Every finding on record at Park Vista at Morningside

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. * The facility failed to maintain an accurate infection control surveillance log and match the data in the QA infection control for June, July, September, and October 2025. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure the EBPs were followed for Resident 55 when the RNA 1 did not wear the appropriate personal protective equipment (PPE) before providing care to the resident. * The facility failed to maintain infection control when the DSD/ IP placed the box of clean gloves on Resident 55's bed, which touched the incontinent pad on the resident's bed during wound care. * The facility failed to follow their Water Management Program's swamp cooler and decorative fountain's testing and maintenance protocol. * CNA 1 failed to maintain infection control standards while feeding Resident 52. * The facility failed to ensure the contact Isolation precautions were followed and implemented by the providers and visitors for Resident 41. * The facility failed to implement the EBPs for Resident 69, who had a central line catheter (a long, thin tube inserted into a large vein near the heart, used for long-term IV access for fluids and medications). These failures posed the risk of not identifying the residents' infections and thereby preventing the implementation of interventions, and control the potential transmission of communicable diseases to other residents in the facility.Findings: 1. Review of the facility's P&P titled Infection Control Guidelines revised on 2/3/22, showed the facility maintains an organized, effective facility-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors and healthcare workers. This program involves the collaboration of many programs and services within the facility and is designed to meet the intent of regulatory and other agencies. The Infection Prevention Oversight Committee is responsible for infection prevention in the facility. The functions of the infection prevention oversight committee include, but are not be limited to establishing, reviewing, monitoring, and approving policies and procedures for investigating, controlling and preventing infections in the facility, and maintaining, reviewing, and reporting statistics of the number, types, sources, and locations of infections within the facility including antibiotic resistance trends. The Infection Preventionist's (IP) responsibilities for infection prevention and control include but may not be limited to conducts surveillance for facility associated infections and/or communicable diseases, assures compliance with state/federal regulatory as they pertain to infection prevention/control matters within the facility, maintains facility infection prevention/control policies and procedures, communicates infection prevention and control data to facility leadership, appropriate facility committees, facility staff and other stake holders as appropriate, is a member of the facility's quality assessment and assurance committee and reports to the committee on the Infection Prevention and Control Program on a regular basis. On 12/5/25 at 1102 hours, an interview and concurrent facility document review was conducted with the DSD/ IP. The DSD/IP stated she completed the Infection Control Surveillance Log and reported the findings to the QAPI Infection Control meeting monthly and quarterly. Review of the Infection Control QAPI Report and Infection Control Surveillance Log for June, July, September, and October 2025 showed the following: - the Infection Control QAPI Report for June 2025 showed a total of 26 new infections, 14 of which were HAIs and 12 of which were CAIs. However, the June 2025 Infection Control Surveillance Log showed 15 were HAIs and 11 were CAIs. - the Infection Control QAPI Report for July 2025 showed a total of 38 new infections, 23 of which were HAIs and 15 of which were CAIs. However, the July 2025 Infection Control Surveillance Log showed 24 were HAIs, and 11 were CAIs. - the infection Control QAPI Report for September 2025 showed a total of 32 new infections, 17 of which were HAIs. However, the September 2025 Infection Control Surveillance Log showed 15 were HAIs. - the infection Control QAPI Report for October 2025 showed a total of 32 new infections, 21 of which were HAIs. However, the October 2025 Infection Control Surveillance Log showed 22 were HAIs. The DSD/IP verified the above findings. On 12/9/25 at 1206 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Review of the facility's P&P titled Laundry Service for PV revised 4/10/25, showed the clean linen will not touch the floor (any linen that touches the floor when being folded or linens that will fall off the shelf or cart are considered soiled and are set aside for re-washing. No food or drinks are allowed in the laundry room. When handling the clean linen to wear a clean gown. On 12/3/25 at 1553 hours, an observation and concurrent interview was conducted with Laundry Personnel 1. The following was observed in the laundry room: - A drinking water bottle was observed on the clean side of the laundry room. Laundry Personnel 1 stated the water bottle belonged to her. - Laundry Personnel 1 was observed folding the linen towards her body, with the linen touching her clothing and the floor simultaneously multiple times. Four bed linens were observed folded by Laundry Personnel 1 in this manner. - Laundry Personnel 1 was observed folding the clean linen without wearing a clean gown per the facility policy. Laundry Personnel 1 acknowledged the above observations and stated the clean linens should not be touching her clothing and the floor. On 12/3/25 at 1620 hours, an observation and concurrent interview was conducted with the Housekeeping Supervisor. The Housekeeping Supervisor acknowledged the drinking water bottle inside the clean side of the laundry room and stated no food, or beverages were allowed in the laundry room. The Housekeeping Supervisor further stated he expected the laundry personnel to wear a gown when folding the clean linen. The Housekeeping Supervisor stated the clean linen should not touch the floor and stated the folded linen will be re-washed. 3.a. Review of the facility's P&P titled Enhanced Standard Precautions Guidelines revised on 10/24/22, showed Enhanced Standard Precautions (ESP) Guidelines primarily includes the expansion of barriers such as gowns and gloves for specific high contact care activities, based on the resident's characteristics that are associated with a high risk of MDRO colonization and transmission, the following might be considered for implementation of ESP: - Presence of indwelling devices [e.g., urinary catheter, feeding tube, endotracheal (insertion of a flexible tube into the windpipe) or tracheostomy tube (surgical procedure that creates an opening in the neck into the windpipe) and vascular catheters (thin, flexible tubes inserted into the blood vessels for long-term access)]. - Wounds or presence of pressure injury (unhealed). - Functional disability and total dependence on others for assistance with activities of daily living (ADL) is also recognized as a risk factor for MDRO transmission and may be considered for residents who do not have an indwelling device or wounds, for example, during transition from contact precautions to ESP for residents identified with MDRO colonization during an outbreak. Review of The Six Moments for Enhanced Standard Precautions posted at Resident 55's room showed for the six groups of care activities, use hand hygiene, gloves, and gowns for residents who are on ESP. The six groups of care activities are morning and evening care; toileting and changing incontinence briefs; caring for devices and giving medical treatments; wound care; mobility assistance and preparing to leave room; and cleaning and disinfecting the environment. Medical record review for Resident 55 was initiated on 12/3/25. Resident 55 was admitted to the facility on [DATE]. Review of Resident 55's H&P examination dated 12/26/24, showed Resident 55 had no capacity to understand and make decisions. Review of Resident 55's Order Summary dated 12/5/25, showed the following physician's orders: - dated 4/29/25, for the enhance barrier precaution due to reopened sacrococcyx (triangle bone at the base of the spine) Stage 3 pressure injury (full-thickness skin loss, where the fat layer is visible, but bone, tendon or muscle is not exposed yet). - dated 11/29/25, to provide wound treatment to the reopened sacrococcyx Stage 3 pressure injury as follows: cleanse with normal saline, pat dry, apply skin prep to peri wound. Apply Medi honey (a medical-grade honey product used to manage a variety of wounds by creating a moist healing environment, debriding necrotic tissue, and reducing bacteria) to wound bed cover with calcium alginate and cover with foam dressing. - dated 1/14/25, for left lower extremity active/ passive range of motion exercises daily five times per week as tolerated. - dated 1/14/25, for right lower extremity active/ passive range of motion exercises daily five times per week as tolerated. - dated 1/15/25, for left upper extremity active/ passive range of motion exercises daily five times per week as tolerated. - dated 1/15/25, for right upper extremity active/ passive range of motion exercises daily five times per week as tolerated. On 12/4/25 at 0915 hours, an observation was conducted with Resident 55 during the range of motion exercises provided by RNA 1. RNA 1 was observed not wearing a protective gown while providing mobility exercises to Resident 55. On 12/4/25 at 1435 hours, an interview was conducted with RNA 1. RNA 1 stated Resident 55 was on ESP. RNA 1 verified she failed to wear a gown while performing the mobility exercises for Resident 55. RNA 1 further stated she should have worn a gown when providing the mobility exercises to the resident. On 12/4/25 at 1508 hours, an interview was conducted with the DSD/ IP. The DSD/IP verified Resident 55 was on ESP. The DSD/ IP stated the expectation was for the RNA to have worn a gown while providing mobility exercises to the resident. b. On 12/5/25 at 1300 hours, a wound care observation was conducted for Resident 55 with the DSD/IP. The DSD/IP was observed placing the clean box of gloves on the resident's bed. There were gloves exposed out of the box, which were touching the resident's incontinent pads. On 12/5/25 at 1332 hours, an interview was conducted with the DSD/IP. The DSD/IP stated she should not have placed the clean box of gloves on the resident's bed while performing wound care to the resident, to prevent contamination of the clean gloves. The DSD/IP stated the gloves were contaminated and would be disposed. Cross reference to F686. 4. Review of the facility's P&P titled Legionella (type of bacteria) Monitoring reviewed 7/19/21, showed the P&P was in place to minimize the risk of microbial growth and spread of legionella and other opportunist water system pathogens to the residents. Review of the facility's Water Safety Plan dated 2022 showed the following:- Quarterly general maintenance and cleaning of the swamp cooler.- Weekly maintenance of the decorative fountain. a. Review of the facility's Quarterly Maintenance Log for Direct Air Evaporative Condensers (Swamp Coolers) showed the maintenance staff to check the chlorine level and ensure it is at least 5 ppm. The Logs for the past 12 months had a blank space for the ppm to be documented, which was incomplete. Review of the facility's Air Evaporative Condensers or Swamp Cooler Maintenance log for 2025 showed the chlorine level was to be 2 – 10 ppm. The log was completed monthly and showed two chlorine tablets were added resulting in a chorine level range of 4 – 5 ppm, with it being under 5 ppm on the following dates:- on 1/17, 5/7, and 6/4/25, with 4 ppm; and- on 2/12, 4/9, and 10/8/25, with 4.5 ppm; b. Review of the facility's Weekly Maintenance Logs for Decorative Fountain for the past 12 months showed to add biocide (chemical substance or living organism designed to kill, deter or control harmful organisms) tablets to achieve 5 ppm and measure the halogen (a group of highly reactive non-metallic elements which include chlorine) residual with test strips. The form also showed to measure the halogen residual and add additional chemicals, if necessary, until 2-5 ppm is reached. The form was blank to show the ppm results for each weekly maintenance. Review of the facility's Maintenance Work Orders for the decorative fountain for 2025 showed every two weeks a work order for two caps full every two weeks. Review of the facility's Weekly Maintenance Log Decorative Fountain for 2025, showed the chlorine level was to be 2 – 10 ppm. The log was completed every two weeks and showed two chlorine tablets were added resulting in a chorine level range of 4 – 5.5 ppm, with it being under 5 ppm on the following dates:- on 1/3, 1/29, 5/7, 6/18, 7/2, 9/10, and 9/29/25, with 4.5 ppm; and- on 4/9, 4/23, 7/16, 7/30, and 12/3/25, with 4 ppm. On 12/5/25 at 1419 hours, an interview and concurrent facility document review was conducted with the Director of Maintenance, Maintenance Supervisor, and Maintenance Technician. The Director of Maintenance stated the facility used chlorine and verified the Water Management Plan templates showed for the chlorine levels to be at least 5 ppm. The Director of Maintenance stated the tasks were completed per the Weekly Maintenance Log Decorative Fountain and the Quarterly Maintenance Log for Direct Air Evaporative Condensers (Swamp Coolers) forms. The Maintenance Supervisor stated the Maintenance Technician checked the chlorine levels for the fountain and he would transfer the information onto the logs. On 12/9/25 at 0848 hours, a follow-up interview was conducted with the Director of Maintenance, Maintenance Supervisor, and Maintenance Technician. The Maintenance Technician stated he maintained the fountain when the task was triggered by the electronic work order system. The Director of Maintenance, Maintenance Supervisor, and Maintenance Technician verified the fountain's work order logs showed the task was to be completed every two weeks, and not weekly as per the Water Management Program. The Director of Maintenance and Maintenance Supervisor verified the Weekly Maintenance Log Decorative Fountain and Air Evaporative Condensers or Swamp Cooler Maintenance logs, showed the acceptable chlorine level was to be 2 – 10 ppm, which did not match the facility's Water Safety Plan. 5. Medical record review for Resident 52 was initiated on 12/4/25. Resident 52 was readmitted to the facility on [DATE]. On 12/3/25 at 0838 hours, CNA 1 was observed feeding Resident 52. CNA 1 was wearing a uniform and sitting on the armrest of the resident's bedside chair, with her knees on the resident's bed, the bed and bedding were observed indented where the CNA's knees were placed. CNA 1 stated she was sitting that way because the chair was too low to feed the resident. CNA 1 verified she should not have her knees on the resident's bed. CNA 1 verified the resident had an electric bed, which could be moved up and down. On 12/4/25 at 1103 hours, an interview was conducted with the DSD/IP. The DSD/IP stated the facility staff's uniforms should not come in contact with the residents' bed linens to avoid contamination. 6. Review of the facility's P&P titled Contact Precaution revised 6/2024 showed guidelines for infection control precautions had been established to assure appropriate techniques are implemented to meet the needs of the resident by decreasing transmission of disease-causing microorganisms. Review of the facility's document titled Infection Control Guidelines revised 2/2022 showed infection prevention and control provided education to residents, families, and visitors as appropriate. According to CDC Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting, Appendix A showed the precautions for C. Difficile (a bacterial infection that causes diarrhea) included to handwash with soap and water because of the absence of sporicidal activity in antiseptic hand rubs and to use hypochlorite solutions for cleaning if transmission continued. Medical record review for Resident 41 was initiated on 12/3/25. Resident 41 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 41's H&P examination dated 12/3/25, showed Resident 41 had a C. Difficile infection. Review of Resident 41's Order Summary Report dated 12/1/25, showed a physician's order to place Resident 41 on transmission-based precautions due to C. Difficile and Burkholderia (bacteria) in sputum. Review of Resident 41's Care Plan Report revised 12/2/25, showed a plan of care for Resident 41's C. Difficile infection. The interventions included to educate the staff, resident, and family the correct procedure to wash hands and importance to adhere to good hand hygiene. On 12/3/25 1049 hours, during the initial tour of the facility, a contact precaution sign was observed by Resident 41's room, informing everyone must clean their hands before entering and when leaving the room. Providers and staff must put on gloves and gown before room entry and discard gloves and gown before room exit, and use the dedicated or disposable equipment and to clean and disinfect the reusable equipment before use on another person. A isolation cart was observed by Resident 41's room, which contained gowns, gloves, and ABHR. a. On 12/4/25 at 1132 hours, the NP was observed performing hand hygiene with the ABHR, then donning a gown and gloves prior to entering Resident 41's room. On 12/4/25 at 1138 hours, the NP was observed removing her gown and gloves prior to exiting Resident 41's room. The NP opened the first drawer of the isolation cart, located outside of Resident 41's room and began to disinfect a yellow stethoscope with the alcohol wipes. The NP then placed the stethoscope into the first drawer of the isolation cart and performed hand hygiene with the ABHR. On 12/4/25 at 1140 hours, an interview and concurrent observation was conducted with the NP. The NP verified Resident 41's contact isolation precautions were because of his C. difficile and Burkholderia (bacteria) infections. The NP was observed placing her hand on the handrail across from Room A in the hallway. The NP verified the wipes she used to disinfect the yellow stethoscope used for Resident 41 were alcohol based. The NP further stated the alcohol wipes were not effective against the C. difficile germs. When the NP was asked if she performed hand hygiene with soap and water after the resident care, the NP stated she sanitized her hands with ABHR and was going to wash hands at the nursing station. b. On 12/4/25 at 0940 hours, an interview was conducted with Family Member 1. Family Member 1 stated the facility staff members educated her about Resident 41's contact precautions: to wear gown and gloves when visiting Resident 41's room and to perform hand hygiene. When Family Member 1 was asked how she performed hand hygiene, Family Member 1 stated she used the ABHR. On 12/5/25 at 0841 hours, and on 12/8/25 at 0905 hours, Family Member 2 was observed removing their gown and gloves prior to exiting Resident 41's room. Family Member 2 was then observed performing hand hygiene with the ABHR after exiting Resident 41's room. On 12/8/25 at 1141 hours, an interview was conducted with the DSD/IP. The DSD/IP stated the transmission-based precautions for C. difficile was to place the resident in contact isolation, use bleach to disinfect the equipment used for the resident, and to perform hand hygiene with soap and water. The DSD/IP was informed and acknowledged the above findings. The DSD/IP stated the contact precautions were to prevent the transmission of organisms to the residents and staff. The DSD/IP stated the best practice for the visitors when they leave a C. Difficile contact isolation was for them to wash their hands with soap and water to protect themselves from the infection. On 12/9/25 at 1346 hours, an interview was conducted with AIT, Executive Director, and DON. The AIT, Executive Director, and DON were informed and acknowledged the above findings for Resident 41. 7. Review of the facility's P&P titled Enhanced Barrier Precautions Guidelines revised 6/2024, showed EBPs are used to prevent, contain, and mitigate MDROs in the facility. Examples of EBPs indicated for residents include infection or colonization with a CDC-targeted MDRO when TBP do not apply and wounds and/or indwelling medical devices including central lines, urinary catheters, feeding tubes. Gloves and gowns shall be worn while performing high-contact tasks associated with the greatest risk for MDRO contamination. Examples of high-contact activities may include: - device care, for example, urinary catheter, feeding tube, tracheostomy, and vascular catheter. - bathing, peri-care, assisting with toileting; and - changing bed linens. Medical record review for Resident 69 was initiated on 12/3/25. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's Care Plan Report revised 11/27/25, showed a plan of care for Resident 69's double lumen PICC line to his right upper arm. On 12/3/25 at 0934 hours, during initial tour of the facility, an observation was conducted of Resident 69 in his room. Resident 69 was observed with a double lumen PICC line located on his right upper arm. There was no EBP signage observed inside or outside of the room. On 12/4/25 at 1239 hours, an interview was conducted with DON. The DON stated EBP precautions were indicated for the residents with central venous catheters. On 12/4/25 at 1247 hours, an observation and concurrent interview was conducted with RN 1 in Resident 69's room. There was no EBP signage or isolation cart observed inside or outside of the room. RN 1 verified the above findings. On 12/9/25 at 1346 hours, an interview was conducted with the AIT, Executive Director, and DON. The AIT, Executive Director, and DON were informed and acknowledged the above findings for Resident 69.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injury (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of the existing pressure ulcer for one of two final sampled residents (Resident 55) reviewed for pressure injury. * The facility failed to ensure Resident 55's pressure injury was evaluated regularly. * The DSD/IP failed to ensure to follow the physician's order to cleanse Resident 55's pressure injury with normal saline during wound care observation. These failures posed the risks of complications and delayed wound healing for Resident 55.Findings: a. Review of the facility's P&P titled Pressure Injury Mitigation and Skin Management Program reviewed on 11/27/24, showed the care and intervention for any identified skin breakdown or wound will be aimed at close monitoring of the response to treatment and manage any pain control issues related to the skin injury. Upon identification of a wound, a full wound evaluation, including its location, size, and description of the tissue involved, shall be completed. Interventions and progress toward outcome focused goals need regular documentation according to established procedures. Review Medical record review for Resident 55 was initiated on 12/3/25. Resident 55 was admitted to the facility on [DATE]. Review of Resident 55's H&P examination dated 12/26/24, showed Resident 55 had no capacity to understand and make decisions. Review of Resident 55's Weekly Pressure Injury Evaluation dated 10/27/25, showed the resident's pressure injury was acquired on 4/21/25. The wound measured at 1 cm in length, 0.8 cm in width, and 0 cm in depth. Further review of Resident 55's medical record failed to show the Weekly Pressure Injury Evaluation was completed after 10/27/25. Review of Resident 55's Order Summary dated 12/5/25, showed the following physician's orders:- dated 4/29/25, for the enhance barrier precaution due to reopened sacrococcyx (triangle bone at the base of the spine) Stage 3 pressure injury (full-thickness skin loss, where the fat layer is visible, but bone, tendon or muscle is not exposed yet).- dated 10/14/25, to provide wound treatment to the reopened sacrococcyx Stage 3 pressure injury daily until 11/4/25, as follows: cleanse with normal saline, pat dry, apply skin prep to peri wound. Apply Medi honey (a medical-grade honey product used to manage a variety of wounds by creating a moist healing environment, debriding necrotic tissue, and reducing bacteria) to wound bed cover with calcium alginate (a natural, highly absorbent, gelatinous substance from seaweed used primarily in wound dressings) and cover with foam dressing and as needed for soilage and dislodgement.- dated 11/29/25, to provide wound treatment to the reopened sacrococcyx Stage 3 pressure injury as follows: cleanse with normal saline, pat dry, apply skin prep to peri wound. Apply Medi honey to wound bed cover with calcium alginate and cover with foam dressing. On 12/4/25 at 1539 hours, an interview and concurrent medical record review was conducted with the DSD/IP. The DSD/IP stated Resident 55's pressure injury had reopened. The DSD/IP was unable to identify when the wound healed after 10/27/25. The DSD/IP stated a Weekly Pressure Injury Evaluation should had been completed after 10/27/25. On 12/4/25 at 1559 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the Resident 55's pressure injury had reopened; however, the DON was unable to identify when it healed and had reopened. The DON verified Resident 55's medical record failed to show the Weekly Pressure Injury Evaluation was completed after 10/27/25. The DON stated she expected a Weekly Pressure Injury Evaluation to be completed weekly for all the residents with pressure injury. The DON was informed and acknowledged the above findings. The DON further stated she would complete a Weekly Pressure Injury Evaluation for Resident 55. b. Review of facility's P&P titled Physician Order revised 10/24/25, showed the facility established clear guidelines for the receipt, documentation, implementation, and review of the physicians, orders ensuring safe, effective and compliant with resident care. All the resident care provided in the facility must be based on a valid physician's order. The physician's orders must be documented, verified, and implemented in accordance with regulatory requirements and facility standards. Nursing staff are responsible for ensuring orders are accurately transcribed, communicated, and carried out. Nursing staff must review and implement physician's orders. Treatment and therapy orders must be scheduled and carried out as directed. On 12/5/25 at 1300 hours, a wound care observation was conducted for Resident 55 with the DSD/IP. The DSD/ IP was observed using Skintegrity wound cleanser to cleanse Resident 55's sacrococcyx pressure injury. The bottle of Skintegrity wound cleanser was observed with another resident's name. On 12/5/25 at 1325 hours, an interview and concurrent observation was conducted with the DSD/IP. The DSD/IP verified she used the Skintegrity wound cleanser to cleanse Resident 55's pressure injury. The DSD/IP verified the Skintegrity wound cleanser spray bottle was labeled with another resident's name with a date opened 10/13/25. The Skintegrity wound cleanser label showed it contained water Polysorbate 80, cocoamphodiacetate, and Lauryl Polyglucose, along with other gentle ingredients like Sorbitol, Lactic Acid, Triethanolamine, Disodium EDTA, Methylparaben, and Diazolidinyl Urea (or Imidazolidinyl Urea) (non-ionic surfactants). The DSD/IP stated this was the wound cleanser supplied by the hospice agency for another resident in which the same hospice agency Resident 55 was admitted to. The DSD/IP stated she did not want to waste the supply. On 12/5/25 at 1620 hours, an interview was conducted with the DON. The DON verified Resident 55's physician's order dated 11/29/25, for the wound treatment for the reopened sacrococcyx Stage 3 pressure injury was to cleanse the pressure injury with normal saline. The DON stated the expectation was for the licensed nurses to follow the physician's order when providing wound care for the residents. The DON was informed and acknowledged the above findings. Cross reference to F880, example #3.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the Dietary Aide sanitized the thermometer before checking the temperature of hot beverage during tray line. * The facility failed to ensure one of the three ice machines (Ice Machine 1) was sanitary, kept free of buildup, and free from accumulation of rust. These failures had the potential to cause foodborne illnesses for the residents receiving beverages and ice from the kitchen.Findings: Review of the facility's MDS Resident Matrix dated 12/3/25, 51 residents consumed food prepared in the kitchen. 1. Review of the USDA Food Code 2022, Section 4-702.11 Before Use after cleaning. Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning. On 12/4/25 at 1200 hours, the Dietary Aide was observed checking the temperature of the hot water during tray line. The Dietary Aide was then observed setting the thermometer down onto a clip board uncovered. The thermometer was observed touching the tie, which kept the thermometer attached to the clip board. The Dietary Aide then continued to use the thermometer to check a resident's hot water temperature without sanitizing the thermometer. On 12/5/25 at 0836 hours, an interview was conducted with the Dietary Aide. The Dietary Aide acknowledged checking the temperature of the hot water beverage using the thermometer that was placed onto the clipboard and touched the tie on the clip board. The Dietary Aide verified the thermometer was not sanitized prior to using it. The Dietary Aide stated the importance of sanitizing the thermometer before and after use was to avoid contamination. On 12/5/25 at 0849 hours, an interview was conducted with the Food and Beverage Manager. The Food and Beverage Manager stated prior to using the thermometer, it should be sanitized. The Food and Beverage Manager stated the importance of sanitizing the thermometer before using it was to avoid cross-contamination. On 12/5/25 at 0859 hours, an interview was conducted with the Executive Chef. The Executive Chef stated the thermometer needed to be sanitized before and after use. The Executive Chef stated there was a risk of contaminating the beverages if the thermometer was not sanitized before using, which could lead to risking the health conditions of the residents. 2. Review of the USDA Food Code 2022, Section 4-601.11 Equipment, food-contact surfaces, nonfood-contact surfaces and utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (C) Nonfood - contact surfaces of equipment shall be kept free from an accumulation of dust, dirt, food reside and other debris. Review of the facility's P&P titles Ice Machine Service revised on 5/27/25, showed it is the policy of the facility to maintain and service the ice machine and ice bin in a matter to obtain a clean and functioning system. To ensure that the ice machine and ice bin are cleaned and sanitized per manufacturer recommendations. On 12/4/25 at 0917 hours, an observation and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated Ice Machine 1 was used for the residents' ice supply and iced beverages. The inside of the ice machine was observed with a brown residue. The Maintenance Supervisor stated Ice Machine 1 was sanitized twice a year, cleaned every three months and as needed, and inspected monthly. The Maintenance Supervisor acknowledged the brown residue observed inside Ice Machine 1. On 12/5/25 at 0955 hours, an interview was conducted with the Plant Operations Director. The Plant Operations Director was informed and acknowledged the finding of the brown residue within Ice Machine 1. The Plant Operations Director acknowledged Ice Machine 1 was not clean and not maintained.

Based on interview and facility document review, facility failed to have a full-time, dedicated IP. This failure had the potential for the Infection Prevention and Control Program not being implemented without the proper oversight.Findings: Review of All Facilities Letter (AFL) Summary dated 12/13/21, showed the SNFs continue to be required to employ a full-time, dedicated IP, a role that may be filled by either one full-time IP or by two staff members sharing the IP responsibilities, provided the total time dedicated to the IP role equals at least the time of a full-time staff member. IP hours are prohibited from inclusion in the calculation of 3.5 direct care hours per patient day provided to SNF residents. Review of the facility's All Home time record showed:- The DSD/IP worked with Infection Prevention 20 hours per week for the months of October and November 2025.- RN 2 worked with Infection Prevention for 18.74 hours for the months of October 2025, and a total of eight hours for the month of November 2025. On 12/5/25 at 1102 hours, an interview was conducted with the DSD/IP. The DSD/IP stated she was working in the facility as DSD, as treatment nurse, and IP. The DSD/IP stated she worked four hours a day as the IP. The DSD/IP further stated RN 2 who was a RN Supervisor on the weekends oversaw the Infection Prevention for the facility. The DSD/ IP further stated the previous IP was on maternity leave since last week of August 2025. On 12/5/25 at 1102 hours, an interview and a concurrent facility document review was conducted with the DON. The DON stated the DSD/IP did not work full time as the IP. The DON further stated the DSD/IP worked as the treatment nurse and as the DSD; however, RN 2 worked as a back-up IP for the facility. The DON verified the All Home time record for the DSD/IP showed the DSD/IP worked with Infection Prevention 20 hours per week for October and November 2025. The DON verified RN 2 worked with Infection Prevention for 18.74 hours for October 2025 and a total of eight hours for November 2025. On 12/9/25 at 1206 hours, a follow-up interview was conducted with the DON. The DON was informed and acknowledged findings as above.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for one final sampled resident (Resident 65) reviewed for the use of an indwelling urinary catheter. * The facility failed to monitor Resident 65's fluid output every shift for the use of the indwelling urinary catheter. In addition, the facility failed to provide bladder training prior to discontinuing the indwelling urinary catheter as ordered by the physician. These failures had the potential for not providing the necessary care and services and posed a risk for adverse complications related to the indwelling urinary catheter use for Resident 65.Findings: Review of the facility's P&P titled Intake and Output Protocol revised 11/11/24, showed the fluid intake and output is recorded for each resident if ordered by the physician, for each resident with new indwelling catheter. Intake and output are recorded daily and evaluated weekly. Residents with justified diagnosis for new indwelling urinary catheters will have their intake and output monitored for 30-day period. Measure and record liquid stools, vomitus, or nasogastric drainage, urostomy, wounds/ drains, and other body fluids as possible and deemed necessary by the licensed nurse. Review of the facility's P&P titled Indwelling Foley Catheter (type of an indwelling urinary catheter) revised 8/19/24, showed indwelling urinary catheters shall be managed according to evidences- based infection control practices should be limited to medically necessary situations, and care will be provided in a manner that respects resident's dignity, prevents complications, and complies with CDC, CMS, and CDPH guidelines. Medical record review for Resident 65 was initiated on 12/3/25. Resident 65 was admitted to the facility on [DATE]. Review of Resident 65's H&P examination dated 11/26/25, showed Resident 65 had the capacity to understand and make decisions. Review of Resident 65's Order Summary dated 12/9/25, showed the following physician's orders:- dated 11/27/25, for the placement of an indwelling urinary catheter closed system size 16 Fr/10 ml for mechanical dysfunction or blockage of the urinary catheter system. - dated 11/27/25, to monitor intake and output every shift for new the indwelling urinary catheter for 30 days. - dated 12/1/25, for bladder training, clamp the indwelling urinary catheter for two hours and unclamp for fifteen minutes every shift until 12/3/25. a. Review of Resident 65's MAR failed to show Resident 65's intake and output was documented/monitored as ordered by the physician. Review of Resident 65's Task-Output monitoring dated November 2025 failed to show entries documentation for the monitoring of Resident 65's output as ordered by the physician. Further review of Resident 65's medical record failed to show Resident 65's fluid output was monitored as ordered by the physician on 11/27/25. b. Review of Resident 65's TAR showed a physician's order for the bladder training, clamp the indwelling urinary catheter for two hours and unclamp for fifteen minutes every shift dated 12/1 until 12/3/25. A check mark was documented on the TAR on the following dates and shifts:- on 12/1/2, for the evening and night shift; and- on 12/2/25, for the day, evening and night shift. Further review of Resident 65's medical record failed to show the bladder training was provided by clamping the indwelling urinary catheter for two hours and for fifteen minutes as ordered by the physician. On 12/4/25 at 0855 hours, an observation and interview was conducted with Resident 65. Resident 65 was observed without the indwelling urinary catheter drainage bag. Resident 65 stated the nursing staff had removed her indwelling urinary catheter. Resident 65 stated she was not aware if the nursing staff were monitoring her fluid intake and output. Resident 65 further stated the nursing staff would clamp her indwelling urinary catheter but was not sure if they had clamped it every two hours because they had a lot of things to do. Resident 65 stated there were a couple of times she felt pressure on her bladder because the nursing staff forgot to unclamp her indwelling urinary catheter. On 12/9/25 at 1018 hours, an interview and concurrent medical record review was conducted with the DSD/ IP. The DSD/IP verified Resident 65's Task -Output monitoring failed to show the resident's fluid output was monitored and Resident 65's MAR failed to show the resident's intake and output was documented on the MAR since 11/27/25. The DSD/IP verified Resident 65's TAR failed to show the resident's indwelling urinary catheter was clamped every two hours and unclamped after fifteen minutes to show the bladder training was provided to Resident 65. The DSD/ IP further stated the clamping of the indwelling catheter should have been scheduled every two hours in the TAR. 12/9/25 at 1030 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of the GT was provided for one of two final sampled residents (Resident 42) reviewed for the GT use. * The facility failed to ensure Resident 42's HOB (head of bed) was elevated at a 90-degree angle during the infusion of the enteral feeding via GT as per the physician's order, to reduce the risk of aspiration (inhaling foreign material i.e. food, liquid or vomit, into the lungs). This failure posed the risk of complications related to the use of the GT for Resident 42.Findings: Review of the facility's P&P titled Physician Order revised 10/24/25, showed to establish clear guidelines for the receipt, documentation, implementation, and review of physician order ensuring safe, effective, and compliant with resident care. Nursing staff must review and implement physician orders. Medical record review for Resident 42 was initiated on 12/3/25. Resident 42 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 42's MDS assessment dated [DATE], showed Resident 42 had a feeding tube and a medical diagnosis of aphasia (inability to understand or produce speech). Review of Resident 42's Order Summary Report dated 12/5/25, showed the following physician's orders:- dated 8/20/25, to elevate the HOB at 90-degrees during feeding and after the feeding has stopped.- dated 9/19/25, to administer Isosource 1.5 (enteral feeding formula) via pump at 65 ml per hour for 18 hours per day, to provide 1170 ml/1755 kcals, and start at 0500 hours, and continue until the required dose was completed. On 12/3/25 at 0851 hours, Resident 42 was observed lying in bed and receiving the enteral feeding with the HOB elevated less than 90-degrees. On 12/4/25 at 1624 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 42's HOB was elevated less than 90-degrees while the resident was receiving the enteral tube feeding. LVN 2 stated Resident 42's HOB should have been elevated while the resident was receiving the enteral feeding as ordered by the physician, to prevent aspiration. On 12/4/25 at 1630 hours, an interview and concurrent medical record review for Resident 42 was conducted with the DON. The DON stated when a resident was receiving the enteral feeding, the expectation was to monitor the resident to ensure they tolerated the feeding and to elevate the HOB at 90 degrees during and after feeding, to prevent aspiration pneumonia (lung infection when food, liquid, or other material are inhaled into the lungs). On 12/5/25 at 1508 hours, an interview was conducted with the DON, AIT, and Executive Director. The DON, AIT, and Executive Director were informed and acknowledged the above findings.

Based on observation, interview, medical record review and facility P&P, the facility failed to ensure the appropriate physicians' orders were obtained for one of two final sampled residents (Resident 35) reviewed for the intravenous therapy. * Resident 35 did not have current physicians' orders for the midline catheter's monitoring and dressing changes. This failure had the potential for the residents not receiving proper midline catheter care, as well as a delay in identifying and preventing potential catheter complications.Findings: Review of the facility's P&P titled Physician Order revised 10/24/25, showed all the resident care in the facility must be based on a valid physician order. Medical record review for Resident 35 was initiated on 12/3/25. Resident 35 was admitted to the facility on [DATE]. Review of Resident 35's IV MAR for November 2025 showed the following physician's orders:- to measure the arm circumference three inches above the midline catheter insertion site every week and PRN with dressing changes. This was last documented on 11/23/25, and the order was discontinued on 11/29/25.- to measure the midline catheter length every dressing change to ensure catheter migration has not occurred. This was last documented on 11/23/25, and the order was discontinued on 11/29/25.- to monitor the IV site every shift for redness, tenderness, edema, and leaking. This was last documented on 11/29/25, for the day shift and the order was discontinued on 11/29/25. Review of Resident 35's Order Summary Report dated 12/4/25, showed the following physician's orders:- dated 11/11/25, for the midline catheter to the right upper arm.- dated 11/29/25, to flush the midline catheter with 10 ml of NS (normal saline) every 12 hours for maintenance.However, there were no other active physician's orders for the midline catheter monitoring and dressing changes. On 12/4/25 at 1139 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated there should have been a physicians' order for the midline catheter maintenance, measuring, monitoring, and dressing changes for all the resident's with a midline catheters. RN 1 reviewed Resident 35's physicians' orders and verified there were no orders for the midline site monitoring, arm and catheter measurements, and dressing changes.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory care and services for two of two final sampled residents (Residents 36 and 66) reviewed for respiratory care. * The facility failed to follow the physician's order for the administration of continuous oxygen and failed to ensure the nasal cannula was labeled with date for Resident 36. * The facility failed to clean Resident 66's CPAP (Continuous Positive Airway Pressure, is a machine that uses mild air pressure to keep breathing airways open while a person sleeps) machine as ordered by the physician. These failures had the potential for the residents not to receive the appropriate care and may negatively impact on the residents' medical conditions.Findings: Review of the facility's P&P titled Physician Order revised 10/24/25, showed to establish clear guidelines for the receipt, documentation, implementation, and review of physician order ensuring safe, effective, and compliant with resident care. The nursing staff must review and implement physician orders. Review of the facility's P&P titled Oxygen Management revised 10/3/25, showed the nasal cannulas, masks, and tubing should be changed every seven days, dated, time, and initialed. 1. Medical record review for Resident 36 was initiated on 12/3/25. Resident 36 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of acute respiratory failure (life threatening condition where the lungs can not get enough oxygen to the blood) with hypoxia (the body or specific part if it doesn't get enough oxygen to function properly). Review of Resident 36's H&P examination dated 10/11/25, showed Resident 36 had no capacity to understand and make decisions. a. Review of Resident 36's Phone Order dated 12/1/25, showed a physician's order to administer continuous oxygen to titrate at a rate of 2 to 5 liters per minute via nasal canula for SOB or when the oxygen saturation level was less than 92%. On 12/3/25 at 0818 hours, an observation and concurrent interview for Resident 36 was conducted with RN 1, inside Resident 36's room. Resident 36 was observed sitting on the wheelchair and the nasal cannula was observed in Resident 36's nostrils. RN 1 verified there was no date on Resident 36's nasal canula. RN 1 stated the nasal canula should have been labeled with the date for the facility staff to know when the nasal canula should be changed, to prevent potential respiratory infection. b. On 12/4/25 at 1218 hours, an observation, interview, and concurrent medical record review was conducted with RN 1. Resident 36 was observed sitting on her wheelchair not receiving oxygen therapy. Resident 36 was asked if she removed the nasal cannula, which she replied that she did not know why she did not have the nasal cannula on. RN 1 verified Resident 36 was not receiving oxygen via nasal cannula. RN 1 was then observed obtaining Resident 36's oxygen saturation level, which was measured at 88%. RN 1 verified the physician's order showed to administer continuous oxygen via nasal cannula at a rate of 2 to 5 liters per minute when Resident 36's oxygen saturation levels were less than 92%. On 12/5/25 at 1508 hours, an interview was conducted with the AIT, DON, and Executive Director. The AIT, DON, and Executive Director were informed and acknowledged the above findings. 2. Review of the facility's P&P titled CPAP Therapy revised 6/1/21, showed the cleaning and maintenance of the CPAP equipment as follows: Follow these steps for cleaning your CPAP patient circuit: - Wash your hands per standard hand washing procedure. - Remove the headgear from the mask or nasal pillows shell. Disconnect the mask or shell, swivel, and tubing. - With a soft cloth, gently wash the mask or pillows with a solution of warm water, and a mild clear liquid detergent. - Rinse thoroughly. If the mask still feels oily, repeat step C. - Allow the mask or pillows to air dry. Do not place any supplies in the dryer. - Wash tubing as necessary with a solution of warm water, and a mild clear liquid detergent. Rinse thoroughly and allow to air dry. - Clean and inspect all components regularly. The mask, tubing, and headgear should last approximately 6 to 12 months, but the actual life of the equipment can vary greatly. - Clean the CPAP unit as necessary - Unplug the unit before cleaning it. Never immerse the unit in water - Using a damp cloth, wipe the outside of the unit. - Use a dry cloth to wipe the unit dry. - Make sure the unit is thoroughly dry before plugging it in. The P&P further showed the filter maintenance will depend on the model of the unit you have. There may be two filters on some models. The first filter is usually disposable, and the second filter is reusable. Disposable filters should be replaced per manufacturers' recommendations. Reusable filters should be rinsed of dust and allowed to air dry. Never put a damp filter in your CPAP unit. Medical record review for Resident 66 was initiated on 12/3/25. Resident 66 was admitted on [DATE]. Review of Resident 66's plan of care showed a focus problem dated 11/23/25, addressing Resident 66's risk for altered respiratory status or difficulty breathing. The interventions included cleaning the CPAP machine and mask per manufacturer's instructions every Sunday on the 7-3 shift. Review of Resident 66's H&P examination dated 11/24/25, showed Resident 66 had the capacity to understand and make decisions. Review of Resident 66's MAR for November 2025 showed LVN 1's initial on 11/30/25, for the physician's order to clean the CPAP machine and mask per manufacturer's instructions every week on (Sunday) on 7-3 shift. Review of Resident 66's Order Summary dated 12/4/25, showed a physician's orders dated 11/23/25, to clean the CPAP machine and mask per manufacturer's instructions every week on (Sunday) on 7-3 shift. On 12/3/25 at 0904 hours, during the initial tour of the facility, Resident 66 was observed on the wheelchair. A CPAP mask and strap were observed hanging on the head of the bed, placed on the mattress and not stored in a bag. Resident 66 stated she used the CPAP machine at night to help her breath. Resident 66 further stated she had not cleaned the CPAP machine since she was admitted in the facility. On 12/3/25 at 0920 hours, an interview and concurrent observation was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated the CPAP equipment should be placed in a bag for infection prevention. On 12/4/25 at 1015 hours, a follow up interview was conducted with LVN 1. LVN 1 stated the facility did not have the manufacturer's manual to refer to when cleaning Resident 66's CPAP machine. LVN 1 verified she had initialed the resident's MAR for the CPAP machine and mask cleaning per the manufacturer's instructions every week on (Sunday) on 11/30/25, for the 7-3 shift as completed, however, LVN 1 did not clean the resident's CPAP machine or check with resident if the CPAP machine was cleaned. On 12/9/25 at 1215 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage. * The facility failed to ensure medications were not kept in the resident's room for one of 15 final sampled residents (Resident 42). The facility failed to ensure a container of CBD Pain Relief Ointment (pain reliever) medication was not kept at Resident 42's bedside table. * The facility failed to ensure the medications were stored and labeled properly in one of two medication carts inspected (Medication Cart A). * The facility failed to ensure the orally administered medications were stored separately from the externally used medications in one of two medication storage rooms inspected (Medication Room A). These failures posed the risk of unauthorized access, drug diversion, and medication administration errors and posed the risk for cross contamination of the medications.Findings: Review of the facility's P&P titled Storage and Expiration Dating of Medications, Biological, Syringes and Needles revised 6/23/25, showed the following:- Facility should not administer/provide bedside medications or biologicals without a physician/Prescriber order and approval by the Interdisciplinary Care Team and facility administration.- Facility should store bedside medications of biologicals in a locked compartment within the resident's room- Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. - Facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals. 1. Medical record review for Resident 42 was initiated on 12/3/25. Resident 42 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 42's H&P examination dated 9/15/25, showed Resident 42 had the capacity to understand and make decisions. On 12/3/25 at 1146 hours, an observation was conducted with Resident 42. Resident 42 was observed awake and a container of CBD Pain Relief Ointment medication was observed on top of the bedside cabinet. On 12/3/25 at 1155 hours, an observation, interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified Resident 42 had container of CBD Pain Relief Ointment medication on top of the bedside cabinet. LVN 1 stated she did not know Resident 42 had the medication on his bedside table. LVN 1 further stated Resident 42 had no physician's order for the CBD Pain Relief Ointment. 2. On 12/3/25 at 1529 hours, an inspection for Medication Cart A and concurrent interview was conducted with DSD/IP. The following was observed:- one open and cut individual pack of Cutimed Sorbion Sachet S (a sterile, hydroactive, gel forming, superabsorbent wound dressing), open and cut. The package description showed it was a single use only dressing.- one open and cut individual pack of Skin Closure Strips Reinforced Wound Closure (strong adhesive bandage). The package instruction showed to not reuse. The DSD/IP was asked about the process of opening an individual pack supply. The DSD/IP stated the individual pack supplies were single use and needed to be discarded after the single use. The DSD/IP verified the above findings. 3. On 12/3/25 at 1255 hours, an inspection of Medication Room A and concurrent interview was conducted with DON. The following was observed:- five bottles Fleet Enema Saline Laxative medications were stored with three bottles of Chest Congestion Relief (cough medication) oral solutions and a box of Lidocaine (pain reliever) relief patch. The DON was asked about the process of storing the medications. The DON stated the external and internal medications needed to be separated and not stored in the same cabinet. On 12/5/25 at 1508 hours, an interview was conducted with the AIT, DON, and Executive Director. The AIT, DON, and Executive Director were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill sets to safely perform the daily operation of the Food and Nutrition Services Department. * The Dietary Aide failed to check the temperature of the hot beverages correctly during tray line. This failure posed the risk of burn injury to the residents receiving hot beverages from the kitchen.Findings: Review of the facility's document titled Residents per Dining Room - Lunch dated 12/9/25, showed seven residents received hot water prepared in the kitchen. Review of the facility's P&P titled Safe Holding and Serving Temperatures for Hot Beverages revised 5/2/17, showed to serve the hot beverages between 140 and 155 degrees Fahrenheit. The Dietary should record hot beverage temperatures for every meal. Allow hot liquids to cool before serving. Review of the facility's in-services for temperature checking and logging of hot beverages dated 9/6, 9/15, 10/23 through 10/26/25, and 12/4/25. The Dietary Aide was in attendance for all in-services. On 12/4/25 at 1200 hours, the Dietary Aide was observed checking the temperature of the hot beverages during tray line. The end of the thermometer was observed touching the base of the cup and the reading was at 158 degrees Fahrenheit. On 12/5/25 at 0836 hours, an interview was conducted with the Dietary Aide. The Dietary Aide stated he checked the temperature for the hot water, juices, and milk by using a thermometer. The Dietary Aide stated the end of the thermometer should not touch sides of bottom of the cup when testing the temperature of beverages. The Dietary Aide acknowledged the thermometer touched the base of the cup when he was testing the temperature of the hot beverages during the tray line on 12/4/25. The Dietary Aide stated if the thermometer touched the base or the sides of the cup, the temperature reading would be inaccurate and could potentially cause a burn to the residents, if not taken correctly. The Dietary Aide stated he was provided in-services on how to check the temperatures of hot beverages in September 2025 and again on 12/4/25. On 12/5/25 at 0859 hours, an interview was conducted with the Food and Beverage Manager. The Food and Beverage Manager stated the correct way to check the temperature of the hot beverages when using a thermometer was to not touch the sides or the bottom of the cup. The Food and Beverage Manager stated if the thermometer touched the bottom or the sides of the cup then the reading of the temperature was inaccurate. The Food and Beverage Manager stated the purpose of checking the temperature of the hot beverages was to prevent the residents from burning injuries. On 12/5/25 at 0859 hours, an interview was conducted with the Executive Chef. The Executive Chef stated the kitchen staff working the front of the house (refers to the part where the residents are received, seated, and served their food and drinks) were provided in-services on how to check the temperatures of the hot beverages. The Executive Chef stated the correct way of checking the temperature of the hot beverages when using a thermometer was to place the thermometer at the center of the liquid, making sure the thermometer was not touching the sides or bottom of the cup. The Executive Chef stated the purpose of checking the temperature of the hot beverages was to prevent the liquids from being too hot and causing a burn. On 12/5/25 at 0920 hours, an interview was conducted with the Dietary Manager. The Dietary Manager acknowledged the Dietary Aide did not check the temperature of the hot beverages correctly. The Dietary Manager stated the Dietary Aide was provided an in-service in October 2025 and again on 12/4/25, on how to check the temperature of hot beverages at the start of tray line. The Dietary Manager stated the thermometer should not touch the base or the sides of the cup when checking the temperature of the liquids. The Dietary Manager stated the importance of checking the hot beverages was to prevent the residents from getting burned.

Based on observation, interview, and facility document review, the facility failed to protect the residents' identifiable information.* The facility's survey results binder for public viewing included four confidential resident rosters. This failure resulted in confidential resident information being accessible to the public.Findings: On 12/9/25 at 0737 hours, the Survey Inspection Results binder was observed in a wall pocket next to the Social Services office and was posted for public view. On 12/9/25 at 1035 hours, a review of the survey binder was completed. The binder included the Confidential Resident Rosters (a list which identified the names of the residents by their identifiers given for surveys to protect the residents' identities) for the following surveys:- A Concurrent Relicensing and Recertification Survey roster dated 12/2 - 12/3/24, with five resident identifiers and their names. - An Abbreviated Survey dated 2/7/20, with six resident identifiers and their names. - An Abbreviated Survey dated 8/26/19, with two resident identifiers and their names. - A Recertification Survey dated 2/27 - 3/5/19, with 22 resident identifiers and their names.The rosters were identified as being confidential and had Confidential printed diagonally across the page in a large grey font. On 12/9/25 at 1041 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified the four confidential resident rosters should not have been in the survey binder for public view.

Based on observation, interview, and medical record review, the facility failed to ensure care was provided in a manner which promoted dignity and respect for one of one final sampled resident (Resident 65) reviewed for the use of an indwelling urinary catheter (flexible tube used to empty the bladder and collect urine in a drainage bag). * The facility failed to ensure Resident 65's indwelling urinary catheter collection bag was inside the privacy bag. This failure had the potential to negatively impact Resident 65's emotional well-being.Findings: On 12/3/25 at 0845 hours, during the initial tour of the facility, Resident 65 was observed lying in bed with an indwelling urinary catheter draining yellow urine into the urine collection bag. The urine collection bag was observed hanging on the right side of Resident 65's bed and not placed inside the privacy bag. On 12/3/25 at 0902 hours, an interview and concurrent observation was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated the urine collection bag should be inside the privacy bag for the resident's privacy. Medical record review for Resident 65 was initiated on 12/3/25. Resident 65 was admitted to the facility on [DATE]. Review of Resident 65's H&P examination dated 11/26/25, showed Resident 65 had the capacity to understand and make decisions. Review of Resident 65's Order Summary dated 12/9/25, showed a physician's order dated 11/27/25, for the placement of an indwelling urinary catheter closed system size 16 Fr/10 ml for mechanical dysfunction or blockage of the urinary catheter system. On12/5/25 at 1107 hours, an interview was conducted with the DON. The DON stated for all the residents in the facility with an indwelling urinary catheter, the expectation was to have the collection bags to be inside the privacy bag to provide the resident with dignity. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for two of 15 final sampled residents (Residents 35 and 41). * The facility failed to develop a care plan to address Resident 41's use of the midodrine (blood pressure medication) medication. * The facility failed to develop a care plan to address Resident 35's midline catheter (long, thin, flexible tube inserted into a peripheral vein and advanced until the tip rests below the armpit) use. These failures had the potential risk of not providing the appropriate, consistent, and individualized care to the residents.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 10/2025 showed all the residents will receive individualized person-centered care through comprehensive care plans that reflect their medical, psychological, and personal preferences. The care plans must include but are not limited to medical diagnosis and treatments. 1. Medical record review for Resident 41 was initiated on 12/3/25. Resident 41 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 41's Order Summary Report dated 12/1/25, showed to administer midodrine HCl oral tablet 2.5 mg via GT two times a day for hypotension and to hold the medication if the SBP is greater than 140 mmHg. Review of Resident 41's H&P examination dated 12/3/25, showed Resident 41 had a diagnosis of hypotension (low blood pressure). Review of Resident 41's plan of care failed to show a care plan problem was developed to address Resident 41's use of the midodrine medication. On 12/8/25 at 1110 hours, an interview and concurrent medical record review for Resident 41 was conducted with RN 2. RN 2 verified Resident 41's use of the midodrine medication. RN 2 verified there was no care plan developed for the use of midodrine medication. On 12/9/25 at 1346 hours, an interview was conducted with the AIT, Executive Director, and DON. The AIT, Executive Director, and DON were informed and acknowledged the above findings for Resident 41. 2. Medical record review for Resident 35 was initiated on 12/3/25. Resident 35 was admitted to the facility on [DATE]. Review of Resident 35's Order Summary Report showed a physician's order dated 11/11/25, for a midline catheter to the right upper arm. Review of Resident 35's plan of care failed to show a care plan problem to address the resident's midline catheter use. On 12/3/25 at 0832 hours, Resident 35 was observed sitting up in bed, and dressing to her right upper extremity and covered with elastic netting. On 12/4/25 at 1139 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 35 had a midline catheter. RN 1 stated the midline catheters should be flushed for maintenance, and the midline site should be checked weekly during dressing changes and measurements. RN 1 reviewed Resident 35's care plan and verified the care plan did not address the resident's midline catheter use, monitoring, and maintenance.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the MDS assessment was coded accurately for one of three residents reviewed for closed records (Resident 6). * Resident 6's MDS assessment was not coded accurately to show he received hospice services. This failure posed the risk for the resident not to have an individualized plan of care based on the resident's specific needs, and incorrect data being transmitted to CMS. Findings: Review of the facility's P&P titled Minimum Data Set (MDS) Guidelines revised 10/3/25, showed the MDS data will be used to guide care planning, monitoring resident outcomes, support facility quality improvement initiatives. Accuracy, timeliness, and interdisciplinary collaboration are essential to ensure compliance and optimal resident care. Closed medical record review for Resident 6 was initiated on 12/3/25. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's Physician's Orders showed an order dated 9/17/25, for hospice services. Review of Resident 6's comprehensive MDS dated [DATE], failed to show the resident received hospice services. On12/5/25 at 1027 hours, an interview and concurrent closed medical record review was conducted with the MDS Coordinator. The MDS Coordinator stated Resident 6's physician's order for hospice services dated 9/17/25, triggered the completion of Resident 6's comprehensive MDS dated [DATE]. The MDS Coordinator stated the MDS assessment was not coded to show the resident received hospice services but should have.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 4) reviewed for safety was free from accident/hazards. * The facility failed to ensure Residents 4 was evaluated to handle and consume hot beverages as per the facility's P&P. In addition, Residents 8 and 9 were also not evaluated to handle and consume hot beverages. * RNAs 1 and 2 failed to notify a licensed nurse immediately after Resident 4 spilled hot tea onto her lap. * The facility failed to ensure Resident 4 was provided the immediate and appropriate interventions when Resident 4 spilled hot tea to her left upper thigh. In addition, the facility failed to obtain a physician's order to properly treat a burn for Resident 4's left thigh. Theses failures resulted in Resident 4 sustaining a blisters to her left thigh and delay in the provision of the necessary and appropriate care/interventions which could potentially affect the resident's well-being.Findings: Review of the facility's P&P titled Accidents and Incidents Investigating and Reporting Procedure revised 2/2022 showed:1. Regardless of how minor an accident or incident may be, including injuries of unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned, and2. The nurse supervisor/charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the residents attending physician or physician on call when there has been a(an) accident or incident involving the resident,2. The nurse will record in the resident's medical record information relative to the changes in the resident's medical/mental condition or status,3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant information for the provider, including (for example) information prompted by the Interact SBAR Communication Form, and4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. According to the United States Product Safety Commission, Avoiding Tap Water Scalds (undated), showed most adults will suffer a third-degree burns if exposed to 150 degree Fahrenheit water for two seconds. Burns will also occur with a six-second exposure to 140 degree Fahrenheit water or with a thirty second exposure to 130 degree Fahrenheit water. Even if the temperature is 120 degrees Fahrenheit, a five minute exposure could result in third-degree burns. According to the National Library of Medicine dated 8/2023 showed the older adults are particularly susceptible to burn injuries due to increasing dementing illness, sensory impairment, poor mobility, slow reaction times, and medication side effects. Review of the facility's letter to CDPH L&C Program dated 9/5/25, showed on 9/4/25, during routine care, CNA observed blisters to Resident 4's left upper thigh. The charge nurse and RN supervisor evaluated the resident and observed three blisters to the left upper thigh. Further investigation was conducted, and it was noted that on 9/3/24, during lunchtime in the main dining room, Resident 4 spilled warm tea on her lap. Medical record review for Resident 4 was initiated on 9/9/25. Resident 4 was admitted to the facility on [DATE]. Resident 4 has a diagnosis of hemiplegia (one side paralysis) and hemiparesis (one sided muscle weakness) affecting the right side, aphasia (impaired ability to understand or form speech) following a cerebral infarction (condition where blood flow to brain was interrupted, causing tissue damage), and generalized muscle weakness. Review of Resident 4's H&P examination dated 11/22/24, showed Resident 4 had no capacity to understand and make medical decisions. Review of Resident 4's Plan of Care initiated on 11/22/24, and revised on 1/24/25, for the OT care plan showed Resident 4 demonstrated a decreased in ADL care function due to deficits in strength aphasia, right sided weakness, deficits in gross motor, and fine motor coordination, aerobic capacity, and balance deficits status post cerebral vascular accident (stroke). Review of Resident 4's MDS assessment dated [DATE], under Section GG-Functional Abilities showed the following:- for Functional Limitation in Range of Motion, showed Resident 4 had impairments on one side for the upper extremities (shoulder, elbow, wrist and hands), and - for Self-Care - Eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food/or liquid once the meal is placed before the resident), showed Resident 4 required supervision or touching assistance (the helper provides verbal cues and /or touching/steadying and/or contact guard assistance as the resident complete the activity). On 9/10/25 at 1216 hours, an observation was conducted for Resident 4. Resident 4 was observed removing her tea bag out of her mug and using both right and left hands to grab the mug and taking sips of her tea. 1. a. Review of the facility's P&P titled Safety of Hot Liquids dated 10/2014 showed the residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission, and on change of condition. The residents who prefer how beverages with meals (i.e. coffee, tea, soups, etc.) will not be restricted from these options. Instead, the staff will conduct regular hot liquids safety evaluations as indicated and document the risk factors for scalding and burns in the care plan. Review of the facility's document titled Beverage Preference by Resident dated 9/3/25, showed Resident 1 preferred hot tea for lunch and dinner. Review of Resident 4's medical records did not show Resident 4 was evaluated to handle hot liquids. A brief review of Residents 8 and 9's medical records showed the residents were not evaluated to handle hot liquids. On 9/12/25 at 1615 hours, an interview was conducted with the Administrator and Administrator Trainee. When asked if an assessment to handle hot beverages should be conducted for all the residents in the facility as per the facility's P&P, the Administrator stated yes. When asked if the facility conducted the assessment for any residents in the facility, the Administrator stated no. On 9/16/25 at 1332 hours, an interview and concurrent medical record review was conducted with the MDS Nurse. When asked if Residents 4, 8, and 9 were assessed to handle hot beverages, the MDS Nurse stated no. When asked if the assessment to handle hot beverages should have been conducted for all the residents based on the facility's P&P, the MDS Nurse stated yes. b. Review of Resident 4's Progress Note dated 9/4/25, showed at approximately 1830 hours, a CNA alerted charge nurse and RN supervisor of the redness on Resident 4's left upper thigh while providing care to the resident. The note further showed Resident 4 had blisters on her left thigh. Two blisters noted to the proximal left thigh, one located medially, measuring 4.5 cm by 1 cm; one located distally, measuring 2 cm by 2 cm; and a third blister noted laterally to mid-thigh, intact with no redness, and measuring 3 cm by 1 cm. On 9/9/25 at 1547 hours, an interview was conducted with RNA 1. RNA 1 stated on 9/3/25, when Resident 4 was eating lunch in Dining room [ROOM NUMBER], she heard a glass fell and was then informed by RNA 2 the tea had spilled onto Resident 4. RNA 1 stated they patted Resident 4 dry, then allowed Resident 4 to finish eating her dessert. RNA 1 stated after Resident 4 consumed her dessert, she was brought back to her room approximately five to 10 minutes later and then she informed CNA 4. When asked if she informed any licensed nurse or supervisor, RNA 1 stated no. On 9/9/25 at 1559 hours, an interview was conducted with RNA 2. RNA 2 stated on 9/3/25, while Resident 4 was holding her cup of tea, the cup tipped over and everything (tea) went into her lap, floor, and table. RNA 2 stated they patted Resident 4 dry. When asked how she knew it was a tea, RNA 1 stated it had the tea bag. When asked if she notified anyone, RNA 2 stated not me, RNA 1 told CNA 4. On 9/10/25 at 0933 hours, a telephone interview was conducted with CNA 3. CNA 3 stated on 9/4/25, she noticed blisters on Resident 4's skin while providing perineal care. CNA 3 stated she immediately notified LVN 2 and RN 1 to see if anyone had reported the blisters on her skin. CNA 3 stated she was not comfortable continuing the perineal care without notifying the licensed nurses as Resident 4's blisters were huge. On 9/10/25 at 1008 hours, a follow up interview was conducted with RNA 1. When asked what time lunch was served, RNA 1 stated approximately at 1200 hours. When asked the process was when an incident occurred, RNA 1 stated to report it right away. When asked if it was reported right away, RNA 1 stated no, it was not. On 9/10/25 at 1019 hours, an interview was conducted with CNA 4. CNA 4 stated on 9/3/25, when Resident 4 returned to her room from Dining room [ROOM NUMBER], she removed the resident's pants, saw redness on her left thigh, and reported it to RN 2 and Treatment Nurse 1. When asked what time she reported it to the licensed nurses, CNA 4 stated sometime between 1230-1345 hours. On 9/11/25 at 0955 hours, a telephone interview was conducted with RN 2. RN 2 stated she was notified on 9/3/25, by CNA 4 when Resident 4 spilled hot water on her thigh. However, RN 2 further stated she was not notified at the time the incident had occurred. c. According to the National Library of Medicine titled First Aid for Burns, the Blister Controversy and Acute Washing of the Burn Wound dated 9/2020 showed cooling the burn with cool running tap water has been shown to decrease cellular damage and edema (swelling), reduce the inflammatory reaction with increased healing and decreased need for skin grafting. Although the ideal temperature of water is unknown, the duration shows maximum benefit when done for 20 min and is useful when done up to three hour/s post burn. Cooling the burn with ice is detrimental and can lead to prolonged vasoconstriction (constrict the blood vessels). Other first aid components include immediate removal of clothing and jewelry, but any clothing melted or firmly adherent to the wound should be left to experienced personnel. * Review of Resident 4's Interdisciplinary Progress Note dated 9/5/25, showed during the routine care on 9/4/25, the assigned CNA observed blisters to Resident 4's left upper thigh. The charge nurse and RN supervisor evaluated the resident and observed 3 blisters to the resident's left upper thigh and the surrounding skin was intact. The note further showed on 9/3/25, during lunchtime in the main dining room, Resident 4 spilled warm tea on her lap and upon returning to the resident's room, Resident 4 was evaluated by the nursing staff and noted slight redness to her left upper thigh to which ice was applied to the area. On 9/9/25 at 1603 hours, an interview was conducted with LVN 2. When asked if you would pat the resident dry after the hot liquid was spilled, LVN 2 stated no, we would remove the clothing and apply cold compress. When asked what can happen if you let hot liquid sit on the resident's clothing for five minutes LVN 2 stated blisters and pain. LVN 2 stated the licensed nurses should have been notified right away rather than waiting until Resident 4 finished eating her dessert. On 9/10/25 at 1019 hours, an interview was conducted with CNA 4. CNA 4 stated on 9/3/25, she was informed by RNA 1 that Resident 4's pants were wet because she spilled hot tea on her lap. CNA 4 stated she proceeded to take Resident 4 to the restroom and noticed redness on her left thigh. When asked if Resident 4 complained of pain, CNA 4 stated she's a little bit burnt that is why I put ice. On 9/11/25 at 1248 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified on 9/4/25, Resident 4 had three blisters on her left upper thigh. When asked if it is an appropriate treatment to apply ice to a burned skin, RN 1 stated no, because it can cause vasoconstriction and damage the tissue. On 9/12/25 at 0950 hours, an interview and concurrent medical record review was conducted with MDS Nurse. The MDS Nurse verified the progress notes dated 9/5/25, showed an ice was applied to Resident 4's burn to her left upper thigh. * Review of Resident 4's medical record for the incident on 9/3/25, failed show documented evidence Resident 4's left thigh was assessed, the physician was notified, treatment was obtained and provided, and the resident was monitored. The documentation was not initiated until 9/4/25 at 1830 hours, approximately 30 hours later. On 9/10/25 at 1119 hours, an interview was conducted with Treatment Nurse 1. Treatment Nurse 1 stated CNA 4 had notified her on 9/3/25, close to 1300 hours, of the incident when Resident 4 had spilled hot tea onto her lap and her clothes were warm. When asked if that would be considered a change in condition, Treatment Nurse 1 stated yes. When asked what the process for a change of condition, Treatment Nurse 1 stated to inform the physician and the resident's family, document, provide the treatment as ordered by the physician, and monitor the resident. Treatment Nurse 1 verified there were no documentation to show a change of condition was initiated on 9/3/25, for Resident 4. On 9/11/25 at 0955 hours, a telephone interview was conducted with RN 2. RN 2 stated on 9/3/25, when she was notified of Resident 4 spilling hot tea on her thigh. RN 2 stated she assessed her skin, noticed slight redness, and was informed by Treatment Nurse 1 that she applied ice to the area. When asked what Resident 4's leg looked like on the second day, RN 2 stated she developed blisters. When asked what type of burn Resident 4 had, RN 2 stated on the first day it was redness, on the second day it was second to third degree burns. RN 2 verified the physician should have been notified on 9/3/25.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for three of nine sampled residents (Residents 4, 6, and 7). * Treatment Nurse 1 failed to perform hand hygiene and changed her gloves after removing the soiled wound dressing for Resident 4. In addition, Treatment Nurse 1 failed to dispose the unused gauze brought in resident's room and ensure the alcohol based sanitizer used was not expired. * CNA 4 failed to wear gloves and perform hand hygiene after touching contaminated items inside Resident 4's contact isolation room. In addition, CNA 4 then proceeded to deliver Resident 7's meal tray without performing hand hygiene. * CNA 4 failed to wear gloves and perform hand hygiene after touching contaminated items inside Resident 6's contact isolation room. In addition, CNA 4 then proceeded to feed Resident 6 without performing hand hygiene. These failures had the potential for the transmission of disease-causing pathogens and infections to the staff and residents.Findings: Review of the facility's P&P titled Wound Care revised 10/2010 showed;1. Verify there is a physician's order;2. Put on exam glove. Loosen tape and remove dressing;3. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly;4. Antiseptic (as ordered)5. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart.6. The following information should be recorded in the resident's medical record. a. The type of wound care given;b. The date and time the wound care was given;c. All assessment data (i.e., wound bed color, size, drainage etc.) obtained when inspecting the wound;d. The signature and title of the person recording the data. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 8/2019 showed all the personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Review of the facility's P&P titled Isolation-Categories of Transmission-Based Precautions revised 9/2022 showed under the section for Contact Isolation, the staff and visitors wear gloves (clean, non-sterile) when entering the room. While caring for a resident, the staff will change gloves after having contact with infective material (for example, fecal material, and wound drainage). Gloves are removed and hand hygiene performed before leaving the room. The staff to avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 1. On [DATE] at 1332 hours, a wound care treatment observation to Resident 4 was conducted with Treatment Nurse 1. Treatment Nurse 1 was observed placing the supplies needed for wound treatment into a small basket, which included a half pack of disposable gauze. Treatment Nurse 1 proceeded to remove the old dressing on Resident 4's left upper thigh and with the same gloves, entered the restroom and grabbed a cup with soapy water. Treatment Nurse 1 proceeded to clean Resident 4's wounds without performing hand hygiene or glove change. Treatment Nurse 1 was then observed while cleaning Resident 4's wounds reached into the gauze package and touched the inside of the gauze package with her gloves. After Resident 4's wound treatment, Treatment Nurse 1 was observed sanitizing her hands with an expired alcohol-based sanitizer after cleaning her workstation. Treatment Nurse 1 also returned the unused package of gauze inside Treatment Cart 1. On [DATE] at 1410 hours, an interview was conducted with Treatment Nurse 1 after completing the wound care for Resident 4. When asked what the expiration date on the hand sanitizer, Treatment Nurse 1 verified it had expired on 5/2025. When asked what she did with the unused gauze, Treatment Nurse 1 stated once she removed one half of the pack, she would continue to use the leftover gauze for the remainder of her residents until the half pack of unused gauze was empty. Treatment Nurse 1 acknowledged hand hygiene practices should have been performed after removing the old dressing and to throw away the unused and contaminated gauze. On [DATE] at 1523 hours, an interview was conducted with the DON. The DON acknowledged the expired hand sanitizer should have been discarded. The DON stated the process for proper hand hygiene while providing wound care would be to perform hand hygiene after removing the soiled dressing. The DON stated any unused disposable supplies would be disposed of if they were brought into a resident's room. 2. On [DATE] at 1209 hours, an observation was conducted for CNA 4 delivering the lunch trays. a. CNA 4 was observed holding a lunch tray, placed the lunch tray on top of the contact isolation cart outside the room, and donned an isolation gown before entering Resident 4's room. CNA 4 placed the lunch tray on Resident 4's bedside table, with bare hands moved Resident 4's bedside table around to accommodate Resident 4's sitting position and then removed the lids from her plateware. CNA 4 proceeded to place the lids of the plateware on top of the isolation cart outside the resident's room and washed her hands inside Resident 4's room. However, after performing hand hygiene, CNA 4 grabbed the same lid on top of the isolation cart outside Resident 4's room and placed it on top of the lunch cart. CNA 4 then grabbed another lunch tray and delivered it to Resident 7 without performing hand hygiene. b. On [DATE] at 1219 hours, CNA 4 was observed entering Resident 6's contact isolation room with an isolation gown with no gloves on to deliver a lunch tray to Resident 6. CNA 4 was observed touching Resident 6's bedside table, adjusting the height of the bed and adjusting Resident 6's blanket with no gloves on. CNA 4 then proceeded to feed Resident 6 without performing hand hygiene. On [DATE] at 1247 hours, an interview was conducted with CNA 4. CNA 4 stated the policy for the PPE for a contact isolation room would include wearing the gown and gloves. On [DATE] at 1325 hours, a follow up interview was conducted with CNA 4. When asked if she wore gloves when dropping off the lunch trays and entering a contact isolation rooms, CNA 4 stated, no and only when working with the residents. When asked what the proper hand hygiene practices would be for contact isolation was, CNA 4 stated to wash hands. CNA 4 acknowledged she did not use the proper PPE and perform hand hygiene practices when entering contact isolation rooms. On [DATE] at 1550 hours, an interview was conducted with the DON. The DON stated the process for entering the contact isolation rooms would include hand washing or sanitizing and wearing a gown and gloves. The DON stated after leaving an isolation room, hand hygiene should be performed. The DON was made aware and acknowledged the above findings. On [DATE] at 1422 hours, the Administrator was made aware and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care services were provided for one of nine sampled residents (Resident 2). * The facility failed to ensure Resident 2 was provided with the continuous oxygen via nasal cannula and Resident 2's oxygen saturation was maintained greater than 92% as ordered by the physician. These failures had the potential for the resident to not receive the necessary respiratory services and negatively impact the resident's well-being.Findings: Review of the facility's P&P titled Physicians Orders and Telephone Orders dated 11/2017 showed the physicians orders shall be obtained prior to the administration of any medication or treatment from a personal lawfully authorized to prescribe for and treat human illness. All orders must be specific and complete and no standing orders shall be accepted. All orders shall be specific and complete with all the necessary details to carry out the prescribed order without any question. Medical record review for Resident 2 was initiated on 8/27/25. Resident 2 was admitted to the facility on [DATE], and transferred to an acute care facility on 8/27/25. Resident 2's diagnosis included lung cancer, acute and chronic respiratory failure with hypoxia (condition where there is an inadequate supply of oxygen to the body's tissues) and dependence on supplemental oxygen. Review of Resident 2's Order Summary Report showed a physician's order dated 8/25/25, to administer oxygen at two to five liters per minute via nasal canula to keep the oxygen saturation greater than 92% every shift. Review of Resident 2's Weights and Vitals Summary showed the oxygen saturation on the following dates and times:- dated 8/26/25 at 1006 hours, 92% on room air;- dated 8/26/25 at 1709 hours, 92% oxygen via nasal cannula; and- dated 8/27/25 at 0323 hours, 93% on room air. Review of Resident 2's Progress Note dated 8/27/25, showed Resident 2 was desaturating with an oxygen saturation of 93% at 0430 hours to 51% at 0520 hours. Resident 2 was sent to an acute care facility via paramedics. On 9/11/25 at 1248 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 2's order showed to keep Resident 2 on continuous oxygen, and the oxygen should remain on at all times. RN 1 verified the oxygen should have been titrated to maintain an oxygen saturation greater than 92% as per the physician's orders . On 9/16/25 at 1422, the Administrator was made aware and acknowledged the above findings.

Based on interview and medical record review, the facility failed to provide the necessary wound care services to one of nine sampled residents (Resident 1). * The facility failed to provided Resident 1's wound treatment as per the physician's order. In addition, the facility failed to accurately monitor and document the wound care provided to Resident 1. This failure had the potential for the resident's wound to become worse and negatively affect the resident's well-being.Findings: Medical record review for Resident 1 was initiated on 8/27/25. Resident 1 was admitted to the facility on [DATE], and transferred to an acute care facility on 8/16/25. Review of Resident 1's SBAR Communication Form dated 7/31/25, showed Resident 1 had a skin tear to the right distal medial aspect of the right lower leg. Review of Resident 1`s Order Summary Report showed a physician's order dated 7/31/25, for full thickness skin tear to the right distal medial aspect of lower leg, to apply Steri-Strips (adhesive bandage strips used to close small wounds) x 1(one) every shift for 21 days; and to monitor for evidence of infection or drainage, if drainage noted, cover with foam dressing and if an infection is noted, to notify the physician. Review of Resident 1's Progress Note dated 7/31/25, showed Resident 1 presented with a full thickness skin tear to the right distal/medial aspect of lower leg, measured size of 6 cm (length) by 2.5 cm (width), able to visualize adipose tissue/muscle, large amounts of serosanguinous (drainage that consists of clear serum and blood), and bleeding stopped when pressure applied. The skin tear was approximated and Steri-Strips was applied. Review of Resident 1's Plan of Care dated 7/31/25, showed a care plan problem addressing Resident 1`s full thickness skin tear to the right distal medial aspect of lower leg. The interventions included to provide treatment as ordered. Review of Resident 1's Treatment Administration Record for August 2025 showed a check mark to indicate the task was completed on 8/1 to 8/15/25, for the full thickness skin tear to the right distal medial aspect of lower leg, to apply Steri-Strips x 1(one) every shift for 21 days; and to monitor for evidence of infection or drainage, if drainage noted, cover with foam dressing and if an infection is noted to notify the physician. Review of Resident 1's Progress Notes showed documentation for the following dates:- dated 8/1/25, the treatment given as ordered;- dated 8/2/25, the treatment given as ordered;- dated 8/3/25, Steri-Strips was intact;- dated 8/4/25, Steri-Strips was intact; and- dated 8/5/25, new orders per physician for cephalexin (antibiotic) three times a day for cellulitis. Review of Resident 1's SBAR Communication Form dated 8/5/25, showed Resident 1 developed cellulitis (bacterial infection of the skin and underlying tissues) on her right lower leg. On 9/2/25 at 1522 hours, a telephone interview was conducted with LVN 1. LVN 1 stated he was notified on 7/31/25, that Resident 1 had a skin tear on her right lower leg as a result of CNA 2 accidently opening the restroom door hitting Resident 1's leg and causing injury to her right lower leg. LVN 1 stated he instructed CNA 2 to apply pressure so he can notify the treatment nurse. When asked what the appearance of the wound was, LVN 1 stated it had a flap and was still bleeding, so it was covered with a foam dressing. On 9/4/25 at 1508 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1's skin tear was being monitored. When asked how the wound was monitored, LVN 2 stated no complaints of pain and was observed for redness. When asked if the foam dressing was opened, LVN 2 stated no, we did not open it unless there was a lot of drainage. When asked how the wound was being monitored if the foam dressing was not removed, LVN 2 stated we monitor around the foam dressing, monitor for increased discharge, and monitor for pain. On 9/4/25 at 1556 hours, an interview and concurrent medical record review was conducted with Treatment Nurse 1. Treatment Nurse 1 stated Resident 1 was observed with a foam dressing on her right lower leg. When asked if a treatment was rendered, Treatment Nurse 1 stated when I saw it, it was covered with a foam dressing, I lifted it up, cleansed with normal saline, and covered it with a foam dressing. When asked what the physician's treatment order for Resident 1's wound, Treatment Nurse 1 stated she assumed the treatment included cleaning the wound because that was what the facility would normally do. Treatment Nurse 1 verified there were no cleansing orders, and stated Resident 1's wound orders were not complete and should have been clarified. On 9/16/25 at 1422 hours, the Administrator was made aware and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical information was complete and accurate for two of nine sampled residents (Residents 1 and 4). * The facility failed to ensure Resident 1's intake, output, and eating percentage documentation were complete and accurate. * The facility failed to document the incident when Resident 4 spilled hot tea on her left thigh on 9/3/24. These failures had the potential for the residents to receive inadequate care as their clinical information were incomplete and inaccurate.Findings: Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed all the services provided to the resident, progress towards the care plan goals, or any changes in the residents mental, physical, functional or psychosocial condition, shall be documented in the residents medical record. The medical record should facilitate communication between the interdisciplinary team regarding the residents condition and response to care. The following information is to be documented in the resident medical record: a. Objective observations;b. Medications administered;c. Treatments or services performed;d. Changes in the resident's condition;e. Events, incidents or accidents involving the resident; andf. Progress toward or changes in the care plan goals and objectives.Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Medical record review for Resident 1 was initiated on 8/27/25. Resident 1 was admitted to the facility on [DATE], and discharged to an acute care facility on 8/16/25. Review of Resident 1's Order Summary Report showed a physician's order dated 7/25/25, to monitor the intake and output every shift, document the intake and output in ml every shift. Review of Resident 1's Documentation Survey Report for August 2025 showed the documentation of the fluid intake and urine output on the following dates and times:- dated 8/1/25 at 2300-0700 hours, showed NA (not applicable);- dated 8/3/25 at 0700-1500 hours, had no entry;- dated 8/5/25 at 2300-0700 hours, showed NA - dated 8/6/25, 1500-2300 hours, had no entry;- dated 8/6/25 at 2300-0700 hours, showed NA- dated 8/8/25 at 2300-0700 hours, showed NA- dated 8/9/25 at 0700-1500 hours, had no entry;- dated 8/11/25 at 2300-0700 hours, showed NA- dated 8/12/25 at 2300-0700 hours, had no entry; and- dated 8/13/25 at 1500-2300 hours, had no entry. Review of Resident 1's Documentation Survey Report for August 2025 showed the documentation of the eating percentage on the following dates and times:- dated 8/5/25 at 0900 hours, showed 10 (not attempted due to environmental limitations (e.g., lack of equipment or weather constraints);- dated 8/6/25 at 0900 hours, showed 10- dated 8/6/25 at 1800 hours, had no entry;- dated 8/8/25 at 090 hours, showed 10- dated 8/9/25 at 0900 and 1300 hours, had no entry;- dated 8/12/25 at 1800 hours, showed 10 - dated 8/13/25 at 1800 hours, had no entry On 9/10/25 at 1550 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and stated the multiple blank entries in Resident 1's Documentation Survey Report were missed charting. The DON further stated documenting NA and 10 for the intake, output, and eating percentage would be an incorrect documentation. On 9/16/25 at 1422 hours, the Administrator was made aware and acknowledged the above findings. 2. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 2/2021 showed our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the residents attending physician or physician on call when there has been a(an) accident or incident involving the resident,2. The nurse will record in the resident's medical record information relative to the changes in the resident's medical/mental condition or status,3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant information for the provider, including (for example) information prompted by the Interact SBAR Communication Form, and4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Medical record review for Resident 4 was initiated on 9/9/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Progress Note dated 9/4/25, showed at approximately 1830 hours, CNA alerted the charge nurse and RN supervisor of the redness on Resident 4's left upper thigh while providing care to the resident. The note further showed Resident 4 had blisters on her left thigh. Review of Resident 4's Interdisciplinary Progress Note dated 9/5/25, showed during the routine care on 9/4/25, the assigned CNA observed blisters to Resident 4's left upper thigh. The charge nurse and RN supervisor evaluated the resident and observed three blisters to the resident's left upper thigh and the surrounding skin was intact. The note further showed on 9/3/25, during the lunch time in the main dining room, Resident 4 spilled warm tea on her lap and upon returning to the resident's room, Resident 4 was evaluated by the nursing staff and noted slight redness to her left upper thigh to which an ice was applied to the area. Review of Resident 4's medical record failed to show any documentation regarding the incident when Resident 4 had spilled hot tea on her left thigh on 9/3/25. On 9/10/25 at 1119 hours, an interview was conducted with Treatment Nurse 1. Treatment Nurse 1 stated CNA 4 had notified her on 9/3/25, close to 1300 hours regarding Resident 4 had spilled hot tea onto her lap, and her clothes were warm. When asked if that would be considered a change in condition, Treatment Nurse 1 stated yes. When asked if a change of condition was initiated for Resident 4 on 9/3/25, Treatment Nurse 1 stated no. On 9/11/25 at 0955 hours, a telephone interview was conducted with RN 2. RN 2 stated she forgot to document and she had endorsed it to Treatment Nurse 1. On 9/12/25 at 0950 hours, an interview and concurrent medical record review was conducted with the MDS Nurse. The MDS Nurse verified Resident 4's medical record did not show any documentation when Resident 4 spilled hot tea on her left thigh on 9/3/25. Cross reference to F689.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the refrigerator used for residents' food brought in by visitors and expired foods were discarded. * The facility failed to ensure the foods were stored off the floor. * The facility failed to ensure the plate lowerator (adjustable heated plate dispenser), can opener, kitchen microwave, oven, and warmer were clean. * The facility failed to ensure the egg salad was not stored on the shelf containing raw meats. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's document titled Diet Count by Diet dated [DATE], showed 50 of 54 residents received food prepared in the kitchen. 1. Review of the facility P&P titled Food Storage revised ,d+[DATE] showed the food items should be stored, thawed, and prepared in accordance with good sanitary practice. All the products should be inspected for safety and quality and be dated upon receipt, when opened, and when prepared. Use use-by dates on all the food stored in refrigerators. Any expired or outdated food products should be discarded. Under the section titled Frozen Vegetables showed the frozen vegetables should be stored as purchased. Review of the facility's P&P titled Labeling and Dating for Safe Storage of Food revised ,d+[DATE] showed when the food is taken out of an original container write the name of the food being stored on the container, the placed date, and the use-by date. On [DATE] at 0802 hours, an initial tour was conducted in the kitchen with the [NAME] and the following were observed: a. In Refrigerator 1, the following was observed prepared but not labeled per the facility policy: - a pan of tilapia filets; - a pan of cleaned chicken; - a container of mushrooms; - a container of egg salad; - two containers of chopped onions; and - a container of tomato wedges. Additionally, the following expired items were observed: - one box of pork chops with a use-by date of [DATE]; - one container of mushrooms with a use-by date of [DATE]; - one container of marinated vegetables with a use-by date of [DATE]; - one container of chopped tomatoes with a use by date of [DATE]; and - one container of Tuscan Caesar dressing with a use by date of [DATE]. b. In Freezer 1, the following was observed not labeled per the facility policy: - one opened and unsealed bag of pearl onions; - one bag of assorted pastries; and - brown rice packets. c. In the pantry area, the following was observed not labeled per the facility policy: - one bottle of breakfast syrup; and - one bag of a dry mixture. d. In Refrigerator 2, the following was observed not labeled per the facility policy: - one uncovered pan of dessert; and - one container of opened lemon meringue pie. e. In the Freezer 2, the following was observed not labeled per the facility policy: - two containers of Thrifty ice cream. The [NAME] verified the above findings. 2. Review of the facility's P&P titled Food from Outside Sources revised ,d+[DATE] showed perishable food should be sealed and dated with a use-by date and placed in refrigeration. On [DATE] at 0852 hours, an observation of Refrigerator 3 was conducted with the Activities Assistant. The following were observed: - one container of whipped cream cheese spread, unlabeled and undated; - one container of veggie spread, unlabeled and undated; - one bottle of ranch dressing, unlabeled and undated; - one container with a croissant sandwich, unlabeled and undated; - one container with a bagel with spread, labeled with resident's name, however, undated; - a bag of tomatoes, labeled with the resident's name and dated ,d+[DATE]; - two disposable cups filled with food, unlabeled and undated; - one Silk soy milk carton, expired on [DATE], unlabeled; - two opened tubs of ice cream, unlabeled and undated; and - a bag of tamales, labeled with resident's name, however, the bag was undated. The Activities Assistant verified the above findings. The Activities Assistant stated the food items should be dated and have the resident's name on it and would be thrown out after three days. On [DATE] at 1542 hours, an interview was conducted with the CDM. The CDM was asked how often the resident refrigerators were checked and cleared out. The CDM stated the dietary staff would do the refrigerator checks daily. On [DATE] at 1308 hours, the CDM, Food and Nutrition Manager, and Chef de Cuisine were informed and acknowledged the above findings. 3. According to the USDA Food Code 2022, Section ,d+[DATE].11, foods should be stored six inches above the floor. On [DATE] at 0802 hours, an initial tour was conducted in the kitchen with the Cook. In Freezer 1, a box of salmon filets was observed on the floor with another box of chicken pot pie stacked on top of it. Additionally, a box of petite peas was observed on the floor with boxes of ice cream cups, chicken wing sections, and deep dish pie shells observed stacked on top of it. The [NAME] verified the findings. 4. According to the USDA Food Code 2022, ,d+[DATE].11 Equipment, Food- Contact Surfaces, Nonfood Contact Surface, and Utensils, the food- contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, ,d+[DATE].13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On [DATE] at 0802 hours, an initial tour was conducted in the kitchen with the Cook, the following were observed: a. The can opener was observed with black and yellow substance on the blade. b. The base of the blender was observed with brown dried residues. c. There was a brown substance observed on the inside top and a white residue on the walls of the microwave. d. The oven door and inside base were observed with dried brown and white substances. e. The plate lowerator was observed with plates. The plate lowerator was observed with a brownish and yellow substance on the bottom warming plate. The [NAME] verified the above findings. On [DATE] at 1308 hours, the CDM, Food and Nutrition Manager, and Chef de Cuisine were informed and acknowledged the above findings. The CDM stated they got a new can opener and cleaned the above mentioned. 5. According to the USDA Food Code 2022, ,d+[DATE].11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation, food shall be protected from cross contamination by separating raw animal foods during storage, preparation, holding and display from cooked ready-to-eat food. On [DATE] at 0802 hours, an initial tour was conducted in the kitchen with the Cook. In Refrigerator 1, there was a container of the egg salad labeled ,d+[DATE] stored on top of an unopened box of lamb loin chops and next to a box of sliced bacon. There was a box containing roasted bacon on the shelf above. The [NAME] stated the egg salad should not have been stored on the shelf because the shelf was only used to store meats.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1) who received the electrical stimulation treatments. * Resident 1 had an electrical stimulation (e-stim) machine applied to him and set at 60 microamperes when the usual setting was 30 microamperes. Then, Resident 1 was left alone while the e-stim treatment was ongoing and was not instructed on how to stop the stimulation when he experienced the intense pain to his left lower leg where the e-stim pad was placed. As as result, Resident 1 [MEDICAL CONDITION] his left lower leg which developed into open wounds into the muscle, requiring prolonged wound care due to wound worsening, debridement procedures (removal of damaged tissues from a wound), and weekly visits by a surgical wound specialist. Findings: Review of the facility's P&P titled Modalities released date of 9/23/16, showed the electrical stimulation is one of the facility's rehabilitation therapy services. The P&P showed the safety of the resident is the responsibility of the clinician at all times during the course of the treatment. Medical record review for Resident 1 was initiated on 2/22/19. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's MDS dated [DATE], showed the resident had moderate cognitive impairment and required extensive assistance of two persons for bed mobility and transfers. Resident 1 was assessed to be able to understand others and make himself understood. Review of Resident 1's Order Recap Report dated 12/20/18 to 1/30/19, showed a physician's orders [REDACTED]. Review of Resident 1's physician's orders [REDACTED]. 12/30/18, Tylenol tablet 325 mg ([MEDICATION NAME]) two tablets by mouth every 8 hours PRN for mild pain. Review of Resident 1's PT - Therapist Progress and Plan of Care dated 1/14/19, showed Resident 1 would receive neuromuscular re-education and electrical stimulation to increase lower extremity functional strength and flexibility. Review of the PT Daily Treatment Note dated 1/22/19, showed PTA 1 provided NMES treatment to the left inner thigh muscle and tibialis anterior (muscle on front of lower leg) of Resident 1 for muscle re-education and strengthening using [MEDICAL CONDITION] placement at 30 mA for 20 minutes. Resident 1 was positioned in a supine position, instructed on the purpose of NMES, and performed the heel slide during the current cycle. Review of the PT Daily Daily Treatment Note dated 1/23/19, showed the electrical stimulation treatment was held due to Resident 1's impaired skin integrity to his left anterior tibia proximal to the left lateral knee joint about 2 inches down. PTA 2 performed the skin assessment to Resident 1 prior to the therapy. The documentation showed Resident 1's skin was red with dark patches. Documentation showed the Director of Rehabilitation, DON, and treatment nurse were all notified about Resident 1's e-stim incident and care of the resident's burn which was the treatment nurse's responsibility. Review of Resident 1's Medication Administration Record [REDACTED]. Resident 1's MAR for (MONTH) and (MONTH) 2019 also showed Resident 1 received 24 PRN doses of [MEDICATION NAME]. Review of Resident 1's wound care physician's progress notes dated 2/13/19, showed Resident 1 had a traumatic wound to his left lateral lower leg, measuring 3.5 cm (length) by 4.5 cm (width) and the depth was unable to be determined. The wound had multiple punctate wounds (a wound with multiple holes in it) separated by skin bridges. The progress notes showed the wound was caused by a electrical stimulation burn, which was the device used by the PT to stimulate the muscles. The progress notes showed the wound was down to the muscle level and required to be surgically debrided. On 2/22/19 at 0810 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 stated Resident 1 was seen weekly by a wound care specialist for his left lower leg wound. LVN 1 stated a change of condition report was completed on 1/23/19, due to five dry brown spots noted on Resident 1's left lower leg where the e-stim pad was placed. LVN 1 stated on 1/30/19, four of the spots opened up and a wound care specialist surgically debrided the areas and started routine wound care. On 2/22/19 at 0900 hours, an interview with Resident 1 and concurrent wound treatment observation was conducted with LVN 1. Resident 1 was observed with four open wound sites, each approximately the size of a pencil eraser and in a pattern of a semi-circle on the resident's left lower leg. Resident 1 stated he had the e-stim therapy every day which contracted his muscles on his left shoulder and left lower leg. Resident 1 stated he usually received this treatment in the facility's rehab gym, but on 1/22/19, he sustained the burn and developed these wounds when he received the e-stim treatment in his room. Resident 1 stated he was not given the control button to stop the e-stim machine nor was he informed there was a pause button on the machine itself. Resident 1 stated the therapist who applied the e-stim machine to his skin left his room. Resident 1 stated he began to notice pain in his leg unlike any of his previous treatments. Resident 1 stated his family member who was visiting at the time left his room to find someone who could turn the e-stim machine off. On 2/22/19 at 0930 hours, an interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated the PTs and PTAs had received education on the use of e-stim during their school and hands-on experience during their clinical rotations while in school. The Director of Rehabilitation stated the facility did not provide training on how to use the e-stim machine unless the staff asked for. The Director of Rehabilitation stated once an e-stim machine was connected to a resident and turned on, the PTA was to stay with the resident while instructing them in active muscle contraction. The Director of Rehabilitation went on to say if the staff needed to leave the resident, they would provide the resident with a safety measure and show the resident how to stop the machine in the event they were in pain. The Director of Rehabilitation stated pain was not an expected response to the e-stim treatment, and it would be stopped right away. The Director recalled on 1/23/19, she was called into Resident 1's room by another PTA and had observed four or five small blackish reddish marks in a semi-circle on Resident 1's left lateral lower leg. The Director of Rehabilitation stated she called PT 1 who was Resident 1's primary PT. She stated PT 1 told her Resident 1 usually tolerated the e-stim treatment very well. The Director of Rehabilitation was asked how Resident 1 had sustained the marks on his left leg. The Director of Rehabilitation stated on 1/22/19, PTA 1 applied the e-stim machine to Resident 1 left lower leg and left the resident's room. Resident 1 complained of high intensity pain and the resident's family member came to look for PTA 1 but was unable to find PTA 1. PT 1 went to Resident 1 and lowered the intensity, gave Resident 1 the safety switch, and instructed the resident on how to use it. When PTA 1 came back to the resident's room and stated he had gone to use the restroom and did not ask anyone to watch Resident 1 while he was gone. On 2/22/19 at 1020 hours, an interview was conducted with the Medical Director. The Medical Director stated the facility had investigated Resident 1's incident involving the e-stim machine and stated it was an event that should have never happened and it had never happened before. The Medical Director confirmed Resident 1 had been left alone while receiving the e-stim treatment without a means to stop or shut off the machine. On 2/22/19 at 1025 hours, an observation of the electrical stimulation machine was conducted with the Director of Rehabilitation. There was a long cord attached to the machine which had a red push button on the end of the cord. The Director of Rehabilitation stated the red push button was a safety button given to the resident receiving the treatment so they could stop the machine if needed. The Director of Rehabilitation also pointed out a button on the machine which showed to stop and another button which showed to pause. The Director of Rehabilitation stated PTA 1 had an upset stomach, left Resident 1 alone, and was in the bathroom a little longer. On 2/22/19 at 1415 hours, an interview was conducted with PT 1. PT 1 stated when the PT service was ordered for a resident, she was the therapist one who determined the resident's treatment plan regarding the use of NMES/e-stim. PT 1 stated the e-stim machine was automatically set for 15 to 20 minutes and left at 20 minutes unless the resident would not tolerate that long. PT 1 stated the resident would not necessarily feel the electrical stimulation, but the therapist was to palpate manually for muscle contraction when the e-stim machine was on. When asked about Resident 1's incident on 1/22/19, PT 1 stated Resident 1's family member came to the gym looking for PTA 1, told PT 1 her dad needed help, and the resident felt uncomfortable with the e-stim machine. PT 1 stated when she ran to Resident 1's room and paused his e-stim machine. PT 1 stated the e-stim machine was set on 60 microamperes, which was a pretty high setting. PT 1 stated the usual setting was 30 microamperes. PT 1 stated she lowered the setting to 30 microamperes on his quadriceps and 16 microamperes on his tibialis anterior (lower leg). PT 1 stated Resident 1 then felt comfortable, and he finished his treatment at the lower setting. PT 1 stated she gave Resident 1 the stop button and told him about the pause button on the machine. PT 1 stated the residents were never to be left alone with the e-stim machine on as they need one-to-one supervision while doing their exercises. PT 1 stated she was not sure but did not think Resident 1 had been educated on the stop and pause buttons of the e-stim machine prior to her instructing him. PT 1 stated PTA 1 told PT 1 he had gone to the bathroom when he left Resident 1 alone. On 2/25/19 at 1410 hours, a telephone interview was conducted with PTA 1. PTA 1 stated he had worked with Resident 1 since Resident 1 was admitted to the facility. PTA 1 stated Resident 1 had a stroke and had limited sensation to his left leg. PTA 1 explained on 1/22/19, he had placed the e-stim [MEDICATION NAME] pads on Resident 1's left thigh and lower leg and then turned up the e-stim setting to Resident 1's tolerance, although this resident had no feeling on his left side. PTA 1 stated if the intensity was too high, he would have lowered the intensity, but Resident 1 did not feel the e-stim at all. When asked if the staff was to remain with a resident while they were having the e-stim treatment ongoing, PTA 1 stated Resident 1's family member was visiting the resident that day. PTA 1 stated he left Resident 1's room because he needed to go to the bathroom and was gone for ten minutes, five to ten minutes. PTA 1 stated he did not remember instructing Resident 1 on how to turn off the e-stim machine, and the resident was immobile and would not have been able to push the pause button on the machine. PTA 1 stated Resident 1's family member was there and could have turned off the e-stim machine. On 3/5/19 at 0910 hours, a telephone interview was conducted with Resident 1's FM 1. FM 1 stated she was visiting Resident 1 for a number of weeks and had been present for approximately 10 or 11 other e-stim treatments prior to the burn incident on 1/22/19, caused by the e-still equipment. FM 1 stated on 1/22/19, Resident 1 was complaining of nausea, dizziness, and not feeling well, so the e-stim session was done while Resident 1 was lying in his bed instead of going to the rehab gym. FM 1 stated PTA 1 set up the e-stim equipment on Resident 1, then PTA 1 sat down in a chair for a few minutes, and worked on his tablet. PTA 1 then got up and stated the electrical stimulation would run for about 15 more minutes and he would be back; PTA 1 then left the room. FM 1 stated after approximately six or seven minutes, Resident 1 told FM 1 the e-stim really hurt him a lot, so FM 1 left the room and went to look for PT 1. FM 1 stated Resident 1 was grimacing, moving his leg some, and looked like the pain was close to a 10. FM 1 stated instead of finding PTA 1, she found PT 1, and told her, Hey, it's really hurting him. PT 1 then came to the room, looked at the e-stim, and stated she wondered why it was set so high. PT 1, then lowered the intensity, and Resident 1 finished the e-stim session. FM 1 stated when PTA 1 removed the [MEDICATION NAME], the lights were off in the room and PTA 1 did not look at Resident 1's leg. FM 1 stated no one had explained to her or Resident 1 how to turn off the e-stim machine if needed until PT 1 came to the room and turned the e-stim intensity down on 1/22/19. On 3/5/19 at 1005 hours, an interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated for neuromuscular re-education, they adjusted the intensity of e-stim unit and felt for muscle contraction or when the resident felt the e-stim. The Director of Rehabilitation stated one-to-one supervision during an e-stim session was the rehabilitation unit's policy.

Based on observation, interview and clinical record review, the facility failed to implement interventions to prevent the development of a pressure ulcer for one of 17 sampled residents (Resident 13). Resident 13 developed a DTI (deep tissue injury) pressure ulcer (purple or maroon colored localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear) on her left heel after being in the facility for 16 consecutive days. The facility failed to develop a plan of care to address Resident 13's risk for skin breakdown as identified in the CAA (a tool used to show areas of concern from the MDS), including body checks to be done every shift. Resident 13 was dependent on staff for her ADLs. Resident 13 stated CNA 9 ignored her initial complaints of left heel pain for three days prior to being diagnosed with [REDACTED]. The facility failed to do a comprehensive assessment of Resident 13's left heel pain, notify the physician of early changes in the skin condition and implement interventions to prevent the DTI. Findings: According to the National Pressure Ulcer Advisory Panel, consider all bed or chair-bound persons or those with the ability to reposition is impaired to be at risk for pressure ulcers. Inspect the skin daily, document assessment results and use proper positioning, transfer, and turning techniques to minimize skin injury due to friction and shear forces. Pressure related injuries to the heel may first present clinically with discoloration, tenderness and changes in the consistency or temperature compared to the surrounding area. Nonblanchable redness is early evidence of abnormal perfusion due to pressure-related injury or friction or shear forces. The progression from local ischemia (insufficient blood supply) to pressure damage may be rapid. On 3/19/14 at 1445 hours, an interview was conducted with Resident 13's family member. Resident 13's family member stated Resident 13 developed a sore on her heel while at the facility, which has impaired her ability to ambulate and progress with her rehabilitation. Resident 13's family member stated Resident 13 was wearing a shoe and is now wearing a boot on her left foot because of the sore. He stated this has impaired her balance. On 3/19/14, clinical record review was initiated for Resident 13. Resident 13 was admitted to the facility on [DATE], from the acute care hospital following surgical repair of her broken left hip. Resident 13 is cognitively intact and able to make her needs known. Review of the MDS (a standardized assessment tool) dated 2/28/14, shows Resident 13 is dependent on staff for bed mobility, transfers, ambulation in the room, dressing, bathing, and is frequently incontinent of both bladder and bowel. The documentation shows Resident 13 does not have any unhealed pressure ulcers, however, is at risk of developing a pressure ulcer. Review of the CAA dated 2/28/14, shows Resident 13 is at risk for skin breakdown due to needing assistance with her ADLs, incontinence episodes of urine with use of incontinence briefs. The plan of care will focus on preventing the development of pressure ulcers. The interventions will include providing good nutrition, turning and repositioning every two hours, body checks to be done every shift and any changes to be reported to the physician promptly. Review of the care plan failed to show a care plan problem to address the resident's risk for pressure ulcers. (cross reference F-279) Review of the physician's history and physical dated 2/18/14, shows Resident 13's skin was examined and her lower legs and heels were within normal limits. Review of the Clinical Notes Reports shows an entry dated 3/4/14, by LVN 6. The documentation shows the CNA noted some discoloration to Resident 13's left heel during ADL care and reported the finding to the charge nurse. Upon assessment, a suspected DTI measuring 3.5 cm by 4 cm of boggy, grey discoloration with a 6 cm by 6 cm non blanchable periwound tissue was observed. The area was tender to the touch. No drainage, no skin openings or signs and symptoms of infection were identified. Physician 1 was present in the facility and was shown the wound, and treatment was initiated. Review of the physician's orders [REDACTED]. The orders show to perform daily wound treatments, apply an APP mattress (Alternating Pressure Pad - an overlay pressure relieving mattress), no shoe to the left foot, fortify the diet, administer multivitamins with minerals daily and vitamin C daily for supplements, and a dietary evaluation. Review of the Wound Review form shows the date of onset for the left heel DTI pressure ulcer is 3/4/14. The documentation shows, due to left lower extremity weakness, possible causes of the wound are from friction on repositioning in bed, using her feet. On 3/20/14 at 0835 hours, Resident 13 was observed self propelling in her wheelchair, using her right foot. Resident 13 was observed with a blue colored boot on her left foot, which was positioned on the foot rest of the wheelchair. Resident 13 stated she uses a wheelchair to get around because of the "sore" on her left heel. Resident 13 returned to her room for an interview. She stated she did not have a "sore" on her left heel when she was admitted to the facility. She stated she was wearing a sock and shoe to attend therapy. She stated she had complained of pain in her left heel to CNA 9 for three days before anything was done. She stated she also complained of pain to her therapist, but no one looked at her heel. She stated she is unable to bear weight on her left foot because of the pain in her heel, not the pain in her hip from surgery. She stated she is able to move herself in bed. She stated, after treatment was initiated, the staff started placing pillows under her heels because of the pain. She stated she was told the wound was starting to heal. She stated the nurse told her it was "like a big blister." On 3/20/14 at 1045 hours, an interview and clinical record review was conducted with LVN 6. LVN 6 verified Resident 13's DTI pressure ulcer to her left heel developed at the facility and was identified on 3/4/14, (Interview was interrupted due to resident care issue). On 3/20/14 at 1135 hours, continuation of the interview was conducted with LVN 6. LVN 6 verified a care plan problem to address the risk for pressure ulcers was not found. LVN 6 stated weekly skin checks are done for every resident and documented on the weekly summary. Review of the weekly summary dated 2/17/14 through 2/27/14, showed reposition every two hours, however, does not show a skin check was performed. LVN 6 was unable to find documentation to show body checks were done every shift as shown in the CAA. On 3/20/14 at 1235 hours, an interview and clinical record review was conducted with Physician 1. Review of the "nSNF Progress Notes" dated 2/28/14, showed the physician assessed Resident 13's legs/feet and the skin was normal. Physician 1 verified she examined Resident 13's lower legs and heels and did not find an issue during her visit on 2/28/14. Physician 1 stated LVN 6 reported a problem with Resident 13's left heel to her on 3/4/14. Physician 1 stated she examined the wound and ordered treatment for [REDACTED]. She stated Resident 13 did not complain of pain during the examination. Review of the nSNF Progress Notes dated 3/4/14, failed to show documentation of the DTI and showed no change in skin condition from the previous note dated 2/28/14. Physician 1 verified the finding and stated Resident 13's left heel DTI pressure ulcer developed between 2/28/14 and 3/4/14. On 3/19/14 at 1710 hours, an interview was conducted with the DON. The DON verified the findings and stated, per the facility's P&P titled Positioning of Resident (undated), when in bed, every attempt should be made to "float heels" (keep the heels off of the bed) by placing a pillow from the knee to ankle or with other devices as recommended by the therapist and prescribed by the physician, unless it is contraindicated in such cases such as hip or knee surgeries. When asked for documentation to show Resident 13 was assessed for the need of offloading the heels and the physician notified, the DON was unable to provide documentation. The DON verified Resident 13 was not assessed for the contraindication of offloading the heels.

Based on interview and clinical record review, the facility failed to ensure one of 17 sampled residents (Resident 13) was free from verbal and emotional abuse. Resident 13 developed a DTI (deep tissue injury) pressure ulcer (purple or maroon colored localized area of discolored intact skin due to damage of underlying soft tissue from pressure and/or shear) on her left heel while in the facility (cross reference F314). Resident 13 stated CNA 9 ignored her initial complaints of left heel pain for three days prior to being diagnosed with [REDACTED]. CNA 9 implied the pressure ulcer was the resident's own fault and Resident 13 was a problem resident. Resident B, Resident 13's roommate, stated she was in the room and heard CNA 9 screaming at Resident 13 and reported the event to the facility. This has made Resident 13 emotionally upset and fearful of retaliation from CNA 9 if she complains about her treatment. Findings: On 3/19/14, clinical record review was initiated for Resident 13. Resident 13 was admitted to the facility on [DATE], from the acute care hospital following surgical repair of a broken hip. Resident 13 is cognitively intact and able to make her needs known. On 3/20/14 at 0840 hours, an interview was conducted with Resident 13. Resident 13 stated she told CNA 9 she was having pain in her left heel for three days prior to being diagnosed with [REDACTED]. Resident 13 stated CNA 9 did nothing to address her complaints of pain. She stated CNA 9 acts like it was "my fault." Resident 13 stated CNA 9 has a "cranky way of treating me" and is "always in a hurry." Resident 13 was reluctant to provide details and stated she does not want to complain because she fears retaliation. Resident 13 stated she "did not want her throat cut in the middle of the night" and she did not want anymore problems with CNA 9. On 3/20/14 at 1025 hours, an interview was conducted with Resident 13 and her family member. Resident 13's family member described Resident 13 as not being a "complainer." He stated Resident 13 had told CNA 9 about the pain she was having in her left heel for three days, and nothing was done. Resident 13's family member stated he was aware of a problem between Resident 13 and CNA 9, but Resident 13 did not want to complain. Resident 13 stated her roommate (Resident B) was present and heard what CNA 9 said to her. She stated she had discussed the situation with Resident B and Resident B's family member. On 3/20/14 at 1610 hours, an interview was conducted with Resident B and her two family members who were present. Resident B stated CNA 9 was not very nice to Resident 13. Resident B stated CNA 9 was "screaming" at Resident 13 and telling Resident 13 she "was the worst patient she had ever had and she was very bad." Resident B stated CNA 9 told Resident 13 she was a "trouble maker." Resident B stated, when Resident 13 complained of pain, CNA 9 disregarded her complaints. When asked when this happened, Resident B stated she did not recall, but this was the second time "they had gotten into it." Resident B stated Resident 13 was very upset, so Resident B and Resident B's family member went with Resident 13 outside to the patio to talk. Resident B stated Resident 13 did not complain to anyone. Resident B stated CNA 9 is always in a hurry and does what is asked but nothing extra. Resident B stated CNA 9 is a "very unhappy person." Resident B stated, at first, she did not want to get involved, but she told her therapist about what had happened. Resident B stated she is not sure if anything has been done. Resident B stated it has been about a week since CNA 9 was last assigned to their room. (cross reference F226)