Every finding on record at Primrose Post-Acute

Based on interview and record review, the facility failed to act upon recommendations from the Pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes), for two of five sampled residents (Resident 4 and Resident 7).This deficient practice placed Residents 4 and 7 at risk for receiving unnecessary medications.Findings:A. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 4's diagnoses included schizoaffective disorder (a mental illness that can affect thought, mood, and behavior), dementia (a progressive state of decline in mental abilities), and major depressive disorder (MDD, a mood disorder that cause a persistent feeling of sadness and loss of interest).During a review of Resident 4's History and Physical (H&P) dated 12/4/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.During a review of Resident 4's Pharmacist Medication Regimen Review ([MRR] - a structured, comprehensive evaluation of a resident's entire medication list, conducted by a pharmacist to ensure safety and effectiveness) dated 3/12/2026, the MRR indicated Resident 4 was receiving Valproic Acid (drug classified as anti-convulsant and also functions as a mood stabilizer) 500 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) twice a day since 12/2025. The MRR indicated to consider a gradual dose reduction (tapering of a medication over time to determine the lowest effective dose to manage symptoms).During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 6/3/2026, the MDS indicated Resident 4's had severe cognitive (ability to think and process) impairment. The MDS indicated, Resident 4 was dependent (helper does all of the effort) on staff for oral hygiene, toileting hygiene, and dressing. During a review of Resident 4's Pharmacist MRR dated 6/16/2026, the Consultant MRR indicated, Resident 4 was receiving Mirtazapine (drug for treatment of depression) 30mg daily since 2/2025. The MRR indicated to consider a gradual dose reduction.During an interview on 7/9/2026 at 2:07 p.m., with the Director of Nursing (DON), the DON stated on 3/12/2026 and 6/16/2026 respectively, the Pharmacist recommended completing a GDR for Valproic Acid and Mirtazapine that were prescribed to Resident 4, and these recommendations were not addressed by the physician. The DON stated the facility failed to take any action on the pharmacist's recommendation by not informing Resident 4's physician. The DON stated the MRR should be acted upon by the licensed nursing staff within 7 days from the date the report was given. The DON stated the consultant pharmacist reviews residents' medications in order to follow the state and federal guidelines and to ensure that the facility was not giving unnecessary medication to the residents.B. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 7's diagnoses included schizoaffective disorder, depression, and dementia.During a review of Resident 7's H&P dated 6/2/2026, the H&P indicated Resident 7 did not have the capacity to make medical decisions.During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 7 was dependent on staff with oral hygiene, toileting hygiene, and dressing. During a concurrent interview and record review on 7/9/2026 at 2:15 p.m., with the DON, Resident 7's consultant pharmacist MRR, dated 6/16/2026, was reviewed. The consultant pharmacist MRR indicated Resident 7 was Mirtazapine 15 mg. daily since 10/2025 and to consider a GDR. The DON stated the MRR was not acknowledged and signed by the physician. The DON stated there was no documentation by the licensed nursing staff in the clinical records that the physician was notified regarding the Pharmacist's recommendation. The DON stated it was important to address and discuss all Pharmacist's recommendations with the resident's physician for the resident's safety.During a review of the facility's undated Policy and Procedure (P&P) titled, Medication Regimen Reviews, the P&P indicated upon receiving the MRR report from the pharmacist, the attending physician reviews, responds to the report and document in the resident's medical record that the pharmacist recommendations have been reviewed and what (if any) actions were taken to address them.

Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sampled residents (Resident 4) prior to administering psychotherapeutic medications (psychotropic, a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior).This deficient practice violated Resident 4's and their resident representative's (RR) right to make an informed decision regarding the use of psychotherapeutic medications.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included schizoaffective disorder (a mental illness that can affect thought, mood, and behavior), dementia (a progressive state of decline in mental abilities), and major depressive disorder (MDD, a mood disorder that cause a persistent feeling of sadness and loss of interest).During a review of Resident 4's Physician Order, dated 12/3/2025, the Physician Order indicated to administer Seroquel (drug used to treat schizoaffective disorder) 25 milligrams (mg, unit of measurement) by mouth twice a day for schizoaffective disorder manifested by screaming and visual hallucinations (perceptual experiences in the absence of real external sensory stimuli).During a review of Resident 4's History and Physical (H&P), dated 12/4/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.During a review of Resident 4's Physician Order, dated 12/31/2025, the Physician Order indicated to administer Mirtazapine (drug for treatment of depression) 30 mg daily for depression manifested by poor oral intake.During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 6/3/2026, the MDS indicated Resident 4's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 4 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and upper and lower body dressing.During a review of Resident 4's Medication Administration Record (MAR, a daily documentation record used by licensed nurse to document medications and treatments given to a resident) from 6/19/2026 to 7/7/2026, the MAR indicated Resident 4 received Seroquel 25 mg twice a day and Mirtazapine 30 mg daily.During a phone interview on 7/7/2026 at 12:48 p.m. with Resident 4's representative (RR 1), RR 1 stated she visited Resident 4 at the facility on 6/25/2026 and Registered Nurse 1 (RN 1) asked her to sign Resident 4's psychotherapeutic informed consent form. RR 1 stated she did not give verbal or written informed consent for the use of psychotherapeutic medications. RR 1 stated she did not have authority to give informed consent for psychotherapeutic medications. RR 1 stated she was allowed and only had the authority to give informed consent for medications used for treatment of dementia.During an interview on 7/8/2026 at 11:40 a.m. with RN 1, RN 1 stated it was the licensed nursing staff's responsibility to obtain psychotherapeutic informed consent from the resident or the resident representative and discuss the side-effects of the psychotherapeutic medications with the resident or the resident representative. RN 1 stated informed consent was required initially and if there was an increase in medication, and the consent needed to be renewed every 6 months. RN 1 stated RR 1 gave verbal consent to administer Seroquel and Remeron to Resident 4 on 6/19/2026. RN 1 stated Resident 4 was prescribed Seroquel for treatment of her schizoaffective disorder, not for dementia, and Remeron for treatment of her depression, not for dementia. RN 1 stated the facility staff could not initiate or administer psychotherapeutic medications without a valid informed consent. RN 1 stated psychotherapeutic medications were medications that help mitigate the resident's mood and behavior, which could affect their activities of daily living. RN 1 stated psychotherapeutic medications have serious adverse reactions (undesired effect of a drug) such as shaking, weight loss, and unsteady gait that could jeopardize resident's health and well-being.During a review of the facility's policy and procedure (P&P) titled, Psychoactive/Psychotropic Medication Use, undated, the P&P indicated prior to administration of a psychotropic medication, the prescribing clinician would obtain informed consent from the resident or resident representative and document the consent in the medical record. The P&P indicated the resident or resident representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives options, and to choose the alternative or option he or she prefers.Cross Reference F757

Based on observation, interview, and record review the facility failed to notify the physician for one of five sampled residents (Resident 1), after Resident 1 had a change in condition and developed diarrhea on 6/26/26.This deficient practice had the potential to result in a delay in care, treatment and worsening of the resident's symptom. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1's diagnosis included gangrene (the death of body tissue caused by a lack of blood flow), chronic kidney disease (the progressive, irreversible loss of renal function), and diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 1's History and Physical (H&P) dated 6/30/2026, the H&P indicated Resident 1 did not have the capacity to make decisions but was able to make needs known.During a review of Resident 1's Minimum Data Sheet ([MDS]- a resident assessment tool) dated 4/23/2026, the MDS indicated Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) from staff for personal hygiene, showers, and dressing.During a review of Resident 1's Order Summary Report dated 6/14/2026, the Report indicated the physician ordered to administer loperamide (medication used to treat sudden diarrhea) two milligrams ([mg.] -a unit of measure for medication dosage) one tablet by mouth every 6 hours as needed for loose stool.During a review of Resident 1's Care Plan titled, .Resident has alteration in gastrointestinal r/t (related to) episodes of loose stools x 2 dated 6/14/2026, the Care Plan goal indicated resident will have normal, formed stool through review date, with target date of 10/20/2026. The Care Plan intervention indicated to notify the physician and responsible party.During a concurrent interview and record review on 7/8/2026 at 1:30 p.m., with Treatment Nurse (TN) 1, Resident 1's MAR dated 6/26/2026 was reviewed. The MAR indicated Resident 1 was given loperamide 2mg on 6/26/2026 due to diarrhea.During a concurrent interview and record review on 7/8/2026 at 1:41 p.m., with TN 1 Resident 1's Care Plan titled, Bowel: Resident has or is at risk for complications with gastrointestinal system (a continuous, twisting muscular tube that runs from the mouth to the anus) due to diarrhea dated 6/14/2026 was reviewed. TN 1 stated the care plan intervention indicated to notify the physician for changes in bowel patterns. TN 1 stated there should have been a COC when Resident 1 had diarrhea, however, was not done. TN 1 stated COCs helped to maintain consistent monitoring and notification to the physician. TN 1 stated it was important to notify the physician in case he wanted to make changes to Resident 1's regimen (a systemic plan or routine designed to improve health routine).During a review of the facility 's undated Policy and Procedure (P&P) titled, Change in a Resident's Condition or Status, The P&P indicated the facility was to promptly notify the physician of changes in the resident's medical conditions. The P&P indicated prior to notifying the physician provider, the nurse will make detailed observations and gather relevant information for the provider including information prompted by the interact Situation Background Assessment Recommendation (SBAR) form.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was completed accurately for two of 16 sampled residents (Resident 4 and Resident 7), who were coded for a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Residents 4 and 7.Findings:A. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 4's diagnoses included schizoaffective disorder (a mental illness that can affect thought, mood, and behavior), dementia (a progressive state of decline in mental abilities), and major depressive disorder (MDD, a mood disorder that cause a persistent feeling of sadness and loss of interest).During a review of Resident 4's History and Physical (H&P) dated 12/4/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive (ability to think and process) skills for daily decision making were severely impaired. The MDS indicated Resident 4 was dependent (helper does all of the effort) on staff for oral hygiene, toileting hygiene, and upper and lower body dressing. The MDS indicated, Resident 4 has no potential indicators of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) such as hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality).B. During a review of Resident 7's admission Record, the admission Record indicated Resident 7 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 7's diagnoses included schizoaffective disorder, depression, and dementia.During a review of Resident 7's H&P dated 6/2/2026, the H&P indicated Resident 7 did not have the capacity to make medical decisions.During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 7 was dependent on staff for oral hygiene, toileting hygiene and dressing. The MDS indicated Resident 7 had no potential indicators of psychosis such as hallucinations and delusions.During an interview on 7/9/2026 at 11:30 a.m., with the Physician Assistant (PA), the PA stated Residents 4 and Resident 7 had a diagnosis of schizoaffective disorder not schizophrenia. The PA also stated Residents 4 and Resident 7 did not have supporting documentation to justify a diagnosis of schizophrenia. There would have been documentation of the residents' long history of schizophrenia and persistent symptoms of behaviors that met the criteria of schizophrenia based on the Diagnostic and Statistical Manual of Mental Disorder (DSM 5, the primary handbook used by mental health professionals to diagnose psychiatric disorders).During a concurrent interview and record review on 7/9/2026 at 12:21 p.m., with the Minimum Data Set Nurse (MDSN), Resident 4's MDS dated [DATE] and Resident 7's MDS dated [DATE], were reviewed. The MDSN stated Residents 4 and Resident 7 MDS assessments were completed inaccurately. The MDSN stated Resident 4 and Resident 7 MDS Section I (Active Diagnoses) 6000 (schizophrenia) should not have been checked to indicate the resident's had a schizophrenia diagnosis. The MDSN stated the facility did not have supporting documentation or evidence that Resident 4 and Resident 7 had a diagnosis of schizophrenia. The MDSN stated inaccuracy of the MDS assessment could affect the plan of care of the residents. During a review of the facility's undated Policy and Procedure (P&P) titled, Resident Assessments, the P&P indicated, all persons who have completed any portion of the MDS resident assessment must sign the document attesting to the accuracy of such information. The P&P also indicated information in the MDS assessment will consistently reflect information in the progress notes, plan of care, and resident observations and interviews.

Based on observation, interview, and record review, the facility failed to ensure there was a one-to-one (1:1) feeder (a caregiver who was assigned to assist a resident with feeding for the duration of a meal) for one of five sampled residents (Resident 13) during meals.This deficient practice placed Resident 13 at risk for poor nutritional intake during meals.Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), muscle weakness (a reduction in a patient's capacity to generate force or activate existing muscle mass), and gastro-esophageal reflux disease (GERD, a digestive condition where stomach acid contents repeatedly flow back up into the esophagus)During a review of Resident 13's History and Physical (H&P), dated 2/6/2026, the H&P indicated Resident 13 did not have the capacity to make decisions but was able to make needs known.During a review of Resident 13's Minimum Data Sheet (MDS, a resident assessment tool), dated 5/12/2026, the MDS indicated Resident 13's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 13 was dependent (helper does all of the effort) on staff for personal hygiene, shower, and lower dressing. The MDS indicated Resident 13 required supervision (helper provides verbal cues to assist in completing the activity) from staff for eating. The MDS indicated Resident 13 was at risk for pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence).During a review of Resident 13's physician order, dated 6/5/2026, the physician order indicated Resident 13 to have a 1:1 feeding for cueing.During an observation on 7/7/2026 at 12:40 p.m., in Resident 13's room, Resident 13 did not have a 1:1 feeder during lunch time.During an observation on 7/8/2026 at 12:53 p.m., in Resident 13's room, Resident 13 did not have a 1:1 feeder during lunch time. Resident 13 was moving food around on his lunch plate.During a concurrent observation and interview on 7/8/2026 at 1:02 p.m., with Treatment Nurse (TN) 1, in Resident 13's room, Resident 13 did not have a 1:1 feeder during lunch time. TN 1 stated there was no feeder assisting Resident 13 while he was trying to eat his lunch. TN 1 stated there should be a staff member sitting next to him while he was eating. TN 1 stated a feeder had to be with Resident 13 to make sure he was eating to prevent malnutrition (a deficiency, excess, or imbalance in person's intake of energy and /or nutrients).During a review of the facility's policy and procedures (P&P) titled, Assistance with Meals, undated, the P&P indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The P&P indicated nursing services or feeding assistants will help residents who require assistance with eating.

Based on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 24) hair was washed and the resident's nails were trimmed during activity of daily living ([ADL]- activities such as bathing, dressing, and toileting a person performs daily) care. This deficient practice placed Resident 24 at risk for poor personal hygiene, skin irritation, and discomfort.Findings:During a review of Resident 24's admission Record, The admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 24's diagnosis included muscle sclerosis (chronic autoimmune disease of the central nervous system), hemiplegia (paralysis of one side of the body), and muscle wasting (involuntary loss of muscle mass and strength).During a review of Resident 24's History and Physical (H&P), dated 4/22/2026 the H&P indicated Resident 24 had the capacity to understand and make decisions.During a review of Resident 24's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 5/6/2026, the MDS indicated Resident 24's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 24 was dependent (helper does all of the effort) on staff for personal hygiene, showering, and lower body dressing.During a review of Resident 24's Care plan titled, Skin dated 5/11/2025, the Care plan intervention indicated to keep the resident's skin clean and dry.During a concurrent observation and interview on 7/7/2026 at 12:06 p.m., in Resident 24's room, Resident 24 had large amounts of dandruff in his hair, on the resident's face and clothes. Resident 24 fingernails were not trimmed. Resident 24 stated he would like to have his nails trimmed and his hair washed.During a concurrent observation and interview on 7/8/2026 at 1:06 p.m., with Treatment Nurse (TN) 1, in Resident 24's room, TN 1 stated Resident 24's fingernails were not trimmed and the resident had large amounts of dandruff. TN 1 stated Resident 24's hair should be washed on his shower days, at least twice a week. TN 1 stated Resident 24's fingernails should be trimmed by the Certified Nursing Assistants (CNA). TN 1 stated it was important for the CNA to provide ADL care daily for Resident 24 so he would feel comfortable. TN 1 stated not having proper ADL care placed Resident 24 at risk for accumulation of dead skin and cause discomfort for the resident. During a review of the facility's undated policy and procedures (P&P) titled, Activities of Daily Living (ADL), Supporting, the P&P indicated residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good grooming, and personal hygiene.

Based on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 13) Low Air Loss Mattress ([LALM]- a specialized medical bed used to prevent and treat pressure ulcers) was maintained in the correct setting.This deficient practice had the potential to place Resident 13 at risk for pressure ulcers (localized damage to the skin and /or underlying tissue usually over a bony prominence).Findings:During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), muscle weakness (a reduction in a patient's capacity to generate force or activate existing muscle mass), and gastro-esophageal reflux disease ([GERD] - a digestive condition where stomach acid contents repeatedly flow back up into the esophagus).During a review of Resident 13's History and Physical (H&P) dated 2/6/2026, the H&P indicated Resident 13 did not have the capacity to make decisions but was able to make needs known.During a review of Resident 13's Minimum Data Sheet ([MDS]- a resident assessment tool) dated 5/12/2026, the MDS indicated Resident 13's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 13 was dependent (helper does all of the effort) on staff for personal hygiene, shower, and lower dressing. The MDS indicated Resident 13 weighed 133 pounds ([lbs.] - a measurement of weight) and was at risk for pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence).During a review of Resident 13's Braden Scale Assessment dated 5/12/2026, the Braden Scale Assessment indicated Resident 13 was at high risk for skin breakdown.During a review of Resident 13's Order Summary Report dated 2/5/2026, the physician orders indicated to provide Resident 13 with a LALM and to have the settings per resident's weight.During a concurrent observation and interview on 7/8/2026 at 12:38 p.m., with Treatment Nurse (TN) 1, in Resident 13's room, TN 1 stated Resident 13 weighed 133 lbs. and the LALM was set at 180 lbs.During a concurrent interview and record review on 7/8/2026 at 12:43 p.m., with TN 1, Resident 13's Physician's order dated 2/5/2026 was reviewed. The TN stated, the Physician's order indicated to set Resident 13's LALM per the resident's weight. TN 1 stated the LALM should have been set closer to Resident 13's weight of 133 lbs. TN 1 stated not having the correct LALM settings placed the resident at risk for pressure ulcers.During a review of the facility's undated policy and procedure (P&P) titled, Low Air Loss Mattress General Procedure, the P&P indicated LALM are therapeutic support surfaces designed to assist in the prevention and treatment of pressure injuries. The P&P indicated pressure setting shall be determined based on the resident's weight.

Based on observation, interview, and record review, the facility failed to ensure:1. Three Hoyer lifts (a mechanical device used to transfer non-ambulatory individuals between surfaces from a bed to a wheelchair and vice versa without manual lifting) were not blocking a fire alarm in the facility's hallway.2. One of five sampled residents (Resident 39) had a physician order for going out on pass (OOP, temporary permission to leave a confined facility) and was signed out before going OOPThis deficient practice had the potential to result in safety hazards for residents, staff members, and visitors and placed Resident 39 at risk for medical complications.Findings: 1. During an observation on 7/7/2026 at 2:39 p.m., three Hoyer lifts were observed blocking one of the facility's fire alarms and posted signs. The sign indicated, Do not park anything in front of fire pull box at any time, keep area clear. in the facility's hallway. During a concurrent observation and interview on 7/9/2026 at 10:26 a.m. with Licensed Vocational Nurse 2 (LVN 2), three Hoyer lifts were blocking one of the facility's fire alarms and posted signs. LVN 2 stated the facility had do not park signs around the facility to keep the area safe for residents, visitors and staff members. LVN 2 stated mechanical equipment, linen carts, trash cans, and any other items should not be parked in front of the signs in the hallway. LVN 2 stated the three Hoyer lifts should not have been parked at the signage area. LVN 2 stated it was a safety hazard to not keep an area with a fire alarm and posted signage clear, which could result in possible injuries for residents, visitors and staff. During a review of the facility's policy and procedures (P&P), titled Accidents and Incidents-Investigating and Reporting, undated, the P&P indicated the facility was in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 2. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including toxic encephalopathy (neurologic disorder characterized by brain dysfunction caused by exposure to toxic substances), muscle weakness (a reduction in a patient's capacity to generate force or activate existing muscle mass), and gastro-esophageal reflux disease (GERD, a digestive condition where stomach acid contents repeatedly flow back up into the esophagus) During a review of Resident 39's History and Physical (H&P), dated 5/8/2026, the H&P indicated Resident 39 had the capacity to make medical decisions. During a review of Resident 39's Minimum Data Sheet (MDS, a resident assessment tool), dated 5/8/2026, the MDS indicated Resident 39's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 39 was dependent (helper does all of the effort) on staff for personal hygiene, shower, and lower dressing. The MDS indicated Resident 39 was dependent on staff for mobility and used a wheelchair. During an interview on 7/10/2026 at 10:26 a.m. with the Business Office Manager (BOM), the BOM stated on 6/17/2026, she escorted Resident 39 to a check cashing place to cash her check. The BOM stated she did not use the OOP log to sign the resident out of the facility. The BOM stated she had thought the resident could just leave without clinical or medical clearance. During a concurrent interview and record review on 7/10/2026 at 10:35 a.m. with Director of Nursing (DON), the sign-out log sheet and physician orders were reviewed. The sign-out log sheet did not indicate Resident 39 was signed out on 6/17/2026. The physician orders indicated there were no OOP orders (on 6/17/2026) for Resident 39. The DON stated for Resident 39 to go OOP, the facility had to obtain an OOP physician order and sign Resident 39 out when she left the facility. The DON stated the purpose of this process was to keep track of Resident 39 and keep Resident 39 safe. The DON stated Resident 39's safety was at risk because the BOM was not aware of Resident 39's medical conditions. During a review of the facility's P&P titled, Signing Residents Out, dated 8/2006, the P&P indicated all residents leaving the premises must be signed out. The P&P indicated registers must indicate the resident's expected time of return. The P&P indicated residents must be signed in upon return to the facility.

Based on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 11) received continuous oxygen (O2) at two liters per minute ([L/min]- a metric unit of volume used to measure liquids and gases) according to the physician's order. This deficient practice had the potential for Resident 11 not to receive adequate O2 and cause respiratory distress (difficulty breathing) to the resident. Findings:During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. The admission Record indicated Resident 11's diagnoses included respiratory failure (occurs when your lungs cannot get enough oxygen into your blood), dysphagia (difficulty swallowing), and cerebral infarction (a medical term for tissue death in the brain). During a review of Resident 11's History and Physical (H&P) dated 3/16/2026, the H&P indicated Resident 11 did not have the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Sheet ([MDS]- a resident assessment tool) dated 5/12/2026, the MDS indicated Resident 11's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 11 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) on staff for personal hygiene, dressing, bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on bed) and transfers. The MDS indicated Resident 11 was receiving O2 therapy.During a review of Resident 11's Order Summary Report dated 6/3/2026, the Report indicated the physician ordered to administer O2 2 L/min continuously to Resident 11 via nasal cannula ([N/C] a small plastic tube, which fits into the person's nostrils for providing supplemental O2) per concentrator tank (a medical device that delivers a continuous stream of concentrated oxygen to a patient) every shift.During an observation on 7/7/2026 at 11:13 a.m., in Resident 11's room, Resident 11 was observed without the N/C on and the O2 set at zero.During a concurrent observation and interview on 7/8/2026 at 12:28 p.m., with Minimum Data Set Nurse (MDSN), in Resident 11's room, Resident 11 was observed with the O2 set at zero. The MDSN stated Resident 11 should be on continuous O2 therapy and should be set at 2 L/min, and not at zero. The MDSN stated not administering the correct O2 therapy as ordered could cause shortness of breath to the resident and lead to hypoxia (a state of inadequate oxygen supply to the body's tissues and cells).During a review of the facility's undated Policy and Procedure (P&P) titled, Oxygen Administration, the P&P indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. The P&P indicated to verify the physician's order, turn on the oxygen, start the flow of oxygen at the rate of two or three liters per minute and adjust so that it is the proper flow of oxygen being administered.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 48) was evaluated by the physician at least every 60 days and documented in the resident's clinical records.This deficient practice had the potential for a delay in the assessment of Resident 48's medical condition and receiving necessary care and treatment.Findings:During a review of Resident 48's admission Record, the admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses included cerebral infarction (type of stroke, loss of blood flow to a part of the brain), Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 48's History and Physical (H&P) dated 11/22/2025, the H&P indicated Resident 48 had the capacity for medical decision making.During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool) dated 5/8/2026, the MDS indicated Resident 48's cognition (ability to think and process) was intact. The MDS indicated Resident 48 was dependent (helper does all of the effort) on staff for toileting hygiene and dressing.During an interview on 7/7/2026 at 9:37 a.m., with Resident 48, Resident 48 stated she seldom saw her physician. Resident 48 stated her physician made a short visit to see her on 3/2026 (date unspecified). Resident 48 stated she needed to talk to her physician regarding her left knee pain.During a concurrent interview and record review on 7/9/2026 at 8:54 a.m., with the Director of Nursing (DON), Resident 48's Progress Notes dated 1/11/2026 to 7/3/2026 were reviewed. The DON stated Resident 48 was visited by a Nurse Practitioner ([NP] - a nurse who has advanced clinical education and training) on 1/11/2026, 1/27/2026, 2/8/2026, 3/13/2026, 3/27/2026, 4/8/2026, 4/20/2026, 5/4/2026, 6/2/2026, 6/19/2026, and 7/3/2026, and was not seen by the physician. The DON stated the Physician saw Resident 48 once this year on 3/3/2026 (in approximately 4 months [120 days]). The DON stated the physician should visit Resident 48 at least once a month and could alternate visits with the NP. The DON stated a physician had more extensive training and knowledge to assess and diagnose residents properly compared to NP. The Physician would document his findings in the Progress Notes about the resident's condition and treatment plan every time he completed his visit and evaluation of the resident.During a review of the facility's undated Policy and Procedure (P&P) titled, Physician Visits, the P&P indicated The attending physician must visit his/her patients at least once every thirty (30) days for the first ninety (90) days following the resident's admission, and then at least every (60) days thereafter. The P&P also indicated the attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation.During a review of the Facility Assessment Tool (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services) dated 3/31/2026, the Facility Assessment Tool under Physician Services, indicated the attending physicians are required to evaluate their patients within 72 hours of admission and at least every 30 days following their initial visit or based on the patient's medical needs.

Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from the responsible party, for one of five sampled resident's (Resident 4), prior to administering psychotropic medications (drugs that changes brain function and results in alterations in perception, mood, consciousness or behavior) to the resident.This deficient practice had the potential to result in the use of unnecessary psychotropic medication that could cause harm to Resident 4.Findings:During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 4's diagnoses included schizoaffective disorder (a mental illness that can affect thought, mood, and behavior), dementia (a progressive state of decline in mental abilities), and major depressive disorder (MDD, a mood disorder that cause a persistent feeling of sadness and loss of interest).During a review of Resident 4's Physician Order dated 12/3/2025, the Physician Order indicated to administer Seroquel (drug used to treat schizoaffective disorder) 25 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) by mouth twice a day to Resident 4, for schizoaffective disorder manifested by screaming and visual hallucinations (perceptual experiences in the absence of real external sensory stimuli). During a review of Resident 4's History and Physical (H&P) dated 12/4/2025, the H&P indicated Resident 4 had fluctuating capacity to understand and make decisions.During a review of Resident 4's Physician's Order dated 12/31/2025, the Physician's Order indicated, to administer Mirtazapine (drug for treatment of depression) 30 mg. daily to Resident 4, for depression manifested by poor oral intake to Resident 4. During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 6/3/2026, the MDS indicated Resident 4 had severe cognitive (ability to think and process) impairment. The MDS indicated Resident 4 was dependent (helper does all the effort) on staff for oral hygiene, toileting hygiene, and dressing.During a review of Resident 4's Medication Administration Record dated 6/19/2026 to 7/7/2026, the MAR indicated Resident 4 received Seroquel 25 mg. twice a day and Mirtazapine (Remeron) 30mg daily.During a review of Resident 4's Psychotherapeutic Drug Informed Consent Forms for Mirtazapine and Seroquel dated 6/19/2026, the Forms indicated verbal consent was documented under section for Resident/ Resident's Representative Name and section for Resident/Resident's Representative Signature was blank.During a phone interview on 7/7/2026 at 12:48 p.m., with Resident 4's representative (RR 1), RR 1 stated she visited Resident 4 at the facility on 6/25/2026 and Registered Nurse (RN) 1 asked her to sign an informed consent for psychotropic medication for Resident 4. RR 1 stated she did not give verbal nor written informed consent for the use of psychotherapeutic medications because she did not have authority to do so. During an interview on 7/8/2026 at 11:40 a.m., with RN 1, RN 1 stated it was the responsibility of the licensed nursing staff to obtain informed consent from the resident or his/her representative prior to administering psychotropic medications. RN 1 stated it was also the responsibility of the licensed nursing staff to discuss the side-effects of the psychotherapeutic medications to the resident or his/her representative. RN 1 stated informed consent for psychotropic medications was required if there was an increase dosage in the medication, and it needed to be renewed every 6 months. RN 1 stated on 6/19/2026, RR 1 gave verbal consent to administer Seroquel and Remeron to Resident 4. Resident 4 was prescribed Seroquel for treatment of schizoaffective disorder and Remeron for treatment of depression. RN 1 stated the facility staff could not initiate or administer any psychotherapeutic medications without a valid informed consent. RN 1 stated psychotropic medications were medications that help mitigate resident's mood and behavior that could ultimately affect their activities of daily living. RN 1 stated the side-effects of psychotherapeutic medications would cause a significant change in resident's health condition. RN 1 stated without a proper or valid informed consent, it was considered as unnecessary medication.During interviews on 7/8/2026 at 2:36 p.m. and 7/10/2026 at 8:25 a.m., with the Director of Nursing (DON), the DON stated psychotropic medications should have a valid informed consent from the resident or resident representative to ensure that the facility did not give inappropriate medication. There was no valid informed consent obtained for Resident 4's Seroquel and Mirtazapine. During a review of the facility's undated Policy and Procedure (P&P) titled, Psychoactive/Psychotropic Medication Use, the P&P indicated, prior to administration of a psychotropic medications, the prescribing clinician will obtain informed consent from the resident or resident representative and document the consent in the medical record. The P&P also indicated the resident or resident representative has the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives options, and to choose the alternative or option he or she prefers

During observation, interview and record review, the facility failed to ensure staff (Physical Therapist [PT] 1) performed hand hygiene (washing hands or using an alcohol-based hand sanitizer) after PT 1 picked up gloves from the floor, prior to obtaining clean gloves from the glove dispenser, donning (putting on) new gloves and providing care to one of five sampled residents (Resident 37).This deficient practice had the potential to lead to cross contamination (the physical transfer of harmful bacteria or viruses from one person or object to another) and the spread of infection to Resident 37, other residents and staff. Findings:During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 37's diagnoses included muscle weakness (a reduction in a patient's capacity to generate force or activate existing muscle mass), atrial fibrillation (irregular and very fast heartbeat) and dementia (a progressive state of decline in mental abilities).During a review of Resident 37's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 4/29/2026, the MDS indicated Resident 37's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 37 was dependent (helper does all of the effort) on staff for personal hygiene, showering, and dressing. During an observation on 7/7/2026 at 12:06 p.m., PT 1 dropped gloves on the floor, was observed picking up the gloves from the floor, proceeded to obtain and don new gloves from the glove dispenser, then provided care for Resident 37 without performing hand hygiene.During an interview on 7/7/2026 at 2:12 p.m., with PT 1, PT 1 stated she dropped gloves on the floor. She picked up the gloves and threw them in the trash. PT 1 stated she obtained another pair of gloves (from the clean glove dispenser) without washing her hands. PT 1 stated the surface of the floor was considered dirty and she should have washed her hands after picking up the gloves off the floor and prior to donning the clean gloves. Hand hygiene practices were important to prevent cross contamination and the spread of infection.During a review of the facility's undated Policy and Procedure (P&P) titled, Handwashing/Hand Hygiene, the P&P indicated this facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors. The P&P indicated to perform hand hygiene after contact with contaminated surfaces, after touching the resident's environment and immediately prior to touching a resident.

Based on observation, interview, and record review, the facility failed to post the recent California Department of Public Health (CDPH, state licensing and certification agency) annual survey results for 2024 and 2025 in the areas of the facility that are prominent and accessible to the residents, resident representatives, family members, and visitors.This deficient practice placed the residents, family members, and visitors at risk of not knowing the status of the facility's non-compliance outcome results and past performance history.Findings:During an observation on 7/7/2026 at 8:25 a.m. at facility hallway, there was one survey binder hanging on the wall. The survey binder contained the Complaint and Facility Reported Incidents and the result of the last standard survey, dated 2/11/2022.During a concurrent interview and record review on 7/7/2026 at 8:45 a.m. with the Administrator (ADM), the survey binder was reviewed. The ADM stated the survey binder was incomplete and not updated. The ADM stated the facility had an annual recertification survey (an unannounced, comprehensive inspection conducted on-site by CDPH to evaluate nursing home's compliance with federal health and safety compliance) in 2024 and 2025. The ADM stated he was responsible for putting the survey results for the past 3 preceding years in the survey binder. The ADM stated the updated survey results should be available and accessible to the public for transparency. The ADM stated the survey binder contained the statement of deficiencies identified by the CDPH and the facility's plan of correction.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, undated, the P&P indicated Federal and State laws guarantee certain basic rights to all residents of this facility and these rights include the right to examine survey results.During a review of the facility's admission packet, titled California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, revised 8/2025, on page 63 and 64 indicated the resident has the right to examine the results of the most recent survey of the facility conducted by Federal and State surveyors and any plan of correction in effect with respect to the facility and should post in a place readily accessible to resident, and family members and legal representative of residents.

Based on observation, interview and record review, the facility failed to post the updated daily nurse staffing information that included the facility name, current date, total number and the actual hours worked by nursing staff directly responsible for resident care per shift along with the resident census, at the beginning of each day.This deficient practice had the potential to affect the care of the residents in the facility and for residents needs to go unmet.Findings:During a concurrent observation and interview on 7/7/2026 at 8:50 a.m., with the Infection Preventionist Nurse (IPN) at Station A, the staffing information, dated 7/6/2026 was observed to be posted. The IPN stated the nurse staffing information for the day, dated 7/7/2026 was not posted and updated. The IPN stated the nurse staffing information should include the projection and the actual hours worked by licensed nurses and CNA's that would be providing direct care and services to residents and the actual total number of residents living in the facility. The IPN stated the daily nurse staffing information should be prepared the day before and posted before the beginning of the shift. The IPN stated the nurse staffing information should be updated daily so the residents, staff, and visitors would know whether there were enough staff present to provide care and accommodate the residents' needs.During an interview on 7/8/2026 at 2:40 p.m., with the Director of Nursing (DON), the DON stated it was important for the nurse staffing information to be updated and posted daily to show that the facility was in compliance with regulations and to show how many staff the facility planned based on the census to take care and manage the residents living in the facility.During a review of the facility's undated Policy and Procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, the P&P indicated, The facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents.

Based on interview and record review, the facility failed to update the care plan for one out of one sampled resident (Resident 2).This failure had the potential to result in Resident 2 not receiving relevant care based on the changes in their medical conditions, in a timely manner.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included hemiplegia (partial paralysis) and hemiparesis (weakness or inability to move on one side of the body), contracture (shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints) of right and left knee, and has a stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral region (a triangular bone at the base of the back bone connecting to a basin-shaped ring of bones located at the base of the spine).During a review of Resident 2's History and Physical (H&P), dated 4/25/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 2/4/2026, the MDS indicated Resident 2's cognition (ability to think and process) was intact. The MDS indicated Resident 2 was dependent (helper does all of the effort) on staff for toileting hygiene, personal hygiene, shower/bathing themselves, lower body dressing, putting on/taking off footwear, and mobility.During a review of Resident 2's Care Plan titled, Skin: Resident has impaired skin integrity present on admission as evidenced by multiple PI (Pressure injuries), dated 5/1/2025, the care plan indicated there was a target date of 8/4/2026, but did not indicate any quarterly review dates between 5/1/2025 and 8/4/2026.During a review of Resident 2's Interdisciplinary Team Psychotherapeutic review (IDT, coordinated group of healthcare professionals who collaborate to manage a resident's care), dated 9/8/2025, the IDT indicated repositioning as a non-pharmacological intervention under the psychotherapeutic review.During a review of Resident 2's Care Plan Report, titled, Skin: Resident 2 has a diabetic ulcer to right lateral calf and is at risk for further breakdown, dated 9/24/2025, the Care Plan Report did not indicate to reposition Resident 2.During a concurrent interview and record review on 5/5/2026 at 2:45 p.m., with the Director of Nursing (DON), Resident 2's care plans and the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plans, dated 4/2026, were reviewed. The care plan indicated there were no quarterly review dates between 5/1/2025 and 8/4/2026. The P&P indicated the interdisciplinary team would review and update the care plan at least quarterly. The DON stated the MDS nurse would update the care plans, but if the care plans were not updated every quarter, the facility was not following the policy. The DON stated residents would be affected if the staff are not providing care on the care plan and if the interventions were not updated on the care plan.

Based on observation, interview, and record review, the facility failed to ensure the facility followed- up with the Medical Doctor (MD 1) of one of three residents (Resident 1), regarding the resident and Resident 1's Responsible Party's (RP 1) request to talk to MD 1.This failure violated Resident 1 and RP 1's right to communicate with and access to persons and services inside and outside the facility.Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted on [DATE] with diagnoses including cognitive communication deficit (a difficulty communicating due to cognitive impairments), retention of urine (the inability to fully empty the bladder), and obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from flowing properly). The admission Record indicated Resident 1 had a responsible party, RP 1.During a review of Resident 1's History and Physical (H&P), dated 7/5/2025, the H&P indicated Resident 1 was capable of making medical decisions.During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 was able to understand and be understood and did not have disorganized thinking or acute mental status change. Resident 1 did not reject care. Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, bathing, and personal hygiene. Resident 1 had an indwelling catheter and was always incontinent of bowel movements. Resident 1 and her family were active participants in the assessment process.During a review of Resident 1's Nursing Progress Notes, dated 1/28/2026, the Progress Notes indicated MD 1 and Nurse Practitioner [unnamed] were notified about RP 1's request for communication regarding Resident 1's medical condition. The Progress Notes indicated the clinical team will follow up with RP 1.During an observation on 1/28/2026 at 1:25 p.m., at Nursing Station 1, RP 1 requested to speak with MD 1 directly. Registered Nurse (RN 1) informed RP 1 that she will notify MD 1 and ensure that MD 1 contacts RP 1.During an interview on 1/28/2026 at 1:40 p.m., with Resident 1, Resident 1 stated she would like to speak to MD 1. Resident 1 stated she made a request with RN 1 for MD 1 to call her [Resident 1] or RP 1 and was awaiting MD 1's call.During an interview on 2/2/2026 at 1:15 p.m. with MD 1, MD 1 stated he and his office were not contacted by the facility about RP 1's request to talk to MD 1. MD 1 stated he had not been notified about Resident 1 and RP 1's request for communication and information. MD 1 stated he had not spoken with RP 1 and would have promptly called RP 1 if the facility had contacted him. During a concurrent interview and record review on 2/2/2026 at 1:40 p.m., with RN 1, Resident 1's Progress Note, dated 1/28/2026, was reviewed. RN 1 stated the Progress Notes indicated she [RN 1] notified MD 1 about RP 1's request to speak with MD 1. RN 1 stated there was no indication staff had followed up with MD 1 about Resident 1 and RP 1's requests. RN 1 stated she did not know if MD 1 responded to RP 1's request or the nursing team received MD 1's response. RN 1 stated she did not have time to follow up with MD 1 about Resident 1 and RP 1's request. During a concurrent interview and record review on 2/2/2026 at 4:12 p.m., with NP 1, Resident 1's Physician Progress Notes, date 9/22/2025 and 10/6/2025, were reviewed. NP 1 stated she was not notified about RP 1's request to speak with MD 1. NP 1 stated she had never spoken with RP 1 on behalf of MD 1. During an interview on 2/11/2026 at 1:50 p.m. with the Director of Nursing (DON), Resident 1's Nursing Progress Notes from 1/28/2026 through 2/10/2026, were reviewed. The DON stated the nursing progress notes on 1/28/2026 indicated RN 1 notified MD 1 about RP 1's request for contact. The DON stated the nursing progress notes did not indicate any follow-up with MD 1 to ensure Resident 1 and RP 1's rights were upheld. The DON stated a licensed nurse should have called MD 1 within one day to ensure RP 1's request was honored. During a review of the facility's policy and procedure (P&P), titled Resident Rights, dated 04/2025, the P&P indicated residents have the right to communicate with and access people and services inside and outside the facility, be supported be the facility in exercising their rights, exercise their rights without interference, and participate in decision-making regarding their care.

Based on interview and record review, the facility failed to conduct a readmission Interdisciplinary Team ([IDT] group of healthcare professionals, including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents) meeting, for one of four residents (Resident 1), and her Responsible Party (RP), to allow participation in planning resident's care.This failure resulted in the resident and her RP not aware of the plan of care, and the potential for lack of coordinated or inadequate care plan and lack of opportunities to improve care.Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted on [DATE]. Resident 1's diagnoses included cognitive communication deficit (a difficulty communicating due to cognitive impairments), retention of urine (the inability to fully empty the bladder), and obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from flowing properly).During a review of Resident 1's History and Physical (H&P), dated 7/5/2025, the H&P indicated Resident 1 could make medical decisions.During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 7/9/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 was able to understand and be understood and did not have disorganized thinking or acute mental status change. The MDS indicated Resident 1 did not reject care. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, bathing, and personal hygiene. The MDS indicated Resident 1 had an indwelling catheter and was always incontinent of bowel movements. The MDS indicated Resident 1 and her family were active participants in the assessment process.During a review of Resident 1's Progress Notes, dated 9/15/2025, the Progress Notes indicated Resident 1 was admitted to the facility with a foley ([indwelling urinary] to drain urine) catheter.During a review of Resident 1's Progress Notes for the month of September 2025, there was no indication a readmission IDT meeting was planned or occurred. During a review of Resident 1's Progress Notes, dated 12/8/2025, the Progress Notes indicated Resident 1 was re-admitted to the facility from a hospitalization related to complications of a urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 1's census tab, the census tab indicated Resident 1 was readmitted on [DATE].During a review of Resident 1's Progress Notes for the month of December 2025, the Progress Notes indicated, on 12/31/2025, an invitation was sent to Resident 1, and her Responsible Party (RP) to an IDT meeting. The Progress Notes did not indicate a readmission IDT meeting was conducted in December 2025.During an interview on 1/28/2026 at 1:40 p.m. with Resident 1 and Resident 1's RP 1, Resident 1 stated she was hospitalized in September 2025 and December 2025. Resident 1 and RP 1 stated facility staff did not inform them about Resident 1's plan of care to prevent future hospitalizations and UTIs after Resident 1 was hospitalized in December 2025. Resident 1 and RP 1 stated they wanted to be involved in the care planning process.During an interview on 1/29/2026 at 10:30 a.m., with the Social Services Director (SSD), the SSD stated IDT meetings must occur for every readmission to the facility.During an interview on 2/2/2026 at 8:40 a.m., with the Licensed Vocational Nurse (LVN 9), LVN 9 stated IDT meetings must occur to review Resident 1's condition, plan care, and uphold Resident 1's right to be informed and involved in care planning. LVN 9 stated Resident 1 could experience more hospitalizations and UTIs if IDT meetings are not conducted after each readmission. LVN 9 stated that Resident 1 and her family had the potential to not know Resident 1's condition or be involved in care planning, causing a potential infringement on their rights.During an interview on 2/2/2026 at 3:30 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Care Planning - Interdisciplinary Team, dated 04/2025, was reviewed. The DON stated the P&P was not followed when an IDT meeting was not conducted when Resident 1 was readmitted to the facility. The DON stated Resident 1's and RP 1's rights were violated when the readmission IDT was not conducted to inform them about the plan of care and allow them to participate in care planning.During a concurrent interview and record review on 2/6/2026 at 3:30 p.m. with the SSD, Resident 1's Progress Notes dated 12/31/2025, the policy and procedure (P&P) titled Resident Rights, dated 04/2025, were reviewed. The SSD stated the P&P indicated that the resident and/or the resident's representative should be part of the IDT meetings. The IDT meetings should occur within one week of readmission to the facility to coordinate care, update interventions, and allow the resident and their representatives to participate in care planning. When Resident 1 was readmitted on [DATE] and 12/8/2025, she did not conduct an IDT meeting to inform and allow Resident 1 to participate in care planning. The SSD stated the IDT invitation provided to Resident 1 and her RP as indicated in the progress note dated 12/31/2025 was for the quarterly IDT in January 2026 and not the readmission IDT. The SSD stated Resident 1's hospitalization and care changes to prevent re-hospitalization were not reviewed in the quarterly IDT meetings.During a review of the facility's policy and procedures (P&P) titled Resident Rights, dated 04/2025, the P&P indicated residents has the right to be informed of, and participate in, their care planning and treatment.During a review of the facility's P&P titled Care Planning - Interdisciplinary Team, dated 04/2025, the P&P indicated the IDT included the resident and/or the resident's representative to the extent practicable. The P&P indicated if the resident or representative cannot participate, an explanation was documented in the medical record.

Based on interview and record review, the facility failed to implement intervention in one of three residents' (Resident 1), care plan titled, Resident 1 has indwelling foley catheter (catheter that drains urine from bladder into a bag outside the body), which indicated to monitor and document Resident 1's urine output.This failure had the potential to delay identification of changes and signs of complications (low urine output, signs of urinary tract infections) in the resident's urinary status, causing delay in care and interventions, that can lead to serious infections and hospitalization.Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted on [DATE] with diagnoses including cognitive communication deficit (a difficulty communicating due to cognitive impairments), retention of urine (the inability to fully empty the bladder), and obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from flowing properly). During a review of Resident 1's History and Physical (H&P), dated 7/5/2025, the H&P indicated Resident 1 was capable of making medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 was able to understand and be understood. The MDS indicated Resident 1 did not have disorganized thinking or acute mental status change. The MDS indicated Resident 1 did not reject care. The MDS indicated Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, bathing, and personal hygiene. The MDS indicated Resident 1 had an indwelling catheter and was always incontinent of bowel movements. The MDS indicated Resident 1 and her family were active participants in the assessment process. During a review of Resident 1's care plan titled Resident 1 has indwelling foley catheter, dated 7/16/2025, one of the interventions indicated nursing staff will monitor and document Resident 1's output. During a review of Resident 1's clinical records, the progress notes for 7/2025 to 9/2025, did not indicate Resident 1's urine outputs were monitored. During a review of Resident 1's Physician Order dated 10/20/2025, the order indicated to monitor intake and output every shift. The physician's order indicated Resident 1's total fluid output monitoring must be performed every shift, starting 10/20/2025. During a concurrent interview and record review on 2/2/2026 at 3:30 p.m. with the Director of Nurses (DON), Resident 1's active care plans dated 7/16/2025, MAR(s) for the months of 7/2025, 8/2025, 9/2025, and 10/2025 and Resident 1's Physician's Order dated 10/20/2025, were reviewed. The DON stated Resident 1's care plan intervention to monitor Resident 1's urine output was not implemented on 7/16/2025 and the physician was not called around 7/16/2025 when the interventions was placed to monitor the urine output. The DON stated Resident 1's MAR for 7/2025, 8/2025 and 9/2025 did not indicate the urine output was monitored. The DON stated the facility called the physician on 10/20/2025 to obtain an order to monitor the urine output that was started on 10/20/2025 (three months later). The DON stated standards in nursing care being Resident 1 with indwelling catheter was to include output measurement and recording. The DON stated not implementing care plan interventions from 7/16/2025 until 10/20/2025 placed Resident 1 at increased risk of urinary infection and catheter-related complications. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated 4/2025, the P&P indicated care plans described the services furnished to residents to attain or maintain the resident's highest practicable physical well-being.

Based on interview and record review, the facility failed to meet professional standards of quality, by failing to ensure Medical Doctor's (MD 1) progress notes on 9/22/2025 and 10/6/2025, for one of three residents (Resident 1), indicating a plan for urology consultation, were clarified, ordered and scheduled.This failure resulted in Resident 1 being not seen by a urologist timely and placed the resident at risk for delayed necessary interventions to provide quality care when needed.Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted on [DATE] with diagnoses including cognitive communication deficit (a difficulty communicating due to cognitive impairments), retention of urine (the inability to fully empty the bladder), and obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from flowing properly). During a review of Resident 1's History and Physical (H&P), dated 7/5/2025, the H&P indicated Resident 1 could make medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2025, the MDS indicated Resident 1 had moderate cognitive impairment. Resident 1 was able to understand and be understood and did not have disorganized thinking or acute mental status change. The MDS indicated Resident 1 did not reject care. Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, bathing, and personal hygiene. Resident 1 had an indwelling catheter and was always incontinent of bowel movements. The MDS indicated Resident 1 and her family were active participants in the assessment process. During a review of Resident 1's Physician (MD 1) Progress Notes, dated 9/22/2025 and 10/6/2025, MD 1 indicated a plan for a follow-up appointment with urology (the branch of medicine and physiology concerned with the function and disorders of the urinary system) for Resident 1's urinary retention. During a review of Resident 1's Nursing Progress Notes for the month of 9/2025 and 10/2025, the progress notes did not indicate the facility clarified with the physician's progress notes or coordinate follow-up appointments with Urology. During a review of Resident 1's Physician Orders, dated 1/27/2025, the orders indicated a urology consultation was ordered for Resident 1 due to diagnoses including obstructive and reflux uropathy and foley catheter dependence. During an interview on 2/2/2026 at 1:15 p.m., with MD 1, MD 1 stated he was unsure if a urologist had been consulted for Resident 1. During a concurrent interview and record review on 2/2/2026 at 4:12 p.m., with Nurse Practitioner (NP 1), Resident 1's Physician Progress Notes, dated 9/22/2025 and 10/6/2025, were reviewed. NP 1 stated consultation with a urologist was standard practice due to Resident 1's obstructive uropathy, chronic indwelling urinary catheter, and history of multiple urinary tract infections (UTI- an infection in the bladder/urinary tract). NP 1 stated Resident 1's medical history and chronic indwelling urinary catheter put Resident 1 at high risk of UTIs, sepsis, and hospitalization. NP 1 stated she never reviewed urology notes or recommendations and did not know if the urology appointments listed on Resident 1's physician progress notes were carried out. NP 1 stated Resident 1 required a consultation with a urologist to assess Resident 1 and provide recommendations for Resident 1's plan of care. During interview on 2/9/2026 at 9:25 a.m., with Registered Nurse (RN) 2, RN 2 stated licensed nurses are responsible for reviewing physician's progress notes, clarify, and carry out planned interventions. RN 2 stated the licensed nurses should have spoken with the physician to clarify if the physician wanted to order a urology appointment. RN 2 stated not following up with the physician could have resulted in Resident 1 not receiving physician-directed care. During a concurrent interview and record review on 2/10/2026 at 1:50 p.m. with the Director of Nursing (DON), Resident 1's Physician Progress Notes dated 9/22/2025 and 10/6/2025, Resident 1's Nursing Progress Notes for the months of September and October 2025, and Nursing Progress Notes from 1/28/2026 through 2/10/2026 were reviewed. The DON stated the physician progress notes on 9/22/2025 and 10/6/2025 indicated a plan for a urology follow-up appointments. The DON stated the progress notes did not indicate documentations that the licensed nurses clarified and followed up with Resident 1's physician about the 9/22/2025 and 10/6/2025 planned urology follow-up appointment. The DON stated the urology follow-up appointment and consultation was recently ordered and scheduled for 1/2026. The DON stated this placed Resident 1 at risk for more UTIs and possible hospitalizations.

Based on interview and record review, the facility failed to maintain an accurate documentation for one of three residents (Resident 1), when the Interdisciplinary Team ([IDT] group of healthcare professionals, including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents) meeting was rescheduled. This failure resulted in Resident 1's medical record being inaccurate and incomplete.Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted on [DATE] with diagnoses including cognitive communication deficit (a difficulty communicating due to cognitive impairments). During a review of Resident 1's History and Physical (H&P), dated 7/5/2025, the H&P indicated Resident 1 could make medical decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/8/2026, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 was able to understand and be understood. Resident 1 did not have disorganized thinking or acute mental status change. The MDS indicated Resident 1 did not reject care. Resident 1 was dependent (helper does all the effort) on staff for toileting hygiene, bathing, and personal hygiene. Resident 1 had an indwelling catheter (catheter drains urine from bladder into a bag outside the body) and was always incontinent of bowel movements. The MDS indicated Resident 1 and her family were active participants in the assessment process. During a review of Resident 1's Progress Notes for the month of 1/2026, the Progress Notes did not indicate Resident 1's IDT meeting was delayed, rescheduled, or cancelled in 1/2026.During an interview on 1/28/2026 at 9:10 a.m. with Resident 1, Resident 1 stated she wanted herself (Resident 1) and Responsible Party (RP) 1 to be informed and involved in IDT meetings and care planning decisions. During an interview on 1/29/2026 at 10:30 a.m., with the Social Services Director (SSD), the SSD stated IDT meetings must occur for every readmission to the facility. During a concurrent interview and record review on 2/6/2026 at 3:30 p.m. with the Social Services Director (SSD), Resident 1's 12/2025 and 1/2026 Progress Notes, were reviewed. The SSD stated Resident 1's IDT meeting was rescheduled three times in 1/2026 due to Resident 1 and RP 1's requests but was not documented in Resident 1's progress notes. The SSD stated that when an IDT meeting is being scheduled or rescheduled, it should have been documented in the resident's clinical records to maintain accuracy. The documentation should include new scheduled date, reasons why the schedule was changed, and if the IDT were informed of the changes. During an interview on 2/11/2026 at 1:50 p.m., with the Director of Nursing (DON), the DON stated Resident 1's medical record was incomplete when the SSD did not document in Resident 1's progress notes when the IDT was cancelled and rescheduled and if the care team were made aware of the changes.

Based on interview and record review, the facility failed to implement its policy and procedures (P/P) titled Emergency Procedures for Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) by not calling 911 (an emergency alert system) when one of one sampled resident (Resident 65), who had full code status (when a medical personal does everything possible to save a person's life in a medical emergency), was observed unresponsive in bed, on [DATE]. This deficient practice resulted in Resident 65's death and placed 54 other residents, who had Full Code statuses, at risk of not receiving timely life saving measures. Findings: On [DATE] at 2:28 p.m., the Administrator (ADM), and Director of Nursing (DON) were notified of an Immediate Jeopardy (IJ- a situation on which the facility's noncompliance with on or more requirements of participation has caused, or is likely to cause serious injury, harm impairment, or death to a resident) was called for the facility's failure to call 911 during a medical emergency for Resident 65. The facility's staff did not call 911 after initiating CPR for Resident 65. The facility's Administrator and DON were notified of the seriousness of all resident's health and safety were at risk due to staff's failure to call 911 after initiating CPR. An IJ removal plan (am intervention to immediately correct the deficient practices) was requested. On [DATE] at 2:20 p.m., the facility submitted an acceptable IJ removal plan. After onsite verification if the IJ Removal Plan was implemented through interviews, and record reviews, the IJ was removed on [DATE] at 2:44 p.m., in the presence of the ADM, DON and Assistant Administrator (AADM). The IJ Removal Plan included the following: a. On [DATE], Cardio-Pulmonary Emergencies/CPR in-services were initiated for all licensed staff and certified nurse assistants (CNAs) and expected to be completed by [DATE]. b. On [DATE], Physician Orders for Life-Sustaining Treatment ([POLST] a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) in-services was initiated by the DSD to licensed nurses. Training referred to the section titled Directions for Healthcare Provider was expected to be completed by [DATE]. c. On [DATE], the Director of Staff Development (DSD) conducted a review of the employee files pertaining to the nursing dept, specially checking for CPR certifications. The DSD did not find any expired CPR certificates. d. On [DATE], the DON conducted an in-service informing licensed nurses about the notification procedures following a death in the facility which included prompt notification to the DON and Administrator. The training was expected to be completed by [DATE]. e. An annotated provider was invited to provide the nursing staff an in-service regarding emergency response during CPR on [DATE]. f. During daily clinical meetings from Monday to Friday, the DON will review all reported changes in condition to ensure comprehensive assessment of changes, evaluation of initial interventions, identification of additional needs, implementation of adjustments, follow-up, and thorough documentation. g. On the weekends, the Registered Nurse Supervisor will review admissions with a particular focus on POLST and their accurate completion. Any review findings will be completed by the RN, and a summary will be submitted to the DON by the next business day. h. On weekends, the RN Supervisor will review any changes of a resident's condition and report any concerns to the DON by the next business day to ensure adequate interventions were provided. i. The DSD will provide weekly reports on the emergency response CPR review for newly hired staff, if applicable. For employees who undergo annual reviews, the DSD will report monthly to the DON. j. The emergency response system will be reviewed during the annual competency evaluation by the DSD and reported to the DON for acknowledgement. k. The Administrator will update the Quality Assessment & Assurance (QA&A) committee during next Quality Assurance (QA) meetings for progress of action plan or if revisions are necessary. Findings: A review of Resident 65's closed record (face sheet), indicated Resident 65 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Resident 65's diagnoses included encephalopathy (brain disease that causes confusion and memory loss), sepsis (a life-threatening condition in which the body responds improperly to an infection), acute respiratory failure (occurs when the lungs cannot release enough oxygen into a person's blood), and pneumonia (an infection that affects one or both lungs). A review of Resident 65's Minimum Data Set ([MDS] an assessment and care screening tool) dated [DATE], indicated Resident 65's cognitive patterns (the process of thinking) were severely impaired. The MDS indicated Resident 65's required extensive assistance from staff for activities of daily living ([ADLs]- an individual's daily self-care activities such as toileting, showering, dressing oneself). The MDS indicated Resident 65's was dependent on staff for toileting, showering and upper/lower body dressing. A record review of Resident 65's Change of Condition document, dated [DATE], indicated Resident 65's code status was Full Code. A review of Resident 65's progress notes, dated [DATE] at 4:30 a.m., indicated on [DATE], at 4:00 a.m., Certified Nurse Assistant (CNA 1) observed Resident 65 in bed, flaccid (loose or floppy limbs), cool to touch with no rise and fall of the chest and nonresponsive to tactile (touch) and verbal stimuli. The progress notes indicated CNA 1 notified Licensed Vocational Nurse (LVN 1) of Resident 65's change of condition at 4:00 a.m. Code Blue (a medical emergency code used to describe a resident who is in cardiac or respiratory arrest) was called, and LVN 1 and LVN 2 performed CPR on Resident 65 for 20 minutes. The progress notes indicated at 4:20 a.m., LVN 1 notified Resident 65's primary physician (Physician 1) via telephone, and the physician pronounced Resident 65 deceased (dead). A review of Resident 65's Death Certificate, dated [DATE], indicated Resident 65's cause of death was respiratory failure. During a telephone interview, on [DATE] at 4:10 p.m., with LVN 1, LVN 1 stated on [DATE] around 4:00 a.m., CNA 1 went to Resident 65's room to reposition him. LVN 1 stated CNA 1 ran back out of the room informing her that Resident 65 did not look good. LVN 1 stated she went into Resident 65's room, assessed the resident's pulses and announced a code blue. LVN 1 stated she initiated CPR on Resident 65 at 4:02 a.m. LVN 1 stated LVN 2 came to assist with CPR for 20 minutes. LVN 1 stated 911 was not called because she called to notify the resident's physician (MD 1) of Resident 65's situation at 4:20 a.m. LVN 1 stated the physician pronounced Resident 65 dead over the telephone at 4:20 a.m., during the phone call. LVN 1 stated the physician did not assess the resident prior to pronouncing the resident dead. During an interview, on [DATE] at 3:25 p.m., with Registered Nurse (RN 1), RN 1 stated during a code blue, a resident's airway, breathing, and circulation should always be checked, followed by the resident's POLST. RN 1 stated if a resident had no vital signs and was a full code, staff start CPR immediately. RN 1 stated another staff should be asked to call 911 right away, and another staff should notify the resident's physician on the resident's condition immediately. RN 1 stated paramedics (healthcare professional trained to respond to emergency calls for medical help outside of a hospital) had the capacity to handle life threatening situations and provide advanced cardiac life support. RN 1 stated 911 was not called on [DATE], after CNA 1 observed Resident 65 unresponsive. During an interview, on [DATE] at 11:46 a.m., with the DON, the DON stated CPR should be initiated if a resident was found unresponsive without a pulse and not breathing. The DON stated during a code blue, staff were supposed to call for assistance, take a crash cart to the resident's room and call 911 immediately. The DON stated 911 was not called on [DATE], when CNA 1 observed Resident 65 unresponsive in bed. The DON stated if 911 was called as soon as a Code Blue was called, Resident 65 might have received prompt lifesaving care. During an interview, on [DATE] at 3:05 p.m., with Resident 65's the physician, the physician stated she could not recall the details but remembered she received an early morning phone call on [DATE], regarding Resident 65. The physician stated LVN 1 informed her Resident 65 was found unresponsive around 4:00 a.m., and staff-initiated CPR for 20 minutes. The physician stated the standard of practice was to initiate CPR and call 911. Physician 1 stated she did not have any notes or documentation from the call received from the facility on [DATE] regarding Resident 65. A record review of the facility's policy and procedure (P/P), titled Emergency Procedures- Cardiopulmonary Resuscitation, dated February 2018, indicated if an individual was found unresponsive, staff would briefly assess for abnormal or absence of breathing and if a sudden cardiac arrest was likely, staff should begin CPR, instruct another staff member to activate the emergency response system (code) and call 911. The P/P indicated staff should continue with CPR until an emergency medical personnel arrived.

Based on observation, interview, and record review, the facility failed to implement infection control interventions to prevent the spread of corona virus ([COVID-19] a very deadly virus that easily spreads from person to person) in accordance with local Public Health guidelines, the facility's infection control policies and procedures (P/P), and mitigation plan ([MP] a plan to reduce the spread of infection) for 30 of 60 sampled residents by failing to ensure: 1. Treatment Nurse (TX) did not return to work with COVID-19 symptoms including cough and shortness of breath, on 1/26/2022, after he tested positive for COVID-19 on 1/21/2022. 2. LVN 1 did not use the same personal protective equipment ([PPE] protective wear to prevent the spread of infections), during medication pass in multiple residents' rooms in the yellow zone (designated for residents suspected to have been exposed to COVID-19) and LVN 1 removed her PPE when exiting rooms in the yellow zone. 3. 22 of 119 staff were fit tested (a test performed to ensure a respirator (mask) forms a tight seal around the wearer's face to prevent the spread of infection) determine correct respirator to wear) for N95 (a respiratory protective device designed to achieve efficient filtration of airborne particles, including those from COVID-19) respirator and wore the correct fit tested N95. (TX 1, Certified Nurse Assistant [CNA] 3, 7, 8, 9, 10, 11, 12, 13, 14, and 15, Licensed Vocational Nurse [LVN] 3 and 4, Physical Therapy Assistant [PTA] 1, Medical Records [MR], Occupational Therapist [OT] 1 and 2, Housekeeping [HK] 1 and 3, Cook [CK] 1, and Laundry Aide [LA] 1) were not fit tested 4. CNA 1 and CNA 6 performed hand hygiene before and after resident contact and properly wore PPE upon entering and exiting rooms in the yellow zone. 5. Staff line list (a table that contains key information about each person in an infection) was updated and included TX 1 who tested positive for COVID-19 on 1/21/2022. 6. Resident 1 did not expose Residents 2 and 3, when Resident 1 tested positive for COVID-19 on 1/29/2022 and was not transferred to the red zone (designated area for residents confirmed with COVID-19) in a timely manner. 7. Activities Assistant (AA) 2 did not re-enter the yellow zone after assisting residents in red zone. 8. Ambulance Staff (AMB) 1 wore proper PPE upon entering Resident 4's room in the red zone. These deficient practices had the potential to lead to an increase in COVID-19 outbreak in the facility. The facility's census included 30 positive residents in the red zone (designated area for COVID-19 residents) and 30 residents in the yellow zone. On 1/27/2022 at 6:16 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to implement measures to prevent the transmission of COVID-19 infection, which threatened the health and safety of the 30 residents in the yellow zone, staff, and the community. On 1/31/2022, the ADM submitted an acceptable Plan of Action ([POA], a plan of interventions that corrects the deficient practices). The IJ was lifted on 2/1/2022 at 3:16 p.m. after POA implementation was verified onsite through observations, interviews, and record review. The accepted POA included the following actions: 1. CNA 1 who did not wear proper PPE entering a room in the yellow zone and did not perform hand hygiene while working in the yellow zone, had competency skills check and return demonstration on proper use of PPE and hand hygiene in the red and yellow zones. CNA 1 was evaluated by Infection Prevention Nurse ([IPN] nurse in charge of infection prevention for the facility) on 1/28/2022. 2. LVN 1 who used the same PPE in multiple residents' rooms during medication administration in the yellow zone, had one-on-one coaching by the DON on 1/28/2022, on proper use of PPE and performing hand hygiene in yellow zone rooms. Competency skills check and return demonstration on proper use of PPE and hand hygiene was performed by LVN 1 and evaluated by IPN on 1/28/2022. 3. 21 staff members who were not fit tested for the N95 respirator; a log was created for all active employees. Each employee's N95 fit testing status was reviewed. The staff working during the current shift was reviewed and fit tested to ensure all the staff wore the correct N95 respirator. 4. TX 1 who had a positive COVID-19 rapid [MEDICATION(S)] test (test used to detect the COVID-19 virus) at home on 1/21/22, returned to work on 1/26/22, and stated he had symptoms including shortness of breath and lightheadedness (a feeling as if you might faint), and was observed by the surveyors to be coughing while administering care to residents in the red and yellow zones, was verified by the DON to have symptoms. TX 1 was asked to return home, self-isolate, self-monitor for fever and COVID-19 symptoms, and update supervisor daily for further instructions on when to return to work. Due to nature of the incident, falsifying documents that he did not have COVID-19 symptoms, and lying on the COVID-19 screening machine, TX 1's employment was terminated on 1/28/2022. 5. The line listing for positive COVID-19 staff was updated by the ADM on 1/27/2022 to reflect TX 1 who was positive on 1/21/2022. 6. On 1/28/2022, the DON reviewed the Facility Activity Report for current residents in all zones (30 residents in red zone and 31 residents in yellow zone and no residents in the green zone [COVID-19 negative area]) for changes of conditions, abnormal vital signs, and symptoms of COVID-19 to ensure no resident was likely affected by the deficient and non-compliant findings. No residents were identified to have been affected. 7. On 1/27/2022, Director of Staff Development (DSD) reviewed list of positive direct care staff and identified 11 positive staff since start of outbreak on 1/25/22. The DSD contacted the 11 staff and verified the return-to-work guidelines. All identified staff members stated they did not have any symptoms when they returned to work and currently remained asymptomatic (not having symptoms). 8. On 1/27/2022, the ADM identified an IPN from a sister facility to assist with the current infection prevention program starting on 1/28/2022 until the full time IPN returned to work on 1/29/2022. 9. On 1/28/2022, screener desk (area where staff and visitors are screened for fever and COVID-19 symptoms) was moved closer to entrance door to better serve the employees and visitors coming into the facility by physically screening each person who walks in. The screeners have been trained by IPN to monitor for symptoms of COVID-19 and have been directed to send anyone home and call their supervisor should they present with symptoms. A list of every employee will be present at the screening desk with their fit tested N95 model number and the screener will provide only the mask that the employee has been fit tested . Registered Nurse (RN), Supervisor, or licensed nurse on night shift will screen employees. No visitation is allowed during this shift. 10. In-service and education started on 1/27/2022 by DON and DSD on infection control practices such as hand hygiene, proper use of PPE in the different zones, donning (to put on) and doffing (to remove) in entering and exiting isolation rooms, N95 fit testing, signs and symptoms of COVID-19, current screening process for staff and visitors, guidelines to return to work, and maintaining an updated line list of positive staff and residents. In-services by the IPN, DSD, and DON will continue until 100% of all staff are trained and will be completed on 2/1/2022. Findings: 1. During an interview on 1/27/2022, at 9:25 a.m. with TX 1, TX 1 stated, If I were you, I wouldn't stand that close to me. I just tested positive for COVID on Friday. TX 1 stated he had COVID-19 symptoms. TX 1 stated, I'm lightheaded and have shortness of breath. TX 1 stated he needed to work to pay his bills. During a concurrent observation and interview on 1/27/2022 at 9:27 a.m., TX 1 was observed wearing an N95 mask and coughing. When asked about his N95 respirator, TX 1 stated, You are stressing me out because I do not know what is happening right now. I do not feel well. I feel short of breath right now. I'm stressing out. During an interview on 1/27/2022 at 11:07 a.m., DON stated TX 1 was assigned to treat residents in the entire building. The DON stated TX 1 treated residents in the yellow and red zones. During an interview on 1/27/2022 at 12:19 p.m. with TX 1, TX 1 stated he does not lie so when the screener questioned him at the start of his shift on 1/27/22, about COVID-19 symptoms, TX 1 stated he told her the truth. TX 1 stated he told the screener he did not feel well and that he had COVID-19 symptoms. TX 1 stated he was sweating and dying and he did not feel good. TX 1 stated he was a new hire and his first day of work was on 1/29/2022. TX 1 stated he felt sick on 1/21/2022, took a COVID-19 rapid test on the same day at home and it resulted positive for COVID-19. TX 1 also stated that he notified the IP and DON of his positive test result on 1/21/22. During an interview on 1/27/2022 at 1:21 p.m. with DON, DON stated TX 1 did not mention he had COVID-19 symptoms. DON stated after a staff had a positive COVID-19 test at home on 1/21/2022, the facility had to perform a COVID-19 polymerase chain reaction ([PCR] type of test used to detect COVID-19 infection) test. DON stated she sent TX 1 a text message on 1/25/2022 asking TX 1 to come to the facility to take a PCR test, but TX 1, did not come. The DON stated TX 1 was off did not work since 1/21/22. DON staff who had COVID-19 symptoms had to notify the DON, ADM, and the IPN. The DON stated, TX 1 should not be working in the yellow zone with symptoms to minimize the spread of COVID-19. During a concurrent interview and record review of the Department of Public Health (DPH) All Facilities Letter (AFL) 21-08.7 guidance with ADM, on 1/27/2022, at 1:30 p.m., ADM stated he followed the DPH AFL 21-08.7 guidance which allowed TX 1 to work if there was a staffing shortage. The ADM stated, the AFL addressed asymptomatic (not having symptoms) staff returning to work. During an interview on 1/29/2022 at 3:08 p.m. with ADM, ADM stated TX 1 admitted he entered information in the electronic screening (an electronic system where staff screen for COVID-19 symptoms/exposure before entering the facility) as not having COVID-19 symptoms so he could work. The ADM stated TX 1 told him he lied about not having COVID-19 symptoms because he needed to work. During an interview on 2/1/2022 at 11:40 a.m. with IPN, IPN stated TX 1 was supposed to quarantine (isolate) for 10 days and if symptoms subsided after 10 days, then TX 1 could return to work on the 11th day. IPN stated when the staff tested positive for COVID-19 and had light symptoms after 10 days of quarantine, and the facility had a staffing shortage, then the staff could work in the red zone. The IPN stated the facility did not follow their protocol by not letting TX 1 back to work until after 11 days after testing positive for COVID-19. The IPN stated TX 1 should have had a COVID-19 PCR test done. The IPN stated TX 1 should not have been working with COVID-19 symptoms. 2. During an observation on 1/27/2022 at 9:11 a.m., LVN 1 exited a room in the yellow zone wearing an N95 respirator, gloves, face shield, and a gown. LVN 1 did not doff (remove) her PPE and did not perform hand hygiene. LVN 1 walked to the medication cart in front of Resident 1's room and entered Resident 1's room, located in the yellow zone. LVN 1 exited Resident 1's room while wearing the same PPE and without performing hand hygiene. LVN 1 then entered Resident 2's room while wearing the same PPE and did not perform hand hygiene. During an interview on 1/27/2022, at 9:28 a.m. with LVN 1, LVN 1 stated she forgot to change her PPEs before entering different residents' rooms in the yellow zone. LVN 1 stated she forgot to do hand hygiene. LVN 1 stated she was supposed to wear a new gown, gloves, shield, and an N95 respirator before entering a room in the yellow zone. LVN 1 stated she had to change her PPEs and perform hand hygiene between residents' care to prevent the spread of COVID-19. 3. During a record review of a facility's form titled Qualitative Fit Test Certificate, undated, in the facility's N95 respirator fit testing binder, indicated 22 staff members were not fit tested for N95 respirator. The staff who were not fit tested included TX 1, LVN 3, LVN 4, CNA 3, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, PTA 1, MR, OT 1, OT 2, HK 1, HK 3, CK 1, and LA 1. During a concurrent observation and interview on 1/27/2022 at 9:25 a.m. with TX 1, TX 1 was observed wearing an N95 respirator. TX 1 stated he was fit tested for the N95 respirator he was wearing. During an interview on 1/27/2022 at 12:40 p.m. with ADM, ADM stated TX 1 did not have a fit test on file because TX 1 was not fit tested . During a phone interview on 1/27/2022 at 1:42 p.m. with the IPN, IPN stated she provided TX 1 the fit test questionnaire weeks prior, but TX 1 had not completed his fit test. The IPN stated she had not done any fit testing for all 22 staff members listed above because she had only been working for two weeks in the facility. The IPN stated not fit testing and providing staff with the correct fit tested N95 mask could lead to a COVID-19 outbreak in the facility and community. During an interview on 1/27/2022 at 2:38 p.m. with ADM, ADM stated he spoke to the DSD and Minimum Data Set ([MDS], assessment tool used to determine the health and well-being of residents) nurses and they stated TX 1 was not fit tested for the N95 respirator. 4. During a concurrent observation and interview on 1/27/2022, at 9:28 a.m. with CNA 1 in the yellow zone, CNA 1 was observed entering a room without a gown. CNA 1 was observed talking with a resident and she touched the resident's bed linen and did not perform hand hygiene when she exited the room. CNA 1 stated the facility's policy was to wear a gown when entering rooms in the yellow zone. CNA 1 stated she should have worn a gown when she entered the room in the yellow zone and performed hand hygiene upon entering and exiting rooms in the yellow or red zone, to prevent the spread of infection and COVID-19. During a concurrent observation and interview on 1/28/2022, at 4:29 p.m. with CNA 6 in the yellow zone, CNA 6 was observed not wearing a gown or gloves. CNA 6 touched a resident while guiding the resident back into his room and did not perform hand hygiene after touching the resident. CNA 6 stated she knew she had to wear PPEs, such as a gown and gloves, but she did not wear any PPE before her contact with the resident in the yellow zone. CNA 6 stated she forgot to perform hand hygiene when she exited the resident's room. CNA 6 stated it was important to wear proper PPE and perform hand hygiene to prevent the spread of infection and COVID-19. 5. During a record review of the Staff Line Listing, dated 1/27/2022, the line listing indicated TX 1 was not added to list of positive COVID-19 staff. During an interview on 1/27/2022 at 1:21 p.m. with the DON, DON stated on 1/21/2022, she notified IPN about the positive COVID-19 test result for TX 1. DON stated, IPN must have forgotten to indicate TX 1 was positive on the Line Listing. During an interview on 2/1/2022, at 11:40 a.m. with IPN, IPN stated DON notified her about the positive COVID-19 test result for TX 1 on 1/21/2022. IPN stated she overlooked and did not add TX 1 to the Line Listing. IPN stated it was important to keep an updated Line Listing to ensure all positive COVID-19 cases were tracked and monitored to identify staff and residents who were exposed and to control the spread of COVID-19. 6. During a review of Resident 1's Admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 1/27/2022, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. During a review of Resident 1's COVID-19 laboratory result, dated 1/29/2022, the laboratory result indicated Resident 1 was positive for COVID-19. During a review of Resident 2's Admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 usually had the ability to understand and be understood by others. The MDS indicated Resident 2 required supervision and setup only for transfer, dressing, and toilet use. The MDS indicated Resident 2 required one-person assistance with bed mobility and personal hygiene. During a review of Resident 2's COVID-19 laboratory result, dated 1/29/2022, the laboratory result indicated Resident 2 was negative for COVID-19. Resident 2 was in the yellow zone. During a review of Resident 3's Admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's MDS dated [DATE] indicated Resident 3 had the ability to understand and be understood by others. The MDS indicated Resident 3 required one-person assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. During a review of Resident 3's COVID-19 laboratory result, dated 1/29/2022, the laboratory result indicated Resident 3 was negative for COVID-19. Resident 3 was in the yellow zone. During an observation on 1/31/2022, at 1:48 p.m., in the yellow zone, Resident 1, who positive for COVID-19, shared a room with Resident 2 and Resident 3. During an interview on 1/31/2022, at 1:54 p.m. with facility clinical consultant (CS) 1, CS 1 stated Resident 1 was not supposed to be in the same room as Resident 2 and 3. CS 1 stated Resident 1 should have been moved to the red zone on 1/29/2022, when the facility received the positive test results for Resident 1. CS 1 stated it was important to isolate residents appropriately to prevent the spread of COVID-19 to staff and other residents. During an interview on 1/31/2022, at 1:58 p.m. with IPN, IPN stated according to the facility's COVID-19 policy, Resident 1 should have been moved to the red zone. IPN stated Mistakenly or forgotten and was not moved to red zone, we practice wearing same PPE as red zone but I'm not denying that the resident should have been moved. IPN stated Resident 1 was not moved to the red zone because she was overwhelmed moving so many residents on 1/29/2022 and she missed Resident 1. IPN stated, I overlooked this resident and did not realize she tested positive just on 1/29/22. 7. During a concurrent observation and interview on 1/29/2022, at 2:04 p.m., in the yellow zone, AA 2 was observed to reenter the yellow zone from the red zone, after assisting a resident with activities of daily living in the red zone. AA 2 stated she was doing room visits and assisting residents in the red zone. AA 2 stated she was supposed to first visit residents in the yellow zone and finish her shift in the red zone. AA 2 stated it was important no to reenter the yellow zone after seeing residents in the red zone to prevent the spread of COVID-19. During an interview on 1/29/2022, at 2:20 p.m. with IPN, IPN stated once staff entered the red zone, staff was not allowed to reenter the yellow zone. IPN stated AA 2 should visit the residents in the red zone last, and should have exited through the red zone, instead of returning to the yellow zone. IPN stated crossing from the red zone to the yellow zone could bring harm to the residents and spread COVID-19. 8. During an observation on 1/31/2022, at 2:10 p.m., in the red zone, AMB 1 entered Resident 4's room in the red zone without wearing a gown. During a review of Resident 4's Admission Record, indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had the ability to understand and be understood by others. The MDS indicated Resident 4 required supervision and setup only for bed mobility and transfers. The MDS indicated Resident 4 required one-person assist for locomotion on and off the unit, dressing, toilet use, and personal hygiene. During a review of laboratory results, dated 1/29/2022, the results indicated Resident 4 tested positive for COVID-19 on 1/29/2022. During an interview on 1/31/2022, at 2:14 p.m., with CS 1, CS 1 stated AMB 1 should be wearing all required PPEs when entering a room in the red zone to prevent the spread of COVID-19. During a review of facility policy titled Coronavirus (COVID-19) Employee Screening & Testing, dated 3/31/2020, the policy indicated the facility implements infection prevention methods and interventions consistent with Government directives and recommendations to reduce COVID-19 outbreak risk. The policy indicated any employee exhibiting respiratory symptoms with a known COVID-19 exposure must self-quarantine, would not be allowed to work and will only return to work when symptoms (e.g., cough, shortness of breath) had improved. The policy also indicated during critical staffing shortages, exposed asymptomatic staff may return to work after day seven from the last exposure, if they have received a negative PCR test from a specimen collected after day five after the date of last exposure. During a review of facility policy titled Employee Return to Work Policy, dated 2/2/2021, the policy indicated symptom-based strategy for determining return to work for healthcare personnel (HCP) with a positive COVID-19 test, who were asymptomatic throughout their infection, may return to work when at least 10 days have passed since the date of their first positive [CONDITION(S)] diagnostic test and symptoms (i.e., cough, shortness of breath) had improved. During a review of California Department of Public Health All Facilities Letter (AFL) 21-08.7, dated 1/8/2022, the AFL indicated from 1/8/2022 until 2/1/2022, HCP who test positive for COVID-19 and were asymptomatic, may return to work immediately without isolation and without testing. AFL 21-08.7 indicated these HCPs must wear an N95 respirator for source control. During a review of the County of Los Angeles Public Health Guidelines for Managing and Preventing COVID-19 in Skilled Nursing Facilities, updated 1/2/2022, the guidelines indicated initial and annual N95 respiratory fit testing was required for all staff per California Division of Occupational Safety and Health (Cal-OSHA). During a review of facility policy titled Coronavirus disease (COVID-19), Infection Prevention and Control Measures, revised July 2020, the policy indicated while in the building, personnel were required to strictly adhere to established infection prevention and control policies, including hand hygiene and appropriate use of PPE. The policy indicated staff would wear gloves, isolation gown, eye protection, and an N95, prior when providing care to a resident with known or suspected COVID-19. During a review of facility's undated policy titled Handwashing/Hand Hygiene, the policy indicated facility considered hand hygiene the primary means to prevent the spread of infections. The policy indicated use of an alcohol-based hand rub or soap and water before and after direct contact with residents, after contact with objects in the immediate vicinity of the resident, before and after entering isolation precaution settings would be implemented. The policy indicated hand hygiene was the final step after removing and disposing of PPE. During a review of facility's undated policy titled Coronavirus (COVID-19) Policy & Procedure: Care & Placement of Residents/Patients with Known or Suspected COVID-19, or Undiagnosed Respiratory Infection, the policy indicated to report each COVID-19 positive test result for resident and staff cases to the state agency, in addition to current health department reporting requirements. During a review of facility's undated policy titled Coronavirus (COVID-19) Policy & Procedure: Care & Placement of Residents/Patients with Known or Suspected COVID-19, or Undiagnosed Respiratory Infection, the policy indicated residents with known exposure to and individual positive for COVID-19 test results would be moved to the red zone if COVID-19 were positive. The policy also indicated residents with confirmed COVID-19 infection in the red zone would either be in single occupancy or multi-occupancy rooms with other confirmed COVID-19 residents, with the door closed and private curtains between. During a review of facility's MP, dated 9/15/2021, the MP indicated the designated infection control lead maintains a Line Listing of all patients and staff who have been confirmed COVID-19 positive or meet clinical criteria of presumed COVID-19 including testing and results.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program for 6 out of 10 residents (Residents 1, 2, 3, 4, 5, and 9) and 3 of 3 staff (Staff 1, 2 and 3) with scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate your skin by intense itching, inflammation, and red patches) or suspicious rash by failing to: 1. Ensure skin rashes of six Residents (Residents 1, 2, 3, 4, 5, and 9) were assessed, identified, documented, implemented and/or had a plan of care initiated to ensure the residents received an effective treatment plan. 2. Conduct an infection surveillance (close observation or monitoring) by completing a line listing (a table that contains key information about each case in an outbreak) of residents (Residents 1, 2, 3, 4, 5, and 9) and staff with positive scabies and suspicious rash . Two staff (Staff 1 and Staff 3) had a suspicious rash. Staff 2 was positive for scabies on 7/8/2021. 3. Provide the necessary care and treatment to Resident 1, who had a severe itchy rash and was suspected to have scabies on 6/18/2021 and a positive skin scraping (a test to confirm or rule out scabies) for scabies on 6/23/2021, by obtaining skin scraping and reporting the resident's scraping results to the physician timely (as soon as possible), administering [MEDICATION(S)] cream (a medication applied to the entire body to treat scabies) 5% to the resident's skin per manufacturer's guidelines. 4. Adhere to its policy and procedure, standard of practice, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was identified with a suspicious rash on 6/18/2021 and skin scraping was ordered to rule out scabies on 6/18/2021. Resident 1 was not placed on contact isolation precaution until 6/21/2021. 5. Implement physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents 2, 3, 4, 5 and 9 were not placed in isolation prior to 7/1/2021. 6. Ensure a qualified person performed the skin scraping on Resident 1, 2, 3, 4, 5, and 9 , who had rashes and were suspected to have scabies. The facility had the licensed nurses, including the Director of Nursing (DON), do the scraping on the residents and the facility was not able to provide documented evidence the licensed nurses had received training . 7. Report an outbreak of scabies to the local health Department after 6 residents (Residents 1, 2, 3, 4, 5, and 9) had rashes with severe itching, which affected their quality of life, while being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Assess, report to physician, and provide necessary care and treatment (skin scraping, administer medication for relief of scabies, and isolation) to Residents 3 and 5, who were reported by the facility's Activity Director (AD) to be in activities for over a month (from 7/1/2021), scratching vigorously for more than 2 hours and not being able to participate in the activities. AD reported that Resident 5 complained, while crying, that she could not sleep at night, for which the AD reported to the treatment nurse (not identified). 9. Ensure [MEDICATION(S)] was applied to Residents 2, 3, 4, 5, and 9 as per manufacturer's guidelines and not weekly for four weeks, for an effective treatment and prevention of excessive toxic exposure to the residents' skin, which could result in liver damage . 10. Ensure Resident 9 had skin scrapings done prior to the application of [MEDICATION(S)] to prevent false negative skin scraping results. These deficient practices resulted in an ineffective control for scabies identification and prevention that resulted in 6 residents (Residents 1, 2, 3, 4, 5, and 9) exposed to scabies and who were itching and suffering from vigorously scratching the rashes. Resident 5 was observed crying from the severe itching and inability to sleep. This deficient practice placed all residents, staff, vendors, and visitors at risk to acquire and be exposed to the scabies infection. On 7/7/2021 at 5:30 p.m., the Department identified an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident and the situation created a need for an immediate corrective action). The administrator (ADM) and the Director of Nursing (DON) were notified at this time of the immediate actions that needed to be taken and the seriousness of the resident's health and safety threatened due to facility's failure to establish and maintain an infection control program. On 7/10/2021 at 2:36 p.m., the ADM provided an acceptable Plan of action (POA) for correction of the IJ. The POA included the following: 1. The staff will conduct and document full skin checks on all residents. Started on 7/7/2021 and completed on 7/8/2021. 2. The staff to document comprehensive line listing of all residents with scabies using a line listing tool. Started on 7/7/2021 and completed on 7/9/2021. 3. The staff will communicate with residents and staff identified at risk from this outbreak but who no longer at the facility. Started on 7/8/2021 and completed on 7/9/2021. 4. The staff will ensure linen and laundry are processed properly for all positive residents with scabies . Started on 7/7/2021. 5. The staff will ensure all positive residents and residents with concerning symptoms identified from 7/7/21 skin sweep was immediately and properly isolated. Ensure proper isolation precaution sign posted and supplies at room entry. Isolation not to be discontinued until 24 hours after treatment is completed, if 2 doses of [MEDICATION(S)] are needed, then 24 hours after second dose. Started on 7/7/2021 and to be completed on 7/23/2021. 6. The licensed nurses on staff will be properly trained by the dermatologist (a physician who specializes in the study of diseases and conditions of the skin) with verified competency validated to perform skin scraping and the staff will maintain proper documentation of competency validation. Started and completed on 7/7/2021. 7. All licensed nursing staff will be trained weekly on comprehensive skin assessments on admission and every 4 weeks, educate all caregiving staff on concerning skin signs and symptoms to report to licensed nurse for further assessment and follow up. Started on 7/7/2021 and ongoing. 8. The dermatologist to complete all needed skin scrapings for the 1 resident (Resident 9) and any others identified as part of full skin sweep conducted on 7/7/2021 and completed on 7/8/2021. 9. The nursing staff education will include the need to regularly monitor skin rashes pending diagnostic tests for results and to report results timely (as soon as possible) to the physician (MD), Infection Preventionist (IP ) (when appropriate) and residents' responsible party (when appropriate). To be completed on 7/16/2021. 10. All care givers will receive the same training content as all staff, which included how scabies is treated, caregiver precautions, how to handle linen and laundry and concerning signs to watch for and report to licensed nursing staff for evaluation and follow up. All licensed nursing staff, caregivers and registry staff will receive in-services on how to perform proper skin assessments on admission and every four weeks, proper documentation and care planning, how scabies is effectively treated, isolation protocols and when it is appropriate to discontinue isolation. The in-services included empowering nursing staff to initiate isolation precautions for any suspicious skin symptoms pending further assessment and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/10/2021 at 2:36 p.m., while onsite, after the POA was verified as implemented by observation, interviews and record review, the ADM was notified and the IJ was lifted. Findings: a. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 5/4/2021, the MDS indicated Resident 1's cognition (ability to reason and think) was intact, required extensive assistance (resident involved in activity; staff provide weight bearing support) of a one-person to two-person physical assist with transfers, toileting, and personal hygiene due to impairment of the upper and lower left extremities. The MDS indicated Resident 1 did not have any skin problems. During a review of Resident 1's nurse's progress note (NPN), dated 6/12/2021 and timed at 4:09 p.m., the NPN indicated Resident 1 received a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's NPN, dated 6/18/2021 and timed at 2:19 p.m., the NPN indicated the facility's medical director (Physician 1) assessed Resident 1's skin and ordered skin scraping to rule out scabies. During a review of Resident 1's care plan titled, Noted with generalized body rash to the right hand and back, dated 6/18/2021, the care plan indicated for the staff to conduct daily skin care and checks, a dermatologist consult, monitor and record any complaints of pain, itching discomfort including location, quantity, quality, alleviating factors, aggravating factors, and observe for new rashes or increased itching. Resident 1's care plan did not indicate for the staff to place Resident 1 on isolation precautions. During a review of Resident 1's NPNs, dated 6/19/2021 and timed at 4 p.m. and 9:21 p.m. the NPNs indicated Resident 1 was being monitored for rashes on her right hand, right arm, and back. During a review of Resident 1's NPN, dated 6/21/2021 and timed at 3:41 p.m., the NPN indicated Resident 1's skin scraping was done by the facility's nurse (not identified), three days after the physician ordered the scraping on 6/18/2021. During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of the [MEDICATION(S)] cream being washed off 8 to 14 hours after the application . During a review of [MEDICATION(S)] Plus article, titled [MEDICATION(S)] Topical dated 1/15/2018, indicated [MEDICATION(S)] cream is applied to the skin from the neck down to the toes in one treatment. The entire [MEDICATION(S)] cream tube could be used to cover the body, the cream should be left on for 8 to 14 hours, then washed off by bathing or showering. Retrieved from https://medlineplus.gov/druginfo/meds/a 7.html. During a review of Resident 1's NPN, dated 6/21/2021 and timed at 8:50 p.m., the NPN indicated Resident 1 was given prophylactic treatment [sic] for scabies and placed on contact isolation precautions. During a review of Resident 1's laboratory record, dated 6/21/2021 and timed at 12 p.m., the laboratory record indicated Resident 1 skin scraping was collected and on 6/23/ at 8:08 p.m., and Resident 1 tested positive for scabies. During a review of Resident 1's NPN, dated 6/22/2021 and timed at 10:15 a.m., the NPN indicated Resident 1's primary physician was notified of Resident 1's rashes of the right hand and the back with continued itching and the resident's primary physician ordered for the staff to apply [MEDICATION(S)] (a medication used for reducing itching, redness, and swelling associated with many skin conditions) 1 % cream to Resident 1's right hand and back twice daily for 14 days. During a review of Resident 1's WS, dated 6/6/2021, 6/12/2021, 6/15/2021, 6/19/2021 and 6/26/2021, the WS indicated Resident 1 did not have a rash. During a review of Resident 1's NPN dated 7/1/2021 and timed at 8:49 p.m., the NPN indicated the facility's Dermatologist assessed Resident 1 and gave orders for the staff to apply [MEDICATION(S)] (a medication used to treat scabies), topical [MEDICATION(S)] (a medication used for reducing itching, redness, and swelling associated with many skin conditions) and [MEDICATION(S)]. During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 7/1/2021 at 10:36 a.m., with the DON, the DON stated Resident 1 was in isolation because Resident 1 had scabies. During an interview on 7/1/2021 at 10:39 a.m., with Resident 1, Resident 1 stated her arms and back were itching, and she was receiving cream for the itching. During an interview on 7/1/2021 at 10:41 a.m., with the facility's Infection Control Nurse ([ICN] a licensed nurse in-charge of identifying, monitoring and preventing infection in the facility), the ICN stated he was not sure when Resident 1 contracted scabies. The ICN stated the medical director was in the facility on 6/18/2021 and observed Resident 1's skin. The ICN stated the facility learned of Resident 1 possibly having scabies and placed the resident in contact isolation on 6/21/2021. The ICN was asked why Resident 1 was not placed on contact isolation precautions when the resident was initially suspected of having scabies to prevent the spread of scabies to other residents and the staff. The ICN stated he was not initially informed about Resident 1's suspected scabies and he did not know why the staff did not place Resident 1 in isolation. During the interview on 7/1/2021 at 10:41 a.m., the ICN stated he did not complete a line list of staff and residents who had a rash and who had direct and/or indirect contact with Resident 1. The ICN stated he did not complete a surveillance infection log indicating Resident 1 had a rash or was suspected of having scabies on and after 6/18/21. The ICN stated he was not able to complete the line listing for scabies due to not being able to obtain the staff's assignments because the Director of Staff Development (DSD) was not in the facility and the DSD's office was locked. During an interview on 7/1/2021 at 12:54 p.m., with the Registered Nurse Supervisor (RNS 1), RNS 1 stated there were three (3) residents (Resident 3, 5, and 9) in the facility with a rash. During an interview and concurrent review of Resident 1's NPN with the ICN, on 7/7/2021 at 9:50 a.m., the ICN was asked about Resident 1's NPN, dated 7/2/2021 and timed at 3:11 p.m., as a late entry, the NPN indicated on 6/24/2021, Resident 1's skin scraping test results were positive and Resident 1's responsible party (RP) was notified. The ICN stated he became aware of Resident 1's positive skin scraping results on 6/24/2021, but he forgot to document Resident 1's positive scabies results in the NPN and did not contact Resident 1's primary physician. The ICN was asked why he did not inform the Local Health Department of Resident 1's positive skin scraping during an interview on 7/1/2021 at 10:41 a.m., when he was asked about Resident 1's skin scraping results, the ICN recanted his prior statement and stated he forgot to check the computer portal for Resident 1's lab results after 6/22/2021. During an interview on 7/1/2021 at 10:03 a.m., with the DON, the DON stated on 7/1/2021, she was informed of Resident 1's positive scabies results by the ICN eight (8) days later (on 6/22/2021) . The DON stated she on 7/1/2021, she informed Resident 1's physician and responsible party on the positive scabies results. During an interview on 7/7/2021 at 12:59 p.m., with the DON, the DON stated the Treatment Nurse (TN) performed Resident 1's initial skin scrapings and demonstrated to the staff how to perform skin scrapings. The DON stated she performed skin scrapings on the remaining residents (Resident 2, 3, 4, and 5). During an interview on 7/7/2021 at 2:30 p.m., with the DON, the DON was asked which area she scraped during the skin scrapings, the DON stated she scraped the rash area where she observed tunneling. b. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's recap physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired, required extensive assistance with a one-person physical assistance with transfers, toileting, and personal hygiene. The MDS indicated Resident 2 did not have any skin problems. During a review of Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's revised care plan, dated 4/29/2021 and titled, At risk for further skin breakdown due to skin condition: [CONDITION(S)] [CONDITION(S)], actinic keratoses (rough, scaly patches on the skin) on the face and arms and limited mobility, bedfast and altered ADL (activities of daily living), the care plan indicated for the staff to follow-up with a dermatology consult for Resident 2, monitor Resident 2's skin for any signs of skin breakdown (sore, tender, red, or broken areas), and weekly skin checks, refer to weekly summary. During a review of Resident 2's recap physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's NPN, dated 5/5/2021 and timed at 4:23 p.m., the NPN indicated the Dermatologist and Nurse Practitioner ([NP] a nurse with additional education and training in a specialty area) assessed and ordered isolation for questionable scabies for Resident 2. The NPN indicated Resident 2's skin was scraped, did not indicated who conducted the scraping and the lab was notified to pick up the skin scraping sample. During a review of Resident 2's Skin Integrity Conditions (SIC) record, dated 5/10/2021, the SIC indicated Resident 2 had a rash to the back, both arms and both legs. The SIC indicated Resident 2 was on strict isolation for queried questionable scabies. During a review of Resident 2's NPN, dated 5/10/2021 and timed at 11:39 a.m., the NPN indicated Resident 2's skin scraping was negative and contact isolation for Resident 2 was discontinued. During a review of Resident 2's NPN, dated from 5/26/2021 at 12:50 a.m., 5/31/2021 at 1:18 a.m., the NPNs indicated Resident 2 received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 2's NPN, SIC and WS , from 5/2021 through 7/2021, there was no documented evidence of a description of Resident 2's rash to the back, arms, and legs. During a review of Resident 2's recap physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] (1) On 7/1/2021-[MEDICATION(S)] 3 milligram ([mg] a unit of measurement), by mouth, once every Friday for [CONDITION(S)]. (2) On 7/2/2021-[MEDICATION(S)] cream 5% once, every Friday evening, for [CONDITION(S)], for 5 weeks. (3) On 7/2/2021- Strict contact isolation for suspected scabies. (4) On 7/2/2021-Skin scraping to rule out scabies. During a review of Resident 2's MAR, dated for the month of 7/2021 the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's skin scraping laboratory test, the lab test indicated Resident 2's skin was scraped on 7/2/2021 for scabies (by the DON) and on 7/5/2021, Resident 2 tested negative for scabies. During an observation on 7/7/2021 at 11:40 a.m., with Resident 2, observed Resident 2 lying in bed with a bed raised rash all over his back area, arms, thighs, head, and face. During an interview on 7/7/2021 at 2:41 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated on 6/23/21, she observed Resident 2 with a rash all over his body . CNA 2 stated while cleaning Resident 2, he was constantly scratching his arms a lot. c. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's care plan, dated 2/3/2021 and titled, Noted with generalized body rash (contact [CONDITION(S)]) to right lateral back and thigh, the care plan indicated for the staff to conduct daily skin care and skin checks on Resident 3, for Resident 3 to receive a dermatology consult, and monitor and record any complaints from Resident 3 of pain, itching, discomfort (location, duration, quantity, quality, alleviating factors and aggravating factors). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognition was severely impaired, required extensive assistance with a two-person physical assist with bed mobility and toileting and a one-person physical assist with personal hygiene. The MDS indicated Resident 3 did not have any skin problems. During a review of Resident 3's recap physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] (1) On 4/28/2021 : [MEDICATION(S)] (medication used to help relieve redness, itching, swelling, caused by skin conditions) lotion 0.05 % twice daily to the back and thighs for 4 weeks for erythematous [CONDITION(S)] (severe inflammation of the entire skin). (2) On 4/28/2021 : [MEDICATION(S)] (an antifungal medication used to treat infections such as athlete's foot (fungal infection that usually begins between the toes), [MEDICATION(S)] (the rash often affects the groin and inner thighs and may be shaped like a ring), ringworm (a common skin infection that is caused by a fungus), and seborrhea (dry, flaking skin or dandruff) cream 2% twice a day to the back and thighs for 4 weeks for erythematous [CONDITION(S)]. (3) On 6/8/2021: [MEDICATION(S)] cream 1% twice daily to the upper body for 4 weeks for unspecified [CONDITION(S)]. During a review of Resident 3's WS, dated 5/6/2021 at 2:56 a.m. and 6/5/2021 at 3:19 p.m., the WS indicated Resident 3 had [CONDITION(S)] to the back and both thighs and received ongoing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's recap physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] (1) On 7/1/2021-[MEDICATION(S)] 3 mg, by mouth, once every Friday for [CONDITION(S)]. (2) On 7/2/2021-[MEDICATION(S)] cream 5% once, every Friday night, for [CONDITION(S)], for 5 weeks. (3) On 7/2/2021- Strict contact isolation for suspected scabies. (4) On 7/2/2021-Skin scraping to rule out scabies. During a review of Resident 3's NPN, dated 7/1//2021 and timed at 9:49 p.m., the NPN indicated the facility's Dermatologist assessed Resident 3, ordered contact isolation precautions, and skin scraping to rule out scabies. During a review of Resident 3's MAR, for the month of 7/2021, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's NPN, dated 7/2/2021 and timed at 10:03 p.m., the NPN indicated Resident 3's skin scraping was completed (by the DON) and picked up by the contracted laboratory. During a review of Resident 3's skin scraping laboratory test, the lab test indicated Resident 3's skin was scraped on 7/2/2021 for scabies and on 7/5/2021, Resident 3 tested negative for scabies. During a review of Resident 3's NPN, dated 7/5/2021 and timed at 4:12 p.m., the NPN indicated Resident 3 was receiving treatment due to a rash and was observed scratching self due to itching. During an interview on 7/8/2021 at 12:50 p.m., with CNA 4, CNA 4 stated Resident 3 was observed itching and scratching a red raised bumpy rash on his back, both sides, and right side of his neck three days ago. During an interview on 7/8/2021 at 2:08 p.m., with the AD, the AD stated Resident 3 was in the activities room prior to 7/1/2021 and was observed scratching his arms and stomach really fast. The AD stated Resident 3 would scratch from 10 a.m. until 12:45 p.m. The AD stated Resident 3 would stop scratching for 3-5 minutes and would start scratching again. The AD stated Resident 3 was moving in his chair from side to side as if he was trying to scratch his back. The AD stated there were other residents (not identified) in the activities room during the same time Resident 3 was in the activities room. The AD stated Resident 3 had been itching and scratching for over a month while in the activities room. The AD stated she had informed the prior TN that Resident 3 was itching. During an observation on 7/8/2021 at 2:22 p.m., with Resident 3, Resident 3 was observed lying in bed with a red raised rash to his entire back and was observed squirming in bed, moving his back from a left to right motion as if he was scratching his back. During a concurrent interview and record review on 7/9/2021 at 11:21 a.m., of Resident 3's WS dated on 6/26/2021 at 2:59 p.m. with RNS 1, the WS indicated Resident 3 had a generalized body rash. The RNS 1 stated the staff should have documented a description of Resident 3's generalized rash in Resident 3's WS and CSI. d. During a review of Resident 4's Face Sheet, the Face Sheet indicated Resident 4 was initially admitted to the facility on [DATE] and last readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognition was intact, required extensive assistance with a two-person physical assist with bed mobility, and toilet use and a one-person physical assist with personal hygiene and dressing. The MDS indicated Resident 4 did not have skin problems. During a review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's WS, dated 5/1/2021, 5/8/2021, 5/14/2021 and 5/21/2021, the WS indicated Resident 4 did not have a rash, but received oxiconazole cream to generalized body. During a review of Resident 4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's WS dated 6/4/2021, 6/12/2021, 6/18/2021 and 6/25/2021, the WS indicated Resident 4 did not have a rash or no new skin conditions. During a review of Resident 4's NPN, dated from 5/1/2021 through 6/28/2021, there was no documented evidence of a description of Resident 4's generalized body condition. During a review of Resident 4's Compromised Skin Integrity (CSI) note, dated 7/1/2021, the CSI note indicated Resident 4 had small, dark spots on her front upper body and arms. During a review of Resident 4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's MAR, dated for the month of 7/2021 the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's care plan, dated 7/2/2021 and titled, Noted with [CONDITION(S)], the care plan indicated for the staff to conduct daily skin care and checks as indicated, dermatology consult, monitor and record Resident 4 for any complaints of pain, itching, discomfort (location, quantity, quality, alleviating factors and aggravating factors), observe Resident 4 for new rashes or increased itching, contact and skin scraping to rule out scabies. During a review of Resident 4's NPN, dated 7/2/2021 and timed at 10:01 p.m., the NPN indicated Resident 4's skin scraping was completed (by the DON) and sent to the lab. During a review of Resident 4's skin scraping laboratory test, dated 7/6/2021, the lab test indicated Resident 4's skin was scraped on 7/2/2021 for scabies, and on 7/6/2021 Resident 4 tested negative for scabies. During a concurrent observation of Resident 4's skin with the DSD on 7/7/2021 at 11:58 a.m., Resident 4 was observed lying in bed with dark scattered spots all over her stomach and upper thighs. Resident 4 stated she had a rash and been itching for the past two months. Resident 4 stated her rash was itchy and was an 11 on a scale of 1 through 10, 10 meaning the itching was worse. Resident 4 stated she scratched like a dog and the itching badly. e. During a review of Resident 5's Face Sheet, the Face Sheet indicated Resident 5 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 5's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 5's the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] (1) On 3/28/2021, Dermatology consult for a rash of unknown origin, [MEDICATION(S)] cream 1% to arms and back, twice daily for 14 days. (2) On 3/31/2021, [MEDICATION(S)] cream 1 % , three times a day bilateral (both) upper extremity itchy rash. (3) On 6/8/2021, [MEDICATION(S)] (medicated cream to treat skin rash) cream 0.05%, twice daily to generalized body for 4 weeks. During a review of Resident 5's WS, dated 4/21/2021, the WS indicated Resident 5 had a rash to the back, bilateral upper extremities and chest and received on-going treatment. During a revi

Based on observation, interview, and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices resulted in Resident 1's left first metatarsal (bones in the foot) and left hip scabs to worsen into an arterial wound (open, painful injuries found on the lower extremities due to poor circulation) on the left foot metatarsals and left hip to worsen into a Stage IV (full-thickness skin and tissue loss in which actual depth of the ulcer is completely obscured by slough [death tissue] and/or eschar [death tissue that falls off from the skin] in the wound bed) pressure ulcer (injury to the skin and/or underlying tissue over a bony prominence as a result of pressure or pressure in combination with shear-layers, and or friction-surfaces sliding against each other) and potentially worsen Resident 2's wounds. Findings: a. During a review of the Resident 1's Admission Record (Face Sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS) a resident assessment and care-screening tool), dated 2/2/2021, the MDS indicated Resident 1 had severe impairment in cognitive skills (ability to think) for daily decision making and was totally dependent on staff with one-person physical assist for bed mobility, dressing, personal hygiene, and eating. During a review of Resident 1's Braden Scale (system to determine if a resident is at risk for pressure sores), dated 1/27/2021, the Braden Scale indicated Resident 1 had no arterial ulcers, no existing pressure ulcer. The Braden Scale also indicated Resident 1 was at high risk of developing pressure ulcers. During a review of Resident 1 's Care Plan titled, Skin Care Plan, dated 1/27/2021, the care plan indicated Resident 1 was at risk for altered skin integrity due to cognitive (thought process) impairment, diabetes, altered activities of daily living ([ADL] grooming, brushing teeth, combing hair, eating), and bowel and bladder incontinence (inability to control urine and feces). The staffs' interventions included to provide pressure relieving devices for bed and chair, keep clean and dry as possible, minimize skin exposure to moisture, monitor for any signs of skin breakdown, pressure relieving devices for bed, turn and re-position frequently and weekly (skin) checks. During a review of Resident's 1 Physician Orders, dated 3/28/2021 with an end date of 4/5/2021, the order indicated for treatment to Resident 1's left foot, and left hip, cleanse daily with normal saline (a mixture of salt and water), pat dry, and apply [MEDICATION(S)] (antiseptic use for skin disinfection) and cover with dry dressing daily as needed for 14 days then reevaluate. During a review of Resident 1's Progress Notes, dated 3/29/2021 at 4:42 p.m., the notes indicated Resident 1 had a blister (small bubble on the skin filled with serum and caused by friction or damage) on the left great toe measuring four (4) by (x) four (4) centimeters ([cm] units of measurement) and left hip open healing scabbed area (crust is formed by coagulation of the blood) measuring 4.5 x 4 cm. The note indicated Resident 1's physician and responsible party (RP) were made aware. During a review of Resident's 1 Wound Care Consultation Note (WCCN [action or process of formally discussing a problem]), dated 4/1/2021, the WCCN indicated Resident 1 had a left first metatarsal arterial wound, measuring 3.1 x 3 x 0.2, 50 percent (%) granular (healing tissue), 50% slough, left hip Stage IV measuring 6 x 3.5 x 2 cm and 100% slough at the base of the wound. The WCCN recommendations indicated for staff to monitor/offload (minimize or remove weight placed on the foot to help prevent and heal ulcers), Santyl (medication used to treat ulcers), [MEDICATION(S)] (cream used to prevent and help with ulcers and skin infections) for moisture prevention, A & D ointment (cream used to help with skin irritation) for skin maintenance, apply heel protectors (boot that helps prevent pressure and friction from the surfaces of a bed or wheelchair) at all times while in bed, every two hours turning at all times while in bed. During a review of Resident 1's Medication Administration Records (MARs), dated 4/2021, the MARs did not indicate wound treatments were initiated for Resident 1's left great toe arterial ulcer and left hip Stage IV from 4/1/2021 through 4/5/2021, five (5) days after the initial wound consultant gave the recommendations for treatment. There was no evidence found to indicate the physician was made aware of the recommendations for wound treatments. During a review of Resident's 1 Progress Notes, late entry dated 4/5/2021 at 1:34 p.m., the note indicated on 4/2/2021 at 8:27 a.m., Resident 1 was seen by the wound care specialist for the left first metatarsal fluid filled blister. The note indicated orders were given to treat the left foot arterial wound with [MEDICATION(S)] solution, heel protectors and offloading. The note indicated Resident 1 had a left hip open scab scar tissue site, reclassified as Stage IV pressure injury with bedside debridement (removal of death skin) with 100 % slough and treatment orders for Santyl ointment cover with foam dressing, place resident on low air loss mattress (LAL), supplement vitamins for wound healing weekly and wound care visits. During a review of Resident 1's physician orders, dated 4/6/2021 with end date of 4/28/2021, the orders indicated the following: 1. Left great toe arterial ulcer treatment daily with normal saline, pat dry, and apply [MEDICATION(S)] and cover with dry dressing daily and as needed for 14 days then re-eval. 2. Left hip Stage IV pressure injury, cleanse daily with normal saline, pat dry, apply Santyl ointment and cover with foam dressing daily and prn for 14 days then re-eval. During a review of Resident 1's MAR, dated 4/2021, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's MAR, dated 1/28/2021 through 4/25/2021, the MARs orders indicated to apply heel protectors to bilateral (both sides) heels when in bed. The TARs had missing signatures on 2/7/2021 am, 2/14/2021 am, 3/7/2021 am, 3/13/2021 am, 3/20/2021 am, 3/21/2021 am, 4/11/2021 am, 4/12/2021 pm, 4/24/2021 am and 4/25/2021 am. b. During a review of Resident 2's Face Sheet, the face sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, a resident assessment and care-screening tool, dated 2/2/2021, the MDS indicated Resident 2 had severe impairment in cognitive skills (ability to think) for daily decision making and required extensive assistance of a one-person physical assist for bed mobility, dressing, personal hygiene, and limited assistance with eating. The MDS indicated Resident 2 was at risk of developing pressure ulcers. During a review of Resident 2's Braden Scale (form to determine risk for pressure sores), dated 2/4/2021, the Braden scale indicated Resident 2 was at high risk for developing pressure ulcers. During a review of Resident 2's Admission Body Check, dated 2/4/2021, the body check indicated Resident 2 had a Stage III sacral wound measuring 2 x 2x 0.2 cm with 100% slough: right 5th metatarsal deep tissue injury measuring 0.5 x 0.5 100 % eschar, right hallux deep tissue injury 1 x 1 with 100 % eschar. During a review of Resident 2 's Care Plan titled, Skin Care Plan, dated 2/4/2021, the care plan indicated Resident 2 was at risk for altered skin integrity related to cognitive impairment. The staffs' approach included to provide pressure relieving devices for bed and chair, keep clean and dry as possible, minimize skin exposure to moisture, monitor for any signs of skin breakdown, treatments for wound care as ordered, turn and re-position frequently and weekly checks. During a review of Resident 2's Care Plan titled, Impaired Skin Integrity, dated 7/1/2021, indicated impaired skin integrity as evidence by maceration area to sacrum. Approaches includes cleanse and treat skin maceration, keep resident representative and medical doctor updated, monitor and document signs and symptoms of infection and notify medical doctor as indicated. During a review of Resident's 2 WCCN, dated 7/8/2021, the WCCN indicated the following: 1. Right distal great toe arterial wound measures 2.0 x 2.0 cm wound base eschar 2. Right fifth lateral toe arterial wound measures 4.5 x 2.5 cm wound base eschar 3. Right lateral ankle arterial wound measures 1.5 x 1.5 x 0.2 cm wound base 100% granular 4. Left great toe arterial wound measures 3.5 x 2.5 cm wound base eschar 5. Right fourth toe dry gangrene measures 2.0 x 1.0 cm wound base eschar 6. Right first metatarsal arterial wound measures 2.0 x 2.0 cm wound base eschar 7. Right lateral plantar foot dry gangrene measures 6.0 x 6.5 cm wound base eschar The orders indicated to treat all wounds with [MEDICATION(S)]. During a review of Resident's 2 WCCN, dated 7/1/2021, the WCCN indicated Sacral Stage III wound measured 3.0 x 0.3 cm with 90 % granular, 10% slough. Wound orders indicated therahoney gel plus foam and offload. During a review of Resident 2's MAR, dated 2/14/2021 through 7/22/2021, the MARS indicated Resident 2's wound treatments were missed on 2/14/2021, 02/21/2021, 04/11/2021, 04/18/2021, 04/25/2021, 04/25/2021, 05/16/2021, 05/22/2021, 05/23/2021, 6/26/2021, 7/22/2021. During a review of Resident 2's MAR, dated 2/14/2021 through 7/24/2021, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation of Resident 2's wound treatment and interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed performing wound care to Resident 2, no heel protector was observed on bilateral heels as ordered by the physician. c. During an interview with LVN 1 on 7/26/2021 at 10:55 a.m., LVN 1 stated if the treatment administration record was not signed, it meant treatment was not done. During an interview with Director of Nursing (DON) on 7/26/2021 at 11:30 a.m., the DON stated the facility had been using registry on the weekend to do treatment to residents. The DON stated if the treatment administration record was not signed, it meant, it was not done. During a phone interview with LVN 1 on 8/5/2021 at 10:48 a.m., LVN 1 stated any recommendations made by wound care specialist were considered as an order and needed to be carried out the same day it was given. LVN 1 stated treatment nurses were responsible for inputting the orders in the resident's chart. LVN 1 stated any delay in initiating recommendations from the wound care specialist can result in a delay of progress of resident's pressure ulcer or injury. During a review of the facility's undated Policy and Procedure (P/P), titled Prevention of Pressure Ulcers/Injuries, the P/P indicated to evaluate, report and document potential changes in resident's skin and review the interventions and strategies for effectiveness on an ongoing basis. During a review of the facility's undated P/P, titled Pressure Injury Management Guidelines, the P/P indicated a Stage IV pressure injury to be treatment with normal saline or wound cleanser, moderate exudate (fluid from a wound), apply collagen (protein in the human body), calcium alginate (wound dressing used to moderate to heavy exudate wound), honey alginate (wound dressing used to absorb fluid from wound), or super absorbent dressing.

Based on interview and record review, the facility failed to ensure for two of three sampled residents (Resident 1 and Resident 2) received all the necessary care and services to prevent pressure ulcer/pressure injury ([PU/PI] injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development. The facility failed to: 1. Adhere to Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Ensure Residents 1 and 2 were turned every two hours to prevent pressure ulcers, as per the resident's plan of care. 3. Ensure Residents 1 and 2 received skin care to prevent PU/PI. This deficient practice resulted in Resident 1 developing a Stage II (shallow opening of the skin tissue with the presence of a blister) pressure ulcer of the coccyx (tailbone) with full thickness (layers of the skin are damaged) skin loss and a fungal rash to both buttocks that required wound care treatment. Resident 2 developed a Stage IV (deep tissue injury with exposure of the muscles and/or bones) pressure ulcer of the sacrogluteal (tailbone and buttocks) that required a wound consultation (a specialist in wounds). Findings: a. During a review of Resident 1's Admission Record (face sheet), the face sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Admission Assessment (AA), dated 2/27/2021 and timed at 4:51 p.m., the assessment indicated Resident 1 had moisture associated skin damage from incontinence (lack of voluntary control over urination or defecation). The AA indicated Resident 1 had a surgical wound to the left chest. The AA indicated Resident 1 did not have any pressure ulcer/pressure injury (PU/PI). The AA indicated Resident 1's Braden Scale (an assessment tool for predicting pressure sore risk) Pressure Sore Risk Assessment (PSRA), dated 2/27/2021, the PSRA indicated Resident 1 was assessed as having a score of 11. According to the Braden Scale Risk Assessment, a total score of 12 or less represented a high risk. The AA's Body Check section indicated Resident 1 had an intergluteal (between the buttocks) cleft (split) skin tear. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's history and physical (H/P), dated 2/28/2021, the H/P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's care plan, dated on 3/1/2021 and titled, At risk for altered skin integrity related to existing pressure ulcer, limited mobility/bedfast, history of resolved ulcer altered activities of daily living ([ADLs] daily routine activities such as eating, bathing, dressing, toileting, transferring and walking) ability, incontinence of the bowel and bladder. The staff's interventions indicated for staff to monitor Resident 1's skin for any signs of skin breakdown (sore, tender, red, or broken areas), keep clean and dry as possible, minimize skin exposure to moisture, pressure relieving device(s) for bed and for the chair(s) as indicated, provide incontinence care as indicated, turn and reposition frequently, weekly skin checks and refer to weekly skin summary as indicated. During a review of Resident 1's Weekly Summaries, dated 3/4/2021, 3/11/2021, 3/30/2021 and 4/6/2021, the Weekly Summary indicated Resident 1 had a surgical wound and did not have documented evidence of any pressure ulcers/pressure injury ([PU/PI]. There was no documented evidence of a Weekly Summary dated for 3/18/2021 and 3/25/2021 for Resident 1. During a review of Resident 1's Physician's Progress Note (PPN), dated on 4/1/2021, the PPN indicated the Nurse Practitioner ([NP] a nurse with additional education and training in a specialty area) indicated for the staff to reposition Resident 1 in bed every two (2) hours and as needed. During a review of Resident 1's Nurse's Progress Note (NPN), dated on 3/1/2021 and timed at 10:53 a.m., the NPN indicated based on the AA, Resident 1's skin was warm, dry, and intact without any open areas. The NPN indicated the staff would provide daily skin observation for monitoring of skin integrity. During a review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 3/6/2021, the MDS indicated the Resident 1's cognition (ability to reason and think) was intact, required extensive assistance with one-person physical assist with transfers, toileting and with personal hygiene. The MDS indicated Resident 1 was at risk for developing PU/PI and skin injuries and did not indicate Resident 1 had any ulcers, wounds, and skin problems. During a review of Resident 1's Nurse's Progress Note (NPN), dated from 3/21/2021 and timed at 10:44 p.m., the NPN indicated Resident 1 did not have any open areas of the skin. During a review of Resident 1's clinical records from 3/21/2021 through 4/12/2021, there was no documented evidence of Resident 1 having any skin breakdown. During a review of Resident1 1's NPN, dated 4/12/2021 and timed at 8:45 p.m., indicated at 8 p.m., the paramedics arrived at the facility due to a call from Resident 1's Family Member (FM 1) indicating Resident 1 was having pain from her wound and a boil was killing her. The NPN indicated Resident 1 requested to be transferred to the general acute care hospital (GACH). During an interview on 6/15/2021 at 4:45 p.m., the Registered Nurse Supervisor (RNS 1) stated the charge nurses and registry nursing staff were currently providing wound care treatments for the residents because the facility did not have a Treatment Nurse ([TN] a Licensed Vocational Nurse [LVN]) for over two months. RNS 1 stated the prior TN worked in the facility for only one month. During an interview on 6/16/2021 at 10:50 a.m. Certified Nursing Assistant 1 (CNA 1) stated the TN did not perform wound care treatments on the residents with wounds that she was assigned to because the resident's skin was not improving. During a concurrent interview and review of Resident 1's AA on 6/16/2021 at 12:05 p.m., RNS 1 stated Resident 1's AA indicated the resident did not have any open areas and the staff would observe and monitor Resident 1's skin daily. RNS 1 was asked for the documented evidence of the staff's observations and monitoring, RNS 1 stated there was no documented evidence provided by the staff and the staff must have forgotten to complete the weekly assessments dated for 3/18/2021 and 3/25/2021. RNS 1 was asked regarding the NP's recommendation on the PPN dated 4/1/2021 for the staff to turn and reposition Resident 1 every two (2) hours, when turning and repositioning a immobile resident was a standard nursing function, RNS 1 stated she was not sure. During a review of Resident 1's GACH Progress Note (GPN), the GPN indicated Resident 1 arrived at the ED on 4/13/2021 at 7:15 a.m. with a Stage II sacral decubitus ulcer with partial thickness skin loss and a fungal rash to both buttocks. The GPN indicated Resident 1 received [MEDICATION(S)] ([Lotrimin AF/Mycelex] a medication to treat a fungal infection) 1 % (percent) Cream. b. During a review of Resident 2's Admission Record (face sheet), the face sheet indicated the resident was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's care plan, dated 12/9/2019 and titled, At risk for altered skin integrity related to DM, limited mobility/bedfast, altered ADL ability, incontinence of the bowel and bladder. The staff's interventions indicated for staff to monitor Resident 1's skin for any signs of skin breakdown (sore, tender, red, or broken areas), keep clean and dry as possible, minimize skin exposure to moisture, pressure relieving device(s) for bed and for the chair(s) as indicated, provide incontinence care as indicated, treatments for wound care as ordered, turn and reposition frequently, weekly skin checks and refer to weekly skin summary as indicated. During a review of Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition (ability to reason and think) was severely impaired, required extensive assistance with two-person physical assist with transfers, toileting and a one-person assist with personal hygiene. The MDS indicated Resident 2 was at risk for developing PU/PI and skin injuries and did not indicate Resident 2 had any ulcers, wounds, and skin problems. During a review of Resident 2's Quarterly Clinical Skin Observation (QCSO), dated 2/19/2021 and timed at 2:33 p.m., the QCSO indicated Resident 2's total Braden Scale score was 15 and was assessed as being at mild risk for skin breakdown. During a review of Resident 2's H/P, dated 3/17/2021, the H/P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 2's nurse's progress notes (NPN), dated 4/21/2021, 4/22/2021, 4/23/2021, 4/27/2021 and 5/4/2021, there was no documentation of Resident 2 having skin breakdown. During a review of Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated for Resident 2 to receive cleansing with normal saline, pat dry, xeroform (an oil- based gauze dressing that covers and protect oozing wounds) and wrap with kerlix (a spongy dry dressing for wounds) to the right heel blister. The orders indicated for Resident 2's left buttock and right heel to be monitored daily for increase in size, shape, skin breakdown and/or signs and symptoms of infection until resolved. During a review of Resident 2's Compromised Skin Integrity (CSI) note, dated on 5/5/2021 and timed at 12:31 p.m., the CSI indicated the TN was informed by the CNA that Resident 2 had redness on her bottom. The CSI indicated Resident 2 was assessed and a 3 centimeter ([cm] a unit of measurement) in length ([L] measurement of something from end to end) x (by) 2.5 cm in width ([W] measurement of something from side to side) to the left buttock with redness and a 2 x 2.5 cm right heel fluid filled blister. According to the CSI, Resident 2's buttocks was cleansed, and a barrier cream applied and covered with a foam dressing and the right heel blister was treated with xeroform and wrapped with a kerlix gauze. According to the CSI note, the TN called Resident 2's physician and spoke with the physician's receptionist. During a review of Resident 2's NPN, dated 5/6/2021 and timed at 7:10 p.m., the NPN indicated an Interdisciplinary team ([IDT] a group of healthcare professionals developing care needs that meets the resident's needs and goals) was conducted. The IDT note indicated Resident 2 was noted with excoriation to the sacral coccyx and right heel fluid filled blister due to incontinence, impaired mobility, and non-compliance with turning and repositioning. The IDT note indicated Resident 2 did not want to be touched or turned. The IDT note indicated the DON and TN were the only two staff members in attendance. During a review of Resident 2's NPNs, dated from 5/6/2021 through 5/27/2021, there was no documented evidence of Resident 2 being resistant to care from the staff. During a review of Resident 2's Weekly Summary (WS), dated 5/11/2021, the WS indictaed Resident 2's skin was intact and was on monitoring for a right heel fluid filled blister and excoriation of the left buttocks. The WS indicated Resident 2 was being turned and repositioned every 2 hours to prevent further skin breakdown. During a review of Resident 2's PPN, dated 5/14/2021, the PPN did not indicate Resident 2 had any skin issues or concerns. During a review of Resident 2's Weekly Summary (WS), dated 5/18/2021, the WS indicated Resident 2's skin was intact and there were no significant changes noted. During a review of Resident 2's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 5/19/2021, the MDS indicated Resident 2's cognition (ability to reason and think) was severely impaired, required extensive assistance with one-person physical assist with transfers, toileting and personal hygiene. The MDS indicated Resident 2 was at risk for developing PU/PI and skin injuries and did not indicate Resident 2 had any ulcers, wounds, and skin problems. During a review of Resident 2's Weekly Summary (WS), dated 5/25/2021, the WS indictaed Resident 2's skin was intact and had a pressure ulcer that was referred to wound management. The WS indicated there were significant changes noted and all treatment orders were carried out by the TN. The WS indicated Resident 2 was currently on a low air loss ([LAL] mattress (a pressure relieving mattress for skin management). During a review of Resident 2's Wound Consultant Note (WCN), dated 5/27/2021 at 8 a.m., the WCN indicated Resident 2 was assessed by the wound care physician. The WCN indicated Resident 2 had a 9 cm x 7.5cm x 3 cm Stage IV sacral wound, with 90 percentage (%) slough (shedding of the outer layer of skin), 10% granulation the development of new skin tissue and treatment orders. During a review of Resident 2's NPN, dated 6/1/2021 and timed at 6:17 p.m., the NPN indicated Resident 2's physician was notified of Resident 2's sacral wound and the resident's poor oral intake. The NPN indicated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 2's NPN, dated 6/3/2021 and timed at 8:39 p.m., the NPN indicated Resident 2's physician called the facility, was informed about Resident 2's sacral wound. The NPN indicated Resident 2's physician was informed of Resident 2's sacral wound being assessed and debrided (removal of damaged, dead or infected skin tissue from a wound to help a wound heal) by the wound care team on 5/27/2021. During a review of Resident 2's Wound Consultant Note (WCN), dated 6/3/2021 at 8 a.m., the WCN indicated Resident 2 was assessed by the wound care physician. The WCN indicated Resident 2 had a 9 cm x 8 cm x 3 cm Stage IV sacral wound, with 50% slough and 50% granulation and treatment orders. During a review of Resident 2's PPN, dated 6/4/2021, the PPN indicated Resident 2 had a Stage IV sacral wound measuring 9 x 7.5 cm and 3 cm deep. During a review of Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's physician's discharge summary (PDS), dated 6/4/2021 and timed at 1:48 p.m., the PDS indicated Resident 2 was transported to the GACH by ambulance. During a review of Resident 2's GACH ED progress notes, dated 6/4/2021, the ED progress note indicated Resident 2 was weak, had a large sacral decubitus ulcer and required an inpatient stay. The GACH progress notes indicated Resident 2 had an 8 cm x 6 cm x 4.5 cm Stage IV sacrogluteal wound with purulent (pus) drainage and a foul odor. The GACH progress note indicated Resident 2's sacrogluteal wound required a wound vacuum ([vac] a device that decreases air pressure around a wound to assist the healing). During an interview on 6/17/2021 at 11:13 a.m., the Director of Staff Development (DSD) stated the TN did not have experience working in the role as a treatment nurse and this was the TN's first time performing wound care management. During an interview on 6/17/2021 at 11:46 a.m., RNS 2 stated during the time the TN worked in the facility she did not perform any wound care treatments on the residents with wounds. During an interview on 6/17/2021 at 2:06 p.m., the Administrator stated the TN did not have a wound care management certificate. During a concurrent interview and review of Resident 2's records on 6/17/2021 at 2:14 p.m., RNS 1 stated we were not aware that Resident 2 had a wound until 5/27/2021. RNS 1 stated the wound care physician was notified to assess and treat Resident 2's wound. RNS 1 stated according to the CNAs, they (CNAs) reported Resident 2's skin conditions to the TN and the TN indicated she performed skin care treatments on Resident 2 from 5/5/2021 through 5/27/2021. During a telephone interview on 6/17/2021 at 11:11 a.m., Resident 2's physician (MD 1) stated he was not aware of Resident 2 having any kind of skin issues with pressure ulcer for the month of 5/2021. MD 1 stated Resident 2 had a PU/PI two years ago when she was initially admitted to the facility but had healed. MD 1 stated he received a telephone call from Resident 2's family member a month ago (5/2021), indicating Resident 2 had a wound. MD 1 stated he was surprised to hear that Resident 2 developed a large decubitus because he assessed Resident 2 in the month of 5/2021 and did not understand how this happened. MD 1 stated when he was in the facility to follow-up on Resident 2 in 5/2021, he was told by the staff that everything regarding Resident 2 was fine. MD 1 stated he was told that the TN was assessing Resident 2 and could not locate any notes from the wound doctor. MD 1 stated he did not provide any wound care and treatment orders for Resident 2 in the month of 5/2021. MD 1 stated Resident 2 was hospitalized for 5 days, received intravenous ([IV] into the vein) antibiotics (medication to treat bacterial infection) and had a wound vac for her significant decubitus ulcer. MD 1 stated Resident 2 was residing at another facility per the request of Resident 2's family. During an interview on 6/17/2021 at 3:06 p.m., CNA 2 stated she provided care for Resident 2 for the month of 3/2021 and Resident 2 did not have any skin issues, such as open wounds or sores. CNA 2 stated on 5/19/2021, Resident 2 had a sore on her bottom and CNA 2 asked the TN what happened. CNA 2 stated the TN did not respond. During a telephone interview on 6/22/2021 at 1 p.m., the TN stated she became certified in wound care and management in the month of 3/2021. The TN stated on 5/5/2021, the CNA told her Resident 2 had skin redness, she documented Resident 2's skin condition and notified Resident 2's family. The TN was asked if she notified Resident 2's physician (MD 1), the TN stated, No, because the DON said she would call MD 1. The TN was asked did she follow-up on the next day to ensure the physician was notified about Resident 2's skin, the TN stated she was out from the facility for one week. The TN was asked upon her return to the facility, did she follow-up regarding Resident 2's skin changes, the TN stated she wrote an IDT note. The TN was asked who attended the IDT meeting regarding Resident 2's skin changes, the TN stated an IDT meeting is only a documented note that goes into the resident's records, she had never attended an IDT meeting, and she was the only person in attendance. The TN stated the DON created the IDT note for Resident 2. The TN stated she did not notify Resident 2's physician or the wound care physician regarding Resident 2's skin changes on 5/5/2021. The TN stated she was not aware that Resident 2 had a wound care consult order dated on 12/9/2019. The TN was asked why she did not communicate Resident 2's skin changes to the wound care physician who visits the facility on Thursdays, the TN stated because the DON stated she would notify the wound care doctor. The TN was asked of her role and responsibility as a TN, the TN stated she should have notified Resident 2's physician and the wound care physician on 5/5/2021. The TN was asked if she obtained Resident 2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the TN facility's employment file (EF) documents, there was no documented evidence of the TN's wound care certification During a review of the facility's undated policy and procedure (P/P) titled, Pressure Ulcer/Injury Risk Assessment, the P/P indicated the purpose of for the structured assessment and identification of residents at risk of developing pressure ulcer/injuries. The P/P indicated once the assessment was conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure ulcers/injuries. The P/P indicated information should be recorded in the resident's medical records includes: the date, time and type of skin care provided, physician notification if new skin alteration was noted with a change in the plan of care. The P/P indicated for the staff to notify the attending physician if new skin alteration was noted.

Based on observation, interview, and record review the facility failed to ensure CNA 1 did not physically abuse one of one sampled residents (Resident 1) by hitting him with his hand on left side of his face, causing swelling and purplish discoloration after Resident 1 asked for food. This deficient practice has potential to cause feeling fearful, afraid, and helpless and had the potential to place other residents at risk for ongoing physical, verbal, and psychological abuse. Findings: On February 13, 2017, at 7:50 a.m., an unannounced visit was made to the facility to conduct a follow-up and abbreviated survey regarding an incident of abuse. This is the second substantiated allegation of abuse. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated December 23, 2016, indicated Resident 1's cognitive skills for daily decision making were slightly impaired and he was dependent on staff for total assistance with activities of daily living. A review of Resident 1's History and Physical (H&P), dated October 24, 2016, indicated Resident 1 has fluctuating capacity to understand and make decisions. During an observation, and interview on February 13, 2017 at 8:40 a.m., Resident 1 showed the surveyor a reddish-purplish large area of discoloration covering the right upper cheek area below his right eye. During an interview at the same time with Resident 1 in his room, (translated Spanish to English by restorative nursing assistant , RNA 1), he stated he was hungry and yelled for food. Resident 1 stated, the male nurse came inside the room and stated I came here already and hit him in his face. Resident 1 while speaking also balled up his hand to make a fist and demonstrated to the surveyor how he was hit. Resident 1 further stated it was the same male nurse that cleaned him up that night. A review of the certified nursing assistant (CNA) assignment, dated February 10, 2017, indicated CNA 1 was assigned to take care of Resident 1 for 11 p.m. to 7 a.m. shift. During a telephone interview with a Licensed Vocational Nurse (LVN 1) on February 16, 2017 at 9:00 a.m., she stated she was asked by CNA 2 to come and check out Resident 1's face. LVN 1 stated when she got into the room right away she noticed swelling and redness to Resident 1's right cheek, and Resident 1 was speaking his native language (Spanish) in a loud tone, while pointing at his face. LVN 1 stated she then had another resident translate for her while interviewing Resident 1. LVN 1 stated Resident 1 was repeatedly stating the male nurse punched me in my face. LVN 1 stated she had been into Resident 1's approximately 30 minutes before to check his blood sugar, and Resident 1 did not have the redness and swelling to his face. LVN 1 stated she had CNA 1 (who was the only male nurse in the building) come into the room to see if Resident 1 would identify him. LVN 1 stated as soon as CNA 1 walked into the room, Resident 1 immediately started pointing and yelling in his native language that guy punched me. LVN 1 stated she immediately asked CNA 1 to leave the facility and notified the police department, the Director of Nursing (DON), and Resident 1's family. A Care Plan for Resident 1 created February 11, 2017, for indication of right cheek reddish discoloration secondary to recent incident, indicated to apply ice packs and monitor for pain and swelling. A Care plan for Resident 1 titled Risk for Psychosocial Well Being related to recent incident, created February 11, 2017, indicated to monitor resident psychosocial well- being by monitoring for signs and symptoms of emotional distress and fear. A progress dated February 11, 2017 at 6:35 a.m., indicated redness discoloration noted to Resident 1 right upper cheek area and ice packs were applied. During an interview with the facility's Director of Staff Development (DSD), on February 13, 2017, at 11:20 a.m., she indicated there was no abuse training or background check in personnel file kept on CNA 1. DSD stated, what the surveyor saw in CNA 1's employee file, a copy of CNA 1's identification card and a copy of his CNA license verification is all the documents the facility had on him. DSD stated, CNA 1 worked 2 shifts total for the facility which were 3-11 p.m. shifts on February 8th & February 10th and provided documentation of proof. During an interview with the Administrator, on February 13, 2017, at 3:30 p.m., she stated she was made aware of the incident. The Administrator stated CNA 1 was a registry staff and the police department and department of public health were also notified right away of the incident. The Administrator further stated she was in the process of trying to have a background check done on all registry nursing staff before using them but it was really expensive to do so. The Administrator also acknowledged CNA 1 had not had abuse training done before employment per policy. Review of a revised policy and procedure dated March 2013 titled Preventing Resident Abuse indicated that the facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff or other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. Abuse is defined as the willful inflictions of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility's goal is to achieve and maintain an abuse-free environment and to train all staff and practitioners how to resolve conflicts appropriately.

The facility failed to ensure CNA 1 did not yell, curse, use obscenities and physically threaten one of one sampled residents (Resident 1) and saying I will have my boyfriend shoot you, after Resident 1 had expressed concerns about CNA 1 pouring urine out of the urinal (container to hold urine) into his sink. This resulted in Resident 1 becoming filled with anxiety, and created an intense fear for his life which resulted in a loss of sleep, and forced him to leave the facility before being medically cleared by his physician. Findings: On October 12, 2016, at 12:30 p.m., an unannounced visit was made to the facility to investigate an allegation that CNA 1 verbally abused and threatened Resident 1. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated September 18, 2016, indicated Resident 1's cognitive skills for daily decision making were intact and he was independent with activities of daily living. A review of Resident 1's physician order [REDACTED]. During an interview with Resident 1 in his room, on October 12, 2016 at 12:50 p.m., he stated the other night around 2 a.m. in the morning he saw CNA 1 emptying and rinsing a urinal into his sink. Resident 1 stated he told CNA 1 that he washed his face in the sink and what she was doing was unsanitary. The resident stated CNA 1 told him to shut up and to drop dead. The resident became upset by CNA 1's words and began to argue with her, when CNA 1 started to yell louder and louder by using obscene language. CNA 1 then told the resident I will have my boyfriend shoot you. Resident 1 stated he had not slept since the incident, he did not feel comfortable staying in the facility, and wanted to leave fearing for his safety. Resident 1 stated even though he was scheduled next week for a bilateral buttocks (either of the two round fleshy parts that form the lower rear area of a human trunk) hidradenitis surgery he was not comfortable enough staying in the facility. During a telephone interview with a Licensed Vocational Nurse (LVN 1) on October 12, 2016 at 1:45 p.m., she stated she had witnessed the verbal abuse and heard CNA 1 tell Resident 1 I will have my boyfriend shoot you. LVN 1 stated she was the nurse who sent CNA 1 home, and notified the DON. During an interview with the facility's Director of Staff Development (DSD), on October 12, 2016, at 3:30 p.m., she indicated there was no personnel file kept on CNA 1. DSD stated she had not conducted a background screening clearance, or abuse training with CNA 1. DSD stated a nurse registry provided CNA 1 but only gave them the person's name before the nurse showed up for work. During a interview with the Administrator on October 13, 2016, at 3:30 p.m., she indicated she was made aware of the incident the next morning and the staff failed to notify the local law enforcement. The administrator also indicated the facility had not screened CNA 1's certification or conducted a background check prior to her working at the facility. The Administrator stated the facility had just started using the nursing registry, and she was going to do an in-service on abuse with all of her staff. She also stated she assured Resident 1 that he was safe by closely monitoring him, and keeping facility doors locked during the night. The administrator stated because using a nursing registry was new to the facility, they did not have a policy and procedure yet regarding registry staff. During a follow up telephone interview with Resident 1 on October 14, 2016 at 2 p.m., indicated he left the faciity on the same day. The resident stated he still feared the retaliation from CNA 1's boyfriend, and felt neither he nor the doors of the facility were monitored closely to ensure his safety. Resident 1 stated he was going to stay at a friend's house until the following week and he did not have any supplies for the treatment of [REDACTED]. A review of revised December 2013 facility's policy and procedure titled Reporting Abuse to Facility Management indicated that the facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff or other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. Abuse is defined as the willful inflictions of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as any use of oral, written, or gestured languages that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. A review of revised April 2014 facility's policy and procedure titled Abuse Investigations indicated the Administrator will provide a written report of the results of the abuse investigations and appropriate action taken to the local police department, within five (5) working days of the reported incident.

Based on observation, interview and record review, the facility failed to implement their abuse policy when a Certified Nursing Assistant (CNA 1) was witnessed verbally, and mentally abuse Resident 1 by yelling obscenities and telling the resident I will have my boyfriend shoot you. The facility also failed by not verifying a background screening clearance was completed prior to CNA 1's employment, ensure there was abuse training, and report the abuse incident to the local law enforcement agency immediately. These deficient practices caused Resident 1 anxiety, created intense fear for his life resulting in loss of sleep, and forcing him to leave the facility before being medically cleared by his physician. Findings: On October 12, 2016 at 12:30 p.m., an unannounced visit was made to the facility to investigate a complaint and an Entity Reported Incident (ERI) about an abuse incident involving CNA 1 and Resident 1. A review of Resident 1's clinical records indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated September 18, 2016 indicated the resident's cognitive skills for daily decision making was intact and he was independent with activities of daily living. A review of Resident 1's physician order [REDACTED]. During an interview with Resident 1 on October 12, 2016 at 12:50 p.m., he stated the other night around 2 a.m. in the morning he saw CNA 1 emptying and rinsing the urinal into his sink. Resident 1 stated he told CNA 1 that he washed his face in the sink and what she was doing was unsanitary. The resident stated CNA 1 told him to shut up and to drop dead. The resident became upset by CNA 1's words and began to argue with her. CNA 1 started to yell louder and louder and used obscene languages. CNA 1 then told the resident I will have my boyfriend shoot you. Resident 1 stated he had not slept since the incident, he did not feel comfortable staying in the facility, and wanted to leave fearing for his safety. Resident 1 stated even though he was scheduled next week for bilateral buttocks (either of the two round fleshy parts that form the lower rear area of a human trunk) hidradenitis surgery he was not comfortable enough staying in the facility. During a telephone interview with a Licensed Vocational Nurse (LVN 1) on October 12, 2016 at 1:45 p.m., stated she had witnessed the verbal abuse and heard CNA 1 tell Resident 1 I will have my boyfriend shoot you. LVN 1 stated she was the nurse who sent CNA 1 home, and notified the DON but the local law enforcement was not called. During an interview with the facility's Director of Staff Development (DSD), on October 12, 2016 at 3:30 p.m., she indicated there was no personnel file kept on CNA 1 because using a nursing registry was a new practice for the facility. DSD stated she had not conducted or verified there was background screening clearance, or abuse training with CNA 1 but she feels she should have. DSD stated a nurse registry provided CNA 1 but only gave them the person's name before the nurse showed up for work. During an interview with the facility's Social Service Designee (SSD), on October 12, 2016 at 3:45 p.m., she stated after the incident Resident 1 told her he was fearful and was going to be watching his back and surroundings. During a telephone interview with licensed vocational nurse (LVN 1) on October 12, 2013 at 1:45 p.m., stated she had witnessed the incident of verbal abuse and threatening by CNA 1 towards Resident 1. LVN 1 stated she was the nurse in charge of Resident ' s 1 care during that shift. LVN 1 stated that after the verbal abuse occurred, CNA 1 was sent home but law enforcement was not called immediately. LVN 1 further stated she removed CNA 1 from the facility, notified the director of nursing (DON), but she had not been trained to notify law enforcement. During a telephone interview with the Administrator on October 13, 2016 at 3:30 p.m., indicated she was made aware of the incident the next morning and the staff failed to notify the local law enforcement. The administrator also indicated the facility had not screened CNA 1's certification or conducted background check prior to her working at the facility. The Administrator stated the facility had just started using the nurse registry, and was going to do an in-service on abuse. She also stated she assured Resident 1 he was safe by closely monitoring him, and keeping facility doors locked during the night. During a follow up telephone interview with Resident 1 on October 14, 2016 at 2 p.m., indicated he left the faciity on the same day. The resident stated he still feared the retaliation from CNA 1's boyfriend, and felt neither he nor the doors of the facility were monitored closely to ensure his safety. Resident 1 stated he was going to stay at a friend's house until the following week and he did no have any supplies for the treatment of [REDACTED]. The facility was unable to provide a policy and procedure that included all the seven components of the mandated abuse prohibition protocol. A review of the facility's policy and procedure titled Reporting Abuse to Facility Management, dated December 2013 indicated it is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, ect., to promptly report any incident or suspected incident of neglect or abuse, including injuries of unknown origin, and theft or misappropriation of resident property to facility management. The facility did not have a policy and procedure regarding screening for registry staff. A review of the facility's policy and procedure titled Background Screening Investigation, dated January 2008, indicated the personnel/human resources director, or other designee, will conduct employment background checks, reference checks, and criminal conviction checks on persons making application for employment with this facility. Such investigations will be initiated within two days of employment or offer of employment.