Every finding on record at Rosecrans Care Center

Based on observation, interview, and record review, the facility failed to ensure the care plans were:1. Updated quarterly for three of seven sampled residents (Resident 4, 5, and 25)2. Revised for one of seven sampled residents (Resident 87)These failures had the potential to result in Residents 4, 5, 25, and 87 not receiving the specific and timely care related to their illnesses and diagnoses.Findings: 1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included dysphagia (difficulty swallowing) and dementia (loss of thinking, remembering, and reasoning). During a review of Resident 4's care plan titled, At risk for impaired skin integrity as evidence by easy skin bruising/skin discoloration, skin tears/abrasions including pressure skin injury due to Braden scale score: 18 – at risk, dated 10/22/2025, the care plan indicated the goals were last revised on 10/22/2025. During a review of Resident 4's care plan titled, Resident 4 is at risk for communication problem related to the diagnosis of Dementia, dated 2/10/2026, the care plan indicated the goals were last revised on 2/10/2025. During a review of Resident 4's History & Physical (H&P), dated 4/23/2026, the H&P indicated Resident 4 had the capacity to make medical decisions, but did not have the capacity to make own needs known. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including occlusion (blockage) and stenosis (narrowing) of the left middle cerebral (brain) artery, and atrial fibrillation (irregular heartbeat). During a review of Resident 5's care plan titled, On anticoagulant (blood thinner) therapy (Apixaban related to CVA (cerebral vascular accident) PPX (prophylaxis) dated 3/31/2025, the care plan indicated the goals were last revised on 11/28/2025. During a review of Resident 5's Minimum Data Set (MDS), a tool used to evaluate the health status, functional abilities, and healthcare needs, dated 3/10/2026, the MDS indicated that Resident 5 had a memory problem and daily decision making is moderately impaired, has an active diagnosis of a stroke, and is receiving an anticoagulant medication. During a review of Resident 5's physician order, dated 05/1/2026, the physician order indicated to administer Apixaban Oral Tablet 2.5 milligram (mg, a unit of measurement), 1 tablet via gastrostomy (stomach) tube two times a day for cerebral vascular accident prophylaxis (stroke prevention). During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 25's diagnoses included neuralgia (pain caused by damaged nerves), neuritis (nerve inflammation), osteoarthritis (arthritis involving flexible tissue), and chronic pain. During a review of Resident 25's physician order dated 02/07/2025, the physician order indicated to administer Baclofen 20mg one tablet by mouth three times a day for neuropathic pain and Diclofenac Sodium topical gel 1% 100 grams to right shoulder every eight hours as needed. During a review of Resident 25's H&P, dated 2/27/2026, the H&P indicated Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated that Resident 25 had a Brief Interview Mental Status score of 15. During a review of Resident 25's Care Plan titled, Chronic Pain related to bone deformities, joint degeneration, muscle spasm, physical mobility as evidenced by decreased ability to perform ADLs (activities of daily living) because of discomfort related to: Diagnosis: Osteoarthritis, dated 7/17/2021, the care plan indicated the goals were last revised on 6/20/2025. During a concurrent interview and record review on 6/4/2025 at 10:06 a.m. with Registered Nurse 1 (RN 1) the care plan for Resident 5, titled, On anticoagulant therapy (Apixaban r/t CVA PPX), dated 3/31/2025 was reviewed. RN 1 stated, the care plan should have been revised three months after 11/26/2025 and by not revising the care plan in three months, the resident could have had an adverse reaction to the anticoagulant therapy. RN 1 stated staff would need to know whether the medication was effective, and if the goal of effectiveness was reached. RN 1 stated blood work would be needed to determine if the resident had an abnormal lab result. RN 1stated if the goals were not revised, it could lead to Resident 5's blood clotting or bleeding and decrease the effectiveness of the anticoagulant treatment. During a concurrent interview and record review on 06/04/2026 at 10:22 a.m., with RN 1, Resident 4's care plan titled, At risk for communication problem related to the diagnosis of Dementia revised on 2/10/2025, and the care plan titled, At risk for impaired skin integrity as evidence by easy skin bruising/skin discoloration, skin tears/abrasions including pressure skin injury due to Braden scale score: 18 – at risk, revised on 10/22/2025, were reviewed. RN 1 stated care plans should be reviewed every three months, and by not reviewing the resident's care plan, the needs of the residents would not be met. RN 1 stated Resident 4's safety could be at risk if the dementia worsens because staff would not be aware if the resident's cognition changed. RN 1 stated staff would not be able to identify if there was a need to change the resident's dementia medication. RN 1 stated that if staff were not meeting the goals of the resident's skin integrity, there was a possibility the skin could heal slowly or worsen, deteriorate and become infected, leading to sepsis. During a concurrent interview and record review on 06/04/2026 at 10:36 a.m., with RN 1, Resident 25's care plan titled, Chronic Pain related to bone deformities, joint degeneration, muscle spasm, physical mobility as evidenced by decreased ability to perform ADLs because of discomfort related to: Diagnosis: Osteoarthritis, dated 6/20/2025, was reviewed. RN 1 stated the care plan should have been revised three months after 6/20/2025. RN 1 stated by not revising the care plan in three months, staff would not know if the pain for Resident 25 was resolving, ongoing, and if the resident was tolerating the pain medication ordered. RN 1 stated the resident could be uncomfortable and complain of pain if the medication was not effective. 2. During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 87's diagnosis included encephalopathy (any diffuse disease or damage that alters brain structure or function), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and tinea unguium (a contagious fungal infection that affects the fingernails and toenails), During a review of Resident 87's physician orders dated 8/23/2025, the physician orders indicated Resident 87 was to have podiatry every two months and as needed. During a review of Resident 87's MDS, dated [DATE], the MDS indicated Resident 87's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 87 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from staff for toilet hygiene, showering, and dressing. The MDS indicated Resident 87 was at risk for pressure ulcers (localized damage to the skin and/or underlying tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 87's progress notes, dated 5/27/2026, the progress notes indicated Resident 87 refused to be seen by the podiatrist. During a concurrent interview and record review on 6/4/2024 at 12:25 p.m. with Registered Nurse (RN) 1, Resident 87's progress note, dated 5/27/2026, was reviewed. The progress note indicated Resident 87 refused to be seen by the podiatrist. RN 1 stated Resident 87 had refused to be seen by the podiatrist. RN 1 stated Resident 87's care plan of non-compliance was not revised. RN 1 stated the non-complaint care plan should have included interventions such as education of risk and benefits, and monitoring of the resident's feet. RN 1 stated the revised care plan should include behavior reinforcement to encourage Resident 87 to be compliant and an updated care plan with new approaches to assist Resident 87 with a successful outcome of care. During a review of facility's P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the interdisciplinary team would review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. The P&P indicated the comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions. The P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.

Based on observation, interview, and record review, the facility failed to date food items in the pantry, refrigerator and freezer, and did not securely store prepared raw fish in flat tray.These deficient practices had the potential to cause food-borne illness for all residents.Findings:During an observation on 6/2/2026 at 9:00 a.m. in pantry number one in the kitchen, a box of 100 tea bags and a box containing Nestle rich chocolate individualized bags did not have a use by date.During an observation on 6/2/2026 at 9:30 a.m. in freezer number one in the kitchen, one package of frozen chocolate chip cookies did not have a use by date.During an interview on 6/2/2026 at 9:35 a.m. with the Dietary Supervisor (DS), the DS stated the two boxed items in the pantry and the frozen package of cookies in the freezer did not have a use by date. The DS stated labeling dried and frozen packages with a use by date was essential to ensure food was stored safely and to prevent contamination, spoilage, and foodborne illness.During an observation on 6/4/2026 at 11:11 a.m. in the kitchen, four flat baking trays containing ten raw fish in yellow liquid were left uncovered and unattended on a three-tier cart. During an interview on 6/4/2026 at 11:13 a.m. with the DS, the DS stated the raw fish had been left uncovered and unattended. The DS stated she could not specify how long the fish remained uncovered. The DS stated leaving raw fish left uncovered on a baking tray exposed the fish to contamination from dust, debris, or airborne particles, and increased the risk of cross-contamination if juices drip or splash onto nearby ready-to-eat foods. The DS stated the tray should have been labeled with the date and time to ensure the fish was used within safe timeframes.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 11/2022, the P&P indicated the facility required staff to handle and store dry foods in a manner that maintained the integrity of the packaging until the items are ready to use. The P&P indicated staff to label and date dry food items with a use by date and to rotate foods using a first in-first out system. During a review of the facility's P&P titled, Food Preparation and Service, dated 11/2022, the P&P indicated cross-contamination could occur when raw food touched or dripped onto cooked or ready-to-eat foods. The P&P indicated staff would track the amount of time potentially hazardous food/temperature control for safety (PHF/TCS, foods that require strict temperature controls to prevent the growth of bacteria and toxins) foods were held out of temperature control and discard the foods accordingly.

Based on observation, interview, and record review the facility failed to ensure the physician for one of five sampled residents (Resident 2) was notified when Resident 2 had redness and exudate (a fluid that leaks out onto skin surface in response to inflammation, injury, or infection) at the insertion site of the perma-catheter (a long, flexible tube inserted into a large vein and threaded near the heart).This deficient practice had the potential to delay medical evaluation and treatment.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnosis included stage three pressure ulcer (full thickness loss of skin. Dead and black tissue may be visible), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and end stage renal disease (the final, permanent stage when the kidneys can no longer filter wase and fluid s from the blood to sustain life).During a review of Resident 2's History and Physical (H&P), dated 3/19/2026, the H&P indicated Resident 2 did not have the capacity to understand and make medical decisions.During a review of Resident 2's Minimum Data Sheet (MDS, a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 2's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 2 was dependent (helper does all of the effort to complete the activity) on staff for toilet hygiene, showering, and dressing. The MDS indicated Resident 2 was at risk for pressure ulcers (localized damage to the skin and/or underlying tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).During an observation on 6/3/2026 at 3:34 p.m., in Resident 2's room, Resident 2 had a right chest perma-catheter double lumen (the hollow, tubular channel inside an intravenous [IV] catheter) with redness and exudate (a fluid that leaks out onto skin surface in response to inflammation, injury, or infection) to the surrounding skin at the insertion site and the lumen had blood in the tubing.During a concurrent interview and picture record review on 6/4/2026 at 12:10 p.m., with Registered Nurse (RN) 1, the picture of the perma-catheter, dated 6/3/2026, was reviewed. The picture indicated Resident 2 had a right chest perma-catheter double lumen with redness and exudate to the surrounding skin at the insertion site. RN 1 stated Resident 2 had redness and exudate surrounding the insertion site. RN 1 stated this was considered a change in condition and the physician should have been notified. RN 1 stated the physician should have been notified to make sure the perma-catheter was properly in place. RN 1 stated it was important to notify the physician in a timely manner to prevent worsening of the redness and exudate of the insertion site.During a concurrent interview and picture record review on 6/5/2026 at 10:05 a.m. with Infection Preventionist (IP) Nurse, the picture of the perma-catheter, dated 6/3/2026, was reviewed. The IP Nurse stated the licensed staff were to monitor the perma-catheter every shift. The IP Nurse there was no documentation of redness, exudate, or blood in the perma-catheter lumen. The IP Nurse stated these issues were reportable to the physician. The IP Nurse stated these issues had the potential for Resident 2 to become septic (a life-threatening blood infection).During a facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated staff would promptly notify the attending physician of changes in the resident's medical condition. The P&P indicated prior to notifying the physician, the nurse was to do a detailed Situation, Background, Assessment, Recommendation (SBAR, a standardized, structured communication framework used in healthcare to quickly and accurately shared critical patient information) communication form.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review ([PASRR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was accurate for one of five sampled residents (Resident 107).This deficient practice had the potential to result in an inaccurate identification of specialized mental health service needs.Findings:During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a severe, chronic mental health condition where a patient experiences a loss of touch with reality), dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 107's History and Physical (H&P), dated 3/19/2026, the H&P indicated Resident 107 did not have the capacity to make medical decisions.During a review of Resident 107's Minimum Data Sheet (MDS, a resident assessment tool), dated 4/17/2026, the MDS indicated Resident 107's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 107 required partial assistance (helper does less than half the effort for lifts /support) on staff for toilet hygiene, showering, and dressing. The MDS indicated Resident 107 was taking antipsychotic medication (drugs used to treat symptoms of psychosis).During a review of Resident 107's physician order, dated 7/18/2024, the physician order indicated to administer Abilify (used to treat mental health conditions) 15 milligrams ([mg] -unit of measurement) one tablet by mouth one time a day for schizophrenia.During a review of Resident 107's PASRR, dated 7/24/2024, the PASRR indicated Resident 107 was not diagnosed with any serious mental illness and was not prescribed psychotropic medications.During a concurrent interview and record review on 6/3/2026 at 1:52 p.m., with the Business Administrator, Resident 107's PASRR, dated 7/24/2024, was reviewed. The PASRR indicated Resident 107 was not diagnosed with any serious mental illness and was not prescribed psychotropic medications. The Business Administrator stated Resident 107 had schizophrenia and was administered psychotropic medication. The Business Administrator stated the PASRR was not accurate. The Business Administrator stated this placed Resident 107 at risk for not adequately identifying cognitive behavior and medication usage which can result in inappropriate care planning and unmet mental health needs.During a review of facility's policy and procedure (P&P) titled, Preadmission Screening & Resident Review (PASRR), dated 11/2023, the P&P indicated the facility would confirm the PASRR process was completed by the General Acute Care Hospitals (GACHs) by accepting and reviewing the PASRR. The P&P indicated when a resident was newly admitted to the facility after a hospital stay, facility staff would review the hospital completed PASRR.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered language and communication care plan for one of five sampled residents (Resident 45).This deficient practice had the potential to result in Resident 45 having a communication barrier with staff.Findings:During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and chronic kidney disease stage 5 (kidneys have lost almost all of their ability to filter waste, extra water, and toxins from the blood).During a review of Resident 45's History and Physical (H&P) dated 6/2/2026, the H&P indicated Resident 45 had the mental capacity to understand but lacked the capacity to make medical decisions.During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 45 was able to understand and be understood by others. The MDS indicated Resident 45's cognition (ability to think and process) was intact. The MDS indicated Resident 45 required substantial assistance (helper does more than half the effort) from staff for activities of daily living and mobility. During a review of Resident 45's care plan, titled Resident 45 was an Armenian speaking resident., dated 5/20/2026, the care plan intervention included to provide staff and volunteers to interpret in native language and a communication board as needed for effective communication.During an observation and interview on 6/2/2026 at 10:35 a.m. with the Director of Staff Development (DSD), Resident 45's room did not have a communication board. The DSD stated she did not know if Resident 45 spoke or understood English. The DSD stated a communication board was not placed in the resident's room. The DSD stated she did not know what resources staff should use to communicate with Resident 45.During a concurrent interview and record review on 6/3/2026 at 10:53 a.m. with Registered Nurse (RN) 1, Resident 45's care plans were reviewed. RN 1 stated Resident 45's care plan did not include measurable objectives, individualized care and interventions, or timeframes based on the resident's assessed needs and preferences. RN 1 stated without measurable goals and timeframes, the facility could not demonstrate staff implemented interventions, understood expectations, reduced communication barriers, or evaluated outcomes.During an interview on 6/4/2026 at 9:06 a.m. with Resident 45 using an interpreter, Resident 45 stated she has never seen the communication board before and her husband was her sole interpreter.During a record review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the care plan must describe the services provided or arranged by the facility, ensure these services were delivered by qualified personnel, and reflect culturally competent, and trauma informed practices.

Based observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) had the correct low air loss mattress (LALM, a specialized mattress support surface used to prevent and treat pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) setting.This deficient practice had the potential for Resident 2 to develop pressure ulcers. Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included stage three pressure ulcer (full thickness loss of skin. Dead and black tissue may be visible), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and end stage renal disease (the final, permanent stage when the kidneys can no longer filter waste and fluids from the blood to sustain life).During a review of Resident 2's History and Physical (H&P), dated 3/19/2026, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Sheet (MDS, a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 2's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 2 was dependent (helper does all of the effort to complete the activity) on staff for toilet hygiene, showering, and dressing. The MDS indicated Resident 2 was at risk for pressure ulcers.During a review of Resident 2's physician order, dated 3/24/2026, the physician order indicated to have a LALM for wound management (the ongoing clinical process of assessing, treating, and monitoring wounds to promote optimal healing and prevent infection).During an observation on 6/3/2026 at 3:34 p.m., in Resident 2's room, Resident 2's LALM setting was set at 200 pounds (lbs., a unit of weight)During a concurrent interview and record review on 6/4/2026 at 3:43 p.m., with Licensed Vocational Nurse (LVN) 5, Resident 2's Vital Sign Summary, dated 5/11/2026, was reviewed. The Vital Sign Summary indicated Resident 2 weighed 169 lbs. LVN 5 stated Resident 2 weighed 169 lbs. and the LALM was set at 200 lbs.During an interview on 6/4/2026 at 11:45 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 2 weighed 160 lbs. and the LALM was set at 200 lbs. RN 1 stated the LALM had the incorrect settings. RN 1 stated the setting should be set at 160 lbs., which was closer to Resident 2's weight (169 lbs.). RN 1 stated the LALM was part of skin management (an approach to maintain, improve, and treat the skin's health and appearance) and to sustain the resident skin integrity (the overall health, strength, and completeness of the skin). RN 1 stated the incorrect LALM could cause worsening of pressure ulcers and slow down the healing process.During a review of the facility's policy and procedures (P&P) titled, Support Surface Guidelines, the P&P indicated any individual at risk for developing pressure ulcers should be placed on a redistribution support surface and settings for static air, alternating air, or air-loss must follow manufacturer's recommendations.During a review of manufacturer operational manual titled, Proactive Medical Products, unknown date, the operational manual indicated the LALM was intended to prevent and treat all pressure ulcer stages. The operational manual indicated to adjust the air mattress according to the resident's weight or the suggestion from a health care professional.

Based on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 70) had an identification (ID) band on their wrist or ankle.This failure had the potential to result in Resident 70 not being properly identified for medical care and procedures.Findings:During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was admitted to the facility on [DATE] with diagnoses including encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function), dementia (loss of thinking, remembering, and reasoning), and muscle weakness.During a review of Resident 70's History & Physical (H&P), dated 6/24/2025, the H&P indicated Resident 70 did not have the capacity to understand and make decisions.During a review of Resident 70's Minimum Data Set (MDS, a resident assessment tool), dated 3/31/2026, the MDS indicated Resident 70's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 70 used a manual wheelchair.During a review of Resident 70's care plan titled, Resident 70 is an elopement (the act of leaving a facility unsupervised and without prior authorization) risk/wanderer related to history of attempts to leave facility unattended, Impaired safety awareness, dated 12/28/2021, the care plan indicated a goal was to maintain Resident 70's safety.During an observation on 06/02/2026 at 11:06 a.m., Resident 70 was in the hallway in a wheelchair without an ID band. During a concurrent observation and interview on 06/02/2026 at 11:13 a.m. with Certified Nursing Assistant (CNA 2), CNA 2 checked Resident 70's wrists and ankles and stated Resident 70 was not wearing an ID band. CNA 2 stated Resident 70 would keep taking off the ID band. CNA 2 stated the facility's policy was that the residents should wear an ID band. During an interview on 6/2/2026 at 11:19 a.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated if there was no ID band, nurses could not check the resident's ID band to verify they were giving the correct resident their medications. LVN 3 stated the facility's policy was that the residents should wear an ID band.During an interview on 6/5/2026 at 9:05 a.m. with the Registered Nurse 1 (RN 1), RN 1 stated all residents had to have an ID band for their safety. RN 1 stated the ID band was used to identify residents when receiving medications and other treatments. RN 1 stated Resident 70 could be at risk of receiving the wrong medications if she was not properly identified. RN 1 stated if Resident 70 were to elope from the facility without an ID band, there would be no way to identify the resident. RN 1 stated it could take a long time to locate the resident, which could lead to the resident being afraid and lost in an unfamiliar environment.During a review of the facility's policy and procedure (P&P) titled, Resident Identification System, dated 12/2007, the P&P indicated a resident identification system was used to help facility personnel provide medical and nursing care.

Based on interview and record review, the facility failed to provide transportation to a dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) clinic for one of five residents (Resident 17).This deficient practice had the potential to result in dangerous buildup of toxins in the body and fluid overload (the body retains too much sodium and water).Findings: During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD, the final most severe stage of chronic kidney disease), anxiety disorder (excessive fear or worry in everyday situations), and dependence on renal dialysis.During a review of Resident 17's History & Physical (H&P) dated 5/4/2026, the H&P indicated Resident 17 had fluctuating capacity to understand and make decisions and was able to make decisions for daily activities. During a review of Resident 17's Minimum Data Set (MDS-a resident assessment tool), dated 5/10/2026, the MDS indicated Resident 17 was able to express ideas and wants and was able to understand others. The MDS indicated Resident 17's cognition (ability to think and process) was intact. The MDS indicated Resident 17 was dependent (helper does all of the effort) on staff for eating, oral and personal hygiene and dressing his upper and lower body.During a review of General Acute Care Hospital (GACH) 1 document, undated, the document indicated GACH 1 arranged round trip transportation for Resident 17 from the facility to dialysis from 5/5/2026 to 5/30/2026.During a review of Resident 17's physician's order, dated 5/15/2026, the physician's order indicated Resident 17 was to be transported to dialysis weekly on Tuesday, Thursday, and Saturday.During a review of Resident 17's care plan titled, Resident 17 needs dialysis related to ESRD, dated 5/29/2026, the care plan intervention indicated Resident 17 was scheduled for dialysis on Tuesday, Thursday, and Saturday.During an interview on 6/2/2026 at 3:45 p.m. with Resident 17 in his room, Resident 17 stated he should be at dialysis right now, but he did not have a ride. Resident 17 stated on Saturday, the transportation driver who took him to dialysis told him the contract ended.During an interview on 6/3/2026 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated social services was aware Resident 17 did not have transportation to dialysis. LVN 4 stated missing dialysis could cause toxic buildup and fluid overload in the body.During an interview on 6/3/2026 at 12:43 p.m. with the Social Services Director (SSD), the SSD stated she usually scheduled transportation after nurses input appointments. The SSD stated the GACH Resident 17 transferred from covered the first 30 days of transportation. The SSD stated the facility should have worked on Resident 17's dialysis transportation before the first 30 days ended to ensure he did not miss his appointment.During a review of the facility's Policy & Procedure (P&P) titled End-Stage Renal Disease, Care of a Resident with dated 9/2010, the P&P indicated residents with ESRD will be cared for according to currently recognized standards of care.

Based on interview and record review, the facility failed to ensure the Social Services Director (SSD) planned for transportation to dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) for one of five residents (Resident 17).This deficient practice resulted in Resident 17 missing one dialysis treatment.Findings: During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD, the final most severe stage of chronic kidney disease), anxiety disorder (excessive fear or worry in everyday situations), and dependence on renal dialysis.During a review of Resident 17's Minimum Data Set (MDS-a resident assessment tool), dated 5/10/2026, the MDS indicated Resident 17 was able to express ideas and wants and was able to understand others. The MDS indicated Resident 17's cognition (ability to think and process) was . The MDS indicated Resident 17 was dependent (helper does all of the effort) on staff for eating, oral and personal hygiene and dressing his upper and lower body.During a review of Resident 17's History & Physical (H&P) dated 5/4/2026, the H&P indicated Resident 17 had fluctuating capacity to understand and make decisions and was able to make decisions for daily activities. During a review of General Acute Care Hospital (GACH) 1 document, undated, the document indicated GACH 1 arranged round trip transportation for Resident 17 from the facility to dialysis from 5/5/2026 to 5/30/2026.During a review of Resident 17's physician's order, dated 5/15/2026, the physician's order indicated Resident 17 was to be transported to dialysis weekly on Tuesday, Thursday, and Saturday.During a review of Resident 17's care plan titled, Resident 17 needs dialysis related to ESRD, dated 5/29/2026, the care plan intervention indicated Resident 17 was scheduled for dialysis on Tuesday, Thursday, and Saturday.During an interview on 6/2/2026 at 3:45 p.m. with Resident 17, Resident 17 stated he should be at dialysis right now, but he did not have a ride. Resident 17 stated on Saturday, the transportation driver who took him to dialysis told him the contract ended.During an interview on 6/3/2026 at 12:43 p.m. with the Social Services Director (SSD), the SSD stated she usually scheduled transportation after nurses input appointments. The SSD stated the GACH Resident 17 transferred from covered the first 30 days of transportation. The SSD stated Resident 17's insurance did not cover transportation, and the facility should have worked on Resident 17's dialysis transportation before the first 30 days ended to ensure he did not miss his appointment. The SSD said the business office was handling the insurance problem. The SSD stated if the resident missed dialysis, the resident could experience fluid overload. During an interview on 6/3/2026 at 12:57 p.m. with the Business Office Manager (BA), the BA stated Resident 17 needed to be switched from traditional Medi-Cal (a system where the state pays providers directly for services) to a Medi-Cal Managed Care (the state assigns residents to a private plan) for transportation to be covered. The BA stated the facility started the process when Resident 17 arrived and expected it to be done by June 1st when GACH 1's arranged transportation ended. The BA stated the facility would cover Resident 17's transportation to dialysis until the insurance pays for it.During a review of the facility's Policy & Procedure (P&P) titled Transportation, Social Services dated 12/2008, the P&P indicated social services will help the resident obtain transportation.During a review of the facility's Director of Social Services (SSD) job description revised August 2024, the job description indicated the SSD was to assist in arranging transportation to other facilities when necessary.

Based on interview and record review, the facility failed to ensure a licensed pharmacist conducted a monthly Medication Regimen Review (MMR) for one of five sampled residents (Resident 10).This failure had the potential to result in Resident 10 receiving unnecessary medication and could lead to adverse side effects.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 50 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and psychotic disorder (mental health condition where a person strongly believes things that are not true, even when there is clear evidence showing otherwise) with delusions (false beliefs).During a review of Resident 10's History and Physical (H&P) dated 1/21/2026, the H&P indicated Resident 10 lacked the capacity to make medical decisions.During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 3/3/2026, the MDS indicated Resident 10's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 10 required supervision (helper provided verbal cues or contact guard assistance) from staff for oral hygiene and mobility. During a concurrent interview and record review on 5/21/26 at 9:28 a.m. with Registered Nurse (RN 1), Resident 10's medical record was reviewed. RN 1 stated the consultant pharmacist did not complete a monthly MMR in January, February, March, April, or May 2026 for Resident 10's psychotropic medications (a medicine that affects how the brain works and can change a resident's mood, thoughts, feelings, or behavior) of Depakote (medication for mood disorder) 125 milligram (mg, unit of measurement), and Risperidone (medication for psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] insomnia and depression) 0.5 mg. RN 1 stated the consultant pharmacist must review Resident 10's antipsychotic medications to ensure a gradual dosage reduction (GDR) was considered, verify the medication dosage remained therapeutic (having a healing effect), and monitor the resident's behavior and laboratory values for effectiveness.During a record review of the facility's policy and procedure (P&P) titled, Medication Therapy, dated 4/2007, the P&P indicated the consultant pharmacist would review each resident's medication regimen monthly, upon staff or practitioner request, or when a clinically significant adverse consequence was confirmed or suspected. The P&P indicated the medical director and consultant pharmacist would collaborate with the practitioners and staff to address issues related to medication prescribing and monitoring.

Based on observation, interview, and record review the facility failed to ensure the cultural and ethnic needs of food choices were identified for one of five sampled residents (Resident 107).This deficient practice placed Resident 107 at risk for being dissatisfied with meals.Findings:During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a severe, chronic mental health condition where a patient experiences a loss of touch with reality), dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 107's History and Physical (H&P), dated 3/19/2026, the H&P indicated Resident 107 did not have the capacity to make medical decisions.During a review of Resident 107's Minimum Data Sheet (MDS, a resident assessment tool), dated 4/17/2026, the MDS indicated Resident 107's cognition (ability to think and process) was moderately impaired. The MDS indicated Resident 107 was independent from staff for eating.During a review of Resident 107's care plan titled, Nutrition and Hydration deficit on Therapeutic Diet, dated 9/11/2025, the care plan intervention indicated to adhere to food preferences within diet order.During a review of Resident 107's physician orders, dated 9/10/2025, the physician orders indicated Resident 107 was on a no added salt, low sugar regular (level 7, the highest and least restrictive food texture for safe eating) diet.During a review of Resident 107's, Dietary Quarterly Assessment, dated 4/17/2026, the Dietary Quarterly Assessment indicated Resident 107 had no food preferences.During a concurrent observation and interview on 6/3/2026 at 11:11 a.m., with Resident 107 in Resident 107's room, the menu and alternative food selection were not in her room. Resident 107 stated she would like to have food choices of her culture. Resident 107 stated she had told the staff she had preferred foods from her culture. Resident 107 stated there was no menu provided for alternative food choices and was not aware the alternative food choices were on the wall near the kitchen. Resident 107 stated she would like to have alternative food choices menu in her room and along with food choices from her culture.During an interview on 6/3/2026 at 1:05 p.m. with the Dietary Supervisor (DS), the DS stated there were no menus in Resident 107's room. The DS stated residents with level 7 diets would be eligible to have the menus in the room to select the diet alternatives. The DS stated Resident 107 had a level 7 diet and was qualified to have the menu in her room. The DS stated having food preferences for the residents helps them to thrive and feel good about themselves.During a concurrent interview and record review on 6/3/2026 at 1:12 p.m., with DS, Resident 107's, Dietary Quarterly Assessment, dated 4/17/2026, the Dietary Quarterly Assessment indicated Resident 107 had no food preferences. The DS stated staff had not reported to her about Resident 107's request for food from her culture. The DS stated she did random rounds with Resident 107 but could not produce documentation of their interaction about random rounds. The DS stated Resident 107's culture food preferences were essential so she could enjoy her meals.During a review of facility's policy and procedure (P&P) titled, Resident Food Preferences, unknown date, the P&P indicated food preferences will be assessed. The P&P indicated staff will interview the resident directly to determine current food preferences based on history and life patterns. The P&P indicated nursing staff will document the resident's food and eating preferences in the care plan. The P&P indicated if the resident was unhappy with his or her diet, the staff will create a care plan that the resident was satisfied with.

Based on interview and record review, the facility failed to ensure the Infection Preventionist attended the February 2026 and May 2026 Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) meetings.This failure resulted in the facility not meeting the minimum required members for the monthly committee meeting.Findings:During a record review of the Monthly QAPI Meeting attendance sheets dated 2/20/2026 and 5/22/2026, the QAPI Meeting attendance sheets indicated there was no signature for the infection preventionist (IP).During a concurrent interview and record review on 6/5/2026 at 11:06 a.m. with the Administrator (ADM) and the Director of Nursing (DON), in the DON's office, the QAPI meeting attendance sheets for the 2/20/2026 and 5/22/2026 meetings were reviewed. The attendance sheets indicated there was no signature for the IP. The ADM stated the IP did not attend the meetings on 2/20/2026 and 5/22/2026. The ADM stated the minimum staff in attendance for QAPI meetings were the ADM, DON, IP and three other members. The ADM stated if the IP was not in the meetings, the IP would not be able to address infection control issues or clarify infection control information, concerns, and questions from the team.During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI), dated 2/2020, the P&P indicated the administrator was responsible for assuring that this facility's QAPI program complied with federal, state, and local regulatory agency requirements.

Based on observation, interview, and record review the facility failed to ensure the perma-catheter (a long, flexible tube inserted into a large vein and threaded near the heart) was maintained in a clean and sanitary manner for one of five sampled residents (Resident 2).This deficient practice had the potential for Resident 2 to develop an infection.Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included stage three pressure ulcer (full thickness loss of skin. Dead and black tissue may be visible), diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and end stage renal disease (the final, permanent stage when the kidneys can no longer filter wase and fluid s from the blood to sustain life).During a review of Resident 2's History and Physical (H&P), dated 3/19/2026, the H&P indicated Resident 2 did not have the capacity to understand and make medical decisions.During a review of Resident 2's Minimum Data Sheet (MDS, a resident assessment tool), dated 2/26/2026, the MDS indicated Resident 2's cognition (ability to think and process) was severely impaired. The MDS indicated Resident 2 was dependent (helper does all of the effort to complete the activity) on staff for toilet hygiene, showering, and dressing. The MDS indicated Resident 2 was at risk for pressure ulcers (localized damage to the skin and/or underlying tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). The MDS indicated Resident was receiving hemodialysis (a treatment to cleanse the blood of wasted and extra fluids artificially through a machine when the kidney (s) have failed).During a review of Resident 2's physician order, dated 3/17/2026, the physician order indicated to monitor right chest perma-catheter dialysis access site for any redness, swelling, bleeding, drainage, and pain. The order indicated to apply pressure on dialysis site if bleeding was noted and notify the physician.During an observation on 6/3/2026 at 3:34 p.m., in Resident 2's room, Resident 2 had redness and exudate (a fluid that leaks out onto skin surface in response to inflammation, injury, or infection) on the skin around the right chest perma-catheter double lumen (the hollow, tubular channel inside an intravenous [IV] catheter) and the lumen had blood in the tubing.During a concurrent interview and picture record review on 6/5/2026 at 10:05 a.m. with the Infection Preventionist (IP), the picture of the perma-catheter, dated 6/3/2026 was reviewed. Resident 2 had a right chest perma-catheter double lumen with redness and exudate to the surrounding skin at the insertion site. The IP stated staff were to monitor the perma-catheter every shift but there was no documentation of the redness or exudate around the perma-catheter. The IP stated the redness and exudate had the potential to cause the resident to become septic (a life-threatening blood infection).During a review of facility's policy and procedure (P&P) titled, Central Venous Catheter Care: Permacath for Hemodialysis, undated, the P&P indicated it was the policy of the facility ensure that residents with a central venous catheter would receive safe, sanitary, and appropriate catheter care to prevent infection. The P&P indicated to promote compliance with infection prevention standards and resident safety requirements. The P&P indicated to assess catheter site for redness, swelling, drainage, warmth, tenderness, or odor.

Based on interview and record review, the facility failed to notify a residents' responsible party (RP) of a change in condition for one of three sampled residents (Resident 3).This deficient practice had the potential to violate Resident 3's RP's rights to be informed of changes to the plan of care.Findings:During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 3's diagnoses included diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), pressure ulcer of the sacral region (directly over tailbone), Stage Four (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing).During a review of Resident 3's History and Physical (H&P) dated 1/14/2026, the H&P indicated Resident 3 was non-verbal and did not have the capacity to make medical decisions.During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 2/28/2026, the MDS indicated Resident 3 had severe cognitive (ability to think and understand) impairment. The MDS indicated Resident 3 was dependent on staff for toileting, bathing and personal hygiene.During a concurrent interview and record review on 3/5/2026 at 10:39 a.m. with the Treatment Nurse (TXN), Resident 3's admission Skin Reassessment dated 2/25/2026 was reviewed. The admission Skin Reassessment indicated upon readmission to the facility from a General Acute Care Hospital (GACH), Resident 3 was observed to have a Stage Four pressure ulcer to her sacrum. TXN stated Resident 3's pressure ulcer was a Stage Two (partial-thickness loss of skin, presenting as a shallow open sore or wound) prior to transfer to the GACH. TXN stated progression of a wound from a Stage Two pressure ulcer to a Stage Four pressure ulcer would be considered a significant change. TXN stated she notified Resident 3's physician, nurse and certified nursing assistant, but was unable to notify Resident 3's responsible party. TXN stated she called Resident 3's responsible party once but was unable to speak with them or leave a voicemail. TXN stated she should have made another attempt to update Resident 3's responsible party. TXN stated notifying residents and their responsible parties of significant changes in condition was important because they have a right to be informed of and participate in their plan of care.During an interview on 3/5/2026 at 2:30 p.m. with the Director of Nursing (DON), the DON stated licensed nurses were responsible for notifying the residents' responsible party when there was a significant change in condition. The DON stated notifying residents' responsible parties of significant changes in condition was important because it was their right to be informed of and included in any changes to the plan of care.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated February 2021, the P&P indicated, Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: there is a significant change in the resident's physical, mental, or psychosocial status.

Based on interview and record review, the facility failed to document behavioral interventions as indicated on the care plan for one of two sampled residents (Resident 1) following an altercation with Resident 2.This failure had the potential to result in continued behavioral escalation and increased risk of physical harm to other residents.Findings:During a record review of Resident 1's admission Record (Face sheet), the admission Record indicated the facility admitted the resident on 12/10/2025 with diagnoses including anemia (low blood cells in body) and schizoaffective disorder (mental health disorder affecting how a person thinks and acts).During a record review of Resident 1's progress note dated 2/28/2026, the progress note indicated Resident 1 was transferred out for 5150 (a law code that allows a person in a mental health crisis to be taken to a hospital or mental health facility against their will) for danger to others.During a record review of Resident 2's admission Record, (Face sheet), the admission Record indicated the facility admitted the resident on 2/14/2026 with diagnoses including chronic kidney disease (kidneys damaged and unable to filter blood) and hypertensive urgency (extremely high blood pressure).During an interview on 3/5/2026 at 11:01 with Registered Nurse (RN) 1, RN 1 stated the incident between Resident 1 and Resident 2 happened on 2/28/2026. RN 1 stated she was alerted when she heard Resident 1 screaming while walking down the hallway. RN 1 stated Resident 1 walked into Resident 2's room, when RN 1 arrived in Resident 2's room, Resident 2 was holding a foldable chair. RN 1 stated Resident 1 reported to her that Resident 2 had hit him on the head with the chair. During a concurrent interview and record review on 3/5/2026 at 11:05 a.m. with Registered Nurse (RN) 1, Resident 1's care plan dated 2/28/2026 and progress notes dated 2/28/2026 were reviewed. The care plan indicated Resident 1 had an episode of increased aggression, was unable to be redirected, and was a danger to others. The care plan indicated intervention including for staff were to provide early redirection and de escalation techniques to reduce episodes of verbal aggression. During a review of Resident 1's progress notes, the progress notes indicated the incident between the residents happened at 11:20 a.m. and Resident 1 was picked up for transfer at 4:45 p.m. RN 1 stated progress notes for 2/28/2026 did not indicate early interventions, redirection, and/or de-escalation that were done during Resident 1's episodes of screaming while awaiting transfer.During a concurrent interview and record review on 3/5/26 at 11:48 a.m. with Assistant Director of Nursing (ADON), Resident 1's progress notes dated 2/28/26 were reviewed. The ADON stated Resident 1 was alert, oriented, and ambulatory (able to walk without assistance), and had episodes of screaming. The ADON stated on 2/28/2026, Resident 1 intermittently continued to yell while awaiting transfer to another facility. The ADON stated the progress notes dated 2/28/2026 did not indicate interventions, including non-pharmacological were documented. During an interview on 3/5/2026 at 2:00 p.m. with the Director of Nursing (DON), the DON stated care plans were initiated for Resident 1 and Resident 2 following the incident and the care plan interventions should have been documented if they were completed. The DON stated following care plan interventions was important to prevent further behavioral escalation and to keep residents and staff safe.During a review of the facility's policy and procedure (P&P) titled, Behavioral Assessment, Intervention, and Monitoring, dated March 2019, the P&P indicated, .If the resident is being treated for altered behavior or mood, the facility will seek and document any improvements or worsening in the individual's behavior, mood, and function.The facility will monitor progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported.

Based on observation, interview, and record review the facility failed to:1. Ensure one out of three sampled residents (Resident 1) unwitnessed injury to the left eye was reported to California Department of Public Health (CDPH).This deficient practice of not reporting to CDPH within 24 hours of an unwitnessed injury resulted in discoloration (a localized area of altered skin color that indicates underlying tissue damage) to the left eye. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses metabolic encephalopathy (an acute or chronic alteration in brain function), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures), dementia (a progressive state of decline in mental abilities), and muscle weakness (a reduction in the ability to generate normal force in muscles, often presenting as impaired physical mobility, fatigue, or decreased functional capacity). During a review of Resident 1's History and Physical (H&P), dated 12/20/2025, the H&P indicated Resident 1 had a fluctuated capacity to understand and make decisions. During a review of Resident 1's Minimum Data Sheet ([MDS]- a resident assessment tool), dated 1/21/2026 the MDS indicated Resident 1 cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 1 required partial/moderate assistance (helper does more than half the effort. Helper lifts or hold trunks or limbs and provides more than half the effort) from staff for toileting hygiene, showers, and dressing. During a review of Resident 1's, Change of Condition (COC), dated 2/25/2026, the COC indicated Resident 1 had discoloration, dark purplish color, and swelling under her left eye. During an observation on 2/27/2026 at 3:36 p.m., in Resident 1's room, Resident had a large dark bruise (an injury of discolored skin on the body) partially around the left eye. During an interview on 2/27/2026 at 3:36 p.m., Resident 1 could not explain how she had sustained an injury to her left eye. During a concurrent interview and record review on 2/27/2026 at 3:44 p.m., with Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 3/2024, the P&P indicated the facility was to notify the Department of Health Services of all unusual occurrences, within twenty-four hours. The P&P indicated any facility related injury of any resident which requires medical treatment. The P&P indicated occurrences that constitute an interference with facility operations that affect the welfare, safety or health of residents. The P&P indicated other injuries that affect the health and safety as identified by the facility and Department of Health Services (DHS) as required reporting. The DON stated Resident 1 had a large bruise on the left eye. The DON stated Resident 1 was impulsive (a patient's tendency to act quickly on a whim, emotion, and immediate desire without thinking about the potential negative consequences) and needed to be monitored. The DON stated the incident was not witnessed by staff and therefore the injury would be considered injury of an unknown source. The DON stated the process was to report within two hours for the federal process and 24 hours to the state. The DON stated that not reporting would impose on the departments final investigation and keeping the residents safe. During a review of Resident 1's progress notes, dated 2/27/26 at 10: 30 p.m., indicated Resident 1's physician was made aware of Resident 1's swelling and discoloration due to hitting her face on her bedside. During an interview on 3/3/2026 at 8:48 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had discoloration to the left eye. LVN 1 stated she had reported the unwitnessed incident to the DON. LVN 1 stated the discoloration to the left eye was considered an injury of unknown source due to Resident 1's poor cognition. LVN 1 stated reports of unknown injury should be reported within two hours to the federal and 24 hours to the state. LVN 1 stated the injury should be investigated to maintain the wellness of Resident 1. During a review of the facility's P&P titled, Investigating Resident Injuries, dated 4/2021, the P&P indicated injury of unknown source is define as an injury that met the following conditions such as the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident. During a review of the facility's P&P titled, Unusual Occurrence Reporting, dated 3/2024, the P&P indicated the facility was to notify the Department of Health Services of all unusual occurrences, within twenty-four hours. The P&P indicated any facility related injury of any resident which requires medical treatment. The P&P indicated occurrences that constitute an interference with facility operations that affect the welfare, safety or health of residents. The P&P indicated other injuries that affect health and safety as identified by the facility and DHS as required reporting.

Based on observation, interview and record review, the facility failed to implement their policy and procedure (P&P) titled, Refrigerators and Freezers which indicated to monitor and record the refrigerator and freezer temperatures daily, for 3 of 3 refrigerators and 2 of 2 freezers.This failure had the potential to cause food spoilage (the deterioration of food due to various factors, resulting in an undesirable change in its appearance, taste, texture, or nutritional value) and lead to foodborne illnesses (any illness caused by consuming foods or beverages contaminated with harmful bacteria, viruses and parasites or their toxins [poisonous substances produced by organisms like bacteria that harm the body]).Findings:During a concurrent interview and record review on 01/05/2026 at 11 a.m., with the Dietary Supervisor (DS), in the kitchen, the refrigerator and freezer temperature logs dated 2026, were reviewed.The refrigerator temperature logs for the following days were blank and did not indicate monitoring was completed:On 1/1/2026 and 1/2/2026 for Produce and Breads, Milk and Dairy and Nourishment during the morning (AM) shiftOn 1/1/2026 for Produce and Breads, Milk and Dairy during evening (PM) shiftThe freezer temperature logs for the following days were blank and did not indicate monitoring was completed:On 1/1/2026 and 1/2/2026 for Frozen Vegetables and Ice cream and Frozen Meat during the AM shiftOn 1/1/2026 for Frozen Vegetables and Ice Cream and Frozen Meat during the PM shiftThe DS stated the AM and PM cooks were responsible for ensuring timely monitoring and documentation of the refrigerator and freezer logs and lack of monitoring and documenting refrigerator and freezers temperatures may cause food spoilage.During a review of the facility's P&P titled, Refrigerators and Freezers, dated 11/ 2022, the P&P indicated the facility will ensure safe refrigerator and freezer temperatures and sanitation, and will observe food expiration guidelines. Refrigerators and freezers are maintained in good working conditions. Refrigerators keep food at or below 41 degrees Fahrenheit (a scale of temperature on which water freezes at 32 and boils at 212 under standard conditions) and freezers keep frozen foods frozen solid. The P&P indicated Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.

Based on observation, interview and record review, the facility failed to implement its infection prevention and control measures for one of two shower rooms (east shower room), by failing to ensure the shower floor and wall were clean and disinfected from fecal matter (the solid waste passed out of the body of a human through the bowel). This failure had the potential to spread bacteria and germs that could lead to infection for facility residents. Findings:During a concurrent observation and interview on 01/05/2026 at 11:39 a.m., with the housekeeper (HK 1), in the east shower room, dry brown fecal matter was observed on the wall of the 2nd shower stall, and a small drop of brown feces was observed on the floor. HK 1 stated failure to clean and disinfect the walls and floors may increase the risk of residents getting sick.During a review of the facility's Job Description titled, Housekeeper, dated 09/2025, the Job Description indicated the primary purpose of this position is to perform the day-to-day activities of housekeeping as directed by the housekeeping supervisor to assure the facility is maintained in a clean, safe and comfortable manner. Perform cleaning procedures in accordance with established infection prevention and control procedures. Clean walls and ceilings by washing, wiping, spot cleaning, disinfecting, deodorizing, etc. Remove dirt, dust, grease, film, etc., from surfaces using proper cleaning/disinfecting solutions.During a review of the facility's Policy and Procedure (P&P) titled, Policies and Practices-Infection Control dated 4/2012, the P&P indicated the facility's infection P&Ps are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on observation, interview, and record review, the facility failed to ensure privacy during care for three of eight residents (Residents 2, 3, and 4) when certified Nursing Assistants (CNA) 1, CNA 2, and CNA 3 did not fully close the privacy curtains while providing care. This failure had the potential to affect the dignity and self-worth of Residents 2, 3, and 4. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/15/2025 with diagnoses including generalized muscle weakness, difficulty in walking, lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system), and morbid obesity (severely overweight). During a review of Resident 2's History and Physical (H&P), dated 9/1/2025, the H&P indicated, Resident 2 had the capacity to make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 8/19/2025, the MDS indicated Resident 2 was understood by staff and was able to understand others. The MDS indicated, Resident 2 required partial to moderate assistance for activities of daily living (ADLs-activities such as bathing, dressing, personal/oral hygiene, and toileting). During an observation on 9/22/2025 at 9:00 a.m. in Resident 's room, Certified Nursing Assistant (CNA) 1 was providing ADLs to Resident 2. The privacy curtain was halfway closed while Resident 1 was being provided with incontinent care. Resident 2's bedside window curtains were open, and the resident was visible from the outside of the window. During an interview on 9/22/2025 at 10:05 a.m. with Resident 2, Resident 2 stated having privacy was important to feeling safe. Resident 2 stated feeling embarrassed if exposed to other residents or staff in the room. During an interview on 9/22/2025 at 12:03 p.m. with CNA 1, CNA 1 stated keeping the curtains closed was important for residents' privacy. CNA 1 stated residents would feel embarrassed if curtains were open while receiving care. b. During a review of Resident 3's admission Record, the admission Record indicated, the facilityadmitted Resident 3 on 3/10/2015 with diagnoses including epilepsy (a long-term chronic disease thatcauses repeated seizures due to abnormal electrical signals produced by damaged brain cells), overactivebladder, dementia (a progressive state of decline in mental abilities), and diabetes mellitus (DM-a disordercharacterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 3's H&P, dated 5/28/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had severe cognitive (ability to think, learn, remember, use judgement, and make decisions) impairment. The MDS indicated Resident 3 required partial to moderate assistance for ADLs. During a concurrent observation and interview on 9/22/2025 at 9:30 a.m. in Resident 3's room, CNA 2 was providing ADLs to Resident 3. The privacy curtain was halfway closed when Resident 3 was being provided with incontinent care. Resident 3 was observed to be naked. CNA 2 stated the curtains must be closed all the way for residents' privacy. c. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 10/4/2023 with diagnoses including epilepsy, generalized muscle weakness, dementia, hemiplegia (total paralysis ofthe arm, leg, and trunk on the same side of the body), hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body), and diabetes mellitus.During a review of Resident 4's H&P, dated 1/26/2024, the H&P indicated, Resident 4 did not have the capacity to understand and make decisions.During a review of Resident 4's MDS, dated [DATE] the MDS indicated Resident 4 had severe cognitive impairment. The MDS also indicated Resident 4 required maximum assistance for ADLs. During a concurrent observation and interview on 9/22/2025 at 9:57 a.m. in Resident 4's room, CNA 3 was providing ADLs to Resident 4. Resident 4 was observed with the entire body exposed. The privacy curtain was only halfway closed. CNA 3 was in the process of cleaning Resident 4 while the resident remained naked. CNA 3 stated curtains needed to be closed all the way to provide privacy. During an interview on 9/22/2025 at 12:16 p.m. with CNA 3, CNA 3 stated closing the curtain was important to provide privacy to Residents. CNA 3 stated residents would feel embarrassed, and uncomfortable if privacy were not provided to them.During an interview on 9/22/2025 at 1:05 p.m. with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated providing privacy such as closing the doors, and curtains were important for respect and dignity purposes. LVN 1 stated residents would feel embarrassed if they were exposed during care. During an interview on 9/22/2025 at 2:45 p.m. with Registered Nurse (RN) 1, RN 1 stated to ensure residents' privacy, staff are expected to knock before entering, introduce themselves, close privacy curtains, and explain the procedures to be performed. RN 1 stated failing to close curtains before providing care can affect a resident's dignity and make them feel embarrassed, which may affect the residents psychologically. During a review of the facility's Policy & Procedure (P&P) titled, Dignity, revised on February 2021, the P&P indicated, Each resident shall be cared for in a manner that respects and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. During a review of the facility's P&P titled, Residents Rights Guidelines for all Nursing Procedures, revised on October 2010, the P&P indicated, facility was to close the room entrance door and provide for the resident's privacy.

Based on interview and record review, the facility failed to notify one of four sampled residents (Resident 1), at least 30 days prior to the resident's discharge plan on 7/19/2025, as indicated in the facility's policy and procedure (P&P) titled, Transfer and Discharge Notice.This deficient practice resulted in Resident 1 not being aware of the discharge plans and had the potential to affect the resident's highest practicable physical, mental and psychosocial well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including muscle weakness, abnormalities of gait and mobility (deviations from the typical manner of walking) and atrial fibrillation (irregular heartbeat.) During a review of Resident 1's History and Physical (H&P) dated 6/26/2025, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 6/30/2025, the MDS indicated Resident 1 had intact cognition. The MDS indicated Resident 1 required supervision or touching assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer and mobility.During a review of Resident 1's progress notes dated 7/21/2025, the progress notes did not indicate an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting was conducted prior to Resident 1's planned discharge on [DATE]. During a review of Resident 1's undated Notice of Medicare Non-Coverage (NOMNC, a form that Medicare providers are required to give to beneficiaries when their Medicare-covered services are ending), the NOMNC indicated the Medicare coverage of current skilled nursing services would end on 7/21/2025.During an interview on 7/18/2025 at 2:45 p.m. with Resident 1, Resident 1 stated the Rehabilitation Director (RD) did not inform him that he had reached his goals in therapy. Resident 1 stated on 7/18/2025 before lunch time, the Business office representative (BO) came to his room and was asked to sign a document. Resident 1 stated the BO representative told Resident 1 that he will be discharged [DATE] and the resident's Medicare benefits will not be used. Resident 1 stated the Social Services Department (SSD) also came to his room on 7/18/2025 and told him that he will be discharged [DATE]. Resident 1 stated the facility did not talk to him in advance or informed him about any discharge plans. Resident 1 stated he applied an appeal to Livanta (a Medicare-contracted Quality Improvement Organization that provides help, support and resources for Medicare beneficiaries) on 7/18/2025.During an interview on 7/18/2025 at 3:43 p.m. with the BO representative, the BO representative stated the NOMNC should be given to residents 72 hours before the discharge date . The BO representative stated Resident 1's last day of Medicare coverage was 7/21/2025. The BO representative stated she went to Resident 1's room on 7/17/2025 but Resident 1 was not in the room. The BO representative stated she did not go back to Resident 1's room to look for him. The BO representative stated she went back to Resident 1's room on 7/18/2025 and asked Resident 1 to sign the NOMNC, but Resident 1 refused to sign. The BO representative stated the facility did not conduct an IDT meeting before Resident 1's discharge date of 7/19/2025.During an interview on 7/21/2025 at 11:37 a.m. with the RD, the RD stated he (RD) could not remember the facility conducted an IDT meeting for Resident 1's discharge. The RD stated the rehabilitation department should inform the residents when therapies are about to end and provide recommendations for home services as part of discharge planning. The RD stated Resident 1 should be informed about discharge planning before asking him to sign any papers. During an interview on 7/21/2025 at 11:45 a.m. with SSD, the SSD stated the facility did not conduct an IDT meeting prior to Resident 1's planned discharge on [DATE]. The SSD stated on 7/18/2025 at 11:00 a.m., Resident 1's doctor gave a discharge order for Resident 1. The SSD stated she went to Resident 1's room and told Resident 1 about the discharge order, but Resident 1 refused to talk about discharge plans. The SSD stated it was important to schedule IDT meetings when a resident is ready to be discharged to discuss the plan of care and discharge needs. The SSD stated the facility should have given Resident 1 the discharge notice prior to 7/18/2025.During a concurrent interview and record review on 7/21/2025 at 3:55 p.m. with the Director of Nursing (DON), Resident 1's progress notes for 7/2025 were reviewed. The DON stated the progress notes did not indicate SSD scheduled an IDT meeting with Resident 1. The DON stated on 7/16/2025, he asked the SSD to schedule an IDT meeting for Resident 1. The DON stated conducting discharge IDT meetings with residents is very important so the residents will be aware of all discharge plans, and whatever the resident would need will be ready providing residents safe discharge. During a review of the facility's policy and procedures (P&P) titled, Transfer and Discharge Notice, dated 6/2017, the P&P indicated for facility -initiated discharges, a written notice of discharge must be provided to the resident and resident representative, with a copy to the State LTC Ombudsman, at least 30 days prior to the discharge or as soon as possible.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was free from injury, by failing to provide two or more staff supervision when providing care with activities of daily living (eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet) as indicated in Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/1/2024. The MDS indicated two or more persons will assist Resident 1 with mobility (rolling from left to right, sit to lying, lying to sitting position and with transfer from bed to chair, chair to bed and with tub/ shower transfer), toileting hygiene, shower, and personal hygiene. This failure resulted in Resident 1 sustaining a right upper arm fracture (broken bone) which required hospitalization at a general acute care hospital (GACH) for evaluation and treatment. Findings: A review of Resident 1 ' s Admission Record, indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included quadriplegia (inability to move all parts of the body below the neck), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of right hand, and aphasia (a disorder that results from damage to portions of the brain that are responsible for language). A review of Resident 1 ' s History and Physical (H&P), dated 10/23/2023, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s MDS dated [DATE], indicated Resident 1 had functional limitation in range of motion, impairment on both upper and lower extremities. The MDS indicated Resident 1 required two or more persons to assist with mobility, toileting hygiene, shower, and personal hygiene. The MDS indicated Resident 1 had contractures of muscles in multiple sites (on the left and right elbow, right hand, left and right knee). A review of Resident 1 ' s undated care plan titled, Impaired ability to perform or complete activities of daily living (ADLs) task, indicated Resident 1 may be up on geri chair (a specialized, padded recliner chair for patients with limited mobility) for comfort and good body alignment. The interventions also indicated the facility will provide Resident 1, a safe environment and emphasize incident and accident precautions as appropriate. The care plan did not indicate interventions for 2 or more persons assist as indicated in Resident 1 ' s MDS. A review of Resident 1 ' s undated care plan titled the resident has impaired physical mobility due to contractures on the right elbow, the goal indicated Resident 1 will remain free of injuries or complications related to contractures. One of the interventions indicated staff will anticipate and meet Resident 1 ' s needs. The interventions did not indicate safety measures to prevent injuries. A review of Resident 1 ' s undated care plan titled, Potential for bleeding, easily get bruised or skin discoloration due to use of aspirin (blood thinner) and Plavix (blood thinner), indicated staff should handle resident gently during care and transfer. A review of Resident 1 ' s Change in condition (COC) form, dated 2/28/2024 at 2:44 p.m., indicated the Certified Nurse Assistant 2 (CNA 2) notified Licensed Vocational Nurse 1 (LVN 1) of Resident 1 ' s right upper arm discoloration. The COC indicated LVN 1 assessed Resident 1 ' s skin and the resident ' s skin was intact with no signs of redness, bleeding, swelling or discoloration. The COC indicated Resident 1 was not in pain. A review of Resident 1 ' s, x-ray (process of taking pictures of tissues and structures inside the body for diagnosis and treatment) report from the facility, dated 2/28/2024, indicated Resident 1 had an acute obliquely (slant) oriented non-displaced (did not move out of alignment) fracture or surgical neck of humerus (upper arm bone). A review of Resident 1 ' s GACH emergency room (ER) notes dated 2/29/2024, indicated Resident 1 presented at ER for evaluation of right upper arm proximal (near) humerus fracture. The ER notes indicated Resident 1 ' s right upper arm was swollen. The notes also indicated Resident 1 ' s x-ray indicated the resident had a nondisplaced proximal humerus fracture with associated soft tissue swelling. A review of Resident 1 ' s GACH discharge summary dated 3/1/2024, indicated Resident 1 was discharged back to the facility with a with a sling (a device to immobilize fractured bones). During an interview on 3/26/2024 at 1:27 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 2/28/2024 at 2:40 p.m., CNA2 reported (to LVN1)that Resident 1 had a baseball-size (a regulation baseball is 9 to 9.25 inches in circumference) bruise (skin discoloration caused by a blow or impact) on her right upper arm. LVN 1 stated Resident 1 did not usually develop bruises. LVN 1 stated, Resident 1 probably got hurt when the CNA moved her harshly. LVN 1 stated it was suspicious for Resident 1 who did not move, to sustain a bruise on top of the arm. During an interview with LVN 2 on 3/26/2024 at 2:00 p.m., LVN 2 stated a bruise on a resident ' s skin, could be caused by excessive pressure or trauma (injury). LVN 2 stated there was light swelling on Resident 1 ' s arm. Resident 1 was quadriplegic and unable to move her body and all extremities without assistance. During an interview with CNA 1 (CNA assigned to Resident 1 on 2/28/2024 7a.m. to 3p.m. shift) on 4/2/2024 at 12:16 p.m., CNA 1 stated on 2/28/2024, she (CNA1) provided Resident 1 morning bed bath alone. CNA 1 stated, she (CNA1) noticed Resident 1 had discoloration on the right arm and Resident 1 seemed to be in pain. CNA 1 stated, she reported the discoloration to LVN 1. CNA 1 stated she had always performed Resident 1 ' s activities of daily living ([ADLs] such as bathing and dressing) alone, and without asking for any staff ' s assistance. During a concurrent interview and record review with Director of Nursing (DON) on 4/2/2024 at 12:41 p.m., Resident 1 ' s MDS dated [DATE], was reviewed. The DON stated according to MDS, Resident 1 required two persons assist with ADLs and bed mobility. The DON stated she was not aware CNAs were performing daily bed baths and resident transfers, turning and repositioning on Resident 1without assistance. The DON stated all total care residents, or residents ' dependent on staff for ADLs, were supposed to be assisted by two staff members to prevent injuries. The DON stated if she had known that CNAs were performing care on Resident 1 without the second person ' s assistance, facility would have identified the possibility of this causing an injury. A review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/2017, indicated the resident ' s safety, supervision, and assistance to prevent accidents were facility-wide priorities. The P&P indicated; employees shall be trained on potential accident hazards to prevent avoidable accidents. The P&P also indicated, the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. The P&P also indicated, due to their complexity and scope, certain resident risk factors and environmental hazards were addressed in dedicated policies and procedures, that included bed safety, safe lifting, and movement of residents. A review of the facility ' s P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P indicated care plan interventions will address the underlying source of the problem area. During a review of the facility ' s P&P titled, Activities of Daily Living (ADLs), Supporting dated 3/2018, the P&P indicated residents will be provided appropriate care and services in accordance with the plan of care.

Based on observation, interview and record review, the facility failed to: 1. Supervise and monitor residents at risk for wandering and elopement (when a resident leaves the facility without the knowledge of the staff), for one of three sampled residents (Resident 1). 2. Ensure the entrance and exit doors of the facility were monitored to prevent Resident 1 from leaving the facility unattended. This deficient practice had the potential to result in an injury for Resident 1. Findings: A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated Resident 1 had diagnoses including atherosclerotic heart disease (a hardening of your arteries from plaque building up gradually incident the arteries), repeated falls, hyperosmolality and hypernatremia (a cause of decrease in body water, an electrolyte problem), type 2 diabetes Mellitus (abnormal blood sugar), pressure ulcer (a sore to the skin and tissue below the skin) of left buttock, muscle weakness (decreased strength in the muscles), difficulty in walking (inability to walk properly due to abnormal and uncontrollable walking patterns), atrial fibrillation (an irregular and often very rapid heartbeat), benign neoplasm of brain (an abnormal growth in the brain), Hemiplegia (muscle weakness on one side of the body that can affect the arms, legs, and facial muscles), gastro esophageal reflux (a digestive disease in which stomach acid or bile irritates the stomach lining), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), hypertension (a condition in which the force of the blood against the artery walls is to high), dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 1's history and physical (H&P), dated 2/3/2024, indicated Resident 1 could not make decisions but could make his needs known. A review of Resident 1's Change of Condition (COC), dated 2/7/2024, indicated Resident 1 wandered aimlessly and attempted to get out of the facility unattended. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/9/2024, indicated Resident 1's cognitive (the ability to think and process information) skills for daily decisions making was severely impaired. The MDS indicated Resident 1 required a cane/crutch and wheelchair for walking. The MDS indicated Resident 1 required moderate assistance in functional abilities with activities of daily living (ADL). A review of Resident 1's care plan titled, elopement, dated 2/13/2024, indicated Resident 1 was at risk for elopement, wandering, and leaving the facility unattended. The care plan intervention indicated Resident 1 would be monitored. A review of the Los Angeles Paramedic Runsheet dated 2/22/24 indicated Resident 1 was found on 2/22/24, at 7:23 p.m., with a head trauma (injury), and injuries indicating a fall. The Runsheet indicated Resident 1 was transferred to a general acute care hospital (GACH). A review of Resident 1's nursing assessment dated [DATE], indicated Resident 1 had an abrasion (scraping) on the nose, forehead, and upper lip. During a concurrent interview and video review on 3/4/24 at 12:01 p.m., with the Administrator (ADM) and Director of Nursing (DON), the facility's video camera was reviewed. The ADM stated Resident 1 was pushing a wheelchair pass the east nursing station, where two nursing staff members were sitting. The ADM stated at 6:12:47 p.m., Resident 1 exited the facility through the east door. The ADM stated at 6:13:55 p.m., the desk nurse was observed going to the east door, opening and shutting the door without looking outside. During an interview on 3/4/24 at 12:45 p.m., with the ADM, the ADM stated the outside video showed it took Resident 1 40 seconds to get around the corner from line of sight. The ADM stated the outside video only keeps the recording for a week. The ADM stated, I knew Resident 1 was a wanderer, he was given a wander guard prior to the elopement date. During an interview on 3/4/24 at 1:03p.m., with the receptionist, the receptionist stated the desk nurse called her to help turn off the door alarm. The receptionist stated the east door alarm was ringing and the nurse did not know how to turn it off and was not aware of Resident 1 leaving the facility. During an interview on 3/4/24 at 1:40 p.m., with LVN 1, LVN 1 stated on 2/25/2024, at an unknown time, she (LVN 1) heard the east door alarm ringing, but she did not get up to check what triggered the alarm. During an interview on 3/4/24 2:00p.m., with the DON, the DON stated the Fire Department dispatch unit called the facility at 7:30p.m., to inform the facility Resident 1 was taken to the hospital after falling and sustaining facial abrasions. A review of Resident 1's GACH record titled History of Present Illness, dated 2/22/2024, indicated Resident 1 was found on the road by paramedics, with a 2-centimeter ([cm] unit of measurement) laceration (skin tear) to his forehead. The record indicated Resident 1's Computerized tomography ([CT] process of taking detailed pictures of internal images of the body for diagnosis and treatment) scan of the brain indicated Resident 1 had a trace parasagittal right frontal subarachnoid hemorrhage (bleeding in the space surrounding the brain). The record indicated Resident 1 was transferred to another GACH (GACH 2) for evaluation and higher level of care. A review of Resident 1's Nursing Notes from the facility, titled Admission Notes, dated 2/24/2024, indicated Resident 1 was readmitted to the facility with a diagnosis of traumatic parasagittal right frontal subarachnoid hemorrhage. A review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated 3/2019, indicated the facility will identify residents at risk of unsafe wandering, strive to prevent harm, and monitor to maintain the least restrictive environment for residents. A review of the facility's P&P titled, Wander Guard Alarm Policy, undated indicated The wander guard alarm system is an essential tool for ensuring residents at the facility are safe and secure at all times, all exit doors in the hallway are equipped with an alarm system to notify staff when wander guard residents attempt to leave the facility without notification. The P&P indicated residents were provided with the highest level of safety and security, while respecting the rights of other residents from unnecessary disruptions due to a wander guard alarm being triggered. The P&P indicated the facility had instituted the wander guard alarm system will be enabled for 24 hours daily, and never be deactivated (turned off). The P&P indicated all personnel were to monitor residents with wander guards to prevent them from leaving the facility without prior approval/authorization. A review of the facility's P&P titled, Wandering and Elopement, dated 1/31/2023, indicated the facility will identify residents at risk for elopement upon admission and when there was a change in condition to minimize the risk of elopement, and enhance the safety of residents.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received all the necessary care and services to prevent pressure ulcer ([PU] injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development by failing to: 1. Adhere to a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Implement Resident 1's plan of care, which included turning and repositioning the elbow every two hours. 3. Report to the physician Resident 1's right elbow wound changes, which worsened to a Stage IV (deep tissue injury with exposure of the muscles and/or bones) with drainage. 4. Ensure Resident 2, who had a Stage IV pressure ulcer, was being turning every two hours while in bed. 5. Ensure the nursing staff completed and initialed the resident turn and reposition sheets every two hours. This deficient practice resulted in Resident 1 developing a Stage IV pressure ulcer measuring 3 centimeter ([cm] a unit of measurement) in length ([L] measurement of something from end to end) x 3 cm in width ([W] measurement of something from side to side) x 0.6 cm in depth (D) to the right elbow. The pressure ulcer wound had scant (small) sanguineous (blood tinged) drainage requiring several wound debridement (removal of damaged, dead or infected skin tissue from a wound) to promote wound healing which had the potential to result in further pressure ulcer development and secondary infections. Resident 1 was no longer in the facility. Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated the resident was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's skin assessment, dated 8/29/2020 and timed at 4:51 p.m., the assessment indicated Resident 1 had discoloration on the right arm but did not have any pressure ulcer/pressure injury (PU/PI). During a review of Resident 1's care plan, dated 11/8/2020 and titled, Alteration in skin integrity pressure injury site right elbow, Stage I (intact or unopened skin with redness) related to right upper extremity contracture (tightening of muscles that prevents normal movement). The staff's interventions indicated for staff to provide treatment as ordered, perform wound assessment and documentation, turn, and reposition every two (2) hours, call the physician if the treatment was ineffective, position Resident 1 in bed in a way that the right elbow was not in contact with the bed by utilizing pillows as right arm is contracted. During a review of Resident 1's Braden Scale (an assessment tool for predicting pressure sore risk) Pressure Sore Risk Assessment (PSRA), dated 12/3/2020, the PSRA indicated Resident 1 was assessed as having a score of 12. According to the Braden Scale Risk Assessment, a total score of 12 or less represented a high risk. During a review of Resident 1's Minimum Data Sets (MDS), a standardized resident assessment and care-screening tool, dated 12/3/2020 and 3/3/2021, the MDS indicated Resident 1 required extensive assistance of a one-person physical assist with bed mobility, toileting, personal hygiene, and a two-person assist with transfers. The MDS indicated Resident 1 was at risk for developing PU/PI and skin injuries and did not indicate Resident 1 had any ulcers, wounds, and skin problems. The MDS indicated Resident 1 had moisture associated skin damage ([MASD] injury to the skin due to prolong exposure to moisture), received skin treatments including pressure reducing device, turning, and repositioning program, application of nonsurgical dressings and applications of ointments and medications. During a review of Resident 1's Nurse's Progress Note (NPN), dated 12/16/2021 and timed at 1:34 p.m., the NPN indicated Resident 1's right elbow ulcer was closed and had thin and fragile skin. During a review of Resident 1's care plan, dated 1/2/2021 and titled, Alteration in skin integrity pressure injury of right elbow abrasion. The staff's interventions indicated for the staff to provide treatment as ordered, perform wound assessment and documentation, turn, and reposition every two (2) hours, call the physician if the treatment was ineffective, provide good skin care and keep dry and clean. During a review of Resident 1's NPN, dated 1/12/2021 and timed at 6:42 p.m., the NPN indicated Resident 1 received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 1's recapitulated ([recap] a summary) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Weekly Wound Observation (WWO) form, dated 2/4/2021 and timed at 11:51 a.m., the WWO indicated Resident 1 had a re-opened right elbow abrasion (Stage I) that measured 3 cm x 2 cm, with no slough (shedding of the outer layer of skin), eschar (dead tissue that sheds or falls off from the skin) or granulation (the development of new skin tissue). The WWO indicated Resident 1's physician was notified. During a review of Resident 1's care plan, dated 2/4/2021 and titled, Alteration in skin integrity pressure injury of right elbow re-opened abrasion. The staff's interventions indicated for staff to provide treatment as ordered, perform wound assessment and documentation, turn, and reposition every two (2) hours, call the physician if the treatment was ineffective, and provide good skin care and keep dry and clean. During a review of Resident 1's WWO, dated 2/18/2021 and timed at 2:30 p.m., the WWO indicated Resident 1's re-opened right elbow abrasion was assessed and measured at 1.8 cm x 0.8 cm with no slough, eschar and/or granulation. The WWO indicated Resident 1's physician and family were notified. During a review of Resident 1's NPN, dated 2/19/2021 and timed at 2:02 p.m., the NPN indicated Resident 1's right elbow Stage I was reassessed. During a review of Resident 1's records there was no documented evidence of an assessment conducted on 2/19/2021. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's WWO, dated 3/11/2021 and timed at 11:50 a.m., the WWO indicated Resident 1's right elbow wound measured 1.9 cm x 0.5 cm with no slough, eschar, or granulation. The WWO indicated Resident 1's right elbow was healing slowly. During a review of Resident 1's NPN, dated 3/19/2021 and timed at 2:48 p.m., the NPN indicated Resident 1's right elbow had light serosanguinous (discharge that contains both blood and serum [a clear yellow liquid]) drainage. The NPN did not indicate Resident 1's physician was notify of the change of condition of the right elbow wound. During a review of Resident 1's WWO, dated 4/2/2021 and timed at 1:30 p.m., the WWO indicated Resident 1's right elbow was unstageable (unable to measure) and it was reclassified as a pressure injury that measured 3 cm x 2 cm x 0.3 cm with no slough, eschar, or granulation. The WWO indicated for the staff to provide offloading (to minimizing or removing weight to help prevent and heal ulcers) to Resident 1's right elbow. During a review of Resident 1's NPN, dated 4/2/2021 and timed at 11:47 p.m., the NPN indicated Resident 1 was being monitored and received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's care plan, dated 4/2/2021 and titled, Alteration in skin integrity pressure injury of unstageable right elbow. The staff's interventions indicated for staff to provide treatment as ordered, perform wound assessment and documentation, turn, and reposition every two (2) hours, call the physician if the treatment was ineffective, provide good skin care and keep dry and clean and wound consultant (a wound consultation for evaluation of pressure injuries). During a review of Resident 1's new physician order, dated 4/15/2021 and timed at 2 p.m., the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's WWO, dated 4/20/2021 and timed at 7:45 p.m., the WWO indicated Resident 1's right elbow wound had worsened to a Stage IV pressure ulcer and measured 2.9 cm x 2.9 cm x 0.6 cm with 100% slough and a small amount of sanguineous (blood tinged) drainage and with no eschar or granulation. The WWO indicated Resident 1 was seen by the wound consultant physician. During a review of Resident 1's Wound Consultant Note (WCN), dated 4/27/2021, the WCN indicated Resident 1 was assessed and indicated Resident 1's right elbow wound had reopened and worsened significantly. The WCN indicated Resident 1's right elbow PU measured 3 cm x 3 cm x 0.6 cm and was a Stage IV sacral wound, with 30% slough, 40% granulation, 30% necrotic (dead) tissue and had an odor. The WCN indicated Resident 1's right elbow PU was debrided. The WCN indicated the wound care consultant recommended aggressive offloading of Resident 1's right elbow PU. During a telephone interview on 10/4/2021 at 10:09 a.m., Resident 1's family member (FM 1) stated Resident 1 had a right elbow contracture since 2/2019 and in 7/2020 Resident 1 developed a small sore on her right elbow. FM 1 stated he and FM 2 were made aware of Resident 1's right elbow pressure ulcer had progressed from a Stage I to a Stage IV during a meeting on 5/31/2021. During an interview on 10/5/2021 at 2:30 p.m., Treatment Nurse/Licensed Vocational Nurse 1 (TN/LVN 1) stated residents with a Stage I PI/PU are reported to the physician, a change of condition (COC) note is completed, the family/responsible party would be notified, a care plan initiated, daily wound documentation and weekly wound documentation would be completed. TN/LVN 1 stated if the resident's skin was not improving then the staff would complete another COC note, notify the physician, and ask the physician for the resident to be seen weekly by the wound care specialist. During an interview on 10/15/2021 at 12:05 p.m., TN 2/LVN 3 was ask what should be done when a resident's skin was blanchable and remained red, TN 2/LVN 3 stated she would notify the physician, monitor the resident's skin, provide wound care treatments, and turn and reposition the resident every 2 hours. The TN 2/LVN 3 was asked how she would know when residents are being turned and repositioned every 2 hours, the TN 2/LVN 3 stated there is a turn and reposition sheet, the LVN must sign after the CNAs sign on each position. During an interview on 11/4/2021 at 4:32 p.m., TN 3/LVN 4 stated she covers for the TNs 1-2 days weekly and conduct resident wound care treatments. TN 3/LVN 4 stated offloading meant placing the resident's extremities up in the air and when residents are lying in bed. TN 3/ LVN 4 stated offloading required the CNAs turning and repositioning every 2 hours and/or as needed to reduce pressure from the resident's pressure sites. TN 3/ LVN 4 was asked how she ensured offloading residents with contractures, TN 3/ LVN 4 stated the facility used proper equipment such as a wedge pillow (a foam pillow that is higher in the front), hand-rolls, hand mittens and foot protectors. TN 3/ LVN 4 stated the CNAs must complete the turn and reposition sheet every 2 hours which the charge nurses sign to ensure offloading was conducted. TN 3/ LVN 4 was asked how she ensured the residents were being turned and repositioned every 2 hours, the TN 3/LVN 4 stated by looking at the residents, how the resident's pillows were positioned and if the linens were tucked in very well. TN 3/ LVN 4 stated she would notify the wound care consultant/physician if the resident had a wound consult order resident and had a skin abrasion and/or opening of the skin. During a review on 11/4/2021 at 4:49 p.m., of the CNAs turn and reposition sheets located in the West nursing station, the sheets dated 11/4/2021 and timed at 8 a.m., 10 a.m., 12 p.m., and 2 p.m., there were a total of eight (8) residents without the CNA and/or the LVN initials to indicate the residents were positioned every 2 hours. Two of the eight reposition forms were blank without any staff signatures to indicate the residents were not being turned. During observations of another resident (Resident 2) who had a Stage IV pressure ulcer and required turning every two hours, the following were observed: On 11/8/2021 at 8:10 a.m., Resident 2 was lying supine (lying on the back) while in bed. On 11/8/2021 at 12:30 p.m., Resident 2 remained lying supine in bed in the same position since 8:10 a.m. During a concurrent interview and review of the West Nursing Station reposition sheets on 11/8/2021 at 10:45 a.m., the Director of Nursing (DON) confirmed there were no CNA and LVN initials for the eight (8) residents who required turning and repositioning every two hours on 11/1/2021 thru 11/7/2021. The DON stated the CNAs and licensed staff should have completed the reposition sheets. The DON stated the TN was responsible for notifying the wound consultant when Resident 1's right elbow worsened or resulted in a pressure ulcer. The DON was asked did the licensed staff notify the wound consultant when Resident 1's right elbow progressed from an open abrasion on 2/4/2021 to a Stage IV on 4/20/2021 since there had been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the staff did not notify the wound consultant until 4/20/2021 and the staff should have because now Resident 1's right elbow was a Stage IV pressure ulcer. During a telephone interview on 11/8/2021 at 12:47 p.m., TN 6/LVN 7 stated she has been performing wound care treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . TN 6/LVN 7 stated Resident 1 had an abrasion on her right elbow that re-opened, gradually went bad and was not healing well. TN 6/LVN 7 was asked what is done when the resident's wounds were not healing, the TN 6/LVN 7 stated she would get the wound consultant involved to see the resident's wounds. TN 6/LVN 7 was asked if she notified the wound consultant for Resident 1's right elbow after her observation of the right elbow not healing, the TN 6/LVN 7 stated she did not notify the wound consultant for Resident 1 and should have. During a review of the facility's revised policy and procedure (P/P), dated 9/2013, titled, Prevention of Pressure Ulcers, the P/P indicated pressure ulcers are usually formed when a resident remains in the same position for an extended period, causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. The P/P indicated the most common site of a pressure ulcer is where the bone is near the surface of the body including the back of head, around the ears, elbows, shoulder blades, backbone, hips, knees, heels ankles and toes. The P/P indicated for a person in bed change positions at least every two hours or more frequently if needed, report any signs of a developing pressure ulcer to the physician.

Based on interview and record review, the facility's nursing staff failed to ensure they followed the physician's order, the resident's plan of care, and their policy and procedure to ensure one of three sampled residents (Resident A) received medications, as prescribed by the physician, to treat high blood sugar levels (the concentration of glucose (sugar) in the blood). Resident A, who had a [DIAGNOSES REDACTED]. sugar, the sliding scale with instructions on how to use it and what to do if the resident's blood sugar was outside the sliding scale range. This deficient practice resulted in Resident A's blood sugar becoming elevated at greater than 400 milligrams per deciliter ((mg/dl) normal reference range (NRR) 80-100 mg/dl) after not receiving insulin for almost three days and required a transfer to a general acute care hospital (GACH) with an altered mental status (AMS) and being admitted for three days for treatment. Findings: A review of Resident A's Admission Records indicated the resident was initially admitted to the facility on [DATE] and last readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of a Minimum Data Set (MDS), an assessment and care screening tool, dated 1/4/19, indicated Resident A scored 6 out of 15 on a Brief Interview for Mental Status ((BIMS) a mental assessment) indicating her cognitive skills for daily decision-making were severely impaired. According to the MDS Resident A received insulin injections for the last seven days. A review of a care plan, dated 10/5/18, and revised on 1/4/19, indicated Resident A was at risk for [DIAGNOSES REDACTED] (low blood sugar) and/or [MEDICAL CONDITION] (high blood sugar) due to diabetes mellitus. The goal indicated Resident A was not to have any signs and symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION] or any complications related to diabetes daily. The staff's approaches/interventions included blood sugar checks as ordered and give [MEDICATION NAME] Regular Insulin ((short-acting insulin) used to control high blood sugar levels) per sliding scale. A review of a physician's order, dated 9/4/18, indicated the following: 1. Call the physician if the blood sugar (B/S) was greater than 400 mg/dl, give insulin coverage and repeat blood sugar check in 1/2 hour. 2. Call the physician if the blood sugar was less than 60 mg/dl, give D50 (a glucose solution used for severe low blood sugar) one [MEDICATION NAME] (a sealed glass or plastic bulb containing solutions for [MEDICATION NAME] (beneath the skin) injection) IVP (intravenous (into the vein) push) and give 1/2 cup orange juice or 1/2 cup of milk if able, give hard candies to eat if able, recheck blood sugar in 30 minutes then call the physician. 3. Check the blood sugar via a finger stick (pricking the tip of a finger to obtain a small sample of blood) with sliding/scale coverage of [MEDICATION NAME] Regular Insulin subcutaneously (under the skin) before meals and at bedtime as follows: B/S level of 151-200 mg/dl = 0 units B/S level of 201-250 mg/dl = 2 units B/S level of 251-300 mg/dl = 4 units B/S level of 301-350 mg/dl = 6 units B/S level of 351-400 mg/dl = 8 units A review of a Physician's Order, dated 9/25/18, indicated Resident A may go out on pass with family and with medication. A review of Resident A's Medication Administration Record (MAR), for the month of February 2019, indicated the resident's glucose levels was elevated and she was receiving insulin ([MEDICATION NAME]) coverage as follows: 2/1/19 6:30 a.m. - B/S level 396 mg/dl, 8 units of insulin administered. 11:30 a.m. - B/S level 340 mg/dl, 6 units of insulin administered. 4:30 p.m. - B/S 260 mg/dl, 4 units of insulin administered. 9 p.m. - B/S 300 mg/dl, 4 units of insulin administered. 2/2/19 6:30 a.m. - B/S 276 mg/dl, 4 units of insulin administered. 11:30 a.m. - B/S 400 mg/dl, 8 units of insulin administered. 2/3/19 6:30 a.m. - B/S 320 mg/dl, 6 units of insulin administered. 11:30 a.m. - 400 mg/dl, 8 units of insulin administered. 2/4/19 6:30 a.m. - 333 mg/dl, 6 units of insulin administered. 11:30 a.m. - 390 mg/dl, 8 units of insulin administered. 4:30 p.m. - 216 mg/dl, 2 units of insulin administered. 9 p.m. - 400 mg/dl, 8 units of insulin administered. 2/5/19 11:30 a.m. - 364 mg/dl, 8 units of insulin administered. 9 p.m. - 350 mg/dl, 6 units of insulin administered. 2/6/19 11:30 a.m. - 346 mg/dl, 6 units of insulin administered. 2/7/19 6:30 a.m. - 304 mg/dl, 6 units of insulin administered. 11:30 a.m. - 361 mg/dl, 8 units of insulin administered. 4:30 a.m., 400 mg/dl, 8 units of insulin administered. A review of the MAR, dated 2/8/19, indicated Resident A's blood sugar was 228 mg/dl and she received 2 units of insulin at 6:30 a.m., and at 11:30 a.m., a blank space indicated that there was no blood sugar was obtained. At 4:30 p.m., the same day, it was circled with documentation indicating Resident A went home with family. There was no written documentation indicating insulin or instructions were sent home with the resident and/or her RP (responsible party). A review of a Licensed Personnel Weekly Progress Note, dated 2/8/19 and timed at 10:50 a.m., indicated Resident A was transferred from the facility, at 12:52 p.m., to a clinic for evaluation related to an unrelated event, and later the same day went home with the family on a pass. A review of a Physician's Order, dated 2/8/19 and timed at 3 p.m., indicated to release three days of medication supply for Resident A for out on pass per family/RP request. A review of a Licensed Personnel Weekly Progress Note, dated 2/8/19 and timed at 5:30 p.m., indicated Resident A's family members came to the facility to obtain the residents three day medication supply. Registered Nurse Supervisor 1 (RN 1) asked Licensed Vocational Nurse 1 (LVN 1) to prepare the three days of medication supply. A review of a GACH's Admission Records, indicated Resident A was seen in the emergency department (ED), on 2/10/19 at 11:47 p.m. The GACH's ED note, dated 2/11/19, indicated Resident A presented to the ED for evaluation of AMS and [MEDICAL CONDITION], per the family, Resident A seemed confused, was agitated and not her normal self. According to the note, the EMS (emergency medical services) checked Resident A's blood sugar and it was high at 499 mg/dl. The family stated Resident A was recently taken out of a nursing home two days prior and had not been receiving her insulin. A review of the GACH's Laboratory results, dated 2/11/19 and timed at 3:15 a.m., indicated Resident A's blood glucose was 353 mg/dl and her urine glucose was elevated at 4+ (indicator of the level of glucose in the urine) (Normal Reference Range (NRR) = negative). A review of the GACH's History of Present Illness,' dated 2/11/19 and timed at 5:04 p.m., indicated Resident A's history was remarkable for diabetes and resided at a skilled nursing facility (SNF), but left the SNF on 2/8/19 without receiving any insulin until her admission to the GACH (2/10/19). The resident presented to the ED because of confusion and elevated blood sugars (greater than (>) 400). A review of Resident A's Hospital Course, dated 2/13/19, indicated Resident A resided at a SNF, but was taken home by family without a prescription for insulin. The resident became more lethargic (sluggish) and less responsive. The resident's blood sugars were greater than 400 mg/dl and she was brought to the emergency department. The resident's diabetes was controlled with [MEDICATION NAME] plus (type of insulin) sliding scale. The resident's family was educated about checking blood sugars and will follow-up with a primary care physician. On 3/12/19, at 4:21 p.m., during an interview, LVN 1 stated Resident A had already left the facility when she arrived on her shift (3 p.m. - 11 p.m.) that day (2/8/19). LVN 1 stated the family requested a three-day supply of the Resident A's medication and she gave the family the medication for each shift, for three days, separating the medication in plastic envelopes, per dosage and with a label on each envelope. LVN 1 stated there was no insulin in the medication cart and she did not ask the family or anyone at the facility if it had been given to the family already, she just assumed the family had already received it. LVN 1 stated she did not provide the family with the sliding scale instructions and did not ask if they knew how to administer the insulin or if they had equipment to obtain the resident's blood sugar. On 4/1/19, at 4:38 p.m., during a subsequent interview, LVN 1 stated RN 1 brought Resident A's family members to her (2/8/19) and instructed her to give them only Resident A's oral medications. At 5 p.m., on 4/1/19, during an interview, RN 1 stated Resident A's family members came to the facility on [DATE], during the evening shift, asking for a three day supply of medication. RN 1 stated the family had previously taken Resident A from the facility and had only taken the resident's oral medications because they had the insulin and equipment at home. RN 1 stated one of the family members was very demanding and she felt intimidated and did not want to risk upsetting her by asking her questions about the Resident A's insulin. RN 1 stated she instructed LVN 1 to only give the family member Resident A's oral medications. On 4/3/19, at 9:40 a.m., during an interview, the Director of Nursing (DON) stated the nursing staff should circle on the MAR and document out on pass when the resident was out on pass from the facility. The DON acknowledged out on pass documentation only indicated that the resident did not receive medication because she was not in the facility, it does not indicate medication was given to the resident and/or her responsible party (RP). The DON stated the documentation should include that medication, equipment and instruction were sent with the resident and/or the RP and if the medication, supplies, instructions were refused by the resident and/or RP that should be documented as well. The DON stated it was the facility's responsibility to ensure a resident who was under their care have the necessary medication, supplies and instructions for use when they are out of the facility on pass. The DON stated everyone assumed, because the family had previously taken Resident A out of the facility, that the family knew what to do and had equipment and insulin at home. A review of the facility's policy on Dispensing Medication to Residents on Leave/Pass, dated 7/2018, indicated the facility will provide residents with necessary medication(s) when they leave the facility temporarily for a pass with family/responsible party. Residents who are away from the facility during medication passes will be given scheduled medications(s) to take with them. They will only be given the amounts and dosages needed for the length of the anticipated absence. The charge nurse will provide verbal or written directions to the resident and/or the person signing out the resident regarding any dispensed medications. The nursing staff will document the resident's absence from the facility on the resident's medicating administration record (MAR), if the resident is absent during one or more medicating passes. If a resident is on leave or pass overnight or for more than three consecutive days, the pharmacy will prepare and dispense his/her medications.

Based on interview and record review, the facility failed to follow its policy and the Interdisciplinary Team's ((IDT)-group of disciplines that work together towards a common goal for a resident) recommendations to ensure one of three sampled residents, who had a high risk for falls (Resident 1) received supervision and used assistive devices to prevent falls and injuries. (Cross Reference F 600) This deficient practice resulted in Resident 1 having an unwitnessed fall and sustaining a left leg/hip area fracture (broken bone) requiring a transfer to a general acute care hospital (GACH) and application of a splint (a device used for support or immobilization of a limb or the spine). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and recently readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Fall Risk Assessment, dated 2/9/18, indicated the resident had a score of 15 (10 or greater = high risk for falls). A review of a care plan, dated 2/9/18, indicated Resident 1 was at risk for falls and required the staffs' assistance with transfers and bed mobility. The staffs' interventions indicated: adequate lighting, monitoring the resident for steadiness and balance, reminding the resident to ask for help during transfers and ambulation, placing the resident's call light close and answering the call light promptly. A review of a Progress Note, dated 3/15/18 and timed at 10 p.m., indicated Resident 1 would often slide toward the bed's right side rail and hang legs out of the bed. A review of another Fall Risk Assessment, dated 3/25/18, indicated Resident 1's fall score had increased to 17. A care plan, dated 3/25/18, indicated Resident 1 had an actual fall. The staff's interventions indicated: to re-educate the resident to use her call light, frequent visual checks, provide activities appropriate for the resident's cognitive abilities, use of positioning pillows and side rails. A review of a Situation, Background, Assessment and Recommendation ((SBAR)-internal communication), dated 3/25/18, indicated on 3/25/18, at 5 p.m., Resident 1 was found on the floor. A review of Resident 1's IDT dated 4/5/18 indicated Resident 1 had a fall on 3/25/18. The IDT Team recommended that the resident be moved closer to the nurses' station for frequent staff monitoring, which was not implemented until after the resident had another fall. A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 5/21/18, indicated the resident had severe impairment in cognitive skills (thought process). According to the MDS, Resident 1 required two or more staff's assistance with bed mobility, transferring to and from bed, chair or a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. The resident used a wheelchair for mobility. The MDS indicated Resident 1 was always incontinent (inability to control) of bladder and bowel functions. A care plan, dated 7/3/18, indicated Resident 1 would dangled her leg off the bed and constantly scooted down towards the foot of the bed. The staff's interventions indicated: the use of a low bed, room change closer to the nurses' station for close monitoring and hourly visual checks to ensure proper positioning while in bed. A review of Resident 1's history and physical report (H/P), dated 7/6/18, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's IDT dated 4/5/18 indicated Resident 1 had a fall on 3/25/18. The IDT Team recommended that the resident be moved closer to the nurses' station for frequent monitoring. A review of SBAR, dated 7/3/18 and timed at 2:45 a.m., indicated Resident 1 was found on the floor next to her bed. A review of another IDT, dated 7/10/18, indicated Resident 1 had a fall with a left [MEDICAL CONDITION] on 7/3/18. According to the IDT, Resident 1's fall could have resulted from the use of a low air mattress. The IDT indicated Resident 1 was placed on a low bed with a floor pad and moved to room [ROOM NUMBER] (closer to the nurses' station). A review of the facility's Investigation Report of incident, dated 7/3/18, indicated Resident 1 had an unwitnessed fall. The report indicated the resident had poor safety awareness and had been scooting down in the bed. The facility's corrective actions included the following: the use of low bed, proper positioning in bed and room change close to the nurses' station for close monitoring, which was recommended by the IDT on 4/5/18, but was not implemented. A review of the facility's follow-up report, dated 7/6/18, indicated Resident 1 required moderate to maximum assistance with activities of daily living (ADL) and was a high risk for falls. A review of an X-ray report of Resident 1's right hip/leg, dated 7/3/18 indicated the resident had a right leg and [MEDICAL CONDITION]. On 7/12/18, at 11 a.m., during an interview, Registered Nurse 1 (RN 1) stated on 7/3/18, at 2:45 a.m., Resident 1 was found lying on her right side, on the floor and with her head facing the foot of the bed. RN 1 stated that Resident 1 was not on a low bed and did not have a floor mat to prevent and minimize injury after a fall, as per the IDT recommendations. RN 1 stated that Resident 1 was cognitively impaired. On 7/12/18, at 11:45 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated Resident 1 would always scoot and moved her legs off the bed. CNA 1 stated the resident did not have floor mats. CNA 1 stated a mat was like a cushion that decreased the impact of a fall. On 7/12/18, at 12:29 p.m., during a concurrent interview and record review, the director of nursing (DON) stated that Resident 1 was restless, had a tendency to scoot and dangle her feet off the bed and fell on [DATE]. The DON stated that floor mats were used for residents who were restless in bed and would attempt to get out of the bed without asking for help. According to the DON, floor mats minimized injuries in case of a fall. The DON added that the Resident 1's fall on 7/3/18, was from sliding off the low air loss ((LAL)-mattress with alternating pressure utilized to reduce pressure on skin) mattress. The DON stated Resident 1 was moved to a room closer to the nurse's station for close monitoring and place on a low bed. At 1:10 p.m., on 7/12/18, during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that Resident 1 always moved her legs off the bed, did not have a floor mat and a low bed to prevent falls and injury. A review of the facility's policy titled Falls-Clinical Protocol, with a revised date of 10/2010, indicated the staff would assess residents for fall risk, categorize fall incidents based on how the falls occurred, determine the cause of each fall and provide interventions to prevent future falls. It also indicated the staff would monitor the residents' responses to the interventions to decrease falls.

Based on interview and record review, the facility failed to follow its policy and a resident's plan of care to provide adequate supervision for one of four sampled residents (Resident 1) to prevent falls. Resident 1, who had a high risk for falls, with a recent fall, fell sustaining a cervical fracture (broken neck bone), laceration (deep skin cut), and abrasions (superficial damage to the skin) and fell again within 24 hours sustaining more injuries. This deficient practice resulted in Resident 1 falling twice within 24 hours with multiple injuries requiring two transfers to the general acute care hospital (GACH); wound closure of the facial laceration and blunt head trauma with a hematoma ( a localized collection of blood outside the blood vessels, due to either disease or trauma). Resident 1 had a physical decline after the two falls and had to be hospitalized for [REDACTED]. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment tool and care-screening tool, dated [DATE], indicated Resident 1 was moderately cognitively (thought process) impaired and unable to make his own daily decisions. According to the MDS, Resident 1 required a two-person physical assist in transferring between bed, chair, wheelchair, and ambulation. A review of Resident 1's History and Physical (H/P), dated [DATE], indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Fall Risk Assessment, dated [DATE], indicated Resident 1 was assessed as a high risk for falls, had problems balancing while standing and walking, and required a wheelchair. The assessment also indicated there was a concern with the level of the resident's mental status and impaired vision related to fall risks. A review of a SBAR (Situation, Background, Assessment, and Recommendation) change of condition form, dated [DATE] and timed at 2:40 p.m., indicated to send Resident 1 to the general acute care hospital (GACH) via 911 for a fall incident. According to the SBAR, Resident 1 was found on the floor in the hallway with abrasions (superficial scrape) to the forehead, right eye brow, nasal bridge, and the 1st and 2nd digit fingers. A review of the physician's orders [REDACTED]. A review of an investigation report, dated [DATE], indicated Resident 1 was found on the floor in prone position (side lying, face down) at 2:30 p.m. on [DATE] by the facility's social worker. Resident 1 had an abrasion to forehead, right eye brow and nasal bridge. According to the report, Resident 1 who was wheelchair bound had an unwitnessed fall. The resident's family and physician were made aware and the resident was sent out to the emergency room for further evaluation. A review of GACH's note, dated [DATE], indicated Resident 1 arrived in the emergency room (ER) with a cervical collar ((C-collar) neck brace) around the neck and a medial forehead abrasion/laceration non-pulsating and oozing of dark red blood. The ER note indicated there was tenderness to palpate the facial area with an underlying hematoma. The physician sutured the facial laceration of the forehead and applied bacitracin (an antibiotic ointment). A review of Resident 1's Computed Tomography ((CT), computerized x-ray image) Scan taken at the GACH, dated [DATE], indicated Resident 1 had a cervical 5 ((C5) cervical spine (neck) a delicate area-housing the spinal cord that sends messages from the brain to control all aspects of the body) fracture of the neck. A review of Resident 1's GACH's Discharge Summary, dated [DATE], indicated the resident had a [DIAGNOSES REDACTED]. 1. Maintain neck and spine injuries by continuing to wearing neck brace at all times; 2. Go to emergency for unconsciousness, severe back or neck pain, tingling or loss of feeling in hands or feet, and loss of bowel or bladder function; 3. Watch for fluid drainage or bleeding from the nose or ears; 4. Keep sutures clean and dry. A review of Resident 1's plan of care titled Actual Fall, dated [DATE], indicated the staff interventions included to do visual check of the resident when up in the wheelchair and place the resident in front of the nurses' station and/or recreational areas was present for visual check. A review of a physician's orders [REDACTED]. A review of a SBAR change of condition form, dated [DATE], and timed at 10:15 a.m., indicated Resident 1 was found lying on the floor with his forehead laceration reopened and bleeding. A review of the physician's orders [REDACTED]. A review of an investigation report, dated [DATE], indicated Resident 1 was provided care by an assigned certified nurse assistant (CNA) and placed in the hallway in the wheelchair. Resident 1 was later found down on the floor screaming after an unwitnessed fall. According to the investigation report, there was minimum bleeding from Resident 1's forehead. The RN supervisor was called and first aid was rendered and vital signs checked and Resident 1 was sent out to emergency room for evaluation. A review of the GACH's records, dated [DATE], indicated Resident 1 arrived to the emergency room with a C-collar around the neck and a re-opened forehead laceration. Resident 1 was only responding to name by opening his eyes. Resident 1 was admitted to hospital for medical observation and consideration for a safe discharge plan, as he has had two falls at the current facility in the last 10 cumulative hours there. A review of the GACH's Discharge Summary, dated [DATE], indicated Resident 1 had a [DIAGNOSES REDACTED]. 1. Keep C-collar brace on at all times; 2. Follow up with neurosurgery in 1 week; 3. Go to emergency for chest pain, shortness of breath, nausea/vomiting; On [DATE] at 7:15 a.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated Resident 1 fell after she had performed morning care and placed him in the hallway. CNA 1 stated she was aware that Resident 1 had fallen the day before, but had received no specific precautions regarding how to care for Resident 1 after he sustained a cervical fracture. CNA 1 stated Resident 1 had a neck brace on and sutures on his forehead when she received him in bed that morning. CNA 1 stated she was not aware if any other staff were monitoring the floor when she placed him out in the hallway and that Resident 1 had wheeled himself down the hallway. On [DATE] at 8:15 a.m., during an interview, Registered Nurse 1 (RN 1) supervisor stated since Resident 1 had been readmitted in the middle of the night from the previous fall there had been no plan put in place yet for provision of care. RN 1 stated CNA 1 should have been briefed before her shift regarding how to care for Resident 1 during her shift since he now had a cervical fracture. At 8:35 a.m., on [DATE], during an interview, the administrator stated he did not report either of Resident 1's fall incidents with a fracture to the Department of Health. During an interview with Resident 1's family member (FM 1) on [DATE] at 1 p.m., FM 1 stated Resident 1's health had declined since the two falls and he had not been eating properly since the fall. A review of a SBAR change of condition, dated [DATE], indicated Resident 1 was experiencing poor meal intake and was noncompliant with wearing the cervical collar (a neck brace). On [DATE] at 8 a.m., during a subsequent interview, RN 1 stated Resident 1 began to vomit greenish fluid during his neurologist appointment on [DATE], and was sent back to the emergency room . RN 1 stated Resident 1 returned back to the facility, but was placed on palliative care with hospice (end of life comfort measures) and expired a few days later on [DATE]. At 8:45 a.m., on [DATE], during an interview, the facility's Administrator stated he was in the process of in-servicing all nursing staff on safety precautions of resident's with a cervical fracture to ensure proper care was provided after Resident 1's cervical fracture. A review of the facility's policy titled, Resident Safety and Accident Prevention, dated [DATE], indicated the staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on observation, interview and record review, the facility failed to provide aggressive preventative care as indicated in their policy to prevent the development and reoccurrence of pressure ulcers for residents who were at a high risk for developing pressure ulcers for two of four residents (6,10) with pressure ulcers in a sample of 18 residents by failing to: For Resident 6, the facility failed to: (a) Monitor and report skin changes to the physician (b) Obtain a treatment order for the right heel pressure ulcer (c) Follow the physician's orders [REDACTED].) (d) Implement the plan of care to float (to take off pressure from the heels, to suspend), the heels and apply heel protectors (devices that help minimize pressure, on your feet, heels and ankles.) to both heels every shift (e) Ensure the pressure reducing mattress was maintained inflated at all times. For Resident 10, the facility failed to (a) Provide a pressure reducing device while the resident was sitting in the wheelchair (b) Follow the physician's treatment order for the right buttock skin redness. As a result Resident 6's healed right heel pressure ulcer reoccurred. Additionally, Resident 10 was not provided pressure ulcer treatment as ordered. Findings: a. A review of the admission face sheet for Resident 6 indicated the resident was readmitted to the facility on ,[DATE] /11, with [DIAGNOSES REDACTED]. A review of Resident 6's Minimum Data Set (MDS-a standardized assessment and care planning tool), dated 6/28/13, indicated the resident was totally dependent in all levels of activities of daily living, and during the brief interview for mental status, was able to make self understood and was able to recall sock, blue and bed. A review of the facility's pressure ulcer risk assessment dated [DATE], indicated that Resident 6's score was 11 (a total score of 8 or above represents high risk), for pressure ulcer development. According to the licensed personnel weekly progress notes dated 7/27/13, Resident 6 was transferred from the skilled nursing facility (SNF) to the acute hospital on [DATE], due to an elevated body temperature and was readmitted to the SNF on 7/29/13, with sacral redness. There was no documentation of a pressure ulcer of the right heel. During multiple observations on 8/5/13, at 10:10 a.m., 8/6/13 at 10:30 a.m., 8/7/13 at 8:50 a.m., and at 11:34 a.m., Resident 6 was sitting in a chair with his heels observed resting on and in contact with a pillow. Further observations on 8/6/13, at 8:55 a.m., 9:30 a.m. and at 3 p.m., 8/7/13 at 8:10 a.m. and 2:10 p.m., and on 8/8/13, at 8:10 p.m., the resident was in bed with his heels resting on the mattress. The resident did not have pressure reducing devices on his heels while sitting in a chair and/or while lying in bed. During the treatment observation on 8/6/13, at 8:55 a.m., Resident 6 was observed lying on the left side on a low air loss mattress (a mattress that provides a flow of air to assist in managing the heat and humidity of the skin). The resident was alert and coherent. The resident's skin on the sacral area was observed clear and intact. Treatment Nurse 1 cleansed the sacral area with normal saline, applied [MEDICATION NAME] (a multipurpose moisture barrier) cream and left the sacral area open to air. The resident was observed wearing socks on his feet and his heels were resting on the mattress. The resident's socks were removed by Treatment Nurse 1 to inspect the resident's heels. The resident's right heel was observed with brown eschar (dead tissue) in the wound bed (base) that measured 1.5 centimeter in length by 1.3 centimeter in width (the size of a nickel). The skin surrounding the wound bed was yellow, red and purple in color. The Director of Nursing (DON) came in to the resident's room at 9:10 a.m., and assessed the resident's skin of the right heel. The DON stated the brownish eschar on the resident's right heel was an unstageable pressure ulcer. (An unstageable pressure ulcer is a full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough or eschar in the wound bed but it will be either stage III (a craterlike sore with involvement of the underlying structures) or stage IV (a full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer). During an interview on 8/6/13, at 9:12 a.m., CNA 1 stated she was not aware of the pressure ulcer on Resident 6's right heel. During an interview on 8/6/13 at 9:15 a.m., Treatment Nurse 1 stated Resident 6 had no treatment order for the unstageable pressure ulcer of the right heel because the physician was not informed of the pressure ulcer. Treatment Nurse 1 disclosed that staff from the previous shifts did not report the change in the resident's skin condition of the right heel. During an observation on 8/6/13 at 2:58 p.m., Resident 6 was yelling "Ouch, ouch my feet" while lying on his back on a low air loss mattress. LVN 2 responded at 3 p.m., to check the resident's feet. When LVN 2 removed the linen on the resident's feet, the low air loss mattress was observed deflated and the resident's heels were resting on the mattress. LVN 2 disclosed the electrical cord was not plugged into the electrical outlet and so the low air loss mattress did not work. LVN 2 stated the last time she saw the resident in a chair was approximately at 2:30 p.m., in the activity room. LVN 2 stated she did not receive a report from CNA 1 that the resident's low air loss mattress was deflated before CNA 1 had left for the day. LVN 2 stated the charge nurse and CNA were responsible for monitoring the low air loss mattress to ensure it is working properly at all times to prevent the resident from having a pressure ulcer. The resident stated, "My feet feels better" after the low air loss mattress was inflated. During interviews with CNA 3 on 8/8/13, at 9:45 a.m., and CNA 4 at 10:12 a.m., they both confirmed the heel protectors were not applied to Resident 6, based on their documentation on the nursing assistant daily flow sheet from 7/1/13 through 8/7/13. They both stated the resident's feet were always elevated on a pillow but they did not know that the resident's heels should be floated while lying in bed or sitting in the wheelchair. On 8/8/13 at 11:30 a.m., the medical record of Resident 6 was reviewed with the DON. According to the licensed nurses weekly assessment and progress notes dated 8/5/13, 11 p.m. to 7 a.m. shift, a registered nurse assessed the resident's skin as having redness on the sacral area. The DON disclosed there was no documented evidence that the change in the skin condition of the resident's right heel was assessed and reported to the physician until the Evaluator intervened on 8/6/13. A review of the skin progress report revealed that Resident 6 developed an unstageable pressure ulcer of the right heel on 4/25/13, and the pressure ulcer was documented healed on 7/30/13. A review of the physician's orders [REDACTED]. The DON stated that the treatment nurse and charge nurse were responsible to monitor the resident's skin and to implement the plan of care to prevent development and reoccurrence of a pressure ulcer for Resident 6. A review of the pressure ulcer care plan last revaluated on 6/2013, indicated to use a low air loss mattress for wound management, to monitor skin for redness, to conduct weekly body check and to report any skin changes to the physician and to apply heel protectors to both heels every shift. Additionally, a plan of care for unstageable pressure ulcer of the right heel dated 8/6/13, indicated to keep the heels off the bed for pressure relief. b. A review of the Admission and Discharge Summary of Resident 10 indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Comprehensive Resident assessment dated [DATE], the resident had a closed fluid filled blister on the left heel. A review of a care plan dated January 25, 2013, indicated Resident 10 is at risk for pressure ulcer formation due to bowel and bladder incontinence, dependence on staff for bed mobility, and [DIAGNOSES REDACTED]. The listed nursing interventions included to use pressure reducing devices, turn and reposition the resident at least every two hours, and administer treatment as ordered and monitor and record progress weekly. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated July 25, 2013, indicated Resident 10 was able to complete the brief mental status interview, sometimes understands other and able to make herself understood, and required extensive assistance with most activities of daily living. The MDS further indicated the resident is at risk for developing pressure ulcer and had two Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) pressure ulcers. According to a short term care plan dated July 30, 2013,Resident 10 has sores that reopened on her left and right buttocks. The care plan goal indicated the sore will resolve within 30 days without complications. The listed nursing interventions included to provide treatment as ordered by the physician, turn and reposition the resident every two hours, and keep areas off from pressure. The physician's orders [REDACTED]. There was another physician's orders [REDACTED]. During an observation on August 5, 2013, at 12:20 p.m., Resident 10 was observed in the dining room, sitting in a wheelchair without a seat cushion or a pressure reducing device in place. During a treatment observation on August 6, 2013, at 9:50 a.m., Treatment Nurse 2 cleansed Resident 10's irregularly shaped Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured blister) pressure ulcers on the right and left buttocks, patted the areas dry, applied triple antibiotic ointment, and covered the areas with a dry dressing. Treatment Nurse 2 was then observed cleansing the redness on the left buttock surrounding the Stage 2 pressure ulcer and applying zinc oxide and [MEDICATION NAME] on the site. However, Treatment Nurse 2 did not administer treatment on the right buttock redness surrounding the Stage 2 pressure ulcer as ordered by the physician. During an interview on August 7, 2013, at 9:30 a.m., Treatment Nurse 2 stated that she forgot to administer the treatment on the right buttock redness as ordered by the physician. On August 7, 2013, at 11 a.m. and 1:50 p.m., during an observation, Resident 10 was observed in the activity room, sitting up in a wheelchair without a seat cushion or a pressure reducing device in place. During an interview on August 8, 2013, at 10:35 a.m., Treatment Nurse 2 stated that Resident 10 has no pressure reducing device in the wheelchair. Treatment Nurse 2 further stated she will obtain an order from the physician and place one in the resident's wheelchair. The facility's policy and procedure titled "Pressure Ulcer Documentation" dated March 2009, indicated each resident having pressure ulcers shall receive necessary treatment and service to promote healing, prevent infection, and prevent new ulcers from developing. Aggressive preventative care shall be provided and included in the resident's care plan. Some of these are: turning and proper positioning, application of pressure reduction or relief devices, providing good skin care, providing clean and dry bed linens, and maintaining adequate nutrition as possible.