire CNA 1. CNA 3 indicated Resident 1 complained CNA 1 pushed her (Resident 1) into the side rail. CNA 3 confirmed Resident 1 had bruises and redness on both arms. During an interview, on 7/2/15 at 7:30 a.m., CNA 2 indicated she was in another resident's room when told to go help with Resident 1. CNA 2 indicated when she entered Resident 1's room the resident was sitting on the edge of the bed and there were bruises on the resident's arms. During an interview, on 7/2/15 at 8:10 a.m., a licensed nurse (LN 1) indicated on the morning of 6/23/15, he was across the hall from Resident 1's room when he heard Resident 1 crying. The door to the resident's room was partially closed and LN 1 indicated he heard raised voices like the resident was having an argument in Spanish. When LN 1 entered the room Resident 1 was sitting on the edge of the bed and CNA 1 was standing near the resident. CNA 1 told LN 1 the resident didn't want her (CNA 1) taking care of the resident. LN 1 indicated he could see Resident 1 was upset so he asked that CNAs 2 and 3 assist with the resident and dismissed CNA 1 from the room. Resident 1 indicated CNA 1 grabbed her (Resident 1's) arms and was rough. LN 1 further indicated he observed quarter size red spots on Resident 1's forearms during his pre-[MEDICAL TREATMENT] assessment. When shown a photograph, taken on 6/23/15, of Resident 1's right forearm, LN 1 confirmed the three bruises closest to the resident's right wrist corresponded with the location of the red spots he'd observed during his pre-[MEDICAL TREATMENT] assessment the morning of 6/23/15. During an interview, on 6/30/15 at 1:30 p.m., the director of nursing (DON) indicated Resident 1 was her own responsible party, was alert and oriented and a good historian. According to the DON, CNA 1 was orienting with CNA 2, and CNA 1 was directed to provide care only under the direct supervision of CNA 2. The DON further indicated Resident 1 doesn't like to be touched, and gets agitated with new staff. When describing the incident CNA 1 said Resident 1 was verbally abusive and asked CNA 1 to leave. The DON confirmed Resident 1 did not have any bruises when the resident left the facility for [MEDICAL TREATMENT] saying Resident 1 had only new red spots.