Every finding on record at Ridgecrest Regional Transitional Care and Rehabili

Based on observation, interview, and record review, the facility failed to implement their policy and procedure for call lights for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for resident needs to go unmet, injuries to occur, pain medication request not to be addressed and other negative consequences.Findings:During a review of Resident 1's admission RECORD (AR), dated 8/18/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia (decline in memory, language, problem-solving, and other thinking skills that interferes with ability to perform everyday activities), generalized anxiety disorder (a feeling of worry, dread, or nervousness about what might happen next), depression (a heavy, ongoing feeling of sadness, emptiness, or a total loss of care for things you normally like), overactive bladder (uncontrollable urge to urinate and frequent bathroom visits), and difficulty walking.During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 8/6/26, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS score was 13 (cognition intact).During a review of Resident 1's MDS, dated [DATE], under the section titled GG - Functional Abilities (GG - an assessment that measures a residents need for assistance with care and mobility), the GG indicated Resident 1 required set up or clean up assistance in eating, oral hygiene, toileting, upper/lower body dressing, putting on/taking off footwear, personal hygiene, lying or sitting on side of bed, and toilet transfer. During a review of Resident 1's Care Plans (CP - a simple, step-by-step roadmap that outlines a person's health needs, daily goals, and who is responsible for providing specific types of help), the CP indicated Resident 1 required staff assistance with bowel (stool) and bladder (urine) to remain clean. An intervention listed for this issue was to encourage Resident 1 to utilize call light and ask for assistance. Resident 1 is at risk for falls related to limited mobility, history of falls, poor safety awareness care plan indicated, Intervention/Tasks. residents (Resident 1) call light is within reach and encourage the resident to use it for assistance. The resident needs prompt response to all requests for assistance.During an observation on 8/18/26 at 11:55 a.m. in Resident 1's room, Resident 1 was observed in bed scrunched up to the left side of bed up against the side rail. Resident 1 was moaning that she was in pain. Her call light was observed to be on the floor behind the head of her bed with Resident 1 not being able to reach.During a concurrent observation and interview on 8/18/26 at 12:04 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, CNA 1 stated she was assigned to Resident 1 today (8/18/26). CNA 1 stated Resident 1 uses her call light when she needs assistance. CNA 1 stated she was assigned to Resident 1 last on 8/16/26 and Resident 1 had used her call light often that day. CNA 1 stated Resident 1 had not used her call light today (8/18/26). CNA 1 observed the floor behind the head of bed of Resident 1 and stated the call light was not within reach for Resident 1 to use. During a review of Resident 2's AR, dated 8/24/26, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnosis of pain, constipation, and unspecified dislocation of the right shoulder (an injury where the top round part of your upper arm bone pops completely out of the cup-shaped socket in your shoulder blade).During a review of Resident 1's MDS, dated [DATE], under the section titled, BIMS, the BIMS score was 15 (cognition intact).During a review of Resident 2's MDS, dated [DATE], under the section titled GG, the GG indicated Resident 1 required set up or clean up assistance in oral hygiene, dependent (resident requires helper to do all the effort, resident does none of the effort) in toileting, lower body dressing, putting on/taking off footwear, personal hygiene, and Chair/bed to chair transfer. Resident 2 required substantial/maximal assist in upper body dressing, rolling left and right, and supervision or touching assistance in eating. During a review of Resident 2's CP, the CP indicated Resident 2 required staff assistance with bowel and bladder to remain clean, dry, and free from body odors. An intervention listed for this issue was to encourage Resident 2 to utilize call light and ask for assistanceResident 2 is a high risk for falls due to incontinence (inability to control bowel and bladder) care plan indicated, Intervention/Task. be sure residents (Resident 2) call light is within reach and encourage resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During a concurrent observation and interview on 8/18/26 at 12:21 p.m. with CNA 1 in Resident 2's room (roommate of Resident 1), Resident 2's call light was observed on the floor on the right side of the head of Resident 2's bed. CNA 1 stated the call light was not within reach for Resident 2. CNA 1 stated Resident 2 does use the call light for assistance with needs.During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, undated, the P&P indicated, Purpose . The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review the facility failed to implement their policy and procedure to report an allegation of abuse for one of three sampled residents (Resident 3). This failure had the potential for ongoing abuse to occur.Findings:During a review of Resident 3's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 6/30/26, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS score was 15 (cognition intact).During an interview on 8/18/26 at 11:17 a.m. with Resident 3, Resident 3 stated, approximately a month and a half ago (could not recall exact date) he reported to Social Services Director (SSD) that he felt he was inappropriately touched by a staff member during a shower. Resident 3 stated he discussed this concern with SSD for about an hour, and she had reassured him she would speak to staff about it.During an interview on 8/18/26 at 12:35 p.m. with SSD, SSD stated, approximately two months ago in early June (could not recall exact date), Resident 3 had approached her and stated a staff member had not given him an option to wash his own genitals, and he felt that he was inappropriately touched. SSD stated she had not documented this conversation and had not reported the concern to leadership. SSD stated in her role as SSD she is to follow the policy and procedures of the facility.During an interview on 8/18/26 at 12:35 p.m. with Director of Nursing (DON), DON stated leadership including herself should have been made aware of Resident 3's allegation of inappropriate touch to SSD. DON stated Resident 3's statement should have been reported immediately as an allegation of abuse. DON stated the allegation of abuse was not reported until 8/14/26.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 2001, the P&P indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies . The state licensing/certification agency responsible for surveying/licensing the facility . The local/state ombudsman . The resident's representative . Adult protective services (where state law provides jurisdiction in long-term care) . Law enforcement officials . The resident's attending physician; and . The facility medical director. Immediately . is defined as . within two hours of an allegation involving abuse or result in serious bodily injury; or . within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone.

Based on observation, interview, and record review, the facility failed to implement two of three sampled residents (Resident 1 and Resident 2) fall care plans (a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care). This failure had the potential for Resident 1 and Resident 2 to be at risk for falls. During a concurrent observation, interview, and record review, on 7/15/26 at 12:45 p.m. with Registered Nurse (RN) 1, Resident's fall care plan dated 6/22/26 was reviewed. Resident 1's care plan indicated, The resident (Resident 1) is high risk for falls. interventions Falling Star Program (yellow or red stars place on resident's name plate). RN 1 observed Resident 1's room, confirmed the falling star intervention for Resident 1 was not implemented. During a concurrent observation, interview, and record review, on 7/15/26 at 1:30 p.m. with Licensed Vocational Nurse (LVN) 1. Resident 2's fall care plan 1/28/26 was reviewed. Resident 2's care plan indicated, The resident (Resident 2) is high risk for falls. intervention. Bariatric Toilet riser (a heavy-duty bathroom safety device designed to increase the height of a toilet bowl)/Or commode on toilet seat initiated 5/15/26. LVN 1 observed Resident 2's bathroom. LVN 1 confirmed no Bariatric Toilet riser/Or commode was observed in Resident 2's bathroom. During a review of the facility's policy and procedure (P&P) titled, Falling Star Program, undated, the P&P indicated, The falling star program is part of our ongoing commitment to preventing injury from falls. The program is based on an admission fall risk assessment or recent fall. Fall risk will be identified by yellow or red stars. If a resident falls they will be given a red star and a red wrist band placed on the program and monitored for 30 days, if no further fall occurs they will be removed from the falling star program. If a fall does happen within that 30 days they will be made a Yellow star and the 30 days will restart. star will be placed on the name plate outside the resident's room.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated, A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.11. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met;

Based on interview and record review, the facility failed to implement their own policy and procedure (P&P) titled, Release of Information, for 88 of 89 residents (Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 65, Resident 66, Resident 67, Resident 68, Resident 69, Resident 70, Resident 71, Resident 72, Resident 73, Resident 74, Resident 75, Resident 76, Resident 77, Resident 78, Resident 79, Resident 80, Resident 81, Resident 82, Resident 83, Resident 84, Resident 85, Resident 86, Resident 87, Resident 88, and Resident 89). This failure resulted in an unknown amount of private medical information for all 88 residents to be obtained by an unauthorized person and had the potential for negative consequences.Findings:During a review of the facility's Summary Report to CDPH (California Department of Public Health) re (regarding): HIPAA ( Health Insurance Portability and Accountability Act - a law passed that establishes national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) Privacy Incident (SRPI), dated 5/27/26, the SRPI indicated, on 5/8/26 the facility provided and unknown amount of private health information for Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 65, Resident 66, Resident 67, Resident 68, Resident 69, Resident 70, Resident 71, Resident 72, Resident 73, Resident 74, Resident 75, Resident 76, Resident 77, Resident 78, Resident 79, Resident 80, Resident 81, Resident 82, Resident 83, Resident 84, Resident 85, Resident 86, Resident 87, Resident 88, and Resident 89 to family member (FM) 1.During an interview on 6/10/26 at 12:05 p.m. with Director of Nursing (DON), DON stated on 5/8/26 the Medical Records Supervisor (MRS) had accidentally provided FM 1 with a thumb drive (a small, portable data storage device that plugs directly into a computer) with an unknown amount of private information for Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 65, Resident 66, Resident 67, Resident 68, Resident 69, Resident 70, Resident 71, Resident 72, Resident 73, Resident 74, Resident 75, Resident 76, Resident 77, Resident 78, Resident 79, Resident 80, Resident 81, Resident 82, Resident 83, Resident 84, Resident 85, Resident 86, Resident 87, Resident 88, and Resident 89. DON stated the information on the thumb drive potentially went back to 2023. DON stated the facility attempted to obtain the thumb drive back from FM 1, but he refused.During an interview on 6/10/26 at 12:52 p.m. with MRS, MRS stated on 5/8/26 she was supposed to provide FM 1 with a thumb drive regarding his father (Resident 2) but it was not completed. MRS stated she called FM 1 to explain the requested information was not ready but FM 1 had became hostile, intimidating, and was yelling at her. MRS stated she had explained what happened to her Operations Manager (OM) and he instructed her to finish FM 1's request so that he can provide it to FM 1. MRS stated she finished obtaining the requested information and handed the thumb drive to OM to give to FM 1 on 5/8/26. MRS stated on 5/13/26, FM 1 had made another request for more information regarding Resident 1. MRS stated FM 1 was at her office door banging on it for the information requested. MRS stated as she began retrieving the requested information she noticed she had provided FM 1 with the wrong thumb drive on 5/8/26. MRS stated at that time she was not sure what other resident information was on the thumb drive handed to FM 1 on 5/8/26, just that there was information that FM 1 should not have access to. MRS stated she reported this incident immediately to her leadership.During an interview on 6/10/26 at 1:44 p.m. with Privacy Compliance Officer (PCO), PCO stated she was informed on 5/13/26 about FM 1 obtaining a thumb drive of resident information that he was not supposed to have. PCO stated multiple attempts to retrieve the thumb drive from FM 1 were made including having the police involved but have not been successful. PCO stated 88 residents (Resident 1, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, Resident 20, Resident 21, Resident 22, Resident 23, Resident 24, Resident 25, Resident 26, Resident 27, Resident 28, Resident 29, Resident 30, Resident 31, Resident 32, Resident 33, Resident 34, Resident 35, Resident 36, Resident 37, Resident 38, Resident 39, Resident 40, Resident 41, Resident 42, Resident 43, Resident 44, Resident 45, Resident 46, Resident 47, Resident 48, Resident 49, Resident 50, Resident 51, Resident 52, Resident 53, Resident 54, Resident 55, Resident 56, Resident 57, Resident 58, Resident 59, Resident 60, Resident 61, Resident 62, Resident 63, Resident 64, Resident 65, Resident 66, Resident 67, Resident 68, Resident 69, Resident 70, Resident 71, Resident 72, Resident 73, Resident 74, Resident 75, Resident 76, Resident 77, Resident 78, Resident 79, Resident 80, Resident 81, Resident 82, Resident 83, Resident 84, Resident 85, Resident 86, Resident 87, Resident 88, and Resident 89) were affected by this data breach but is not certain what exact documents are in the thumb drive.During a review of the facility's policy and procedure (P&P) titled, Release of Information - Minimum Necessary Use (RIMNU),dated 3/2014, the P&P indicated, Whenever practical/feasible, only the minimum information necessary to achieve the purpose of the use or disclosure will be released from, or used by, the facility in response to a request for information.During a review of the facility's P&P titled, Release of Information (ROI), dated 2001, the P&P indicated, Our facility maintains the confidentiality of each resident's personal and protected health information . Each resident will receive confidential treatment of his or her personal and medical records and may approve or refuse their release to any individual outside the facility, except in case of a transfer to another healthcare institution or as required by current HIPAA law. Medical records are the property of the facility. All information contained in the resident's medical record is confidential and may only be released by the written consent of the resident or his/her legal representative (sponsor), consistent with state laws and regulations. Resident records, whether medical, financial, or social in nature, are safeguarded to protect the confidentiality of the information. Only those persons concerned with the fiscal affairs of the resident will have access to the resident's financial records as permitted by current HIPAA laws.

Based on observation, interview, and record review, the facility failed to provide suprapubic catheter (a soft, flexible tube inserted through the lower part of the belly into the bladder [portion of the body that holds urine] to drain urine into an outside collection bag) care to one of three sampled residents (Resident 1). This failure had the potential to result in infection.Findings:During an observation on 5/19/26 at 11:45 a.m. in Resident 1's room, Resident 1 was observed to have a suprapubic catheter. The tubing was noted to have thick discolored white and yellowish growth/sediment (a buildup of mineral crystals and mucus, typically caused by bacteria. If left untreated, this sediment can form crusts that completely block the catheter, causing painful bladder distention [meaning to be swollen or enlarged], urinary leakage, and dangerous infections) from the insertion point into the lower down to the collection bag. The collection bag was noted to have discolored white to yellow brown type growth and sediment stuck to the sides.During a concurrent observation and interview on 5/19/26 at 12:10 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, Resident 1's suprapubic Catheter was observed. LVN 1 stated there was white to yellowish growth/sediment in Resident 1's tubing and white to yellowish brown type growth adhered to the sides of Resident 1's collection bag.During a concurrent observation and interview on 5/19/26 at 12:10 p.m. with Treatment Nurse (TX) 1 in Resident 1's room, Resident 1's suprapubic catheter was observed. TX 1 stated Resident 1's suprapubic catheter appeared to not have been flushed (a method of using sterile water to clear/clean out any sediment and mucous (a natural slippery gel that the body produces) and allow the urine to flow freely) in a long time. TX 1 stated Resident 1's suprapubic catheter needed to be flushed. TX 1 stated, It (Resident 1's suprapubic catheter) looks like it has not been flushed in over a week.During an interview on 5/19/26 at 12:29 p.m. with Treatment Nurse (TXN) 2, TXN 2 stated she was the treatment nurse assigned to Resident 1. TX 2 stated she provided treatment to Resident 1's suprapubic catheter earlier in the day at approximately 7:50 a.m. TX 2 stated part of her process with providing treatment is to observe the suprapubic catheter for any issues. TX 2 stated she did not notice any issues with Resident 1's suprapubic catheter. TX 2 stated an indication for Resident 1 to have his suprapubic catheter flushed, is if there was sediment or mucous in the tubing. TX 2 observed a photo of Resident 1's suprapubic catheter taken on 5/19/26. Tx 2 confirmed Resident 1's suprapubic catheter tubing and bag contained sediment and mucous. TX 2 stated during Resident 1's suprapubic catheter treatment, she did not look at Resident 1's suprapubic catheter tubing or bag and did not flush Resident 1's suprapubic catheter. TX 2 stated Resident 1's suprapubic catheter needed to be flushed.During an interview on 5/19/26 at 1:50 p.m. with Director of Nursing (DON), DON observed a photo of the condition of Resident 1's suprapubic catheter and stated, My expectation is that they (staff) look at all of the . suprapubic (catheter) not just the insertion site. DON confirmed Resident 1's suprapubic catheter should have been flushed. During a review of Resident 1's Order Summary Report (OSR), dated 5/2026, the OSR indicated, Resident 1 was to have his suprapubic catheter flushed with sterile water as needed for obstruction or malfunction.During a review of Resident 1's MEDICATION ADMINISTRATION RECORD (MAR), dated 5/2026, the MAR indicated, MONITOR SUPRAPUBIC CATHETER FOR: S/S (signs and symptoms) INFECTION: HEMATURIA (blood in the urine), INCREASED SEDIMENTS IN URINE, TEMPERATURE, FOUL ODOR, CLOUDY APPEARANCE. S/S CATHETER RELATED PAIN AND/OR URINARY RETENTION every shift. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 10/2010, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. If the catheter material contributes to obstruction, notify the physician and change the catheter if instructed to do so. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately . if urine has an unusual appearance.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure on medication administration for one of three sampled residents (Resident 1). This failure had the potential for medication induced negative health consequences.Findings:During an observation on 5/19/26 at 11:45 a.m. in Resident 1's room, a medication cup was observed on Resident 1's overbed table. The medication cup had nine medications (unable to identify) observed inside.During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 5/22/26, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS score was 15 (cognitively intact status).During an interview on 5/19/26 at 11:48 a.m. with Resident 1, Resident 1 stated the medications on his overbed table have been there since between 6:30 a.m. and 8 a.m.During an interview on 5/19/16 at 12:10 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she provided Resident 1 with the medications observed on his bedside table at approximately 8:30 a.m. LVN 1 stated the medications included vitamins, blood pressure (the measured force of blood as the heart pumps it through the body) medication, and a stool softener (medication used to assist with having a bowel movement). LVN 1 stated she is not to leave medications at the resident's bedside but had done so in the hope Resident 1 would take his medications eventually.During an interview on 5/19/26 at 1:12 p.m. with Director of Nursing (DON), DON stated it is not in the facility's policy to leave medications at the resident bedside. DON stated leaving medications at the resident bedside that they did not take is considered a medication error.During a review of the facility's policy and procedure (P&P) titled, PREPARATION AND GENERAL GUIDELINES, dated 12/2019, the P&P indicated, The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre poured either in advance of the med pass or for more than one resident at a time. Medications are administered within (60 minutes] of scheduled time . The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate.

Based on observation, interview, and record review, the facility failed to follow infection control practices for 33 of 33 sampled residents when:1. A Water Management Program (WMP) was not developed and implemented to identify, assess, monitor, and prevent the potential growth of opportunistic waterborne pathogens (germs that grow well in water) in the facility's water system. This failure had the potential to result in serious illness or death of residents, visitors, and staff. 2. Linens and other laundry items were left wet and unattended in washing machines after environmental services staff work shift ended. This had the potential to result in growth of mold (type of fungus), mildew (type of fungus or mold) and bacteria (organisms that can cause infection) and illness of residents, staff, and visitors.Findings: 1. During an interview on 2/25/26 at 9:39 a.m. with Infection Preventionist (IP), IP stated the WMP was overseen by the maintenance department and the hospital. IP stated he did not participate in the WMP for the facility. IP stated he does not participate in the identification or prevention of potential water borne pathogens at the facility. During a concurrent interview and record review on 2/25/26 at 11 a.m. with Maintenance Supervisor (MS), a policy and procedure (P&P) titled, [Hospital Name] Domestic Water Management Plan, dated 1/7/20 was reviewed. The P&P indicated , This policy identifies all hospital water systems. MS stated the P&P was for the Hospital and did not include the long-term care facility. MS stated the facility did not have a P&P for WMP. MS stated he did not have training for WMP and was unable to verbalize areas within the facility that were at for risk for bacteria growth in the water system. MS was unable to verbalize measures used to mitigate and monitor the risk of growth. MS was unable to identify control limits and parameters of the measures used. MS stated there was no diagram or documentation of description of the facility water system with identified areas of concern for growth. During a review of the Center for Disease Control (CDC) document titled, Toolkit for Controlling Legionella [bacteria that can grow in man-made water systems like cooling towers and plumbing, especially in warm water] in Common Sources of Exposure (LCT - Legionella Control Toolkit), dated 12/26/24, the LCT indicated, [S] Sediment [Mineral build-up in a water system that uses up disinfectant and encourages growth of bacteria] and biofilm [layer produced by germs that stick to and grow on moist surfaces; provides an environment for growth of bacteria including Legionella], Temperature [T], water Age [A], and disinfectant Residuals [R] (STAR) are the key factors that affect Legionella growth in potable [water that is safe for ingestion] water systems. A comprehensive WMP allows water system operators to layer a series of complementary control measures to create environmental conditions that prevent bacterial intrusion, growth, and transmission. Develop or refine a WMP with the following guidelines in mind: . Monitor temperature, disinfectant residuals, and pH [potential of hydrogen - measures a substance's acidity or alkalinity] frequently. Store hot water at temperatures above 140 F [Fahrenheit] and ensure hot water in circulation does not fall below 120 F. Store and circulate cold water at temperatures below the favorable range for Legionella 77-113 F. Ensure a disinfectant residual [Chlorine (disinfectant added to tap water as a disinfectant to kill harmful bacteria) and Monochloramine (longer-lasting disinfectant)] is detectable throughout the potable water system. Flush low-flow piping runs and dead legs at least weekly and flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as-needed to maintain water quality parameters within control limits. Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly. 2. During an observation on 2/25/26 at 3:44 p.m. in the laundry area, two washing machines contained white linens and blue mop heads. No staff were present in the laundry area. During an interview on 2/25/26 at 3:58 p.m. with IP, IP stated the laundry staff leave at 3 p.m. each day and there was no staff in laundry at night. During a concurrent observation and interview on 2/25/26 at 4 p.m. with IP in the laundry area, IP opened a washing machine that contained white linens. IP stated the linens were damp and warm. IP opened the second washing machine that contained blue mop heads. IP stated the mop heads were also damp and warm. IP stated the laundry staff should have finished washing and drying the linen and mop heads before leaving for the day. During an interview on 2/25/26 at 4:06 p.m. with IP and Environmental Services Supervisor (EVSS), IP confirmed with EVSS that laundry staff were gone for the day. EVSS stated the linens and mop heads were not to be in the washing machines overnight. IP stated there were concerns for mold and bacterial growth. During a review of the facility's P&P titled, Safety - Laundry, dated 10/25/25, the P&P indicated, Turn off all equipment and leave the doors to washers and dryers slightly ajar when closing the Laundry at the end of the day. Do not leave laundry unattended.

Based on interview and record review, the facility failed to ensure a discharge notice was sent to Ombudsman (representatives who assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences) for one of two sampled residents (Resident 88). This failure had the potential to result in Resident 88 not having an advocate who could inform them of their admission, transfer, and discharge rights and options.Findings:During a concurrent interview and record review on 2/25/26 at 1:51 p.m. with Minimum Data Set Coordinator (MDSC), Resident 88's admission Record (AR), undated was reviewed. The AR indicated Resident 88 was discharged to home on [DATE]. MDSC stated Resident 88 was discharged home and the Ombudsman was not notified.During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notices, dated 2001, the P&P indicated, 4. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on interview and record review, the facility failed to accurately complete the annual Pre-admission Screening and Resident Review (PASRR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for one of one sampled resident (Resident 12). This failure had the potential for Resident 12 to be placed in an inappropriate setting and not receive required services. Findings:During a review of Resident 12's Preadmission Screening and Resident Review (PASRR -mandatory federal program which requires Residents to be screened for mental illness or intellectual disability/developmental disability) Level 1 Screening, dated 9/24/25, the PASRR indicated, Level I-positive for (SMI) [serious mental illness].During a concurrent interview and record review on 2/26/26 at 2:10 p.m. with Minimum Data Set Coordinator (MDSC), Resident 12's Notice of Attempted Evaluation (NAE-for SNF residents, a new Level I screening must be submitted to restart the process), dated 9/28/25 was reviewed. The NAE indicated, Unable to complete level II evaluation for serious mental illness (SMI).Facility staff [long term care staff] were unresponsive to two or more separate attempts of communication within 48 hours of the Level I Screening. MDSC stated the PASRR level II was not completed for Resident 12.During a review of the facility's policy and procedure (P&P) titled, admission Criteria, dated 2019, the P&P indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process: b. If the Level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents' (Resident 66) was free from medication error rate of greater than five percent (%) when two medication errors occurred within 35 opportunities resulting in a 5.51% error rate. This failure had the potential for Resident 66 not receiving the full therapeutic effects of the medication and potential for adverse health outcomes. Findings:During an observation on 2/25/26 at 8:38 a.m. in Resident 66's room, Registered Nurse (RN) 1 administered Resident 66's morning (a.m.) medications. RN 1 stated to Resident 66 she (RN 1) did not have two of her medications to administer, lisinopril (medication to treat high blood pressure) and fluoxetine (medication to treat depression).During an interview on 2/25/26 at 8:39 a.m. with RN 1, RN 1 stated she did not administer Resident 66's lisinopril and fluoxetine because they were not available. RN 1 stated the pharmacy should have been notified regarding the unavailability of the medications and this was not done. During a review of Resident 66's Medication Administration Record (MAR), dated February 2026, the MAR indicated, 2/25/26 at 8 a.m. Lisinopril Tablet 10 mg (milligram) Give 1 tablet by mouth one time a day for hypertension, and Fluoxetine Capsule 20 MG Give 1 capsule by mouth one time a day for depression. No check mark was documented to indicate the lisinopril and fluoxetine were given to Resident 66.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on interview and record review, the facility failed to ensure the medical record was complete and accurate when physician's verbal order and change in condition physician notification was not documented in the Electronic Medical Record (EMR) for one of six sampled residents (Resident 82). This failure had the potential for Resident 82 to not have his medical needs met which could result in a negative health outcome. Findings:During a review of Resident 82's admission Record (AR), dated 2/25/26, the AR indicated Resident 82 was admitted to the facility on [DATE].During a concurrent interview and record review on 2/24/25 at 3:34 p.m. with Director of Nursing (DON), Resident 82's Physician Order (PO), dated 1/25/26 to 2/24/26 were reviewed. DON stated she was unable to provide documentation of a physician order or notice of a change in condition for Resident 82's transfer to the hospital emergency room on 1/25/26. DON stated it was the expectation of the facility nursing staff to document the physician notification and the physician's order in the Resident's EMR. During a concurrent interview and record review on 2/24/25 at 3:40 p.m. with Licensed Vocational Nurse (LVN) 8, Resident 82's EMR was reviewed. LVN 8 stated on 1/25/26 he was Resident 82's nurse. LVN 8 stated Resident 82 had decreased urine output on 1/25/26. LVN 8 stated Registered Nurse (RN) 9 attempted to flush Patient 82's suprapubic catheter (a thin, flexible tube inserted through a small abdominal incision directly into the bladder to drain urine) but was unsuccessful. LVN 8 stated he telephoned the physician to inform him of Resident 82's change in condition and the physician gave a verbal order (VO) for Resident 82 to be sent to the hospital emergency room. LVN 8 was unable to find the physician's VO in the EMR or documentation the physician was notified of Resident 82's change in condition. LVN 8 stated he got caught up in the transfer and forgot to document the physician notification and the VO. LVN 8 stated he should have documented the information in Patient 82's EMR.During a review of the facility's policy and procedures (P&P) titled, Verbal Order, dated 2001, the P&P indicated, The individual receiving the verbal order must write it on the physician's order sheet as verbal order or t.o. (telephone order).During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 2001, the P&P indicated, Our facility promptly notifies the residents, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.During a review of the facility's P&P titled, Charting and Documentation, dated 2001, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy interpretation and implementation 1. Documentation in the medical record may be electronic, manual or a combination. 2. The following information is to be documented in the resident medical record.Change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure essential equipment was maintained in safe operating condition when: 1. A food preparation sink located in the kitchen had an air gap and floor sink drain in accordance with the Food and Drug Administration Food Code (FDAFC), dated 2022. Facility failure to ensure proper plumbing installation may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food-contact surfaces. (FDAFC, 5-402.11, 2022) 2. Two of two ice-machines located near two different nursing stations had an air gap per the ice-machine's manufacturer's guidelines (MG) and FDAFC, dated 2022. In addition, the ice-machine located near 300 hall nursing station was not stored in a manner that eliminates harborage of pests when there was opened holes/crevices between the baseboard and wall, peeling paint coming off the wall, and the floor was not clean with cracked tiles. Findings: 1. During an observation on 03/04/25 at 12:02 p.m. in the kitchen, a pipe was observed directly plumbed into the wall with the other end of the white colored plastic pipe coming out of the wall and connecting to a long thin pipe running underneath, and along the length of, a food preparation counter with the outlet of the pipe extending over a above-ground floor drain in which the water trap was filled with water. During an interview on 03/06/25 at 09:46 a.m. with Maintenance Supervisor (MS), MS stated the outlet for the hose connected to the coffee maker was draining into the above-floor drain which caused coffee grounds to accumulate in the drain which was why the drain had standing water. MS stated the pipe under the food prep sink was plumbed into the wall into the water system and the white colored pipe under the food prep sink was a P trap and that was why there was no outlet with an air gap nor a floor sink drain for the food prep sink. MS stated he was unaware of the requirement for a food prep sink to have an air gap per the FDA Food Code 2022. During a review of an e-mail communication on 03/07/25 at 6:29 a.m. with Compliance Officer (CO) from Department of Health Care Access and Information Office of Statewide Hospital Planning and Development (HCAI), after CO observed a picture of the plumbing structure located underneath the food preparation sink in the kitchen, the CO's e-mail indicated, The [food] prep sink is a problem, this sink is required to be discharged to a floor sink with copper DWV (Drain, Waste, and Vent) piping per the local health department requirements. During a review of California Health and Safety Code (HSC) Section 114193, dated 2024, the HSC indicated, All steam tables, ice machines and bins, food preparation sinks, warewashing sinks, display cases, walk-in refrigeration units, and other similar equipment that discharge liquid waste shall be drained by means of indirect waste pipes, and all wastes drained by them shall discharge through an airgap into a floor sink or other approved type of receptor. During a review of the FDAFC, dated 2022, the FDAFC indicated, An air gap between the water supply inlet and the flood level rim of the plumbing fixture [such as a food preparation sink], equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm [millimeters] (1 inch). (FDAFC; 5-202.13 Backflow Prevention, Air Gap). During a review of the FDAFC, dated 2022, the FDAFC indicated, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. During a review of an e-mail communication on 03/07/25 at 6:29 a.m. with Compliance Officer (CO) from HCAI, the e-mail indicated, The work at the prep sink will require a HCAI project record. The deficiencies.are beyond normal maintenance. 2. During a concurrent observation and interview on 03/06/25 at 10:46 a.m. with MS, an ice-machine near 200 hall nursing station was observed. MS stated the ice machine did not have a visible air gap nor a drain. During a concurrent interview and record review on 03/06/25 at 10:55 a.m. with MS, MS provided ice-machine manufacturer's guidelines and stated the MGs were for the ice-machine located near 200 hall nursing station. The MGs indicated, Maintain the air gap required by local code between the end of the drain tubes and the building drain receptacle. During a concurrent observation and interview on 03/06/25 at 11:33 a.m. with MS, an ice-machine near 300 hall nursing station was observed to have a pipe inserted into a white plastic pipe which did not allow for a 1 inch air gap of space that separates a water line from an ice machine drain. During a review of an e-mail communication on 03/07/25 at 6:29 a.m. with Compliance Officer (CO) from HCAI, after CO observed a picture of the plumbing structure for the ice machine located near 300 hall nursing station, the e-mail indicated, The ice machine fixed air gap is installed wrong. The pipe should terminate as high as possible in the air gap. The pipe is inserted into the air gap where any blockage would contaminate the pipe. The drain piping should be copper with DWV fittings. During an observation on 03/06/25 at 11:35 a.m. near 300 hall nursing station where the ice machine was located, the wall surrounding the ice machine above the baseboard had cracks and crevices due to the baseboard separating from the wall with extensive peeling paint coming off the wall. The floor was dirty with cracked tiles. During a review of the FDAFC, dated 2022, the FDAFC indicated, Floors that are smooth.are required to ensure effective cleaning is possible. During a review of the FDAFC, dated 2022, the FDAFC indicated, The presence of .dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food [ice is food]. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During a review of the FDAFC, dated 2022, the FDAFC indicated, shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings. During a review of the facility's policy and procedure (P&P) titled, Walls, Ceilings, And Light Fixtures (WCL), dated 2023, the P&P indicated, 1.Walls and ceilings must be free of chipped and/or peeling paint. 2. It is important to repair peeling paint areas as soon as they appear.

Based on observation, interview, and record review, the facility failed to ensure a sanitary environment within the foodservice operation and safe food handling when: 1. One of six sampled residents (Resident 34) had three unopened milk cartons left unrefrigerated in her room. This failure had the potential for Resident 34 to consume spoiled milk and develop foodborne illness. 2. Raw pasteurized shell eggs were stored under a pan of covered raw beef inside a walk-in refrigerator. This failure had the potential for cross-contamination and placed residents at an increased risk of foodborne illness. 3. There lacked adequate cleaning schedules, identifying, and reporting of unsanitary conditions in the kitchen by Dietary Manager (DM) and Registered Dietitian (RD) 1 when multiple drains were extensively covered with black, yellow and or white colored substances, an area of pooled water was on the floor near the steamer, accumulation of dust was on the ceiling vents, and there were cracked and/or chipped flooring and rims of the floor drains in various areas throughout the kitchen which impeded the ability to be effectively cleaned. These failures had the potential to cause foodborne illness. 4. A cracked cover to a light fixture, located in the dish machine room, was not identified and reported for repair. This failure posed a risk for an unrecognized fragment of foreign object to fall on or into a clean plate or serving pan and was a safety issue. 5. Three of three ice-machines were not sanitized in accordance with the manufacturer's guidelines. This failure placed the residents at an increased risk of foodborne illness. Findings: 1. During a concurrent observation and interview on 3/3/25 at 12:47 p.m. with Resident 34 in Resident 34's room, there were three unopened cartons of milk on Resident 34's bed side table. Resident 34 stated two of the unopened milk cartons had been in her room since 8 a.m. this morning and the other unopened carton of milk was from last night. During a review of Resident 34's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/8/25, the MDS indicated Resident 34 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (score of 13-15 means cognitively intact). During an observation on 3/3/25 at 12:51 p.m. in Resident 34's room, three cartons of unopened milk were still on Resident 34's bedside table. During a concurrent observation and interview with Registered Dietitian (RD) 1 in Resident 34's room, RD 1 took the temperature of the milk cartons with the facility's thermometer. The temperature readings were: Unopened milk carton one 73.6 Degrees Fahrenheit ( F-temperature scale) Unopened milk carton two 73.8 F Unopened milk carton three 72.3 F RD stated, I'm sure the milk temperature are out of temperature by now. During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, dated 11/2022, the P&P indicated, Policy Statement: Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: 1. Danger Zone means temperatures above 41 degrees Fahrenheit (F) .that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours .may cause foodborne illness outbreak if consumed. 2. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e. [for example], bacterial or viral organisms capable of causing disease or toxin formation). Examples of PHF/TCS foods include .milk. 27157 2. During a concurrent observation and interview on 03/04/25 at 8:53 a.m. with Dietary Manager (DM) in a walk-in refrigerator, a crate of raw pasteurized shell eggs located on a food storage tray on a rack was stored under a pan of covered, raw beef was placed on a food storage tray above the raw pasteurized shell eggs. DM stated he was not aware pasteurized shell eggs should be stored above raw meat. During a concurrent interview and record review on 03/04/25 at 9:40 a.m. with DM and Registered Dietitian (RD) inside the kitchen, a poster located on the door of the walk-in refrigerator titled Proper Refrigerator Storage; Policy #B006 (PRS), undated was reviewed. The PRS poster indicated the top shelf should store Raw Pasteurized Eggs and raw Whole Meat should be stored on the shelf below the raw pasteurized shell eggs. RD and DM stated the facility's policy on proper refrigerator storage was not followed. 3. During a concurrent observation and interview on 03/04/25 at 11:06 a.m. with DM in the kitchen, a floor sink drain located underneath the dish machine had extensive build-up of thick black and orange-colored substances on the sides, rims and floor of the floor sink drain. The floor sink drain's rim was chipped off one side. DM stated the floor sink drain was not maintained in a sanitary manner. During a concurrent interview and record review on 03/04/25 at 11:31 a.m. with DM in the kitchen, an accumulation of dust was on vents located on the ceiling directly over trayline with exposed food. The vents on the ceiling located in the dish machine room also had an accumulation of dust. DM stated they were not currently on a cleaning schedule because he only used the vents when the kitchen's swamp cooler and/or air conditioner was on during the hot summer. During a concurrent observation and interview on 3/4/25 at 11:34 a.m. with DM in the kitchen, located in an alcove room, back behind, and adjacent to the janitorial closet, was an ice-machine and a large drying rack that held clean foodservice equipment. A wire mesh covered a large drain located underneath the ice-machine. The wire mesh had extensive white and yellow colored dried discoloration on the floor in multiple areas underneath the ice-machine. A black round/elongated shape was observed under the ice-machine which was not identifiable by DM. DM stated the bad smell was strongest around that area. During a concurrent observation and interview on 3/4/25 at 11:35 a.m. with DM in the kitchen, a small flat floor drain located in front of the ice-machine had cracked/chipped flooring around one part of the drain and build -up of black/brownish colored debris with a small amount of pooled water. DM stated he did not think the water was coming up out of the drain but thought it was due to melted ice that was accidentally dropped when dietary staff obtained ice. DM stated he had not reported the cracked/chipped flooring to the maintenance supervisor and it should have been reported. During an interview on 3/4/25 at 11:36 a.m. with Food Service Assistant (FSA) 1 in the kitchen, FSA 1 stated she sometimes smelled a bad odor in that area where the dish machine and janitorial closet were located. During a concurrent interview and record review on 03/04/25 at 11:37 a.m. with DM in the kitchen, the Cleaning Schedule for Cook, undated, Cleaning Schedule for Trayside, undated, and Cleaning Schedule for Dish Room, undated, were reviewed. DM stated the facility's maintenance supervisor (MS) was not responsible for cleaning of the floor sink drains. DM stated the floor sink drains located in the kitchen were not noted on any of the cleaning schedules and were not being cleaned. During a review of the Food and Drug Administration Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. (FDA Food Code Annex: 4-601.11) During an observation on 3/4/25 at 11:39 a.m. with DM in the kitchen, the vents on the ceiling located in the dish machine room had an accumulation of dust. During a concurrent observation and interview on 03/4/25 at 11:50 a.m. with [NAME] 1 in the kitchen, an elongated grated floor drain with thick black colored debris, located in front of the steamer, had chipped flooring near it and water around the drain. [NAME] 1 stated the water was from the steamer and demonstrated by opening and then closing the steamer door in which a significant amount of water began to leak from the bottom of a green hose connected to the steamer. The water fell , and pooled, directly on the floor and had not reached a drain. During a concurrent observation and interview on 03/4/25 at 11:55 a.m. with DM and RD 1 in the kitchen, a large floor drain, located under a small shelving rack, was covered with a grate that had extensive discoloration of a white and yellow colored substance. The shelving rack front right leg and back right leg were propped up on a white colored material with grooves that had build-up of white colored substance. RD and DM stated the area was not maintained in a sanitary manner. RD stated the legs were propped up because the floor was not even. During a concurrent observation and interview on 03/04/25 at 12:02 p.m. with DM and [NAME] 1 in the kitchen, a pipe was observed directly plumbed into the wall with the other end of the white colored plastic pipe coming out of the wall and connecting to a long thin pipe running underneath, and along the length of, a food preparation counter with the outlet of the pipe extending over a above-ground floor drain in which the water trap was filled with water. [NAME] 1 stated there was a work order for the backed up drain. In addition, the tile floor underneath the long food preparation counter was not clean as evidenced by extensive brownish color particularly along the rim of the floor and baseboard. During an interview on 03/04/25 at 12:05 p.m. with DM, DM stated once he entered the work order into the electronic software the facility used for work orders he could no longer see them or retrieve them. During a review of the FDAFCA, dated 2022, FDAFCA indicated, Liquid wastes need to be quickly carried away to prevent pooling which could attract pests such as insects and rodents. (FDA Food Code Annex; Chapter 6: Physical Facilities) During a review of the Food and Drug Administration Food Code [FDAFC], dated 2022, the FDAFC indicated, Floors.shall be designed, constructed, and installed so they are smooth and easily cleanable. During a review of the facility's policy and procedure (P&P) titled, Sanitization, dated November 2022, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All.equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper. 4. During a concurrent observation and interview on 03/04/25 at 12:07 p.m. with DM in the kitchen, a light fixture located on the ceiling on the clean side of the dishmachine room, had a crack in the light cover. DM stated he had not identified the damaged light cover and thus had not reported the need for repair to maintenance. During a review of the facility's P&P titled, Walls, Ceilings, And Light Fixtures (WCL), dated 2023, the P&P indicated, Replace light fixtures as needed. 5. During a concurrent interview and record review on 03/06/25 at 10:08 a.m. with Maintenance Supervisor (MS), MS stated he was the one that cleaned the ice-machine located in the kitchen. MS showed a bottle labeled as Nu-Calgon Nickel-Safe Ice Machine Cleaner Food Grade.for removing scale deposits. MS stated he circulates the Nickel-Safe descaler which was both a cleaner and a sanitizer through the ice-making apparatus (top part of the ice machine) on a monthly basis. MS stated he used bleach only in the bin of the ice-machine to sanitize. MS was asked what product he circulated through the water distributor to sanitize and MS pointed to the bottle of Nickel-Safe Cleaner. MS stated that was all he had to use because it was both a cleaner and a sanitizer. During a concurrent interview and record review on 3/6/24 at 10:13 a.m. with MS, the manufacturer's label located on the bottle of Nu-Calgon Nickel-Safe Ice Machine Cleaner (IMC) was reviewed. The IMC label indicated, Rapid scale remover. The back of the IMC label indicated, 6. To clean evaporator and recirculating water system add Nickel-Safe Ice Machine Cleaner to the water in ice maker according to manufacturer's instructions. 7. Allow cleaning solution to circulate for up to 10 minutes.9. Recommend: Sanitize the machine with IMS-III Sanitizing concentrate. During a concurrent interview and record review on 03/06/25 at 10:46 a.m. with MS, the ice-machine manufacturer's guidelines (IMMGs) titled, Sanitizing and Water System Cleaning, undated, were reviewed. The IMMGs indicated, The water system is cleaned by pumping a mixture of water and nickel safe type ice machine cleaner through the water distributor, over the evaporator and back to the reservoir.Note: The ice making portion of the water system should be sanitized after cleaning by repeating steps 7-9, except substitute an approved sanitizing solution. MS stated IMMGs were for the ice-machine located in the kitchen. MS stated the ice machine's manufacturer's guidelines were not followed as MS missed the sanitizing step. During an interview on 03/06/25 at 10:50 a.m. with MS, MS stated he did the same cleaning process for the ice-machine located near 200 hall nursing station and for the ice-machine located near 300 hall nursing station. MS stated he thought the Nickel Safe Cleaner was also a sanitizer. During a review of the facility's P&P titled, Sanitization, dated November 2022, the P&P indicated, Ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions.

Based on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, develop, and implement infection prevention and control action plans to correct infection control deficient practices identified by the survey team (Reference tags F-880, F-882 and F-945). This failure placed all 73 facility residents at risk for infectious diseases. Findings: During a concurrent interview and record review on 3/6/25 at 11:50 a.m. with the Administrator, the minutes of the facility's Quality Assurance and Performance Improvement (QAPI) (a committee that identifies quality deficits and implements corrective plans) meeting dated 1/23/25 (the most recent QAPI meeting) were reviewed. The Administrator indicated the 1/23/25 QAPI meeting covered the period of October, November, and December 2024. The facility's QAPI meeting minutes dated 1/23/25 were reviewed. The QAPI meeting minutes indicated a one page infection prevention control report titled Quarterly Report Infection Prevention 2024. The Quarterly Report Infection Prevention 2024 report indicated the rate of Urinary Tract Infections (UTIs) (infection of the urinary system), respiratory infections, and skin infections at the facility. No other infection and prevention control concerns or issues were documented in the 1/23/25 meeting minutes. The surveyor reviewed the survey team's infection prevention and control deficient practices identified during the current survey with the Administrator. The facility's deficient practices reviewed included failure to clean and disinfection glucometers (devices use to measure blood sugar levels) between resident use, infection prevention and control education not provided to staff, enhanced barrier precautions (an infection control strategy) not implemented in the facility, and failure to ensure the Infection Preventionist conducted surveillance activities (collecting, analyzing, and tracking and trending of infection control practices and data) (Reference tags F-880, F-882 and F-945). The Administrator stated the above infection control deficient practices had not been identified by the facility and were not covered during the most recent (1/23/25) QAPI meeting. During a review of the facility policy and procedure (P&P) titled QAPI [Facility Name], dated 1/18/24, the P&P indicated: Our QAPI activities will cross service areas and departments and we will work together to assure we address all concerns and strive to continuously improve the provided services.

Based on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 14, Resident 38, and Resident 56) were informed of the process to file a grievance (formal complaint) with the facility. This failure had the potential for residents' concerns to go unaddressed by the facility. Findings: During an interview on 3/4/25 at 10:04 a.m. with Resident 14, Resident 14 stated he did not know how to file a grievance. During a review of Resident 14's Minimum Data Set, (MDS- a federally mandated resident assessment tool) dated 1/17/25, the MDS indicated Resident 14 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 (score of 13-15 means cognitively intact). During an interview on 3/4/25 at 10:05 a.m. with Resident 38, Resident 38 stated she does not remember if the facility informed her on how to file a grievance. Resident 38 stated she just goes directly to the person she had a problem with to address her issues. During a review of Resident 38's MDS dated [DATE], the MDS indicated Resident 38 had a BIMS score of 12 (score of 8-12 means moderate cognitive impairment). During an interview on 3/4/25 at 10:07 a.m. with Resident 56, Resident 56 stated she did not know how to file a grievance. Resident 56 stated the facility did not let her know how to file a grievance and who to file it with. During a review of Resident 56's MDS dated [DATE], the MDS indicated Resident 56 had a BIMS score of 15. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2/2021, the P&P indicated, residents have the right to.voice grievances to the facility. During a review of the facility's P&P titled, Grievances/Complaints-Staff Responsibility, dated 10/2017, the P&P indicated, 3. Staff members will inform the resident or the person acting on the resident's behalf as to where to obtain a Resident Grievance/Complaint Form and where to locate the procedures for filing a grievance or complaint.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices when: 1. One of six sampled residents (Resident 6) had three opened gallons of distilled water on top of a commode. This failure had the potential for contamination of the distilled water. 2. Treatment Nurse (TN) dropped an item from the treatment cart, picked it up off the floor, and placed it back in the treatment cart. This failure had the potential for contamination of clean items in the treatment cart. 3. Infection Preventionist (IP) did not follow the facility's policy and procedure (P&P) titled, Monitoring Compliance with Infection Control for surveillance (monitoring) activities, collecting, analyzing, and tracking and trending of data. This failure had the potential for facility to be unaware of outbreaks and transmission of infectious diseases. 4. Enhanced Barrier Precaution (EBP-a set of infection control measures that use gowns and gloves to reduce the spread of multi-drug-resistant organisms [MDROs-bacteria resistant to antibiotics]) was not implemented for three of three sampled residents (Resident 6, Resident 31, and Resident 11). This failure had the potential to spread infections to residents, staff, and visitors. 5. The facility failed to clean and disinfect glucometers (medical devices that measure blood sugar levels) between resident use according to manufacturer's instructions for two of two sampled residents (Resident 30 and Resident 61). This failure placed Resident 30 and Resident 61 at risk for bloodborne (diseases that spread via the blood) infectious diseases. Findings: 1. During a concurrent observation and interview on 3/3/25 at 10:32 a.m. with Resident 6 in Resident 6's room, there were three opened gallons of distilled water on top of Resident 6's commode. Resident 6 stated the gallons of water were used for her continuous positive airway pressure machine (CPAP-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in). Resident 6 stated she used the commode occasionally. During a review of Resident 6's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/28/25, the MDS indicated Resident 6 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (score of 13-15 means cognitively intact). During a review of Resident 6's Client Diagnosis Report (CDR), dated 3/5/25, the CDR indicated Resident 6 had a diagnosis of Obstructive Sleep Apnea (airflow blockage during sleep). During a review of Resident 6's Physician's Telephone Order'' (PTO), dated 2/19/25, the PTO indicated, CPAP MACHINE WITH PRE-SET SETTINGS AT NIGHT WHILE SLEEPING EVERY BEDTIME. During an interview on 3/3/25 at 11:23 a.m. with IP, IP stated there were three gallons of used distilled water on top of Resident 6's commode. IP stated the distilled water was used for Resident 6's CPAP machine. IP stated the distilled gallons of water should not be stored on top of the Resident 6's commode. IP stated the water storage on top of the commode was unsanitary. 2. During an observation on 3/3/25 1:03 p.m. in the hallway, TN opened a drawer of the treatment cart, a packaged (medical device) kit fell out of the treatment cart, TN picked up the item from the floor, and placed item back into a drawer in the treatment cart. During a concurrent observation and interview on 3/3/25 at 1:04 p.m. with TN in the hallway, TN opened the drawer of the treatment cart and the packaged (medical device) kit that fell out of the cart was in the treatment cart next to an opened package of gauze. TN stated she should not have put the packaged item that fell on the floor back into the treatment cart. 3. During an interview on 3/5/25 at 8:53 a.m. with IP stated he only monitored hand hygiene which included hand washing and hand rub, and donning on and doffing (removing) of Personal Protective Equipment (PPE-clothing and equipment that is worn for protection against hazardous substances and/or environments). IP stated, I try to go out to the floor every other day and on every shift. IP stated glucometer use and cleaning was not part of his infection control surveillance. During a review of the facility's Hand Hygiene Monitoring Tool (HHMT), dated January 2025, February 2025, and March 2025, the HHMT did not indicate an adherence rate for staff hand hygiene compliance or actions taken to correct non-compliance with infection control practices. IP stated he did on-the-spot education with staff who are non compliant with hand hygiene but he did not document it. IP did not provide tracking and trending of the staff noncompliance of hand hygiene practices analysis of the surveillance, or actions taken to correct non-compliance. During a review of the facility's P&P titled, Monitoring Compliance with Infection Control, dated 8/2019, the P&P indicated, Policy Statement: Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and practices. 6. The infection preventionist and/or the IPC committee provides reports to the QAPI [Quality Assurance and Performance Improvement] committee that reflect: all infection surveillance data. 4 a. During a concurrent observation and interview on 3/3/25 at 10:32 a.m. in Resident 6's room, Resident 6 had a dressing to the right leg. Resident 6 state she had an ulcer (open sore) on the right side of her heel. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had a BIMS score of 15. During a review of Resident 6's AOR dated 3/6/25, the AOR indicated, Cellulitis (bacterial infection of the skin) of right lower limb, Cellulitis of left lower limb. During an observation on 3/3/25 at 10:55 a.m. outside Resident 6's room, there was no EBP signage posted and there were no PPE supplies in Resident 6's room or outside the room. During a review of Resident 6's Active Orders Report (AOR), dated 3/5/25, the AOR indicated, Venous wound to the Right/Left heel Cleanse venous wounds on the Right and Left heel with wound spray, pat dry, apply Xeroform [treats wounds], then apply non-adherent pad, wrap with Kerlix [gauze] The AOR also indicated, Right Lower Extremity Open Wound Cleanse with wound spray, pat dry, apply adaptic, apply non-adhesive pad, wrap with kerlix .Non-pressure chronic ulcer [an open sore] of right calf with fat layer exposed. b. During a concurrent observation and interview on 3/3/25 at 10:39 a.m. in Resident 34's room, Resident 34 had swelling to bilateral legs with a dressing to her right leg. Resident 34 stated she had cellulitis (a skin infection that causes swelling and redness) to both of her legs. During a review of Resident 34's MDS dated [DATE], the MDS indicated Resident 34 had a BIMS score of 15. During an observation on 3/3/25 at 10:55 a.m. outside Resident 34's room, no EBP signage was observed and no PPE supplies were in Resident 34's room or outside the room. c. During an observation on 3/3/25 at 2:21 p.m. in Resident 11's room, Resident 11 was sitting in her wheelchair with a Foley catheter (a hollow tube inserted into the bladder to drain or collect urine) bag in a privacy bag behind wheelchair. No EBP signage was observed. No PPE supplies were in the resident's room or outside the room. During a review of Resident 11's Physician's Telephone Order, (PTO) dated 3/5/25, the PTO indicated, FOLEY CATHETER .Retention of urine. During an interview on 3/5/25 at 10:05 a.m. with IP, IP stated EBPs were not really implemented in the facility, and he did not know what the criteria was for EBP. IP stated he did not know what type of PPE was required for EBP. During an interview on 3/5/25 at 10:41 a.m. with Licensed Vocational Nurse (LVN) 13, LVN 13 stated this was the first time she heard about EBP. During an interview on 3/5/25 at 10:47 a.m. with Certified Nursing Assistant (CNA) 9, CNA 9 stated she was unaware of EBP. During an interview on 3/5/25 at 10:52 a.m. with Assistant Director of Nursing (ADON). ADON stated she did not know much about EBP. During an interview on 3/5/25 at 11:54 a.m. with Director of Staff Development (DSD), DSD stated she had not heard much about EBP. During an interview on 3/5/25 at 12:35 p.m. with Director of Nursing (DON), DON stated she went to an infection prevention conference, but was not sure when the AFL (All Facilities Letter) indicated EBPs were required. During a review of the California Department of Health's AFL (CDPHAFL), dated 6/13/24, the CDPHAFL indicated, On March 20, 2024, CMS [Centers for Medicare & Medicaid Services] distributed CMS QSO-24-089 NH (PDF), which updated its infection prevention and control guidance for long-term care facilities to include the CDC [Centers for Disease Control and Prevention] guidance for EBP. During a review of the facility's P&P titled, Enhance Barrier Precaution, dated 12/2024, the P&P indicated, 2. Enhanced barrier precautions apply when: a. A resident is infected or colonized with a CDC-targeted MDRO .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices .5. Indwelling medical devices include .urinary catheters, feeding tubes .7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering, c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin .10. Residents on EBPs may come out of their rooms and participate in group activities and dining with other residents .16. Staff are trained prior to caring for residents on EBPs. 17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. 18. Personal protective equipment .are readily accessible to staff. 37797 5. During a concurrent observation and interview on 3/5/25 at 11:20 a.m. with LVN 1, LVN 1 checked the blood sugar level of Resident 36 using an ACCU-CHEK Inform II (brand name) Glucometer and placed the glucometer on top of the medication cart without cleaning or disinfecting the device. After administering insulin (a medication to control high blood sugar levels) to Resident 36, LVN 1 took the same glucometer used for Resident 36 from the top of the medication cart, inserted a test strip, went into Resident 61's room, poked Resident 61's finger with a lancet (a small, sharp needle), brought the glucometer with the strip's tip towards Resident 61's finger when LVN 1 was stopped by the surveyor and questioned if she had cleaned and disinfected the glucometer after using it to check Resident 36's blood sugar. LVN 1 stated she had not cleaned the glucometer. During a concurrent observation and interview on 3/5/25 at 11:40 a.m. with LVN 2, LVN 2 checked the blood sugar level of Resident 10 using an ACCU-CHEK Inform II Glucometer and placed the glucometer on top of the medication cart without cleaning or disinfecting it. After administering insulin to Resident 10, LVN 2 took the same glucometer used for Resident 10 from the top of the medication cart, inserted a test strip, went into Resident 30's room, poked Resident 30's finger with a lancet, brought the glucometer with the strip's tip towards Resident 30's finger when LVN 2 was stopped by the surveyor and questioned if she had cleaned and disinfected the glucometer after using it to check Resident 10's blood sugar. LN 2 stated she had not cleaned the glucometer. During an interview on 3/6/25, at 10:45 a.m. with the facility's IP, IP stated nurses should clean and disinfect glucometers after each resident using purple wipes (Sani-Cloth Sanitizing Wipes - a type of healthcare disinfectant that kills bloodborne pathogens) observing a two-minute contact time (the amount of time the glucometer surfaces must be wet with the disinfectant solution to kill the pathogens). During a review of the ACCU-CHEK Inform II Glucometer Operator Manual (OM), undated, the OM indicated: The meter should be cleaned and disinfected between each patient use. During a review of the facility's policy and procedure (P&P) titled, Blood Sampling - Capillary (Finger Stick), dated September 2014, the P&P indicated, The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees . Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use.

Based on observation, interview, and record review, the facility failed to enusre call lights were withing reach for four of 36 sampled residents (Resident 47, Resident 61, Resident 16, Resident 15). This failure had the potential for residents' needs to go unmet and place residents' safety at risk. Findings: During an observation on 3/3/25 at 10:53 a.m. in Resident 47's room, Resident 47 was laying on her back toward her left side and was restless, moving both feet back and forth on the mattress. Resident 47's sensitive call light (a system to be used for limited mobility) was tied to the right upper side rail where she could activate or use call for assistance. During a concurrent observation and interview on 3/3/25 at 10:56 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 47's call light was observed tied to the right upper side rail. LVN 1 stated Resident 47 was able to use the round sensitive call light and it should be within her reach. During an observation on 3/3/25 at 1:19 p.m. in Resident 61's room, Resident 61's call light was hanging over the headboard out of reach of Resident 61. During a concurrent observation and interview on 3/3/25 at 1:23 p.m. with Certified Nursing Assistant (CNA) 1, Resident 61's call light was located hanging over her headboard out of reach. CNA 1 stated Resident 61 should be able to reach her call light. During a concurrent observation and interview on 3/3/25 at 1:26 p.m. with Resident 16 in Resident 16's room, Resident 16 was up in a wheelchair sitting next to her bed without a call light. Resident 16 stated she did not know where her call light was but probably mixed up in the bed linens. Resident 16 stated she would use the call light to call for help. Resident 16 stated, Where is it [call light]? During a concurrent observation and interview on 3/3/25 at 1:28 p.m. with CNA 4 in Resident 16's room, Resident 16 was up in a wheelchair sitting next to bed without a call light within reach. CNA 4 stated Resident 16 should have had a call light within reach. 50939 During a concurrent observation and interview on 3/3/25 at 11:05 a.m. with CNA 7 in Resident 15's room, Resident 15's call light was on the floor. CNA 7 stated Resident 15's call light should be in Resident 15's hand or within her reach. During a review of the facility's Policy and Procedure P&P titled, Call System, Residents, undated, the P&P indicated, Policy Statement: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation: 6. Calls for assistance are answered as soon as possible and at a reasonable time. Urgent requests for assistance are addressed immediately.

Based on interview, and record review, the facility failed to follow its Policy and Procedure titled, Employee Training on Infection Control, for 11 of 25 sampled Licensed Vocational Nurses (LVN) (LVN 1, LVN 2, LVN 3, LVN 4, LVN 5, LVN 6, LVN 7, LVN 8, LVN 10, LVN 11, and LVN 12) and four of six sampled Registered Nurses (RN) (RN 1, RN 2, RN 4, and RN 5). This failure resulted in licensed nursing staff being unaware of standard infection prevention precautions, increasing the potential for the spread of infectious diseases to residents, staff, and visitors. Findings: During a concurrent interview and record review on 3/5/25 at 2:39 p.m. with Infection Preventionist (IP) the facility's education titled,Infection Prevention (IP), dated 6/18/24, 6/19/24, 1/24/24, and 1/25/24 was reviewed. The IP education indicated some of the topics that should have been covered during the training included: the six elements of Standard Precautions, the importance of hand hygiene, contact wet time of disinfectants, proper use of personal protective equipment, the difference between cleaning and disinfecting, and maintaining separation between clean and soiled devices to prevent the spread of infection. IP stated he did not remember what he trained staff on and did not provide training documents. During an interview on 3/6/25 at 10:27 a.m.with Licensed Vocational Nurse, (LVN)3, LVN 3 stated he could not remember the last Infection Control training he attended. During a review of the facility's policy and procedure (P&P) titled, Employee Training on Infection Control, dated January 2012, the P&P indicated all staff and personnel would complete orientation and training on preventing the transmission of healthcare associated infections.

Based on interview and record review the facility failed follow their Policy and Procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, for all residents (73) when direct care service hours per patient day for Certified Nursing Assistants (CNAs) fell below the minimum standard of 2.4. This failure had the potential for residents care needs not to be met by staff. Findings: During an interview on 3/4/25 at 2:39 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated when staff call off from work, they work short staffed. LVN 3 stated they would divide up the tasks that would have been completed by the staff who called off work. During an interview on 3/6/25 at 9:45 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated she has worked short staffed frequently. During a concurrent interview and record review on 3/6/25 at 11:12 p.m. with Director of Nursing (DON), Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 3/1/25 and 3/2/25 were reviewed. DHPPD indicated on 3/1/25 actual CNA DHPPD was 2.31. A signature indicated the patient census and direct care service hours were reviewed and. acknowledge the information was true and correct. DHPPD indicated on 3/2/25 the actual CNA DHPPD was 2.24. DON stated some staff were unable to stay over to cover for the short staffed shifts. Facility DHPPD documents for the followed dates only: 2/6/25 2/25/25, 2/26/25, 2/27/25, and 2/28/25 3/3/2025. Requested 6 months DHPPD documetation, facility was unable to provide documentation all data. During a review of the facility's policy and procedure (P&P) titled Staffing, Sufficient and Competent Nursing, dated August 2022, the P &P indicated, Minimum staffing requirements imposed by the state, if applicable, are adhered to when determining staff ratios but are not necessarily considered a determinization of sufficient and competent staffing.

Based on observation, interview, and record review, the facility failed to provide a home-like environment for one of six sampled residents (Resident 72) when the bathroom had an odor. This failure had the potential to cause a decrease in Resident 72 and visitors' comfort level and failed to protect Resident 72's right to a home-like environment. Findings: During a review of Resident 72's Admission Record (AR), dated 12/6/25, the AR indicated, Resident 72's admitted was 12/6/25. During a concurrent observation and interview on 3/5/25 at 8:08 a.m. with Resident 72's family member (FM) in Resident 72's room, there was a strong odor of urine in the bathroom. FM stated when the bathroom door is left open, there was a strong stale urine smell. FM stated she had visited Resident 72 every day since he was admitted three weeks ago. During an interview on 3/5/25 at 8:16 a.m. with Resident 72, Resident 72 stated, The bathroom stinks. During a review of Resident 72's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 2/13/24, the MDS indicated Resident 72 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 (score of 13-15 means cognitively intact). During an interview on 3/5/25 at 8:16 a.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated the shared bathroom for Resident 72 had a strong urine smell especially in the mornings. During an interview on 3/5/25 at 2:20 p.m. with Housekeeping Aide (HKA), HKA stated she was assigned Resident 72's room. HKA stated the shared bathroom always smelled like urine. HKA stated she cleaned the bathroom daily but the smell of urine lingered. During an interview on 3/6/25 at 10:07 a.m. with Environmental Services Supervisor (EVSS), EVSS stated Resident 72's bathroom urine smell was still there. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 10/2018, the P&P indicated, Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment.

Based on observation, interview, and record review, the facility failed to protect one of two sampled residents from abuse (Resident 1) when Resident 2, who had a history of inappropriate behavior, was not adequately supervised. This failure resulted in abuse when Resident 2 touched Resident 1's breasts and perineal area. Findings: During a review of Resident 1's clinical record the Record of Admission (ROA), indicated Resident 1 was admitted on [DATE]. The SOAP [Subjective, Objective, Assessment and Plan - method of documentation used by healthcare workers] Note dated 3/14/22 at 11:09 a.m., indicated, Major neurocognitive disorder [decreased mental function and loss of ability to do daily tasks] due to dementia [a group of symptoms affecting memory, thinking and social abilities], R/O [rule out] Alzheimer's disease [a progressive disease that destroys memory and other important mental functions]. The Minimum Data Set (MDS) assessment dated [DATE] indicated, Resident 1's Brief Interview for Mental Status (BIMS-screening tool to identify the cognitive condition of a resident with a scoring of 0 to 15, 15 being cognitively intact) assessment score was 4 which indicated Resident 1 has severe impaired cognitive ability. The MDS assessment dated [DATE] indicated Resident 1 is in a wheelchair and is not ambulatory. During a review of Resident 1's Plan of Care dated 3/30/24, the Plan of Care indicated, Victim: Resident [1] was inappropriately touched by another resident [Resident 2]. The interventions included: perform a body check, provide one-on-one reassurance, monitor for changes in mood, behavior, socialization, sleep, or appetite, and Social Services Director to provide supportive one-to-one visits. During a review of Resident 1's Physician Progress Note (PPN), dated 4/8/24 at 12:57 p.m., the PPN indicated, LATE ENTRY FOR 04/01/2024 08:30 [8:30 a.m.]: Patient [Resident 1] was involved in an incident with another resident [Resident 2] recently [3/30/24] but does not recall any of the details. She [Resident 1] continues to demonstrate cognitive [mental] decline/dementia. She continues to be unable to make her own medical decisions. She does have varying degrees of clarity and can carry on conversations and express her needs. Overall has poor safety awareness. When asked about these incidents she does not seem to recall any details of specifics. During a review of the facility's Initial and Final Report (IFR), dated 4/1/24, the IFR indicated, On 3/30/2024 at about 0900 [9 a.m.] hours [Resident 1] was found by the C.N.A. [Certified Nursing Assistant- CNA 2] lying on her bed with her adult brief down and [Resident 2] was standing on the right side of her bed. During a review of Resident 2's ROA, the ROA indicated Resident 2 was admitted on [DATE]. The MDS assessment dated [DATE] indicated Resident 2's BIMS score was 13 which indicates the resident is cognitively intact. Resident 2 is independent with mobility and can walk 150 feet independently. During a review of the Behavior Management Note (BMN), dated 2/22/24 at 6:50 p.m., the BMN indicated, Resident [Resident 2] provided comfort by touching resident [Resident 6] arm. Resident [6] later explained to writer that she does not prefer to be touched on the shoulder or arm when resident [Resident 1] comes to visit her. During a review of Resident 2's Nurses Notes (NN), dated 2/26/24 at 4:20 p.m., the NN indicated, Informed SS [Social Services] to work on setting healthy boundaries with him [Resident 2], in regards to friendship with another resident [Resident 1] telling her to move to Trona with him. During a review Resident 2's Behavioral Management Note, Alert Charting Note (BMNACN - when staff monitor and document a resident's change in condition every shift for 72 hours), dated 2/26/24 at 11:21 p.m., the BMNACN indicated, Resident [2] is on alert charting for behaviors relating to [Resident 1] and inappropriate sexual comments towards staff. Resident [2] was heard stating to CNA [Certified Nursing Assistant - unidentified] ' I would like to see more of your chest tattoo that is covered' and ' are there any tattoos you have tattoos are covered that I could see if you were naked' [sic]. Resident [2] also said to another CNA [unidentified] 'Your freckles look good all over your body'. CNA [unidentified] staff has reported many inappropriate comments from resident [2] today. During a review of Resident 2's Plan of Care dated 2/27/24, the Plan of Care indicated, Conflict: Resident [2] has been identified as having a high potential for conflict with staff/other residents/family. Resident [2] is at risk for conflict due to crossing professional boundaries with staff AEB [As evidence by]: asking to see staff tattoos and freckles under clothing. Potential for crossing platonic boundaries with other residents AEB: discussing moving with another resident. The interventions include: if resident is assigned one-on-one staff assignments will be rotated regularly to avoid burnout, staff will regularly document notes on behavior and refer to social services, Social Services will review resident chart documentation 1x monthly to identify any trends/issues. During a review of Resident 2's Plan of Care dated 3/30/24, the Plan of Care indicated, SEXUAL-BEHAVIORAL SYMPTOMS: PUBLIC SEXUAL ACTS: Resident [2] has engaged in sexual behaviors [with Resident 1] such as: Needs continual reminders of acceptable public behavior and of resident's rights. May be unable to comprehend or remember appropriate behavior related to a diagnosis of dementia The interventions include to schedule and coordinate a care conference with resident and family, provide secured privacy, explain acceptable behavior and expressions of sexuality based on cognitive evaluation, evaluate resident's cognitive status for memory and social reasoning, remind resident in a private setting of the need to observe specific limits, protect other residents by close monitoring, educate staff on behavior approaches designed to effectively manage unacceptable sexual advances, and psychiatric evaluation. During a review of Resident 2's Plan of Care dated 3/30/24, the Plan of Care indicated, SEXUAL-BEHAVIORAL SYMPTOMS: PUBLIC SEXUAL ACTS : Resident has engaged in sexual behaviors such as .touches/fondles other resident, Makes verbally explicit comments and suggestions Needs continual reminders of acceptable public behavior and of resident's rights.03/30/24: Resident [2] found in a female resident's room with door closed.Resident [2] initially reports he did not touch female resident [1]. Resident [2] later reported to staff that he touched female resident's [1's] breasts and he reported to state surveyor tht [that] he ' tickeld [tickled]' the same female resident's [1's] vagina. The goals include Resident [2] will not engage in sexual behavior in public by re-evaluation date [6/28/24], resident will not squeeze/slap/touch/fondle staff, resident will not make sexual advances to other non-consenting residents, and resident will respond to redirection and staff monitoring. The interventions include to protect other residents by close monitoring - every 15-minute checks x 3 days, every 30 minutes checks x 3 days and hourly checks x 14 days and re-evaluate for continued monitoring need, checks to include monitoring for activity and location and change room to near nursing station. During an interview on 4/8/24 at 11:24 a.m. with Resident 2, Resident 2 stated, I did pull her [Resident 1] clothes down. I wanted to see what she looked like. I wanted to tickle her. I did tickle her down there [in her private area]. I find her to be attractive and I was interested. During an observation and interview on 4/8/24 at 11:46 a.m. with Resident 1, in Resident 1's room, Resident 1 was sitting in her wheelchair. Resident 1 stated, I do not remember that this [sexual abuse] happened. What did he [Resident 2] do to me? I do not know who this resident [2] is. Resident 1 was unable to recall the 3/30/24 incident where Resident 2 admitted to touching Resident 1's breasts and perineal area. During an interview on 4/8/24 at 12:06 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 touched staff members in their private parts. LVN 1 stated Resident 1 has been displaying these behaviors for almost a month. LVN 1 stated he would inform Resident 1 the behavior was not appropriate but LVN 1 did not report the behavior to anyone. During an interview on 4/8/24 at 12:16 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 2 was in Resident 1's room prior to the incident on 3/30/24. CNA 1 stated she keeps an eye on Resident 2 because she has noticed Resident 2 watches staff to see when they are busy and not at the nurses' station. CNA 1 stated Resident 2 is alert and oriented, and Resident 1 is confused. CNA 1 stated Resident 1 and Resident 2 would sit in the dining room holding hands. CNA 1 stated he seemed more interested in her [Resident 1] two weeks prior to the incident. During an interview on 4/8/24 at 2:15 p.m. with Director of Nursing (DON), DON stated she is aware Resident 2 has said inappropriate words to staff but was not aware of any other inappropriate behavior with other residents. During a concurrent interview and record review on 4/8/24 at 2:47 p.m., with Social Services Director (SSD) Resident 2's Plan of Care dated 3/30/24 the Plan of Care was reviewed. The Plan of Care indicated, SEXUAL-BEHAVIORAL SYMPTOMS: PUBLIC SEXUAL ACTS: Resident [2] has engaged in sexual behaviors such as touches/fondles other resident, Makes verbally explicit comments and suggestions Needs continual reminders of acceptable public behavior and of resident's rights.03/30/24: Resident [2] found in a female resident's room with door closed.Resident [2] initially reports he did not touch female resident [1]. Resident [2] later reported to staff that he touched female resident's [1's] breasts and he reported to state surveyor tht [that] he ' tickeld [tickled]' the same female resident's [1's] vagina. The goals include Resident will not engage in sexual behavior in public by re-evaluation date [6/28/24], resident will not squeeze/slap/touch/fondle staff, resident will not make sexual advances to other non-consenting residents, and resident will respond to redirection and staff monitoring. The interventions include to protect other residents by close monitoring - every 15-minute checks x 3 days, every 30 minutes checks x 3 days and hourly checks x 14 days and re-evaluate for continued monitoring need, checks to include monitoring for activity and location and change room to near nursing station (not added until 4/9/24). SSD stated close monitoring means just checking on him [Resident 2] when we are on the floor. I am not sure if it is specific enough. SSD stated to make sure close monitoring is occurring for Resident 2, he would review alert chartings (when staff monitor and document a resident's change in condition every shift for 72 hours). During a subsequent interview on 4/29/24 at 8:30 a.m., with SSD, SSD stated looking back now at the prior alert charting for Resident 2, shows the interventions were not effective. During an interview on 4/11/23 at 3:06 p.m. with CNA 2, CNA 2 stated Resident 1's room door was always open. On 3/30/24 after coming out of another resident's room, she noticed Resident 1's room door was closed and when she went in, she noticed Resident 2 was standing on Resident 1's right side and Resident 1's brief was all the way down to her ankles. CNA 2 stated Resident 1 and Resident 2 looked surprised. CNA 2 stated the time of the incident was right after breakfast during morning rounds approximately 9:30 a.m. CNA 2 stated this was the first time she noticed Resident 1 had her brief all the way down. CNA 2 stated she heard when the police [during the sexual assault incident that occurred on 3/30/24] asked Resident 1 if Resident 2 touched her breast, Resident 1 said yes. During an interview on 4/11/23 at 3:24 p.m. with LVN 3, LVN 3 stated she was notified of what CNA 2 witnessed [Resident 2 on the right side of Resident 1's bed and Resident 1 having her briefs down to her ankle] during med pass on 3/30/24. LVN 3 stated Resident 1 does not have the capacity to understand. LVN 3 stated she heard Resident 1 tell the police that Resident 2 touched her breast. During an interview on 4/29/24 at 9:46 a.m. with LVN 3, LVN 3 stated a few months ago Resident 2 had gone into Resident 1's room. LVN 3 stated Resident 2 had gone into Resident 1's room multiple times. LVN 3 stated during those incidents, she was made aware, and she informed staff to keep any eye on them [Resident 1 and Resident 2]. During a review of the Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, the P&P indicated, Residents have the right to be free from abuse. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse by anyone including, but not necessarily limited to: b. other residents. 8. Identify and investigate all possible incidents of abuse. 10. Protect residents from any further harm during investigations.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received adequate care and services necessary to prevent a pressure injury/ulcer to her left hand. This injury developed when her contracted fingers pressed her untrimmed fingernails into the palm of her left hand, causing a 2.5 centimeter (cm) pressure injury. This required surgery to multiple areas to her left arm to release the contractures and to repair the pressure injury, creating surgical risks (potential complications include nerve damage and pain). Note: Contracture is when the normally stretchy or elastic tissues are replaced by nonstretchy fiber-like tissue. This makes it hard to stretch the area and prevents normal movement. Contractures mostly occur in the skin, the tissues underneath, and the muscles, tendons, ligaments surrounding a joint. They affect range of motion and function in a certain body part. Often, there is also pain. Findings: During a review of the clinical record, the Record of Admission indicated Resident 1 was admitted to the facility on [DATE], was a, 80-years-old female, and had [DIAGNOSES REDACTED]. The Surgical Report, dated 4/9/18 indicated Resident 1 entered the hospital on this date for surgery to repair her left hand contracture. The report also indicated there was Left hand poor hygiene because of the contracture, left palm pressure wound due to pressure of the nails. The patient has got a significance (sic) hand contracture with the nails digging into the left palm. The patient is in quite a bit of pain and does not let anybody touch the hand or the (sic) let us examine it. At this stage, the patient has extremely poor hygiene of the left hand. The Surgical Report also indicated Resident 1 was then placed under general anesthesia, which is a state of deep unconsciousness induced by medications, which carries risk of changes in blood pressure, irregular heartbeats, [MEDICAL CONDITION], allergic reactions, [MEDICAL CONDITION], airway blockage, lack of oxygen, physical injury such as chipped teeth, loss of teeth, muscle cramps, and death. Risks are more common in the elderly. The Surgical Report indicated the procedure consisted of making cuts into the skin to cut her arm and finger tendons. The Surgical Report indicated the surgeon then repaired the wound to her palm. The report indicated At this stage, there was a significant amount of maceration (softening of tissues) on the skin of the palm and in between the fingers. At this stage, with the help of a [MEDICATION NAME] scrubber, thorough cleaning of the hand and nails was carried out. All the nails of the left hand were really elongated and really dirty, and had not been cleaned for months. At this stage, there was approximately about a 2.5 cm wound in the palm from the digging of middle finger nail (the surgeon then surgically cut another tendon in the area). Thorough irrigation and debridement (the removal of damaged tissue or foreign objects) of the wound was carried out at this stage. The Minimum Data Set (a standardized comprehensive assessment) dated 2/11/18, indicated Resident 1 never rejected care that was necessary to achieve the resident's goals for health and well-being. The Nursing Home Progress Note, dated 3/5/18, written by Resident 1's physician, indicated Physical Exam, and she is currently stable, and makes no mention of her left hand contracture. During a concurrent review of Resident 1's clinical record and interview with Licensed Vocational Nurse 1 (LVN 1), on 10/9/18, at 10:12 AM, she stated for any residents with hand contractures, she would clean and clip their fingernails. LVN 1 stated to ensure this care was delivered, We inform the CNAs (Certified Nursing Assistants) to continue care, we have RNAs (Restorative Nursing Assistants) who helps with ADLs (Activities of Daily Living). LVN 1 could not find a care plan for any wound care for Resident 1's left hand wound. During an interview with LVN 2, on 10/9/18, at 12:15 PM, she stated if a resident has a hand contracture, I would ask the doctor to order nail clipping if we were unable to. During an interview with the RNA, on 10/11/18, at 10 AM, she described Resident 1's left hand as a fist closed with long nails. The RNA stated she reported these findings to the nurse on duty. The RNA stated, When her daughter was here, she would too inform the (unknown) nurse. During an interview with Registered Nurse 2 (RN 2), on 10/12/18, at 10 AM, she stated Resident 1's left hand was very contracted and her nails were long. RN 2 did not recall Resident 1's nails ever getting filed or cut. RN 2 stated she noticed a wound to Resident 1's left palm. There was a smell, too. RN 2 stated she did not start a wound care plan for Resident 1. During an interview with Resident 1's daughter, on 11/6/18, at 2:20 PM, she stated, I have been to every care conference (at the facility) for a year prior to my mom having surgery. I had to force them to call a specialist to see her hand. For one year, my mother's hand was clenched. Every time I would ask the staff (to provide care for her hand) they would say 'someone is going to do it,' or they were going to send her to the foot doctor. She would come back (to the facility) with her toenails clipped, but not her fingernails. During a review of the clinical record for Resident 1, there was no documentation found to indicate nail trimming was ever performed. The Screening Referral to Rehabilitation Services, dated 8/28/17, indicated Resident 1 was identified as high risk for worsening contractures. The RNA Referral Form, dated 8/29/17 indicated a RNA was ordered to perform gentle range of motion exercise to left hand (contracture) as tolerated. to prevent further contracture. The Interdisciplinary Progress Notes dated 11/21/17, at 4:03 PM, indicated Resident 1 had a left hand contracture. Discussed hygiene and pressure injury risks. Pressure injury risks discussed. The Notes dated 2/27/18, at 12 PM, indicated Resident 1 has no skin issues. Her hands are swollen and contractured. The Interdisciplinary Progress Notes dated 3/15/18, indicated Resident 1 had a manicure and polished her nails. The Interdisciplinary Progress Notes dated 3/22/18, at 5:33 PM, indicated that Resident 1 had a Odorous, foul smell coming from left hand, after shower, when attempt made to evaluate Left contracture hand, resident begins swinging her right hand to hit, at the nurse examining hand. Resident complains of pain to Left hand. Nail beds of fingers, number 3, 4, 5, noted to be imbedded of Left hand. (Resident 1's physician) notified, and stated to send to ER (emergency room ) for Evaluation and treatment. The Notes dated 3/22/18, at 8:36 PM, indicated the ER physician states that this is not an emergency and should be sent back. Staff is aware that this is not a change in condition for the resident (a strong muscle relaxer and sedative were ordered to be given routinely to the resident). The Notes dated 3/22/18, at 10:31 PM, indicated Resident has a strong foul odor coming from hand, suspected infection. The Notes dated 3/27/18, at 4:29 PM, indicated Resident 1's physician was notified of fall and continued problem with nail beds of left hand digits 3, 4, 5, imbedding into skin of left palm related to contracture. New orders noted (orders were for medications, not treatment to the hand, nails, or dressings to wound). The Post Fall Assessment, dated 3/27/18, indicated Resident 1 was started on antibiotics on that date, five (5) days after a foul odor was noted from the area, and her ER visit, for Right (sic) hand infection related to contracture of hand. The Notes dated 3/30/18, at 12:41 PM, from the Wound Care Registered Nurse, indicated no new treatment was ordered to the area, unable to provide dressing treatment due to fused fingers. An appointment was made for a surgeon to evaluate on 4/4/18. The Medication Administration Record [REDACTED]. The facility policy and procedure titled Transitional care and rehab unit Care of Fingernails/Toenails Level II, dated 11/30/16, indicated Nail care includes daily cleaning if needed and regular trimming. Nail care is always provided during showers. Stop and report to the nurse supervisor if there is evidence of ingrown nails, infection, pain, or if nails are too hard or too thick to cut with ease. If the resident refused the treatment, the reason(s) why and the intervention taken should be recorded in the resident's medical record.

Based on observation, interview, and record review, the facility failed to follow its pain policy and procedure to control the pain of one of two sampled residents (1). Resident 1 fell in the bathroom and sustained a fracture to right arm. This failure resulted in a delay of pain management and loss of independence in self-care. These failures had negatively impacted Resident 1's quality of life. Findings: During an interview with the Director of Nursing (DON), on 7/14/16, at 9:35 AM, she stated on 7/1/16, Resident 1 transferred herself from wheelchair to the toilet and fell on the floor. Resident 1 sustained a cut to her right eyebrow. The facility sent the resident to the local acute hospital. However, the local acute hospital transferred the resident to another out of town acute hospital due to Resident 1 needing a higher level of care. Resident 1's [DIAGNOSES REDACTED]. The DON stated the resident returned to the facility on [DATE], and was being monitored for any change in condition. During a concurrent observation and interview with Resident 1, on 7/14/16, at 10:30 AM, in her room, she was sitting in her wheelchair and stated she fell in the bathroom (BR). She was noted with approximately one inch stitched cut and a brownish/yellowish discoloration (bruise) above her right eyebrow. Resident 1 stated her right arm hurt Do you want to see? She pulled her right arm out of her sweater in a slow manner, grimaced and stated Ouch. Resident 1's right arm was noted with approximately eight centimeters brownish/yellowish discoloration resembling bruising to her right middle arm, again she stated My arm really hurts. Resident 1 stated her right arm had been hurting since she fell and it was painful all the time. Resident 1 stated she told the staff regarding her pain and Yes, it's like talking to a wall, they could care less. She stated the intensity of the pain she had on a pain scale of 0-10 (0-no pain, 10-worst pain) was seven. The clinical record for Resident 1 was reviewed. Resident 1's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a comprehensive assessment tool) dated 5/6/16, indicated under Brief Interview for Mental Status (BIMS) for Resident 1 indicated a score of 12 (moderately impaired cognition). The NURSING NOTES dated 7/1/16, at 8:30 AM, indicated Resident was calling/crying found on bathroom floor face down (sic) .c/o (complaint) rt (right) arm & rt knees pain, noted laceration to head approx (approximately) 3 inches line/cut above right eyebrow .8:40 AM, taken to ambulance via paramedics gurney. Ten days later, the NURSING NOTES dated 7/11/16, at 9 PM, indicated Physician called stating Resident's husband left a message for her saying that Resident 1 broke her arm and the facility wont (sic) give her pain medicine .I went to check on patient right arm. She said it was sore. There is a bruise to her right forearm .New order for a (sic) X-ray (XR) of patient's right forearm to be done in AM . The XR Forearm result dated 7/12/16, indicated under Impression 1. Minimally-displaced [MEDICAL CONDITION] right ulna (wrist fracture) . During a concurrent observation and interview with Resident 1, on 7/14/16, at 12:30 PM, in the Main dining room, she was sitting in her wheelchair with a spoon in her right hand. Resident 1 switched the spoon to her left hand in an attempt to eat her food. Resident 1 stated she had pain to her right arm and it was constant. The clinical record for Resident 1 was reviewed. The ACTIVITIES OF DAILY LIVING (ADL) FLOW SHEET for the month of 7/2016, indicated before Resident 1's fall incident on 7/1/16, 7-3 shift, her ADL's were coded 1/1 (Supervision/Set help only) for bed mobility, transfer and toilet use. On 7/4/16, 7-3 shift, after the resident's fall incident, Resident 1's ADL's had declined to 3/2 (Extensive assistance/One person physical assist) for bed mobility, transfer, and toilet use. During a review of the clinical record for Resident 1, the physician's orders [REDACTED]. Another physician's orders [REDACTED].= YES, N=NO. The Medication Administration Record [REDACTED]. The following were noted; a) There was no pain scale documentation on the following dates (7/4/16, 7-3 day shift, 7/9/16, 3-11 PM shift and 11-7 night shift, and 7/12/16, 3-11 PM shift). b) Nurses signature was noted in the MAR (Medicine Administration Record) however, resident pain scale was not documented on the following dates (7/4/16, 7-3 day shift, 7/5/16, 7-3 day shift, 7/6/16, 7-3 day shift). c) There was no documentation of the location of pain for five of five days reviewed. d) There was no documentation of pain medication effectiveness for three of three days reviewed. e) Resident 1 complained of pain scale of 6/10, on 7/13/16, 3-11 PM shift and also on 11-7 night shift. However, there was no documentation a pain medication was given on both times. During an interview Licensed Nurse (LN) 1 on 7/14/16, at 12:55 PM, LN 1 verified the following: a) No pain scale was documented on the following dates (7/4/16, 7-3 day shift, 7/9/16, 3-11 PM shift and 11-7 night shift, and 7/12/16, 3-11 PM shift). b) The nurses were signing the MAR but pain scale was not documented on the following dates (7/4/16, 7-3 AM shift, 7/5/16, 7-3 AM shift, 7/6/16, 7-3 AM shift). c) There was no documentation of the location of pain for five of five days reviewed. d) There was no documentation of the pain medication effectiveness for three of three days reviewed. LN 1 stated he gave Resident 1 the Tylenol at 9 AM, however, did not follow up with Resident 1 for the pain medication effectiveness. e) The findings Resident 1 complained of pain scale of 6/10, on 7/13/16, 3-11 PM shift and also on 11-7 night shift. However, there was no documentation a pain medication was given on both times. At this time, LN 1 was informed the resident stated she had a pain scale of seven. LN 1 stated he would call the physician to obtain an order for [REDACTED]. During an interview with Resident 1, on 7/14/16, at 1:22 PM, in Resident 1's room. She stated due to the pain in her right arm, she was now staying more in her room. She could not propel her wheelchair like she used to. She needed more help with transfer and with all her activities of daily living. Resident 1 stated she loved to read books, but she could not read as much anymore due to the pain. During an interview with the Registered Nurse/Quality Assurance (RNQA), on 7/14/16, at 1:45 PM, she was informed there was no pain assessment/reassessment in the clinical record for Resident 1. The RNQA provided a document titled PAIN FLOW SHEET (used to evaluate the effectiveness of the as-needed medication regimen) for the month of 7/2016. However, the document was blank. The RNQA verified the PAIN FLOW SHEET for the month of 7/2016, was blank. No further information was provided. During an interview with the RNQA, on 7/15/16, at 12:30 PM, she was informed regarding the resident telling the staff she had a constant pain to her right arm. However, the facility had no documentation the resident's right arm was assessed until the resident's physician called the facility on 7/11/16, stating the resident's husband called saying the resident broke her arm and the facility was not giving the resident a pain medication. The RNQA stated the facility should have done a pain assessment/re-assessment after the resident's fall incident. The facility policy and procedure titled Pain- Clinical Protocol, revision date 6/2013, indicated under Assessment and Recognition 1. The physician and staff will identify individuals who have pain or who are at risk for having pain .2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a change in condition, and when there is onset of new pain or worsening of existing pain. 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. Indicated under Treatment/Management .3. The staff will evaluate and report how much and how often the individual asks for PRN (as needed) pain medication . Indicated under Monitoring 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain .a. For example, review frequency and intensity of pain, ability to perform activities of daily living (ADL's), sleep pattern, mood, behavior, and interventions for pain .

br>Based on observation, interview, and record review, the facility failed to use adequate mechanical lift and personnel required to transfer one of one sampled resident (1) from chair to bed when Certified Nursing Assistant (CNA) 1 decided to transfer Resident 1 alone using a wrong mechanical lift, Sara Lift (an assistive device used on those residents who have difficulties getting up into a standing position). The facility had a written care plan for Resident 1 to be transferred only by a Marisa Lift (a mechanical lift using a sling to transfer patients who are unable to use their legs. It requires two staff to assist residents). This failure resulted in Resident 1's falling from the wrong lift and fracturing her left shoulder. Findings: During a concurrent observation and interview with Resident 1, on 10/22/15, at 8:47 AM, in Resident 1's room, Resident 1 was sitting in her wheelchair. Resident 1 had left sided weakness with left arm and left leg weakness. Resident 1's left arm was flaccid (hanging loosely) and her left foot had foot drop (dropping of the front of the foot due to weakness or paralysis of the upper muscles of the lower leg). Resident 1 stated, I broke my left shoulder. When asked how did it happen, she stated, When I was getting ready to go to bed, she (Certified Nursing Assistant-CNA 1) went to turn me at the side of the bed. I heard my right leg crack. When asked what did CNA 1 use to help her transfer, she stated, She made me stand up. My body did not turn as fast as the machine did, I slipped through the machine to the floor. During an interview with Registered Nurse (RN) 1, on 10/22/15, at 9 AM, she stated, (CNA 1) used the Sara lift. She (CNA 1) was suppose to use a Marisa lift. RN 1 stated, (Resident 1) was lying on her back, when she slid off, I'm guessing she might have hit her left hand on the ground. When asked how was Resident 1 supposed to be transferred, she stated, (CNA 1) supposed to use Marissa lift for (Resident 1) and supposed to be 2 person assist. During a review of the clinical record for Resident 1, the CNA Mini Care Plan, undated, indicated, Lift used: Marissa Lift. The Fall Risk Evaluation, dated 8/11/15, indicated a score of 14 (total score of 10 or above represents high risk). The At Risk for Fall Care Plan, dated 5/8/15, indicated, PT (Physical Therapy) states: Marissa (lift) only. The Functional Status, dated 7/28/15, indicated, Transfer: Extensive assistance, two person assist. The Nurses' Progress Note, dated 10/8/15, indicated, Body Control Problems: History of Cerebro-Vascular Disease (disorders of the blood vessels that supply blood flow to the brain), left hemiparesis (weakness of one side of the body), contractures (deformity) bilateral (both) upper and lower extremities. During an interview with CNA 1, on 10/22/15, at 9:35 AM, when asked what happened on 10/6/15 with Resident 1, she stated, I could not reach for the sling underneath her back so I decided to use the Sara lift. When asked if she called for help, she stated, No, I did not call for help, everybody was busy. I thought it will be ok to use the Sara lift. When asked if CNA 1 was aware what was in Resident 1's care plan, she stated, Yes, I know she's suppose to use the Marissa lift and needs 2 person assist. When asked how did Resident 1 fall, she stated, (Resident 1's) right leg bended and was about to fall so I grabbed her on her rib area and slowly lowered her on her bottom and then I laid her down to get help. During a review of the clinical record for Resident 1, the Nursing Notes, dated 10/6/15, at 3:40 PM (post fall), indicated, Complained of pain at the left shoulder and right leg, medicated with Norco (strong medication for pain) 10-325 mg (milligram) (1 tablet). The PRN (as needed) Medication Record, 10/2015, indicated Resident 1 received Hydrocod-Acetaminphen (strong medication for pain) 10 mg-325 mg (milligram) tablet for severe pain on 10/6/15. The Pain Flow Sheet, dated 10/6/15, at 2:45 PM, indicated, Location of pain: left arm and right leg, Current intensity: 7/10 (intensity of pain scale where 0 means no pain and 10 means very painful), Precipitating/Aggravating factor: movement. During an interview with the Director of Nursing (DON), on 10/22/15, at 10:49 AM, she stated, The staff did not follow the policy and procedure, I told the CNA (1) we cannot downgrade a lifting device. Resident (1) had flaccid arm. During a review of the clinical record for Resident 1, the X-ray (pictures to see the inside parts of the body) results, dated 10/11/15, indicated, Impression: Nondisplaced impacted fracture of the left humerus at the surgical neck (broken bone on the left shoulder). During a review of the clinical record for Resident 1, the Nursing Notes, dated 10/12/15, at 3:30 PM, indicated, Received X-ray results of left shoulder findings: nondisplaced fracture of the left humerus at the surgical neck (broken bone on the left shoulder) possibly related to impact from recent fall (recent fall incident happened on 10/6/15). The facility policy and procedure titled, Safe Lifting and Movement of Residents, dated 12/2013, indicated, Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; Provides training on safety, ergonomics and proper use of equipment. The facility policy and procedure titled, Lifting Machine, Using a Portable, dated 12/2013, indicated, Review the resident's care plan to assess for any special needs of the resident. General Guidelines: Two (2) nursing assistants are required to perform this procedure.

NOTE: Pressure Sores (aka Bed Sores, Decubitus Ulcers, and Pressure Ulcers) are areas of damaged skin caused by staying in one position for too long. They commonly form where bones are close to the skin, such as ankles, back, elbows, heels and hips. A person is at risk if bedridden, or unable to change position. Pressure sores can also cause serious infections, some of which are life-threatening. (From the National Pressure Ulcer Advisory Panel, or NPUAP): Pressure sores are measured in Stages and grouped by their severity. Stage I is the earliest stage. Stage IV is the worst. Stage I: A reddened area on the skin that, when pressed, does not turn white (non-blanchable). This is a sign that a pressure ulcer is starting to develop. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. There is damage to the tissue below the skin. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. Unstageable: Full thickness loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (black, tan, or brown in color, leathery necrotic, or dead tissue) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be considered a Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. Suspected Deep Tissue Injury (SDTI): Depth Unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister present due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Based on interview and record review, the facility neglected to provide services necessary to prevent two (2) deep tissue injuries (DTI), and one (1) unstageable pressure sore from forming on one of one sampled residents (Resident A) during a five (5) day stay at the facility. Resident A had previously been cared for at home by her family, with the assistance of a home health and hospice agency (one that specializes in end-of-life care). On their advice, the family admitted Resident A to the facility for a planned 5-day stay to give the family member "a break." After the five days were over, Resident A was discharged back home with three, new, wounds that were not present on admission to the facility. These three wounds were: 1) a DTI on her sacrum (tailbone area), 2) a DTI on her right heel, 3) an unstageable pressure sore on her right lower calf. These wounds resulted in actual physical harm to Resident A. Findings: During a review of the clinical record for Resident A, it was documented she first arrived at the facility in the morning of [DATE] from her home, then discharged back home on the afternoon of [DATE], for a facility stay totaling five (5) days. During an interview with Family Member 1 (FM 1) on [DATE] at 9:15 AM, she indicated she had been taking care of Resident A for the last five (5) years or so, and a local home health and hospice agency has been coming to her home three to five times a week for the last several months to assist with feeding, dressing, and bathing. FM 1 indicated that, at the advice of the home health and hospice agency, she agreed to admit Resident A to the facility for a five (5) day stay, in order to give her respite, or "a break" in providing daily care for Resident A. FM 1 stated "I'd been caring for her for so long without a break." FM 1 indicated Resident A's skin at the time of admission to the facility was clear, stating "there were no sores on her" prior to [DATE], except for a small scab on her right knee. FM 1 indicated, however, upon returning home from the facility five (5) days later on [DATE], Resident A had "two really, really bad, black bedsores, one on her ankle and one on the back of her leg, and also an area on her coccyx (tailbone). She was ordered a special air mattress, but it took 2 or 3 days before she actually got it." FM 1 indicated Resident A was transported to and from the facility via ambulance. During an interview with a facility Registered Nurse 1 (RN 1) on [DATE], at 2:30 PM, she indicated she remembered Resident A being at the facility. RN 1 stated "I remember her. She was hospice care, here over a long weekend for respite care." RN 1 stated there was "nothing on her heel at admit." RN 1 indicated she recalled Resident A having only one leg (her left leg had been amputated above the knee some years ago) and now, her remaining right leg was contracted, or drawn together at the knee, into a position where she would essentially be sitting on her heel. RN 1 indicated she believed it was possible this contracted position contributed to her wound(s). During a review of the clinical record with RN 1, the document titled "Admission Assessment Report", dated [DATE], indicated "Heel Assessment - Clear", her left knee was "scabbed over", and "Coccyx Assessment - Red, blanchable" (meaning Resident A ' s skin would turn white when pressed with a finger, and, according the Centers for Medicare and Medicaid Services - recognized NPUAP, does not meet the criteria for a Stage 1 pressure sore, as only "non-blanchable skin" does). There were no entries indicating an issue with Resident A's calf, or back of her lower leg. The document titled "Physician's Admitting Orders" dated [DATE], read under "Treatment - knee wound - leave open to air." There were no admitting orders for any other areas. There was an additional "Physician's Telephone Order" dated [DATE] for "Calazyme Topical Cream - apply to intact / irritated skin for skin barrier." The facility policy & procedure titled "Skin Care Protocols/Procedures", dated [DATE], was reviewed. It read, in part, that facility nursing staff "shall initiate pressure ulcer management guidelines..., or consult Certified Wound Specialist (CWS) for at-risk patients on admission... The following conditions create at-risk patients (partial list): immobility, incontinence, [MEDICAL CONDITION], altered mental status, peripheral / arterial disease." The document titled "Progress Notes Report", dated [DATE], at 1:17 PM (Resident A's fourth day at the facility), the first entry by a CWS was noted, and read: "Wound care: Hospice Patient with multiple sDTI (suspected deep tissue injury) deep purple and red color R & L trochanter (bony prominence at hips), sacrum (tail bone) (pear shaped), and heels (sic). Left AKA (above knee amputation), right leg contracted to buttock. Right calf unstageable pressure caused by femur (thigh bone) due to contracted leg. Right knee eschar with wound odor noted." Another entry was made on [DATE], at 8:05 AM, which read "Pt noted to have DTI on buttocks, and on heel of right foot. Hospice was told and stated they will inform family." The document titled "Licensed Nurse Progress Notes" dated [DATE], and written by RN 1 was reviewed. It read Resident A was "noted to have pear shaped area of red blue discoloration approx. 6 X 6 centimeters with no depth on sacrum (tail bone), and an area of red blue discoloration approx. 3 X 6 cm with no depth on heel. Admission Assessment notes red area on coccyx. Res is on a lateral rotation mattress. Hospice Nurse (Manager) RN notified & she stated she would inform family. She has been bedridden > 5 years & has severe contractures, poss due to end stage dementia. Her leg is folded up behind her with the foot resting on the periarea (area between the thighs) & buttocks." The document titled "Minimum Data Set" (MDS, a comprehensive assessment tool), with an assessment reference date of [DATE], was reviewed. The MDS indicated Resident A had, by that date, two (2) "unstageable pressure ulcers with suspected deep tissue injury in evolution." However, the MDS indicated these two areas were not present at time of Resident A's admission to the facility. The MDS indicated Resident A's cognitive skills for daily decision making were "severely impaired - never/rarely made decisions", and had "Altered level of consciousness", and that the "Behavior was continuously present, does not fluctuate." The MDS also indicated she required "extensive assistance... staff provide full weight - bearing support" for the activity of bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). The MDS indicated Resident A was "Always incontinent (lacking control)" of bowel and of the urinary bladder. During an interview with a Home Health and Hospice Registered Nurse (HHN) on [DATE], at 8:30 AM, she indicated she had cared for Resident A before and after her 5-day stay in the facility. The HHN stated she had seen Resident A twice prior to her admission to the facility, on [DATE] and on [DATE] (the day before admission). The HHN indicated Resident A had a single wound on her knee and "no other wounds" prior to admission to the facility. The HHN indicated she saw Resident A again a third time, in her home on [DATE], the day after she was discharged from the facility. The HHN indicated at that time, Resident A had two (2) new, deep tissue injuries that were dark purple in color, to her lower back and to her heel, which were not present prior to Resident A's 5-day stay at the facility. During a review of the clinical record, the document titled "Hospice RN Non Billable Visit", dated [DATE], written by the HHN, read she had informed FM 1 that Resident A "has new deep tissue injuries on her left heel and on her buttocks. (FM 1) is extremely upset by this information and becomes tearful stating 'I knew I shouldn't have sent her there.' States that she visited patient daily in (facility) and was told that patient would not eat, but she was able to feed patient at each of her visits with patient there." During an interview with the facility Nurse Manager (NM) on [DATE], at 1:25 PM, she indicated since Resident A was a hospice resident, a specialized, "lateral rotation air flow mattress" would not have been provided by the hospital, but by the home health & hospice agency. The NM indicated even though the facility had a supply of such mattresses on the premises, Resident A could not use them, and indicated her mattress would have had to come from the hospice agency due to "payment issues." During an interview with the facility Certified Wound Specialist (CWS), who was also a Registered Nurse, on [DATE], at 1:55 PM, she indicated she had a total of four (4) such "lateral rotation air flow mattresses" available in the facility. The CWS indicated Resident A was not provided with one of the four mattresses that were available in the facility. The CWS also indicated that since Resident A was classified as a hospice resident, the mattress would have to have come from the home health and hospice agency, not from the hospital. The CWS also indicated she had seen Resident A on [DATE], and recalled her sitting on her heel while in bed. During a concurrent record review and interview with the NM and CWS on [DATE], at 2:05 PM, the NM indicated Resident A was on a lateral rotation air flow mattress at the facility on [DATE]. The NM was not able to find documentation that Resident A was on such a mattress prior to that date. Both the NM and CWS were not able to find any documentation Resident A had any other wounds at admission to the facility, other than a minor scab on her knee. The NM also indicated that as soon as a resident is admitted to the facility, a "Mini-Care Plan" is completed "immediately... so we know what to do for the resident as soon as they are admitted ." The NM was not able to find any information on the Mini-Care Plan addressing Resident A's skin condition, risk for skin breakdown, or contractures. During an interview with FM 1 on [DATE] at 1 PM, she stated Resident A had passed away at home on [DATE], forty-five (45) days after discharge from the facility. FM 1 stated she visited Resident A at the facility on [DATE], the first day of her admission, and had noticed she wasn't on a special air mattress, like the one she had at home. FM 1 stated that while at home, Resident A was provided a special air mattress that "revolves, it deflates and blows up certain sections at a time. It's to keep people from getting bed sores. (In addition to the special mattress), I turned her all the time, every two hours (while at home)." FM 1 indicated during her visit on [DATE], she asked facility staff 'where is her air mattress?' and was told 'We don't have any.' FM 1 indicated the special mattress did arrive finally on Monday, [DATE]. FM 1 stated "Until then, she had a regular mattress. They ordered one, but it didn't arrive until Monday." During an interview with the Home Health and Hospice agency Manager (HHM) on [DATE] at 1:45 PM, she indicated the agency continued to assist in caring for Resident A after discharge from the facility. The HHM indicated Resident A had been a patient of the agency since [DATE], and died on [DATE]. The HHM stated the specialized, "lateral rotation air mattress" was ordered for Resident A on Friday, [DATE]. The HHM stated the mattress did not arrive in the facility for Resident A until Monday, [DATE], or the morning of the fourth day of admission to the facility. The HHM indicated the reason for the delay was the company they get the mattresses from stated they never got, or lost, the order from Friday, [DATE]. The HHM indicated on Monday, [DATE], when it was noted Resident A had never received the mattress, the company was contacted again, and delivered the lateral rotation air mattress that same day. The HHM indicated that for this type of hospice resident, who is admitted to a facility for short stay respite care, the agency takes a copy of their own care plan, and adds it to the facility's clinical record, and then coordinates care with the facility staff. During a review of the clinical record, the document titled "RRH Home Health", dated [DATE], under "Plans", there are no entries regarding Resident A's significant risk of skin breakdown secondary to her age, disease processes, poor nutritional status, inability to reposition herself, and bowel & urinary bladder incontinence. During an interview with the NM on [DATE], at 5 PM, she indicated hospice staff didn't arrive in the facility until Day 4 of Resident A's stay. The NM stated there was no Hospice documentation in the clinical record for the dates of [DATE], [DATE], or [DATE], "because they weren't here those days.... (they) don't come on weekends. We (the facility) didn't have a care plan in place for her, on what we're doing for her in this facility, other than some routine things, things we'd normally be doing. But much of their care plan covers areas of care in the home. I looked and couldn't find anything else. The NM indicated there was no care plan for Resident A from the facility that addressed her skin care issues. During an interview with a Home Health and Hospice agency Certified Nursing Assistant (HHA) on [DATE], at 3:30 PM, she stated she knew and remembered Resident A well. The HHA indicated she had cared for Resident A for about eight months, since [DATE], coming to her home two to five times a week, with five times a week occurring more recently. The HHA indicated her duties included feeding her breakfast, bathing, oral care, and changing the linens & clothing. The HHA stated prior to entry to the facility, Resident A only had a sore on her knee, but then "she went to (the facility) and became a huge mess. She came home with huge sores on her." The HHA indicated she went to the facility for the first time on [DATE], Resident A's fourth day of her stay, to bathe her and became upset at what she observed. The HHA indicated she told her supervisor (HHM) what she observed, who then directed her to put her observations in writing. The document from the HHA, dated [DATE], and addressed to the Home Health and Hospice agency's Medical Director (HHP), read in part, the following: "Re: Incident involving (Resident A) This is a written report about things I have observed while the patient was staying in the (facility) to give the family a week off. On Monday, ([DATE]) I... went to the (facility) to bathe (Resident A). Pt. was visibly altered, sleepy and lethargic... not her usual state of being. She was not on the standard air mattress that our Hospice patients get. When we undressed the patient for her shower... we observed an angry red, inflamed area that reached from both groins all the way up to the top of her crack and spread side to side about 2 inches. On her butt area she had a deep purple colored like a blister approximately 2 inches in diameter. Also her severely bent left leg had her foot in her crotch which was also angry red and inflamed that reached from her heel to her calf area. To me, it looked like she had been left in her own poop and pee and her skin burned. At this time I went to get (RN 1). As I was telling her about my findings, she told me, 'The patient came in with that wound.' I told her 'The wound on her left knee, yes, but not this.' And, I showed her the groins, the butt, and leg of the patient. We finished the shower... several nurses including (the CWS) were inspecting the sores. Throughout this whole time, (Resident A) was out of it. At this time, we knew we had to report it to (a supervisor). I believe (Resident A) had not eaten for a couple of days. I asked if I could go back and feed her. (She) ate about ,[DATE] of her pureed oatmeal. During the meal, the nurse came in to administer... [MEDICATION NAME] (a [MEDICAL CONDITION] medication that effects mood, behavior & alters thought processes). I asked if she could wait until I finished feeding the patient because I felt it might make her more out of it than she was. At that point, the patient opened her mouth very wide, and the charge (nurse) said she was choking (she wasn't choking) and I stopped, none the less, and sat with her and talked to her for five minutes until I knew she was okay. Then the nurse gave her her [MEDICATION NAME]. I felt it was necessary to write all this down while it was fresh in my mind." During a review of the clinical record, the document titled "Hospice Registered Nurse Routine Visit", dated [DATE], was reviewed. It read "Noted a deep tissue (injury) on patient's coccyx and also on patient's right heel. Right leg noted to be retracted up against patient's peri region causing friction and pressure, placed a small folded pillow case between both places to reduce pressure." During a review of the clinical record, the document titled "Measurements Report", dated [DATE] through [DATE], indicated Resident A was served thirteen (13) meals while at the facility. The word "refused" is documented next to every meal entry, except for two: 75% of lunch, and 25% of dinner, both on [DATE]. During an interview with HHA on [DATE], at 11 AM, she indicated normally at home, she placed a pillow between her foot and perineal area, to reduce pressure. The HHA indicated she saw "nothing like that" during her visit at the facility on [DATE], and added she didn't think there was any repositioning with pillows occurring. The HHA also indicated the facility staff told her Resident A couldn't swallow. The HHA stated "I said 'What are you talking about?' I feed her breakfast every morning, five times a week. And she ate fine after she came home. So, I was like, 'what do you mean, she can't eat?' " During an interview with FM 1 on [DATE], at 11:30 AM, she stated the HHA and herself always fed Resident A with spoon and straw, never a syringe, or 'by force'. FM 1 stated the facility staff had often told her Resident A "wasn't hungry". FM 1 indicated neither HHA or herself had any difficulties feeding her by spoon. FM 1 indicated she didn't want to place Resident A in the facility, but was repeatedly assured by facility and home health & hospice agency staff that she "will be fine" there. FM 1 indicated she, with the assistance of HHA, had kept Resident A clean and free of wounds for the past year, however, after admission the facility, she experienced multiple deep tissue injuries after just three days.