Every finding on record at San Bruno Skilled Nursing

Based on interviews and record reviews, the facility failed to follow transfer and discharge requirements related to transfer and discharge for 7 out of 14 residents (Residents 1, 2, 3, 4, 5, 6, and 7). This failure resulted in or had the potential to result in residents experiencing inappropriate or unsafe transfer or discharge decisions, and increased risk of unmet care needs or disruption in continuity of care.During an interview on 07/02/2026 at 10:12 AM with Family Member 1 (FM 1) of Resident 6), FM 1 stated the Social Worker (SW) informed FM 1 that Resident 6 would have to move out because the facility is no longer a long term care facility and is converting to short term care only.During an interview on 07/03/2026 at 10:55 AM with FM 2 of Resident 6, FM 2 stated the social worker informed her that FM 2 would need to find an alternative due to the facility's conversion to short term care only. FM 2 reported that the Nursing Home Administrator (NHA) directed FM 2 to contact the Institute on Aging (IOA) for assistance with transferring Resident 6.During an interview on 07/03/2026 at 12:31 PM with FM 3 of Resident 5, FM 3 stated that Resident 5 is a long term care resident and the social worker told FM 3 that Resident 5 would have to move because the facility is converting to short term care only. FM 3 stated the social worker said the transition would be complete by the end of the year and asked FM 3 to contact IOA to help transfer Resident 5. FM 3 reported the facility has been aggressive in trying to push Resident 5 out and has witnessed other residents similarly pressured. FM 3 stated communication from the facility has only been verbal, and no written notice of discharge has been received.During an interview on 07/06/2026 at 1:08 PM with FM 3 of Resident 5, FM 3 stated that FM 3 was told documents for IOA needed to be signed and was asked to provide a departure timeframe.During a concurrent interview and record review on 07/06/2026 at 1:08 PM with FM 3 of Resident 5, correspondence notes between FM 3 and the facility showed a sustained pattern of pressure from the facility regarding IOA enrollment and relocation. Documentation indicated the facility first notified FM 3 of its transition to short term care on 01/08/2026. Starting 01/09/2026, staff repeatedly urged IOA enrollment, including introducing IOA representatives on 01/15/2026 and again on 01/27/2026, when an IOA assessment was conducted without FM 3's knowledge or presence. FM 3 contacted the Ombudsman on 01/29/2026 and raised concerns with facility leadership on 01/30/2026 about assessments occurring without FM 3's involvement, noting Resident 5 cannot speak or sign documents due to cognitive impairment. Despite these objections, the SW continued approaching FM 3 and Resident 5 about IOA on 02/04/2026, 03/11/2026, 04/02/2026, 04/16/2026, and 04/24/2026. IOA staff also contacted FM 3 on multiple dates, including 04/04/2026 and 06/17/2026, and on 05/22/2026 requested a timeframe for relocating Resident 5 at the NHA's direction. Additional notes showed the NHA discussing IOA involvement on 03/31/2026 and 05/18/2026.During an interview on 07/03/2026 at 12:51 PM with resident Resident 1, Resident 1 stated Resident 1 is a long term care resident and the SW informed Resident 1 that Resident 1 would have to move due to the facility converting to short term care only. Resident 1 reported that in October 2025, SW asked Resident 1 to sign a form that Resident 1 later realized was discharge paperwork, plus a form authorizing IOA to access medical records. Resident 1 sought help from the Ombudsman. Resident 1 stated no additional paperwork has been provided. Resident 1 reported that the SW enrolled Resident 1 with IOA without Resident 1 initiating it. Resident 1 stated the SW had shown photos of alternative facilities and arranged conversations with other facilities to encourage Resident 1 to relocate. Resident 1 reported the facility has been aggressive in attempting to discharge Resident 1 and has made it clear long term care residents are no longer wanted.During an interview on 07/06/2026 at 10:25 AM with FM 4 of Resident 3, FM 4 stated Resident 3 is a long term care resident and the facility informed FM 4 that Resident 3 needed to move out because it was converting to short term care only. FM 4 reported significant pressure from the facility for Resident 3 to leave. During an interview on 07/08/2026 at 9:23 AM with FM 4 of Resident 3, FM 4 stated the facility rushed Resident 3's discharge, causing unnecessary stress. FM 4 stated the facility told FM 4 that Resident 3 had to leave because long term care residents were no longer accepted. FM 4 reported that at one point, the social worker said the social worker would personally take Resident 3 to Resident 3's parent's home. FM 4 was pressured to sign paperwork while Resident 3 was being transported out of the facility. FM 4 stated Resident 3 was discharged with wounds.During an interview on 07/06/2026 at 10:44 AM with FM 5 of Resident 4, FM 5 stated the facility originally extended Resident 4's life and that the facility later informed the family it was converting to a short term care facility. FM 5 felt the facility forced Resident 4 out.During an interview on 07/06/2026 at 11:25 AM with FM 6 of Resident 4, FM 6 stated Resident 4 was a long term care resident and the social worker informed FM 6 that Resident 4 would have to move because the facility was converting to short term care only.During an interview through email correspondence regarding Resident 4 on 07/09/2026 at 6:34 PM with FM 6, FM 6 stated that FM 6 was contacted by Outreach & Engagement Coordinator (OEC) from IOA on 02/20/2026 and FM 6 and FM 7 were not interested in enrolling Resident 4 in the IOA. After 02/20/2026, each month FM 6 received phone calls from the SW to get the family to agree to move Resident 4. FM 6 also mentioned that the NHA had told FM 6 over a phone conversation they couldn't do anything more for Resident 4 at the facility and that the nearby hospital needed the facility's space for patients that really needed their care. During an interview on 07/10/2026 at 4:25 PM with FM 8, FM 8 stated they been harassed and pressured by the facility to agree to her Resident 7's discharge, including being told that Resident 7 has to go and being threatened with a 30 day discharge notice. FM 8 stated Resident 7 requires skilled nursing care, has complex medical conditions, and needs constant care including frequent blood draws. FM 8 stated the facility repeatedly contacts FM 8 every week by phone or email urging discharge, and that staff have told FM 8 the facility is now a short term care facility. FM 8 feels the facility discriminates because Resident 7 has Medi Cal, and FM 8 believes the facility receives more money for short term Medicare residents. FM 8 stated the facility has offered incentives, including paying for one month of a caregiver, to get FM 8 to agree to discharge. FM 8 stated Resident 7 has no place to go, and fears Resident 7 will die if discharged . FM 8 added that staff tell FM 8 they are not cooperating when FM 8 refuses to agree to a discharge.The resident and family interviews consistently show that the facility pressured long term care residents and their families to relocate because the facility claimed it was converting to short term care only. Family members and residents repeatedly reported being told they had to move, being pushed to enroll with IOA, and being urged to agree to discharge even when residents required ongoing skilled nursing care. Several families described frequent calls, verbal pressure, rushed or coerced discharge processes, and IOA assessments performed without consent. Some residents were shown alternative facilities, or asked to sign discharge related paperwork. Multiple interviewees also reported aggressive tactics, inconsistent information, lack of written notices, and fear of harm if residents were forced to leave. Collectively, these accounts show a sustained pattern of inappropriate, pressured discharge efforts driven by facility preference-not resident need.During an interview with Case Worker (CW) from IOA on 07/06/2026 at 12:08 PM, a CW at IOA and CW for Resident 4, the CW stated they heard the facility is trying to discharge long term care residents and they have been kind of aggressive at trying to push long term care residents out of the facility. CW states the IOA has been receiving a high number of referrals from the facility to assist in helping long term care residents find alternative places to live. During an interview on 07/07/2026 at 1:17 PM with SW, SW stated the facility continues to accept long term care residents and that residents such as Resident 8 and Resident 6 are not stable for discharge. SW stated long term care residents are being offered IOA as an opportunity to be in the community and that these offers are options, not directives. SW stated short term residents generally already have housing, and IOA referrals are offered because there is life after this place. SW stated the administrator assists because we are a team and denied receiving any directive to discharge long term care residents, stating discharges occur only when a resident is fit to go home and agrees. SW stated they have not told residents or families they must move due to conversion to short term care, and that IOA representatives obtain signatures directly from residents or provide copies for review. SW stated they are unaware of any plan to convert to short term care and continues to ask residents if they are interested in IOA. SW stated they have offered IOA to approximately 5-6 residents, primarily as an option for placement, but could not identify short term residents who were offered IOA. SW stated they were not directed by administration to encourage IOA referrals and described their role as suggesting options while IOA obtains consent. SW stated IOA assessments are scheduled with family notification, including for residents unable to consent, and stated IOA provides authorization copies. Regarding the 01/27/2026 IOA visit for Resident 5, SW stated IOA was assessing who might benefit from services, that they introduced IOA staff to residents, and that they apologized to FM 3, stating no assessment occurred without their knowledge. SW stated signed documents are provided only upon request and that residents have expressed differing views about relocating. SW stated leadership becomes involved when families need assistance or communication support, and acknowledged showing pictures of other facilities to Resident 1 and Resident 5 as options. SW stated they are responsible for providing residents with appeal rights information.During an interview on 07/08/2026 at 12:35 PM with NHA, NHA stated the facility has not converted to a short-term only model and continues to accept long-term care residents if they have a clinical need. NHA stated residents are referred to IOA for placement only if they no longer meet skilled nursing criteria, and that no residents or families have been told they must move out due to conversion. NHA stated discharge notices are not issued unless necessary, preferring to work with families first, and that communication is often verbal or via email. NHA stated there is no quota for long-term residents, but there is an incentive to limit them for profitability. NHA stated they directed staff to refer residents to IOA, including Resident 4, Resident 1, Resident 6, and Resident 5, and that some families declined referrals. NHA stated residents have not been given timelines to leave, discharge planning begins on day one, and care conferences are held. NHA stated IOA assessments require family notification and representatives are present for residents unable to consent. NHA stated IOA handles paperwork and residents must request copies if desired. NHA stated FM 2 was asked to contact IOA for Resident 6's transfer. NHA stated compliance with discharge requirements includes proper notice, physician documentation, interdisciplinary team involvement, and identifying safe placements. NHA stated the facility follows discharge planning policies and aims to avoid patient dumping, and feels IOA helps find homes for residents who no longer need skilled nursing care.During an interview on 07/08/2026 at 2:04 PM with Director of Nursing (DON), the DON stated the facility is not transitioning to short-term care only and aims to serve the community's skilled nursing needs. DON stated there are no specific instructions for nursing staff regarding long-term residents or discharge planning, and nursing staff continue to provide care regardless of resident type. DON stated discharge planning is mainly handled by social services, with nursing focusing on care conferences and wound care. DON stated clinical justification for discharge is determined when residents no longer require skilled care, documented by physicians. DON stated they were not aware of any long-term residents being told to leave without a physician order, nor have they been instructed to inform residents or families about moving due to conversion. DON stated residents are not pressured to relocate, and nursing staff have not communicated that long-term residents are unwanted. DON stated social services provide discharge notices and help families find placements. DON stated they are not aware of residents signing discharge paperwork without understanding or receiving copies, nor have they observed repeated approaches to residents or families about IOA or relocation. DON stated social services have assisted residents in finding alternative placements and with guidance from the NHA.During an interview on 07/07/2026 at 1:17 PM with the SW, the SW stated all communications regarding Resident 1 are conducted through email, confirmed Resident 1 is a long-term care resident, and was unsure if Resident 1 had been asked to sign IOA documents. SW stated [NAME] is handling communications with Resident 1 and the Health Care Agent (HCA) for Resident 1, and that Resident 1 has toured care homes and is happy with one. SW was unsure if an IOA agreement was signed and indicated NHA is managing this process, but confirms stated the Resident 1 was asked if they were interested in IOA options. SW stated NHA is the primary contact for communicating with the family about other placement options. During a concurrent interview and record review on 07/08/2026 at 2:04 PM with the DON, Resident 1's medical record was examined. The record showed that no Notice of Proposed Transfer or Discharge had been issued. The DON confirmed there is no physician documentation indicating that Resident 1 needs to be moved because the facility cannot meet the resident's care needs, nor is there documentation showing that Resident 1's health has improved to the point that the current level of care is no longer required. The DON further confirmed that the facility is preparing to discharge the resident.During a review of admission Record for Resident 1, accessed on 07/09/2026, indicated an admission Date of [DATE] and the resident has not been discharged .During a review of the Minimum Data Set (MDS) - Version 3.0 Resident Assessment and Care Screening for Resident 1, dated 06/23/2026, the MDS indicated Resident 1 has a Brief Interview for Mental Status (BIMS) Summary Score of 14. The Brief Interview for Mental Status (BIMS) is a short test used in nursing homes to check how clearly a resident is thinking and how well the resident remembers information. A score between 13 and 15 means the resident is thinking clearly with little to no memory problems. A score between 8 and 12 shows the resident has some memory or thinking difficulties, while a score between 0 and 7 indicates more serious problems with memory or thinking.During a review of History and Physical (H&P) for Resident 1, dated 08/19/2022, the History and Physical indicated Resident 1 was transferred to the facility on [DATE] following acute hospitalization from [DATE] to [DATE] for altered mental status, sepsis, and a urinary tract infection (UTI). The H&P also indicated that Resident 1 was admitted to the facility to complete intravenous antibiotics and to receive skilled physical and occupational therapy. During a review of a Nurse Practitioner (NP), Physician Assistant (PA) and Medical Doctor (MD) Progress Notes, from 01/08/2026 to 06/09/2026, the Progress Notes indicated that Resident 1 was identified as a custodial resident. The notes did not indicate that a discharge is necessary for Resident 1's well being or that the facility is unable to meet Resident 1's care needs. In addition, the NP Progress Note dated 01/08/2026 noted that according to the SW, Resident 1 had been referred to IOA for possible placement.During a review of Medi-Cal Long-Term Care Facility admission and Discharge Notification dated 10/02/2025, the Medi-Cal Long-Term Care Facility admission and Discharge Notification indicates it was signed by Resident 1 and the SW on 10/02/2025. The document noted a reason for discharge as discharged to residence or home of another and a date of discharge as [DATE]. The document was not signed by the Resident 1's HCA.During a review of the Social Services Note dated 10/03/2025 at 3:16 PM, the Social Services Note documents a discussion the SW had with Resident 1 about the living conditions of a house. The note does not indicate why the living conditions of a house was discussed.During a review of the Social Services Note dated 10/03/2025 at 3:27 PM, the Social Services Note briefly mentions that the SW will allow the resident choose the home health services.During a review of the Social Services Note dated 10/03/2025 at 5:55 PM (noted as a late entry), the Social Services Note indicated that the SW contacted the Resident 1's HCA to inform them that the resident owed money to San Francisco County and Medi Cal for Resident 1's stay at the facility. The SW explained that the resident would need to pay more than one thousand dollars to Medi Cal to continue residing at the facility, as Medi Cal was covering the cost of his stay. The HCA asked whether the resident could remain until November 2025, and the SW clarified that an additional month would result in further Medi Cal charges. The note indicated that the HCA agreed to discharge the resident on 10/30/2025. It also stated that the SW would arrange Home Health services and In Home Supportive Services (IHSS) and had provided the resident with two Home Health agency business cards for selection.During a review of the Social Services Note dated 10/06/2025 at 1:29 PM, the Social Services Note indicated that the Ombudsman had spoken to Resident 1 and Resident 1 did not agree with the discharge on [DATE].During a review of the Social Services Note dated 10/14/2025 at 11:39 AM, the Social Services Note indicated that the Resident 1 was okay with discharging on [DATE].During a review of the Social Services Note dated 1/6/2026 at 6:32 PM, the Social Services Note indicated the SW documented that the HCA for Resident 1 agreed to IOA.The findings show the facility pursued discharge of Resident 1 without clinical justification, required notices, or proper involvement of the resident and representative. The SW and NHA focused on alternative placement and IOA enrollment despite Resident 1 being a long term care resident with no physician documentation supporting discharge, no improvement indicating a lower level of care, and no evidence the facility could not meet Resident 1's needs. Collectively, the findings demonstrate a pattern of pressured discharge planning.During an interview on 07/08/2026 at 2:04 PM with the DON, the DON stated, the reason for the Resident 2's discharge was that their condition improved.During a review of admission Record for Resident 2, accessed on 07/06/2026, indicated an admission Date of [DATE] and a discharge date of [DATE].During a review of the MDS - Version 3.0 Resident Assessment and Care Screening for Resident 2, dated [DATE], the MDS indicated Resident 2 has a BIMS Summary Score of 11. During a review of the H&P for Resident 2, dated 12/26/2024, the H&P indicated Resident 2 was transferred to the facility on [DATE] following acute hospitalization from [DATE] to [DATE] for a fall at home. The H&P also indicated that Resident 2 was admitted to the facility for skilled physical and occupational therapy.During a review of Physician Discharge Summary for Resident 2, dated [DATE], the Physician Discharge Summary indicated that the resident was discharged without a formal discharge visit from one of the facility's care providers due to late notification. It also noted that the Discharge Summary was completed for documentation purposes only. The Discharge Summary did not indicate a reason for discharge.During a review of a NP, PA, and MD Progress Notes, from 09/08/2025 to 09/29/2025, the Progress Notes did not indicate that a discharge was necessary for the Resident 2's well being or that the facility was unable to meet the resident's care needs. During a review of the Notice of Medicare Non-Coverage (NOMNC) for Resident 2, dated 09/26/2025, the NOMNC indicated Resident 2's Medicare coverage for current physical and occupational services would end on 09/30/2025. Resident 2 was informed five days before discharge on [DATE].During a review of Notice of Proposed Transfer or Discharge for Resident 2, with effective date of [DATE] at 11:01 AM, the Notice of Proposed Transfer or Discharge indicated a typed-in date of resident representative notification and verification on 10/01/2026, and an actual signature from Resident 2 dated [DATE] (a typed-in date). The Notice of Proposed Transfer or Discharge was faxed to the Ombudsman on 10/01/2026 at 12:45 PM. The Notice also included Appeal Rights and Contact Information, stating that residents have the right to appeal and were provided contact details for the Long Term Care Ombudsman, Office of Hearings and Appeals, and Developmental Disability (DD)/Mental Illness (MI) advocacy agencies. These appeal rights were not provided to Resident 2 until the discharge date of [DATE].During a review of Discharge Summary and Post-Care Instructions for Resident 2, with effective date of [DATE] at 10:49 AM, the Discharge Summary and Post-Care Instructions listed a discharge date and time of [DATE] at 11:00. It stated Resident 2 was discharged to another skilled nursing facility because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility. During a review of Change in Condition Evaluation for Resident 2, with effective date of 09/30/2025 at 9:00, the Change in Condition (COC) Evaluation indicated the resident had a functional decline that had started that morning. The COC Evaluation that the resident had demonstrated a noticeable increase in generalized weakness during activities of daily living (ADLs) compared to Resident 2's usual baseline function. The findings show Resident 2 was discharged without clinical justification and without proper notice. Although the DON stated the discharge occurred because the resident's condition improved, clinical records-including provider notes, the H&P, and the MDS-did not support that Resident 2 no longer required skilled care. A functional decline was documented the day before discharge, further contradicting the stated reason. Required discharge procedures were not followed: the physician did not complete a formal discharge visit, and appeal rights were given only on the day of discharge. Notice documents were issued too late for meaningful review or appeal. Resident 2 was discharged despite documented need for continued care.During a 07/07/2026 interview at 1:17 PM, the SW provided multiple reasons for Resident 3's discharge, including: a change in condition related to a cerebrovascular accident (stroke); the family agreeing to transfer Resident 3 to hospice; the family preferring a skilled nursing facility or hospice; limited bed availability at the facility; another facility having more bed availability; and the family being unable to care for Resident 3 at home.During an interview on 07/08/2026 at 2:04 PM with DON, DON stated, the reason for Resident 3's discharge was that Resident 3's health had improved. During a review of admission Record for Resident 3, accessed on 07/06/2026, indicated an admission Date of [DATE] and a admission date of [DATE].During a review of the MDS - Version 3.0 Resident Assessment and Care Screening for Resident 3, dated 03/03/2026, the MDS indicated Resident 3 has a BIMS Summary Score of zero. During a review of H&P for Resident 3, dated 02/13/2026, the H&P indicated Resident 3 was transferred to the facility on [DATE] following acute hospitalization from [DATE] to [DATE] for complications from brain aneurysm. The H&P also indicated that Resident 3 was admitted to the facility for skilled physical, occupational, and speech therapy along with gastrointestinal tube care. During a review of H&P for Resident 3, dated 03/04/2026), the H&P indicated Resident 3 was transferred to the facility on [DATE], following acute hospitalization from [DATE] to [DATE] for seizures. The H&P also indicated that Resident 3 was admitted to the facility for skilled physical and occupational therapy.During a review of COC Evaluation for Resident 3, with an effective date of 02/14/2026 at 3:01 PM, the COC Evaluation indicated the reason for the evaluation was a fever and a seizure that had started on 02/14/2026.During a review of COC Evaluation for Resident 3, with an effective date of 03/23/2026 at 12:15 PM, the COC Evaluation indicated the reason for the evaluation was a wound on the left heel. During a review of Notice of Proposed Transfer or Discharge for Resident 3, with effective date of 05/22/2026 at 5:02 PM , the Notice of Proposed Transfer or Discharge indicated a typed in date of resident representative notification and verification on 05/27/2026, and an actual signature from FM 4 of Resident 3 dated 06/02/2026. The Notice of Proposed Transfer or Discharge was faxed to the Ombudsman on [DATE] at 12:00 PM. Although the form lists an effective date of 05/22/2026, the resident representative did not sign until [DATE]-one day before the effective date of transfer/admission date of [DATE]. The Notice also included Appeal Rights and Contact Information, stating that residents have the right to appeal and were provided contact details for the Long Term Care Ombudsman, Office of Hearings and Appeals, and DD/MI advocacy agencies. These appeal rights were not provided to FM 4 until one day before the admission date of [DATE].During a review of Discharge Summary and Post-Care Instructions for Resident 3, with effective date of 05/22/2026 at 5:02 PM, the Discharge Summary and Post-Care Instructions listed a discharge date of [DATE], with no discharge time noted. It stated [NAME] was discharged to another skilled nursing facility because the facility could not meet the resident's needs, citing unstable medical or behavioral conditions requiring a higher level of care. Under Special Treatments, Devices, and Procedures, the form showed checked boxes for tube feeding, wound care, and Enhanced Barrier Precautions. The document was signed by FM 4 of Resident 3 on 06/02/2026.During a review of a NP, PA, and MD Progress Notes, from 04/24/2026 to 05/28/2026, the Progress Notes did not indicate that a discharge was necessary for the Resident 3's well being or that the facility was unable to meet the resident's care needs. There was no Physician Discharge Summary in the resident's medical chart.The findings show Resident 3 was discharged without meeting the regulatory criteria for transfer or discharge. Staff provided conflicting and unsupported reasons for discharge. Resident 3 had significant medical needs, including seizures, tube feeding, wound care, and a BIMS score of zero, indicating severe cognitive impairment. Provider notes did not document an inability to meet Resident 3's needs or a requirement for higher level care, and there was no physician discharge summary. Required discharge notices and appeal rights were issued only one day before the effective discharge date , preventing meaningful review or appeal. Collectively, the inconsistent explanations, lack of clinical justification, late notification, and absence of required documentation demonstrate an improper and pressured discharge.During an interview on 07/07/2026 at 1:17 PM with the SW, the SW stated Resident 4 was discharged to a care home on [DATE] so the resident could be closer to family, as requested by the sister FM 6, and that this was coordinated with IOA. SW stated Resident 4 had a stroke, was stable, and the family agreed to work with IOA and signed transfer documents.During an interview on 07/08/2026 at 12:35 PM with the NHA, the NHA stated, confirmed Resident 4 had been referred to IOA.During an interview on 07/08/2026 at 2:04 PM with DON, the DON stated Resident 4 had been discharged because his health improved and no longer needed the services provided by the facility. During a review of admission Record for Resident 4, accessed on 07/06/2026, indicated an admission Date of [DATE] and a discharge date of [DATE]. During a review of the MDS - Version 3.0 Resident Assessment and Care Screening for Resident 4, dated [DATE], the MDS indicated Resident 4 has a BIMS Summary Score of that was not completed. During a review of the MDS - Version 3.0 Resident Assessment and Care Screening for Resident 4, dated 03/18/2026, the MDS indicated Resident 4 has a BIMS Summary Score of zero.During a review of Notice of Proposed Transfer or Discharge for Resident 4, with effective date of 06/04/2026 at 5:18 PM, the Notice of Proposed Transfer or Discharge indicated a typed in date of resident representative notification and verification on 06/05/2026, and an actual signature from FM 7 dated [DATE]. The Notice of Proposed Transfer or Discharge was faxed to the Ombudsman on [DATE] at 4:22 PM. Although the form lists an effective date of 06/04/2026, the resident representative did not sign until [DATE]--three days before the effective date of transfer/discharge date of [DATE]. The Notice also included Appeal Rights and Contact Information.During a review of Discharge Summary and Post-Care Instructions for Resident 4, with effective date of 06/04/2026 at 6:18 PM, the Discharge Summary and Post-Care Instructions listed a discharge date and time of [DATE] at 11:00. It stated Resident 4 was discharged to another skilled nursing facility because the resident's health has improved sufficiently so that the resident no longer needs the services provided by the facility. During a review of all of MD Progress Notes for Resident 4, from 11/02/2025 to 02/01/2026, the MD Progress Notes do not indicate that a discharge was necessary for the Resident 4's well being or that the facility was unable to meet the resident's care needs. There was also no Physician Discharge Summary in the resident's medical chart and the MD Progress Note dated 02/01/2026 was the last MD Progress Note in the chart. During a review of Physician Order for Resident 4, dated 05/31/2026 at 5:51 PM (marked as a late entry), the Physician Order indicated occupational therapy order clarification for skilled occupational therapy two times per week for eight weeks (07/26/2026). The resident was discharged on [DATE].During a review of Physician Order Resident 4, dated 05/29/2026, the Physician Order indicated discharge to the Residential Care Facility for the Elderly (RCFE) with home health on [DATE].During a review of the Notice of Medicare Non-Coverage (NOMNC) for Resident 4, dated 06/05/2026, the NOMNC indicated his Medicare coverage for current physical and occupational services would end on 06/10/2026. Resident 4 was informed six days before discharge on [DATE].During a review of the IOA Authorization for Use and Disclosure of Protected Health Information, signed on 04/09/2026 by FM 7, the document indicates that Resident 4's protected health information (PHI) is used to determine his eligibility for the IOA, for their care management, and for their health or psychosocial assessments, and for administra

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process and ensure an orderly discharge for one of three sampled residents (Resident 1).The facility discharged Resident 1 to the emergency department solely due to exhaustion of Medicare benefits, despite no documented change in condition. The facility did not assist Resident 1 and/or their representative in applying for Medical Assistance or offered the option to pay privately to continue residing at the facility. The facility failed to provide and document adequate preparation and orientation prior to Resident 1's discharge.The deficient practice resulted in Resident 1 being transferred to an emergency department unnecessarily, without appropriate discharge planning, financial counseling, or orientation, placing the resident at risk for emotional distress and care disruption.Review of Resident 1's admission record indicated, was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation (COPD - an ongoing lung condition caused by damage to the lungs), centrilobular emphysema (a type of COPD that affects the upper lobes of the lungs, primarily caused by smoking), other abnormalities of gait and mobility, unsteadiness on feet, difficulty of swallowing, chronic kidney disease (CKD - the long-term, progressive loss of kidney function, where kidneys are damaged and unable to filter blood properly), and retention of urine.Review of Resident 1's Notice of Medicare Non-Coverage (NOMNC - a form given by the facility to all Medicare beneficiaries at least two days before the end of a Medicare covered Part A stay or when all Part B therapies ending) dated 12/2/25 indicated Medicare coverage ended on 12/6/25.Review of Resident 1's discharge care plan initiated on 11/15/25 indicated, Discharge/Transfer Planning Preference: Resident, Resident's Responsible Party/Family Members indicates preference to discharge to: [blank] . The care plan did not address the specific discharge problem(s), goals, and interventions for Resident 1. Additionally, the care plan was not revised/updated with changes in Resident 1 and/or RP's discharge preferences. Review of the Medical Practitioner Narrative Note with a service date of 12/4/25 and electronically signed on 12/7/25 indicated, .Patient was medically stabilized but not strong enough to return home . Reason for consultation is to optimize therapy, pain control and discharge planning . Discharge planning. Pending therapy progress. Will continue discussion with therapy team, family and SW (Social Worker).Review of Resident 1's physician's order dated 12/8/25 indicated, Discharge to home with home health services on 12/8/2025 with RN (Registered Nurse), PT (Physical Therapist), OT (Occupational Therapist), HHA (Home Health Aide), SW (Social Worker).Review of the physician's note titled, Discharge Summary, dated 12/5/25 indicated a discharge date of 12/7/25 for Resident 1. The physician's Discharge Summary indicated, .Limited improvements post SNF (Skilled Nursing Facility) rehab.discharge condition: stable. Discharge disposition: home . Home Health Orders and Physician Certification of Face-To-Face Encounter .12/4/25.3. Medical Necessity: My clinical findings support the need for the following skilled services: PT for skilled instruction in falls prevention, safety and mobility, therapeutic exercises .Review of the Notice of Proposed Transfer/Discharge (NOPTD) dated 12/4/25 indicated, .Effective date of discharge: [DATE].Reason for transfer/discharge: The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility . Location which resident is being transferred/discharged : To go to VA [facility location] to check benefits eligibility and assign a Social Worker to work on placement .Review of the Discharge Summary and Post-Care Instructions with an effective date 12/4/25 indicated, Resident 1 was scheduled for discharge on [DATE] 11:00 AM. The Discharge Summary and Post-Care Instructions also indicated, .Discharge Location Name and Address: To Go to VA [facility location] and check benefits eligibility and assign a Social Worker with Placement under VA Program. Mode of transportation: other - [Name of RP]-Friend.Review of the Social Service Note dated 12/5/25 indicated, .I will bring him to VA on Monday (12/8/25) and go to benefits eligibility and he will go to ER (emergency room) and the social worker will attend to him. Approved by the Admin. I arranged transport for pick up at 10:30 AM.During a concurrent interview and record review on 12/30/25 at 12:47 PM, the Director of Nursing (DON) and Assistant DON (ADON) reviewed Resident 1's clinical record for any change in condition before and on the discharge day. The record showed no significant change warranting an emergency transfer. The DON and ADON confirmed that Resident 1 was stable with no change in condition during the discharge day (12/8/25).Review of the Nurse's Note dated 12/8/25 indicated Resident 1 was discharged from the facility via [name of transportation company] at 10:50 AM. The Nurse's Note did not indicate Resident 1's discharge destination and home health information as indicated in the physician's order.Review of the Social Service Note dated 12/8/25 indicated, .I brought him to the ER (emergency room) for them to assign a social worker, a VA PCP and to check how he is doing. He has exhausted days at the SNF from [Name of previous SNF] to [SNF where resident was discharged ]. The VA Social Worker will help find a place to stay with VA programs.During an interview on 12/30/25 at 1:07 PM, the Social Worker (SW) stated that the facility's Administrator had approved of taking Resident 1 to the VA [location] on 12/8/25, to verify his benefits eligibility since his Medicare benefits were exhausted and brought Resident 1 to the emergency department so that a case manager, outpatient social worker, and a new primary care physician could be assigned to him. The SW also confirmed that Resident 1 was in stable condition with no changes when he was taken to the emergency department.During a phone interview on 12/30/25 at 5:26 PM, Resident 1's representative (RP) stated they were not informed about applying for MediCal or paying privately. The RP described the discharge as rushed and claimed nothing was prepared in advance. The RP mentioned that the SW knew Resident 1 had no place to stay since his previous apartment was demolished for new construction. However, the SW told her they couldn't keep him due to exhausted Medicare coverage. Additionally, the RP stated that the SW scheduled an appointment for Resident 1 at the VA hospital to check for benefits eligibility and that she was not present when the resident was taken to the emergency department. The RP was informed that the doctor at the emergency department said that Resident 1 was not eligible to stay or be admitted in the hospital.During a phone interview on 1/8/26 at 10:26 AM, the complainant stated that he received a call from the VA [location] that Resident 1 was discharged from a SNF to the emergency department for no apparent medical necessity. The complainant described it as patient dumping for the reason that Resident 1 was brought to the emergency department due to exhausted Medicare benefits.During a phone interview on 1/22/26 at 9:24 AM, VA staff confirmed there was no appointment for Resident 1 on 12/8/25 for benefits eligibility. VA staff stated that Resident 1, his RP, or the SNF SW can call to check veterans' benefits without needing an appointment. During further interview, VA staff stated that the SNF SW brought Resident 1 straight to the emergency department on 12/8/25 when there was nothing wrong with the resident. Furthermore, SNF SW was told by the [ED] doctor that she cannot just bring the patient in for no reason. VA staff added, It was a messy discharge. Patient ran out of 100 days Medicare and they never filed a MediCal application for him.Review of Resident 1's clinical record revealed a lack of care coordination and discharge planning discussions with the interdisciplinary team, resident, and RP before discharge. Additionally, the discharge summaries from the medical provider, social services, and nursing contained conflicting information. Review of the facility's policy and procedures titled, Transfer or Discharge, Emergency, revised 8/2018, indicated, .1. Residents will not be transferred unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot bet in the facility . 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures.b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident.Review of the facility's undated policy and procedures titled, Transfer or Discharge, revised 8/2018, indicated, .1. When the facility transfers or discharges a resident, the following information is documented in the medical record and appropriate information is communicated to the receiving health care institution or provider: a. basis for the transfer or discharge; b. That an appropriate notice was provided to the resident and/or legal representative; c. The date and time of the transfer or discharge; e. The new location of the resident .3. If the basis for the discharge is that the resident's health has improved sufficiently so that the resident no longer needs the care of the facility, the resident's physician (or provider) documents information about the resident's condition and the appropriateness of the discharge . 2. It is the policy of the facility to notify residents of a change in payment status and ensure the residents have the necessary assistance to submit any third-party paperwork . 5. If the resident continues to need long-term care services, the facility will offer the resident the ability to remain, which may include: a. offering the resident the option to remain in the facility by paying privately for a bed; b. providing the Medicaid-eligible resident with necessary assistance to apply for Medicaid coverage in accordance with S483.10(g)(13), F579, with an explanation that:(1) if denied Medicaid coverage, the resident would be responsible for payment for all days after Medicare payment ended; and (2) if found eligible, and no Medicaid bed became available in the facility or the facility participated only in Medicare (SNF only), the resident would be discharged to another facility with available Medicaid beds if the resident wants to have the stay paid by Medicaid .

Based on interview, and record review the facility failed to ensure residents were provided a private space to participate in resident council meetings (regular gatherings where residents meet to discuss concerns or suggest improvements for their living environment).This failure resulted in residents not receiving adequate privacy during their group meetings.Findings:During a group interview on 12/03/2025 at 3:00 PM with Residents (58, 24, 26, 27, 43), Resident 24 stated, Resident Council meetings are often held in a hallway due to limited private spaces within the facility. Resident 24 stated, The only space is the old dining room, but that is being used for the gym now. When asked if a private space to participate in resident council meetings was requested by the participating residents. Resident 24 stated, Yes! But they told us there was no room available. Resident's 26 and 27 also verified group meetings were held in facility hallways as well.During an interview on 12/5/2025 at 10:18 AM with the Activity Director (AD- a professional responsible for planning, organizing, and leading programming), AD stated, Sometimes we hold the resident council meeting in the hallway if the gym is busy.A small group in the corner of the hallway.During a review of several Resident Council Minutes dated 9/26/2025, 10/24/2025, and 11/28/2025, the resident council minutes indicated 22 residents attended resident council meetings with no specified location documented.During a review of the facility's policy and procedure titled, Resident Council undated, the policy and procedure indicated 3. The resident council group is provided with space, privacy, and support to conduct meetings.

Based on interview and record review the facility failed to provide adequate monitoring for antipsychotic medications (a class of psychiatric drugs that helps manage severe mental health symptoms) for two out of five sampled residents (Residents 2 and 5) and PRN (as needed) medications were ordered beyond 14 days for three out of five sampled residents (Residents 7,8,18).This failure had the potential to result in adverse consequences ranging from functional decline, hospitalization, permanent injury, or death. Findings: During a concurrent interview and record review on 12/04/2025 at 5:37 PM with Licensed Vocational Nurse 1 (LVN1), Resident 2's blood pressure values on 11/07/2025 was reviewed. The blood pressure values indicated, Resident 2's blood pressure was documented as 156/77 on 11/07/2025 at 11:51 AM, 136/83 on 11/07/2025 at 4:17PM, and 135/77 on 11/08/2025 at 02:38 AM. LVN1 verified no additional blood pressure values were documented on 11/7/2025. Review of Resident 2's Medication Administration Record (MAR) dated 11/1/2025- 11/30/2025, indicated, Orthostatic BP (blood pressure) r/t (related to) antipsychotics every day shift every Fri (Friday) laying, sitting, and standing with an order start date of 11/07/2025. LVN1 defined Orthostatic blood pressure as Take BP (blood pressure) in sitting, lying, and standing position, wait at least 5 mins in each position before taking new bp (blood pressure). It should be documented in the vitals tab, the tab that we just reviewed. LVN1 verified Resident 2's November 2025 MAR, orthostatic blood pressure values on 11/7/25, 11/14/2025, 11/21/2025, and 11/28/2025 were All same blood pressures with no documentation on time BP was taken. LVN1 stated, This is not right. I don't think she would have same BP each time. During a concurrent interview and record review on 12/04/2025 at 5:57 PM with the Assistant Director of Nursing (ADON), Resident 2's November 2025 MAR was reviewed. The MAR indicated, duplicate blood pressure readings were documented for each orthostatic blood pressure order. ADON stated side effects of antipsychotic drug use are monitored to assess orthostatic blood pressure changes and potential fall hazards. ADON and LVN1 confirmed only one blood pressure was documented per shift. ADON validated documentation does not accurately reflect orthostatic blood pressure monitoring and increases risk for Resident 2 Becoming hypotensive and falling. During a concurrent interview and record review on 12/05/2025 at 12:20 PM with ADON, Resident 7 and 8's Note to Attending Physician/Prescriber, dated 11/06/2025 were reviewed. The Note to Attending Physician/Prescriber indicated, CURRENT ORDER: Lorazepam 2 mg/mL, give 0.5 mL q (every) 4h PRN Anxiety or Agitation, missing stop date.RECCOMENDATION: Please clarify the order.1) If the order is to be continued beyond 14 days, please update to include a specific duration of use and provide clinical rationale to support use beyond the CMS 14 day limit.OR 2) add a 14 day stop to the order. ADON confirmed, Resident 7 and Resident 8 both have current Lorazepam 2 mg/mL, give 0.5 mL q4h PRN Anxiety or Agitation orders with no stop date documented. ADON was unable to locate clinical rationales to support use beyond 14-day limit. During a record review of Resident 18's, admission Record, dated 8/6/25, indicated Resident 18 was admitted to the facility 8/6/25 with a history of schizophrenia (a chronic brain disorder that disrupts how a person thinks, feels and behaves, causing them to lose touch with reality through symptoms like hallucinations (hearing/seeing things) and delusions (false beliefs), leading to disorganized thinking, difficulty with emotion and problems with focus), weakness and low blood pressure. During a review of Resident 18's, Order Summary Report, dated October 2025, November 2025 and December 2025, indicated Resident 18 was prescribed olanzapine (antipsychotic medication for the treatment of schizophrenia), oral tablet 5 milligrams, give one tablet by mouth every 24 hours as needed for agitation/psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality) which was started on 10/20/25 and did not have an end date, meaning the medication would have had a stop date for taking the medication. During a review of Resident 18's, Medication Regime Review dated 8/7/ 2025 conducted by the pharmacist indicated the medications the Resident 18 had been admitted to the facility were reviewed and no other pharmacist review had been conducted through to 12/4/2025 at the time of the survey. During concurrent interview and record review on 12/4/25 at 12:21 PM with Licensed Nurse A (LNA), Resident 18's, Order Summary Report, dated December 2025 and Resident 18's, Medication Administration Record (MAR) dated December 2025 were reviewed. Resident 18's order for Olanzapine, 5 milligrams, one tablet by mouth every 24 as needed for agitation/psychosis. was reviewed and LNA stated the medication was prescribed or started on 10/20/25 and confirmed the facility policy for as needed medications was usually for doctors to only prescribe medications for 14 days at a time and then either renew the medication or discontinue. LSA stated the reason why this medication does not have a stop date was that it was not prescribed by the usual doctors at the facility and this resident really needed the medication as it was written. The MAR was reviewed for November 2025, and it appeared that Resident 18 did not use or need the medication once that month, LSA stated she did not know anything about that, but Resident 18 had needed it in the past. LSA stated if this medication had been prescribed by the doctors at the facility, then it would have had a stop date at 14 days, so LSA stated they did not know why the medication did not have an end date. During a concurrent interview and record on 12/4/25 at 2:12 PM with Director of Nursing (DON), Resident 18's, Order Summary Report dated December 2025 was reviewed with the DON. [NAME] confirmed the olanzapine order as needed and start date of 10/20/25 and asked what the facility policy was regarding as needed medications. DON stated, as needed medication usually has a stop date of 14 days and DON stated they thought the order could be placed indefinitely if the behaviors were still in place and the resident needed the medication as ad needed bases than it would be acceptable. DON stated, as in this case, this medication does not need a stop date and can continue as needed indefinitely. During a review of the facility's policy and procedure titled, Medication Regime Review, dated 2001, indicated, 1. A licensed consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication.g. other medication errors, included related to documentation.1. Medication regimens are done upon admission (or as close to admission as possible and at lease monthly thereafter, or more frequently if indicated depending on a resident's condition.

Based upon interview and record review the facility did not provide adequate medication review for five out of five sampled residents (Residents 2,5,7,8,18) when: 1) One out of five sampled residents (Resident 18)'s as needed antipsychotic orders, did not include end dates or rationales were not addressed in the medical record. 2) One out of five sampled residents (Resident 18)'s medication profile was not reviewed monthly after admission. 3) Four out of five sampled residents (Resident 2,5,7,8 )'s recommendations made by the pharmacist were not followed up, implemented, or addressed. 4) One out of five sampled residents (Resident 5)'s is on multiple antipsychotic medications for same diagnosis of MDD. These failures had the potential to cause harm from adverse consequences related to medication therapy, due to lack of timely implementation of pharmacy recommendations. 1. During a record review of Resident 18's, admission Record, dated 8/6/25, indicated Resident 18 was admitted to the facility 8/6/25 with a history of schizophrenia (a chronic brain disorder that disrupts how a person thinks, feels and behaves, causing them to lose touch with reality through symptoms like hallucinations (hearing/seeing things) and delusions (false beliefs), leading to disorganized thinking, difficulty with emotion and problems with focus) and low blood pressure. During a review of Resident 18's, Order Summary Report, dated October 2025, November 2025 and December 2025, indicated Resident 18 was prescribed olanzapine (antipsychotic medication for the treatment of schizophrenia), oral tablet 5 milligrams, give one tablet by mouth every 24 hours as needed for agitation/psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality) which was started on 10/20/25 and did not have an end date, meaning the medication would have had a stop date for taking the medication. During concurrent interview and record review on 12/4/25 at 12:21 PM with Licensed Nurse A (LNA), Resident 18's, Order Summary Report, dated December 2025 and Resident 18's, Medication Administration Record (MAR) dated December 2025 were reviewed. Resident 18's order for Olanzapine, 5 milligrams, one tablet by mouth every 24 as needed for agitation/psychosis. was reviewed and LNA stated the medication was prescribed or started on 10/20/25 and confirmed the facility policy for as needed medications was usually for doctors to only prescribe medications for 14 days at a time and then either renew the medication or discontinue. LSA stated the reason why this medication does not have a stop date was that it was not prescribed by the usual doctors at the facility and this resident really needed the medication as it was written. The MAR was reviewed for November 2025, and it appeared that Resident 18 was not administered or need the medication once that month, LSA stated she did not know anything about that, but Resident 18 had needed it in the past. LSA stated if this medication had been prescribed by one of the doctors at the facility, then it would have had a stop date at 14 days, and so LSA stated they did not know why the medication did not have an end date. During a concurrent interview and record review on 12/4/25 at 2:12 PM with Director of Nursing (DON), Resident 18's, Order Summary Report dated December 2025 was reviewed with the DON. [NAME] confirmed the olanzapine was prescribed as needed and the start date of 10/20/25 was confirmed. DON confirmed the facility policy was regarding as needed medications was to prescribe the medication for 14 days only. DON stated in this case with Resident 18, they continued to have the same behaviors necessitating the prescribed medication so it would then be acceptable to prescribe the mediation as needed but indefinitely without a stop date. 2. During a concurrent interview and record review on 12/4/25 at 2:12 PM with DON, Resident 18's Medication Regime Review, dated 8/7/25 (conducted by the pharmacist) at the time of admission was reviewed. DON was asked if there were any other reviews by the pharmacist and DON stated no, the pharmacist reviews were done on admission and then every quarter so Resident 18 would not have been due until later that month (December). DON stated that would have been the facility policy to have the resident medication reviews done every quarter after the initial admission. DON stated in the case of Resident 18 for example, there would have been no need to review their as needed medications stop dates since the application for a stop date did not apply to this particular resident for the olanzapine medication prescription. During a review of the facility's policy and procedure titled, Medication Regime Review, dated 2001, indicated, 1. A licensed consultant pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication.g. other medication errors, included related to documentation.1. Medication regimens are done upon admission (or as close to admission as possible and at lease monthly thereafter, or more frequently if indicated depending on a resident's condition. 3. During a concurrent interview and record review on 12/05/2025 at 12:20 PM with the Assistant Director of Nursing (ADON), Resident 7 and 8's Note to Attending Physician/Prescriber, dated 11/06/2025 was reviewed. The Note to Attending Physician/Prescriber indicated, CURRENT ORDER: Lorazepam 2 mg/mL, give 0.5 mL q (every) 4h PRN Anxiety or Agitation, missing stop date.RECCOMENDATION: Please clarify the order.1) If the order is to be continued beyond 14 days, please update to include a specific duration of use and provide clinical rationale to support use beyond the CMS 14 day limit.OR 2) add a 14 day stop to the order. ADON stated, Resident 7 and 8's current orders listed above were active on Resident 7 and 8's medication administration record with no stop dated noted. ADON also confirmed no physician/ prescriber response was documented on Note to Attending Physician/Prescriber received on 11/06/2025. A concurrent interview and record review on 12/05/2025 at 12:42 PM with the Director of Nursing (DON), Resident 2's Note to Attending Physician/Prescriber, dated 11/06/2025 was reviewed. The Note to Attending Physician/Prescriber indicated CURRENT ORDER: Heparin 5,000 units BID (twice a day) for post DVT (deep vein thrombus) PPX (prophylaxis).The patient is on the above medication with no stop date indicated. RECCOMENDATION: Please consider adding a stop date to this order if clinically appropriate. DON stated, the above recommendation was provided to Resident 2's physician on 12/03/2025 and a telephone order was provided to discontinue the medication on 12/03/2025, although the pharmacist recommendation was originally made on 11/06/2025. DON stated, physician/prescriber response to pharmacist recommendations noted on the Note to Attending Physician/Prescriber should be uploaded in chart timely. DON later confirmed no attending physician/prescriber response was provided for Resident 7 and 8's recommendations. I will get it signed now. Review of Resident 5's admission Record, indicated admitted on [DATE] with diagnoses including: Pneumonia, (a lung infection), Dementia (a brain disorder that causes decline in memory and thinking), Anxiety Disorder ( a mental condition like persistent worry, fear and nervousness), Major Depression(condition with persistent sadness, hopelessness and loss of interest). During a record review, Order Summary Report, dated 10-25-12-5-25, indicated, Seroquel Oral Tablet 25 mg (Quetiapine Fumarate) give one tablet by mouth three times a day for Delusions. Target Behavior: Delusion at the end of each shift. Review of Medication Administration Record (MAR) dated 10/25/-12/4/25, indicated, Seroquel 25 mg for MDD (Major Depressive Disorder). Review of facility document, Medication Regimen Review (MRR) with Recommendation to Physician, dated 11/6/25. Indicated Seroquel 25 mg, please review for appropriate diagnosis. During an interview on 12/5/25/ at 10:53 AM with facility pharmacist, per Pharmacist, MRR review was done on 11/6/25 and he recommended to physician, to use the appropriate diagnosis for Seroquel The pharmacist next visit will be on 12/8th. Per pharmacist, if there is no response from the physician, he will re- recommend again. As of 12/5/25 during this interview the recommendation was not acted upon. During an interview on and concurrent record review on 12/5/25 at 11:30 A, with Director of Nursing (DON), per DON, the process is to leave a copy of the pharmacist recommendation for the physician, in a folder and physician will review and sign the recommendation if he agrees or disagrees. Then the page is checked by medical records and entered in EMR if there is order or any changes. Review of the medical records, no order or change in the diagnosis for Seroquel. DON confirmed. 4. Review of Resident 5's admission Record, indicated admitted on [DATE] with diagnoses including: Pneumonia, (a lung infection), Dementia (a brain disorder that causes decline in memory and thinking), anxiety disorder (a mental condition like persistent worry, fear and nervousness), Major Depression(condition with persistent sadness, hopelessness and loss of interest). Review of Order Summary Report dated 10/25-12/4/25, indicated, Clonazepam Oral Tablet 0.5 mg, give 1 tablet orally three times a day for (Major Depressive Disorder) MDD, start date 11/25/25. Mirtazapine Oral Tablet 15 MG Give 1 tablet by mouth for MDD start date 10/25/25.Paroxetine HCI Oral Tablet 40 mg Give 1 tablet by mouth one time a day for MDD. Seroquel Oral (Quetiapine Fumarate) Give 1 Tablet by mouth three times a date for MDD, start date 10/25/25. Review of facility document, Consultant Pharmacist's Medication Regimen Review, dated 10/27/2, indicated Current Orders: Clonazepam, Mirtazapine, Paroxetine and Quetiapine. Recommendation: Please enter orders in PCC to monitor target behavior and SE for the medications listed above. No indication that these four antipsychotic drugs can be given together. During an interview on 12/5/25/ at 10:53 AM with facility pharmacist, per Pharmacist, another pharmacist came on 10/27/25. Pharmacist recommendation to enter orders in the PCC to monitor target behavior.Pharmacist aware resident is on four different antidepressant /antipsychotic medications. No Notes

Based on observation, interview, and record review the facility failed maintain sanitary (hygienic and clean) durable medical equipment (medical equipment prescribed by a doctor for home use) used for the completion of activities of daily living (fundamental self-care tasks done daily) for one out of three sampled residents (Resident 2).This failure had the potential to result in the spread of disease-causing organisms due to ineffective cleaning and sanitation.Findings:During an observation 12/2/2025 at 10:06 AM, a white metal commode riser (a mobility aid attached to a standard toilet to increase its height) with affixed handrails and toilet seat was placed over the toilet in the shared bathroom of rooms [ROOM NUMBERS]. One dime sized area of chipped paint and red/brown discolorations were present on the middle of the horizontal metal back bar and multiple locations on the right posterior (back) leg post.During a concurrent interview and record review on 12/3/2025 at 11:06 AM with the Maintenance Director (Mnt), Monthly equipment checklist, dated [DATE] was reviewed. The monthly equipment checklist indicated, Resident Recliners/Chairs condition were inspected. Mnt stated, All areas on sheet are checked. It takes longer than 1 day, so we just put November.The equipment titled Recliners/Chair includes all our toilet bedside commodes and risers.During a concurrent observation and interview on 12/3/2025 at 11:18 AM with Mnt in the shared bathroom of rooms [ROOM NUMBERS], Mnt verified chipped paint and red/brown discolorations in multiple locations on the equipment. Mnt stated, That should be replaced. Yes. That is rust (a reddish- or yellowish-brown flaky coating of iron oxide that is formed on iron or steel by oxidation). I will replace it right now. When asked why the durable medical equipment should be replaced, Mnt stated Because it is not safe, it's not clean and it's not sanitary. It's not safe for the residents, before we used to paint, but now we replace them.During a review of the facility's policy and procedure titled, Annual Inspections, last revised on 11/18/2009, indicated, .Patient Care and Other Equipment.The maintenance manager is ultimately responsible for maintaining other equipment such as, but not limited to,.oxygen concentrators, scales, lifts, and the like.and proof retained that such equipment is maintained per manufactures specifications.

Number of residents sampled: 2Number of residents cited: 1Based on observation, interview and record review, the facility did not ensure, one resident, (Resident 40) of 2 residents, have his Preadmission Screening and Resident Review( PASARR) re-evaluated on the 30th day.This failure has potential for further screening and referrals for needed services will not be provided. Review of admission Record, dated, 12/5/25, indicated, admitted on [DATE], with diagnoses including: Cerebral Palsy ( a neurologic disorder caused by abnormal development or damage to the developing brain), Bipolar Disorder (a serious mental illness causing extreme mood swings), Depression (condition with persistent sadness, hopelessness and loss of interest), Autistic Disorder (a complex neurodevelopmental condition that affects communication and social interaction). Review of PASARR Level 1 Screening submitted on 10/30/25. Result: Negative.Reason: Exempted Hospital Discharge.During an interview on 12/2/25 at 3 PM, with DON, asking her who completes the PASARR. Per DON the Marketing director completes and submits the PASARR on all new admits. Asked for a copy of PASARR. During an interview on 12/3/25 at 10 AM, with Marketing Director, per MD she completes and submits PASARR for all new admits. Per MD she completed and submitted for this resident on 12/3/25, copy was provided.Review of the new level 1 Screening submitted by nursing facility, dated 12/3/25.Result: Negative Reason: Exempted Hospital DischargeLevel II Mental Health Evaluation. Referral : Not required.If the individual remains in the NF longer than 30 days, the facility must resubmit a new Level 1 Screening as a Resident Review on the 31st day.Review of California Department of Health Care Service (DHCS), Preadmission Screening and Resident Review (PASARR) Level 1 Screening Assessment Guide, dated 10/2024, indicated; Definition1: Status Change: For current SNF residents.exceed the number of days allowed for their Categorical Determination or Exempted Hospital Discharge.Review of facility's document, Tool Tip Legend, undated, indicated, 2. The Screening type Resident Review (RR) is selected for an individual who: 3) Is identified as an Exempted Hospital Discharge who exceeds a stay of thirty (30) calendar days.

Based on observation, interview, and record review the facility failed to provide services that maintained professional standards of quality for one out of three residents (Resident 8), when a certified nursing assistance administered a medication.This failure resulted in Resident 8 being administered medication by non-licensed staff that had the potential for clinically significant adverse consequences.Findings:During an interview on 12/04/2025 at 3:01 PM in Resident 8's room, with a certified nursing assistant (CNA 2), CNA 2 stated, Resident 8 has her own eye wipes due to eye buildup. CNA 2 stated, We put this on the eyes. I do not use towels. CNA 2 reached in Resident 8's top drawer in bedside cabinet and removed an individually wrapped pre- moistened packet of OCuSOFT LID SCRUB eyelid cleanser.During a phone interview on 12/05/2025 at 10:23 AM with the consulting pharmacist (PharmD), PharmD stated, due to the active ingredients in OCuSOFT LID SCRUB eyelid cleanser it is a medication that must have an active physician order, administered by a licensed nurse, and stored in a locked location.During a concurrent observation and interview on 12/05/2025 at 12:54 PM with the Assistant Director of Nursing (ADON) in Resident 8's room, a blue box containing the OCuSOFT LID SCRUB eyelid cleanser wipes were found in Resident 8's bedside cabinet. ADON stated, Yes. This I have definitely seen this in the medication cart given by nurses. I will remove, get MD order, and have LN administer it. ADON stated he was unaware of medication being administered by certified nursing assistants and it is the facility expectation that only licensed nurses administer medications.During a review of the facility's policy and procedure titled, Administering Medications, dated 04/2019, indicated, 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review the facility failed to provide the necessary services to maintain good grooming, personal, and oral hygiene for one out of three residents (Resident 8).This failure resulted in Resident 8 having difficulty opening both eyes due to white greasy build up on her bilateral (left and right) upper and lower lash line and thick white build up on the base of her lower gums and bottom row of her natural teeth.Findings:Review of Resident 8's medical records titled MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated 09/23/2025, indicated Resident 8:Had limited function range of motion and impairments on both upper and lower extremities that interfered with daily functions.Was dependent on staff for oral hygiene needs (the ability to use suitable items to clean teeth).Was dependent on staff for personal hygiene needs (the ability to maintain personal hygiene, including washing/drying face).During an observation on 12/02/2025 at 10:23 AM, Resident 8 was observed lying flat in bed with television on, placed in front of her. Resident 8 was observed having difficulty opening both eyes due to white greasy build up on bilateral upper and lower lash line and thick white build up on the base of her lower gums and bottom row of her natural teeth.During an interview on 12/02/2025 at 10:25 AM with a Certified Nursing Assistant (CNA1), when asked what were Resident 8's care needs, CNA1 stated, We keep her clean and dry. We turn her every 2 hours, so she does not get pressure sores. But sometimes she is soaking wet and we change her more often. She is nonverbal.During a concurrent observation and interview on 12/04/2025 at 3:01 PM with Certified Nursing Assistant 2 (CNA 2) in Resident 8's bedside, Resident 8 was laying in bed with white greasy buildup on outer bilateral outer corners and inner corners of eye. CNA 2 stated, Resident 8's eyes were Dirty. I will clean after I get finished with another resident. CNA 2 reported resident has own eye wipes due to eye buildup. We put this on her eyes. I do not use towels. CNA 2 opened Resident 8's top drawer in the wooden bedside chest of drawers and removed a blue plastic box that contained individually packaged pre-moistened pads, labeled OCuSOFT LID SCRUB eyelid Cleaner.During a review of Job Description: Certified Nursing Assistant, dated 02/2024, the job description indicated General Purpose- The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan.Assist residents with daily functions (dental and mouth care, bath functions, combing of hair, dressing and undressing as necessary).During a review of Resident 8's Care Plan Report initiated on 10/08/2024 was reviewed. The Care Plan Report indicated, interventions provided to Resident 8 included Assist with maintaining good personal hygiene Q (every) shift and as needed.Provide assistance with care and ADL.During a review of the facility's policy and procedure titled, Activities of Daily Living (ADL), Supporting, (undated), indicated .5. Appropriate care and services are provided for residents who are unable to carry out ADL's independently, with the consent of the resident, and in accordance with the plan of care, including.assistance with: a. hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review the facility failed to provide received individualized and ongoing activities and stimulation for one of three residents (Resident 7).This failure resulted in Resident 7 not receiving individualized activities designed to meet her interests and support psychosocial well-being.Findings:During an observation on 12/02/2025 at 09:43 AM, Resident 7 was observed lying in bed arousable (able to be easily woken up) to voice, with no music or television playing at Resident 7's bedside. On multiple subsequent observations, on 12/04/2025 at 9:23 AM, 12/04/2025 at 5:31 PM, 12/05/2025 at 10:34 AM and 10:50 AM Resident 7 was lying in bed with no individualized activities or stimulation observed.During an interview on 12/05/2025 at 10:18 AM with the Activities Director (AD- a professional responsible for planning, organizing, and leading programming), AD stated, We just go by room to room and do room visits. There is no set schedule. If they're (residents) bedbound they have the TV (television) and music should be on continuously. We play music for them (residents) because it is soothing for them. AD stated each room visit lasts approximately 10 minutes each offered 2-3 times a week.During a record review of Activity Assessment dated 12/05/2025 , the Activity assessment indicated Resident 7 likes music and it was somewhat important for Resident 7 to do her favorite activities and to do things with groups of people.During a review of the facility's policy and procedure titled Activity Programs dated 06/2018, indicated, Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident.12. Individualized and group activities are provided that: reflect the cultural and religious interests, hobbies, lie experiences and personal preferences of the residents.

Based on observation, interview and record review the facility failed identify an environmental hazard for one out of four residents (Resident 2), when the hot water temperature in a shared resident bathroom was greater than 120 degrees Fahrenheit.This failure resulted in Resident 2 having increased risk for burns caused by scalding.Findings:During an observation on 12/02/2025 at 10:07 AM in the shared resident bathroom for rooms [ROOM NUMBERS], the hot water in the resident's face bowel was recorded at 121.5 degrees Fahrenheit on a calibrated (correlated with those of a standard) thermometer. During a concurrent observation and interview on 12/03/2025 at 11:47 AM with the Maintenance Director (Mnt) and the Director of Staff Development/Infection Preventionist (DSD/IP), the hot water in the shared resident room for rooms [ROOM NUMBERS] was intolerable to touch after five minutes of continuous running of the water. The hot water was tested by Mnt with the facility calibrated thermometer, water temperature was recorded as Between 124-26 (degrees Fahrenheit) per DSD/IP and Mnt stated, Its around 125 degrees. We check the hot water every week. I will go lower the boiler now.I will check the remaining facility bathrooms to verify temps (hot water temperatures) DSD/IP stated, I will inform residents not to use the bathroom faucet until hot water is verified within safe temps (temperatures). DSD/IP confirmed Resident 2 is the only resident that utilizes the resident bathroom independently (without staff assistance).During a review of the facility's policy and procedure titled, Water Temperatures, Safety of, dated 12/2009, indicated, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents.3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log.

Number of residents sampled:2Number of residents cited:1Based on observation, interview and record review, the facility did not ensure one of two residents, (Resident 5) is receiving the correct amount of oxygen according to physician's order, when order indicates 1L/min. Resident observed to have 2 L/min for three consecutive days.This failure has potential for resident to have oxygen toxicity (lung damage that happens from breathing in too much extra supplemental oxygen. Review of Resident 5's admission Record, indicated admitted on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease (COPD)(chronic lung condition causing shortness of breath), Pneumonia, (a lung infection),Shortness of Breath, Anxiety Disorder ( a mental condition like persistent worry, fear and nervousness), Major Depression(condition with persistent sadness, hopelessness and loss of interest). Review of Order Summary Report, dated 10/25-12/5/25, indicated, Continuous oxygen via NC @1L/min Goal sat of 88%. Begin weaning from oxygen as tolerated every shift. Start date 11/5/25.Review of Medication Administration Record, dated 10/25-12/5/25, Oxygen saturation recorded every shift indicated, readings from 94 % to 97 %. No recorded weaning of oxygen done.During an observation of resident on 12/1/25 at 2 PM, resident in bed, awake, alert and responsive, on oxygen via nasal cannula at 2 L/min. Asked if she goes to activities, she said no, she does not know, and no one told her about it. asked if she knows how much oxygen they are giving her, per resident, I dont know no one tells me During an observation and interview of Resident 5 on 12/2/25 at 12 noon, resident in bed, sleeping on and off, responds to questions. Observed to be on oxygen via nasal cannula at 2 L/min. DON around the hallway, asked to confirm the oxygen level. Per DON that is a 2 L/min. Asked resident if nurses ever try to take her off oxygen as trial, resident said no, I always have this on pointing to her nasal cannula.During an observation on 12/3/25 at 9:49 AM, resident is in the room sitting up by side of the bed. Has oxygen via nasal cannula at 2L/min. Asked resident why she is on oxygen, per patient, her oxygen level was low that is why she was sent to the hospital. Will have oxygen when i go home.During a concurrent interview and record review on 12/3/25 at 11 AM, with Licensed Vocational Nurse 2, (LVN) 2, per LVN2, the resident has always been on oxygen. The order is at 1 L/min, oxygen saturation ranges from 92-97%, it is given continuously. There is an order to wean off when sat is over 90%. Per LVN, in review of her progress notes, she had weaned her off one time 12/3/25 at 9 am. Review of care plan, for oxygen use initiated 12/3/25 physician's ordered oxygen on 11/5/25. Review of facility Policy and Procedure, Oxygen Administration, undated, indicated: Purpose: The purpose of the procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration.

Based on observation, interview and record review, the facility did not ensure one out of two sampled residents (Resident 11) had adequate monitoring of their dialysis (a life sustaining medical treatment that filters waste products, excess fluid, and salt from the blood when kidneys fail, performing the kidneys job of cleaning the blood and balancing minerals) access site (a surgically created connected to the bloods stream that allows blood to be removed, cleaned by a dialysis machine); when it had been surgically changed from one site of the body to another.This failure in inadequate nursing assessment and documentation of Resident 11's current dialysis access stie had the potential for missed bleeding or other untoward side effects a dialysis resident could experience without adequate monitoring of the access site resulting in harm and even death.During a review of Resident 11's, admission Record, dated 6/19/24 indicated Resident 11 had been admitted to the facility on [DATE] with a history of diabetes and chronic kidney disease requiring dialysis treatment. During a review of Resident 1's, Order Summary Report dated December 2025, November 2025, October 2025 and September 2025, indicated Resident 11 had a physician order to Check A.V. (atrio-venous fistula, a surgically created connection between an artery and a vein, typically in the arm for hemodialysis) site to right upper chest dressing QS (every shift) leave intact for 4-6 hours following dialysis, change (dressing or bandage) if soiled or fallen off. If bleeding is noted from dialysis access site, immediately apply pressure to site to stop bleeding., also included the order for dialysis treatment to occur routinely on Tuesday, Thursday and Saturday at a specified offsite location The orders were written on 6/19/2024 and had not been discontinued when the surveyor had reviewed Resident 11's medical record on 12/3/25. During an observation and interview on 12/3/25 at 9:30 AM with Resident 11, Resident 11 was asked where the access for dialysis was located, and Resident 11 had pointed to the left upper arm bandage. Resident 11 was asked if there was anything on his chest and Resident 11 stated that there was nothing on his chest. Resident 11 was wearing a white t-shirt, and the surveyor was unable to observe anything underneath the shirt and no indication Resident 11 was unable to provide an accurate history. During a concurrent interview and medical record on 12/3/25 at 1:25 PM. with Director of Nursing (DON), DON, Resident 11's, Order Summary Report dated December 2025 and November 2025 was reviewed with the corresponding, Medication Administration Record (MAR) for December 2025 and November 2025 where the order to Check A.V. site to right upper chest dressing QS, leave intact for 4-6 hours following dialysis. was indicated for the nurses to document on the MAR each shift for each day of the month. DON stated when reviewing the physician order on the Order Summery Report for November and December 2025, that Resident 11 did not have an access sit on his right upper chest and that had been changed (surgically) in November 2025 and Resident 11's current access site for dialysis was on his left upper arm. All physicians' orders were reviewed, and no other access site physician orders were found. DON stated that it was strange, since the site had been changed back in November and Resident 11 no longer had an access site on his chest. DON was asked where the nurses would document Resident 11's access site and the MAR was reviewed for November and December 2025; where the same physician order of checking Resident 11's right upper chest order was found. The months of November 2025 and December 2025 indicated the nurses documented each day of the month that Resident 11's access site for dialysis was located on the chest compared to the current site of the left upper arm. DON stated they were aware of Resident 11's current left upper arm access site and was asked if documenting on the wrong site was a problem, DON stated it could be a problem if the nurses had no other place to document that the dialysis access site was clean, dry and intact but could not explain why the physician order had not been updated. DON was asked if there was a new nurse who did not know Resident 11 and viewed the physician orders, wouldn't they assess and document the old access site and not assess the current access site? DON stated Resident 11 would alert the nurse as to the current access site since he was very knowledgeable and would make sure the nurse assessed the correct access site. DON was asked since there was documentation that an audit was done every month to check the physician orders for accuracy for situations such as this why wasn't this update in Resident 11's current dialysis access caught, DON stated I do not know again I would have to look into this situation. During a concurrent interview and record review on 12/3/25 at 2:25 PM with Licensed Staff A (LSA), Resident 11's, Medication Administration Record (MAR) for November 2025 and December 2025 was reviewed. LSA reviewed the current date of 12/3/25 and reviewed the physician order of Check AV site to right upper chest. LSA reviewed the MAR with surveyor and stated that was the only place where the nursing would be able to document Resident 11's dialysis access site, even though LSA stated Resident 11 no longer had that as the current access site for dialysis. LSA stated as an example most dialysis days when Resident 11 was having dialysis, they would not see Resident 11 on day shift and would document not at the facility but on the days when Resident 11 was not having dialysis, then that's the only place to document that Resident 11's dialysis site was okay (not bleeding and the bandage were clean and dry). During a review of the facility's policy and procedure titled, Hemodialysis Catheters-Access and Care of dated 2001, indicated, Documentation The nurse should document in the resident's medical record every shift as follows: 1. Location of catheter (a flexible tube acting as an access point to the bloodstream for filtering waste and excess fluid). 2. Condition of dressing (bandage) (interventions if needed). 3. If dialysis was done during shift. 4. Any part of report dialysis nurse post - dialysis being given. 5. Observation post- dialysis. During a review of the facility's policy and procedure titled, Charting Documentation, dated 7/2017, indicated, 3. Documentation in the medical cord will be objective (not opinionated or speculative), completed, and accurate.

Based on observation, interview, and record review the facility failed to secure medications for one out of three residents (Resident 8) in a locked storage area and to limit access to non- authorized personnel.This failure resulted in Resident 8's medication being stored in unsecured and unsafe storage location, accessible to non-authorized personnel and other residents.Findings:During a concurrent current observation and interview on 12/04/2025 at 3:01 PM in Resident 8's room, with a certified nursing assistant (CNA2), CNA 2 reached in Resident 8's top drawer in the bedside cabinet and removed an individually wrapped pre- moistened packet of OCuSOFT LID SCRUB eyelid cleanser from a blue box.During a phone interview on 12/05/2025 at 10:23 AM with the consulting pharmacist (PharmD), PharmD stated, due to the active ingredients in OCuSOFT LID SCRUB eyelid cleanser it is a medication that must have an active physician order, administered by a licensed nurse, and stored in a locked location.During a concurrent observation and interview on 12/05/2025 at 12:54 PM with the Assistant Director of Nursing (ADON) in Resident 8's room, a blue box containing the OCuSOFT LID SCRUB eyelid cleanser wipes were found in Resident 8's bedside cabinet. ADON confirmed that all medications should be stored in medication room (storage).During a review of the facility's policy and procedure titled, Mediation Labeling and Storage (undated), indicated The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on observation, interview, and record review the facility failed to establish and implement infection prevention measures when; Enhanced barrier precautions were not implemented for one of three sampled residents (Resident 7) during high contact care. One out of four sampled residents (Resident 15), had flecks of debris and crust in their oxygen tubing (delivers supplemental oxygen from a source like a machine or oxygen tank, to a resident usually through tube through the nose also called a nasal cannula). This failure had the potential to result in Resident 7 and 15 developing a transmission based communicable disease or infection. Findings: 1. During a concurrent observation and interview on 12/04/2025 at 2:22 PM with Certified Nursing Assistant 2 (CNA 2) in Resident 7's room, Resident 7 received wound care for a stage three pressure injury (a deep wound where skin is lost, revealing the yellow, fatty tissue underneath) on her sacrum (a triangular bone in the lower back). CNA 2 stated, I'm going to get the nurse to change her (Resident 7) dressing because it is dirty. When asked how frequently wound care was provided, CNA 2 stated A lot. Whenever it is dirty. The Assistant Director of Nursing (ADON) provided wound care for Resident 7 at 2:24 PM. No enhanced barrier precautions were observed by ADON or CNA 2 during the high contact wound care for Resident 7. During a review of Resident 7's Care Plan Report, initiated on 07/22/2025, the care plan indicated interventions to Utilize Enhanced Barrier Precautions (EBP) during high-contact resident care activated were to be implemented. During a concurrent interview and record review on 12/05/2025 at 10:34 AM with a Licensed Vocational Nurse (LVN 3), LVN 3 stated, Resident 7's wound dressing is changed by the treatment nurse and floor nurses with the certified nursing assistants (CNAs). LVN 3 reviewed current wound care orders on Resident 7's medical record. When asked if enhanced barrier precautions are utilized when wound care is provided, LVN 3 stated No, she (resident 7) is not on EBP. During an interview on 12/05/2025 at 12:10 PM with ADON, ADON stated Resident 7 was not currently on EBP. ADON confirmed no EBP was utilized during Resident 7's observed wound care provided on 12/04/2025. During a concurrent interview and record review on 12/05/2025 at 12:58 PM with the Director of Staff Development/Infection Preventionist (DSD/IP), Resident 7's Care Plan Report initiated on 07/22/2025 was reviewed. The care plan indicated interventions to Utilize Enhanced Barrier Precautions (EBP) during high-contact resident care activated were to be implemented. DSD/IP stated, Yes. I see that now. EBP should be in place for infection control measures to protect the resident from infections in her (Resident 7's) wounds and for her safety. 2. During a review of Resident 15's, admission Record, dated 12/23/24, indicated Resident 15 had been admitted to the facility to the facility on [DATE] with a history of stroke (when blood flow to part of the brain is blocked or a blood vessel burst cutting off blood flow, causing brain cells to die and leading to damage) and pulmonary edema (fluid buildup in the lungs making it hard to breathe by blocking oxygen from entering the blood). During a concurrent observation and interview on 12/1/25 at 1:04 PM, with Licensed Staff A (LSA), LSA was asked to observe Resident'15 oxygen tubing. LSA observed the tubing from a machine (oxygen concentrator) going up to the pillow on the bed and then exiting through two small holes into each nostril of Resident 15's nose. LSA was asked when the oxygen tubing was usually changed, and they stated it was usually changed every day and on the night shift. The surveyor asked when it was last changed since there was no label or indication of when the tubing had been changed. LSA stated they did not know since there usually would be a label to indicate the date, time and initials of the licensed staff who provided the new tubing. LSA was asked to inspect the tubing closer since the room was dark and then noticed the brown, crusty beige area on the tubing and LSA stated the tubing looked dirty and proceeded to flick it off with their gloved fingers. LSA confirmed the oxygen tubing did not look clean, it was dirty and could cause an infection if it was not changed, since the tubing was going through Resident 15's nose. During a review of the facility's policy and procedure titled, Departmental (Respiratory Therapy)- Prevention of Infection dated 2001, indicated, 7. Change the oxygen cannula and tubing every seven (7) days or as needed.

Based on observations, interviews, and a review of records, the facility failed to ensure that one of 9 sampled residents (Resident 1) receive consistent range of motion (ROM) exercises to the left lower extremity (LLE) during the period from admission on [DATE] to hospital transfer on 07/16/2025, to prevent contractures. This failure resulted in the development of contractures in the resident's LLE.During a review of Resident 1's Physical Therapy Medicare, PT Evaluation & Plan of Treatment (PTEPT), dated 11/20/2024, the PTEPT indicated, Resident 1 did not have contractures and that Resident 1's right lower extremity (RLE) and the left lower extremity (LLE) had range of motion (ROM) that was within normal limits (WNL). During a review of Resident 1's Joint Mobility Screen (JMS), dated 01/02/2025, the JMS indicated Resident 1 had full ROM of the left and right hips, knees, and ankles. During a review of the Occupational Therapy Treatment Encounter Notes ([NAME]) dated 01/22/2025 to 03/06/2025, the documentation failed to indicate that Resident 1 participated in lower extremity ROM exercises.During a review of Occupational Therapy Treatment Encounter Note ([NAME]), dated 02/27/2025, the [NAME] indicated Resident 1 still had trouble straightening her [left] knee when standing up during transfers and while getting dressed. The therapist said a physical therapy evaluation would be recommended.During a review of Physical Therapy Medicare, PT Evaluation & Plan of Treatment (PTEPT), dated 03/06/2025, the PTEPT indicated New Goal in which Patient will increase PROM Left Knee Extension to -60 degrees in order to facilitate weight acceptance during gait with a target date of 03/20/2025. The PTEPT also indicated that Resident 1's baseline extension was -85 degrees, with a prior level of function (PLOF) of zero degrees. A normal degree of knee extension is typically considered to be zero degrees, which represents a fully straightened leg.During a review of Physical Therapy Treatment Encounter Note (PTTEN), dated 03/06/2025, PTTEN indicated that Resident 1's ability to do everyday tasks had recently gotten worse. It also said that the muscles in both of her legs were tighter than before, especially the hamstrings (the muscles at the back of the thigh). The therapist thought she might be starting to develop contractures, which means her muscles could become stuck in a bent position.During interview on 11/12/2025 at 1:50 PM with interim Director of Rehabilitation (DOR), interim DOR stated Resident 1 started to have a decrease in ROM of the left knee in March 2025, but they were not considered contractures. Interim DOR also confirmed the degree of left knee flexion had not been documented in March 2025.During interview on 11/10/2025 at 1:41 PM with Director of Nursing (DON), DON confirmed a change-of-condition (COC) evaluation for changes in lower extremity mobility in March 2025 had not been performed and documented in the medical records for Resident 1, during the period from admission on [DATE] to hospital transfer on 07/16/2025.During a review of Physical Therapy Progress Report (PTPR) for Resident 1, dated 04/22/2025, the PTPR indicated that passive range of motion (PROM) extension of the left knee was zero degrees; baseline was -85 degrees on 03/06/2025; previous was -70 degrees on 04/03/2025; and current was -60 degrees on 04/22/2025. This indicated a documentation of improvement in left knee extension between the period of 03/06/2025 to 04/22/2025. During a review of Physical Therapy Progress Report (PTPR) for Resident 1, dated 05/21/2025, the PTPR indicated that passive range of motion (PROM) extension of the left knee was zero degrees; baseline was -85 degrees on 03/06/2025; previous was -50 degrees on 05/01/2025; and current was -50 degrees on 05/21/2025. This indicated a documentation of no improvements in left knee extension between the period of 03/06/2025 to 05/21/2025. During a review of Physical Therapy Progress Report (PTPR) for Resident 1, dated 06/18/2025, the PTPR indicated that passive range of motion (PROM) extension of the left knee was zero degrees; baseline was -85 degrees on 03/06/2025; previous was -85 degrees on 05/29/2025; and current was -85 degrees on 06/18/2025. This indicated a documentation of no improvements in left knee extension between the period of 03/06/2025 to 06/18/2025.During a review of the Physical Therapy Treatment Encounter Note (PTTEN) for Resident 1, dated 06/19/2025, it was noted that the Resident 1 required assistance with transferring from the bed to a wheelchair using skilled physical therapy services. The resident needed support with hand and foot placement during the transfer. Due to a contracture in the left leg, the resident was only able to bear weight on the right leg throughout the therapy session. This was the last PTTEN documented in Resident 1's medical record.During a review of Resident 1's Care Plan Report dated 07/08/2025, it was noted that a care plan addressing Physical Therapy-focused on abnormal gait, difficulty walking, impaired dynamic balance, impaired strength, mobility deficit, and muscle weakness-was initiated on 12/02/2024 and resolved on 01/28/2025. Additionally, the report indicated that a Restorative Nursing Range of Motion (ROM) care plan, including focus, goals, and interventions, was initiated on 01/02/2025 and resolved on 08/15/2025. However, there were no documented revisions to the Restorative Nursing ROM care plan to reflect changes in Resident 1's left lower extremity (LLE) ROM observed in March 2025.During a review of Hospitalist Progress Note, dated 07/17/2025, written shortly after hospital admission into Hospital 1, indicated Resident 1 had left lower extremity (LLE) contractures. In addition, the resident was noted to have a serious wound on the left heel that was covered with dead tissue and had a bone infection. There was also a deep pressure injury on the back of the left ankle, near the Achilles tendon, and another wound on the front of the same ankle that was also covered with dead tissue. Doctors were concerned there may be gangrene on the third and fourth toes of the left foot. In addition, the resident had a mild pressure injury on the tailbone area. Blood flow was noted to be poor in both legs, especially in the left leg where one of the main arteries is blocked. The doctors at the hospital considered doing surgery to loosen the tight leg muscles in the left leg. Doctors from the foot and blood vessel teams said that because the resident had poor nutrition, a tight left leg, and poor blood flow, it would be very hard for wounds on the heel and ankle to heal after surgery.

Based on observation, intervention and record review, the facility did not ensure that re-assessment of one of two residents, Resident 1, when Resident 1 developed an ulcer of left leg, no weekly skin assessment and no MD assessment done to evaluate for healing or change of treatment. This failure has the potential for other residents to not receive necessary care Review of admission Record, dated 8/6/25, indicated, admitted on [DATE] with diagnoses including : Severe Dementia with Psychotic Disturbance, Adult Failure to Thrive, Moderate Protein - Calorie Malnutrition, Altered Mental Status. Full Code Status.Resident transferred to acute 7/16/25.During an interview with Marketing/Admission, on 8/1/25 at 12:10 PM, per Marketing, she assessed resident from Alameda Hospital, approved of her admission meeting skilled criteria. Plan is short term rehab and discharge to Assisted Living facility per daughter, as RP. Patient was skilled for 2 months and discontinued and work on discharge plan.Interview on 8/1/25 at 1:25 PM, with CNA, per CNA she worked for 2 years at facility and knows this resident. Patient's vision is not good, but she is used to my voice. Takes time to give her care, her knees are really stiff, and she needs to move slowly. Left leg and knees are very stiff. The therapist instructed me to do some stretching every day and up on wheelchair, she won't eat when in bed. She was able to spoon food to her mouth. Escorted to activities, she knows her name but does not understand what is going on. Non skin breaks, knees are elevated with pillows, heels have boots and pillows. She is a feeder; at breakfast she eats 100%. She is on Ensure drink 2 times a day, not on pureed diet. I give her a shower, she helps when given a face towel. Interview on 8/1/25 at 1:50 PM, with Social Services, per SS she knows the daughter, they are in constant update and communication with her. Daughter will request for appointment transportation and escort and requests to talk to RD and other staff. Daughter spoke to Ombudsman about conservatorship. Daughter spoke to Hospice but decision was not made to enroll to Hospice till transferred to acute.Concurrent interview and record review on 8/1/25 at 3 PM with Director of Nursing, per DON, the resident came at high risk for skin breakdown, Preventive measures were put in place. Resident is on psychotropic medication, has a neurologist managing her medication. Has telehealth consult with daughter and facility staff regarding medication changes. Resident discovered on 5/27/25 with left heel opened blister, treatment order given. We did all possible interventions to prevent ulcer. Daughter was talking to Hospice agency for possible Hospice referral, but did not make decision to enroll to Hospice.On Wound MD evaluation? Per DON, they did not refer patient to Wound MD because of the Kind of wound the patient has, that for Hospice patients that just developed, like the [NAME] Ulcer? The reason she was transferred to acute was, the ulcer was getting worst so MD decided to send her for evaluation.Review of MD progress notes dated 11/22/24, Physical Exam: Skin: No open sores, cellulitis or wounds, feet with extremely long and curled under nails, very poor hygiene.Review of facility MD progress notes dated 5/7/25, Physical Exam: Extremities: calves non tender, no edema. Skin: warm and dry. Progress notes dated 6/9/25, indicated, no recent CBC noted, order to repeat [DATE], Elevated A1c and Lipids. Physical Exam: Extremities: calves nontender, no edema. Skin: warm and dry.Progress Notes dated 7/9/25, indicated, Left leg cellulitis, treated Bactrim 6/18-6/25/25, Continue wound care, diet changed to CCHO A1C-6.3. Physical Exam: calves non-tender, no edema. Skin: warm and dry. Review of facility Admission/ readmission Evaluation/ Assessment, dated 11/14/2024, indicated Ambulation status: Ambulatory. During skin assessment, patient noted with dry scalp and no other skin issues noted.Review of nursing weekly summaries dated 5/9/25, 5/15/25 and 5/20/25., indicated no skin problem . Braden Score is 13- moderate risk for skin breakdown.Review of Registered Dietitian progress notes dated 5/12/25, indicated weight gain of 8 lbs. Current weight is 99 lbs. on 6/7/25, notes indicated weight loss of 8 lbs. in 3 weeks. Weight at 85 lbs. No mention about left heel ulcer. On 6/24/25 notes, indicated, resident is being referred to Hospice, will hold off on weekly weights for now. On 7/17/15, progress notes indicated resident gained 4 lbs. x 1 month. Continue with all interventions. No mention about left heel wound.Review of Nutritional care plan: RD has no care plan, goal and intervention for wound.Review of Skin Problem care plan: Risk at high risk for skin breakdown.interventions, air mattress, barrier cream, assist to turn and repositioned.on 5/27/25, impaired skin integrity. popped and open left heel blister, treatment as ordered, notify if signs of infection occur pad rails. on 6/18/25, resident noted to have cellulitis on left leg related to left heel opened blister.on 7/16/25 noted opened blister to left heel worsening and not healing and discoloration on left ankle. Resident transferred to ER.During an interview on 8/19/25 at 11:30 AM, with charge nurse, per charge nurse, he knows resident since admission. When patients come for admission, we try to prevent developing pressure ulcers by checking skin, CNAs to report any skin redness, turning and repositioning. For this resident, the wound on the heel was not treated as pressure ulcer, due to the wound classification, that it is related to Peripheral Artery Disease) PAD, there was a delay in referral and treatment. When wound was escalated to referral to Wound MD, the Wound MD will not evaluate the resident since no order for Hospice. The family was talking to MD and Hospice but did not make decision to enroll to Hospice till she was transferred out for worsening wounds. During an interview on 8/19/25 at 2:20 PM, with DON, per DON, weekly skin assessments are done for pressure ulcer, since her wound is the left heel popped ulcer was not considered a pressure ulcer. There is no documentation to this diagnosis but, MD diagnosed her with Cellulitis on 6/18/25 and ordered antibiotic. The nurses were monitoring the opened blister Q shift in the Treatment sheet. No wound assessment since 5/27/25. On 7/16/25 when MD saw patient had multiple open areas, on legs and on buttocks and decided to send patient to ER. Review of facility Skin Breakdown-Clinical Protocol, dated 4/18, indicated: The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers or skin breakdown.the physician will assist the staff to identify the type (for example, arterial, or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc. ) of an ulcer. Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive or poorly healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing or new wounds develop despite existing interventions. A. healing may be delayed or may to occur, or additional ulcers may occur because of other factors which cannot be modified.

Based on observation, interview, and record review, the facility failed to provide a sufficient space to accommodate group activities and communal dining for 43 residents. This failure resulted in limiting residents to participate in group activities and communal dining; caused inconvenience to residents whose rooms were in the hallway where the activities are conducted; and placed residents at risk for feelings of being isolated or depressed. Findings: The facility is licensed for 45 beds and the resident census on 6/11/24 was 43. During an observation on 6/11/24 at 9:29 AM, in the hallway between room [ROOM NUMBER] and 5, four residents were sitting on their wheelchair with one staff in front of them playing music on an iPad (a brand of a tablet computer). During an interview on 6/11/24 at 9:48 AM, Resident 32 mentioned about the noise outside his room especially when they play music or karaoke in the hallway. Resident 32 stated, a man comes every Wednesday to sing karaoke together with the residents in the hallway outside his room. Resident 32 further stated, he would close his door whenever the noise from the activities outside his room became loud. During an interview on 6/11/24 at 12:17 PM, the Activities Assistant (AA) stated, there is no designated activity room that is why group activities are conducted in the hallway. During an observation on 6/11/24 at 12:18 PM, in the hallway, Today's Activities June 11th 2024 Tuesday was posted on the wall between room [ROOM NUMBER] and 7 indicating, 9:30 daily news, 10:00 music/coffee social, 10:30 movement exercise/balloon toss, 11:30 table games, 2:00 ball toss, 2:30 word finds/puzzles. During an interview on 6/11/24 at 12:19 PM, the Activities Director (AD) stated, group activities are conducted in the hallway since there is no designated activity or dining room. The AD also stated the number of residents joining depends how many are up. The AD further stated residents in the room close to the hallway where the activities are conducted do not like the noise and would close the door to minimize the noise. During concurrent observation, two tables were in the hallway right outside a resident's room who was on transmission based precautions (are used in addition to standard precautions when the route of transmission is not completely interrupted). The AD stated the two tables were set up in the hallway for the board games. During an observation on 6/12/24 at 11:06 AM, on the patio outside the rehab room, six residents were on their wheelchairs listening and watching [person's name] sing and dance for them. During dining observation on 6/12/24 at 12:15 PM, residents were eating their meals (lunch) inside their rooms. During concurrent observation and interview on 6/12/24 at 12:16 PM, in resident's room, Resident 20 was sitting on a wheelchair at his bedside eating his meal. During concurrent interview, Resident 20 stated that he prefers to eat sitting up on a chair rather than in bed, would be nice to have a dining room. Resident 20 also stated he participates in the activities conducted in the hallway, plays bingo three times a week. Resident 20 further stated, It would be nice to have a room than the hallway. During an interview on 6/14/24 at 1:39 PM, the Administrator (ADM) stated, the designated spot for activity/dining were the therapy (rehab) room, the hallway, or outside on the patio when weather permits. Review of facility's policy and procedure titled, Activity Programs, revised August 2006, indicated, .9. Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. 43913 During an interview on 6/11/24 at 9:30 AM, with Certified Dietary Manager (CDM), per CDM all meals are served in the patient's rooms. There is no one who eats in the dining room, there is no dining room. Since pandemic, everyone eats in their own room. They did not open that room for dining , its now a rehab room. During an interview on 6/14/24 at 10:43 AM, with Administrator, per Administrator it's patient's preference, they prefer to eat in the room or in the hallway. We have a dining room set up in the patio offered to patients, but nobody wants to go. There are tables and chairs in the rehab room that we can set up for small group if they want to.

Based on observation, interview and record review, the facility did not ensure that resident's unique care instructions for one resident (Resident 12) are made private, when care instructions are posted in two places in her bedroom wall. This failure can result in exposing her medical condition to other residents and visitors. Findings: Review of Admission Record, dated, 6/18/24, indicated, admitted to SNF on 10/28/22 with diagnoses including: Parkinson's Disease(a disorder of the central nervous system that affects movement including tremors), Diabetes Mellitus(a condition when the body has trouble controlling blood sugar) Major Depressive Disorder( a mental health disorder characterized loss of interest in activities causing impairment in daily life). Review of MDS (Minimum Data Set) Section C, BIMS (Brief Interview for Mental Status) result is 8= with cognitive impairment. During an interview on 6/12/24 at 3:30 PM, with CNA 2, per CNA 2, the daughter was the one who posted it for her mother's care. Not sure if we can post it here. During an interview on 6/12/24 at 3:40PM, with DON, per DON, there is nothing wrong with that, its instructions for CNAs since we have registry working here. Maybe the name should not be there. I know its dignity and privacy. It is the family who wanted it posted. Review of care plan, not found for the posting of instructions. Review of facility's Policy and Procedure, Resident's Rights, dated 2/2021, indicated, Policy Statement, Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: a. a dignified existence; b. be treated with respect, kindness, and dignity.

Based on observation, interview, and record review, the facility failed to ensure that a resident could safely administer a medication when one out of one sampled residents (Resident 11) did not receive an assessment or education regarding the self-administration of doxycycline (an antibiotic). This failure could result in the resident inappropriately taking the medication resulting in overdose (taking beyond the safe amount of a medication), drug interactions (typically unwanted reaction between two medications that someone takes), or unrecognized side effects of the medication. Findings: A review of the facility policy and procedure titled, Self-Administration of Medications, undated, indicated that the interdisciplinary team (IDT) should assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The policy and procedure further indicated that The IDT considers the following factors when determine whether self-administration of medication is safe and appropriate . the resident can follow directions and tell time to know when to take the medication .resident comprehends the medications' purpose, proper dosage, timing, signs of side effects and when to report these to the staff. In addition, it indicated, If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. During a concurrent observation and interview on 06/12/24 at 3:16 PM with Resident 11, inside of Resident 11's room, a bottle of doxycycline labeled for Resident 11 was observed on the resident's bedside table. Resident 11 indicated that they have been taking the medication because I have a bacterial infection. During a concurrent observation and interview on 06/12/24 at 3:18 PM with Registered Nurse (RN) 1, at Resident 11's bedside, a bottle of Doxycycline labeled for Resident 11 was observed on the resident's bedside table. RN stated that Resident 11 takes medications by himself and that she is not aware of a care plan for the doxycycline at bedside. During an interview on 06/13/24 at 12:23 PM with the Case Manager (CM), the CM stated that residents who self-administer medication should have a self-mediation assessment and the medication should also be in their care plan. During a concurrent interview and record review on 06/13/24 at 4:13 PM with the Director of Nursing (DON), Resident 11's care plan for self-administration of medication, dated 10/19/23, was reviewed. The care plan indicated that the resident could self-administer five different medications. The DON stated that medications the resident was care planned to self-administer were an inhaler [handheld device used to deliver medication to lungs to help with breathing] and vitamin, triamcinolone cream [cream applied to skin to reduce redness or irritation], ketoconazole [an antifungal] . nitroglycerin [medication used to reduce chest pain]. The DON stated these were the only medications she is aware that the resident self-administers. During a concurrent interview and record review on 06/13/24 at 4:51 PM with the Assistant Director of Nursing (ADON), a nursing assessment for Resident 11 titled, NURSING - SELF-ADMINISTRATION OF MEDICATION OBSERVATION, dated 02/28/24, was reviewed. The nursing assessment indicated that a licensed staff reviewed five medications for Resident 11 to self-administer. The ADON stated that these were the same five medications in the resident's current care plan for medication self-administration. The ADON stated that he was not aware of the resident taking Doxycycline stating, not sure how he [Resident 11] got that one. The ADON further stated that his concern for a resident self-administering a medication they were not educated on is the Resident's risk for overdose. During a concurrent interview and record review on 06/14/24 at 9:25 AM with the DON, Resident 11's care plan for self-administration of medication, updated on 06/13/24, was reviewed. The care plan included doxycycline as a self-administered medication. The DON stated that care plan was updated the day prior. The DON also stated that the resident was taking the doxycycline prior to the care plan being updated. During a concurrent interview and record review on 06/14/24 at 11:11 AM with the DON, Resident 11's medication orders, dated 06/14/24, was reviewed. The medication orders did not indicate that the resident is taking doxycycline. The DON stated that since the resident is self-administering doxycycline, the medication should be there [in the list of medication order] but it is currently not.

Based on observation, interview, and record review, the facility failed to provide preventive care and treatment to avoid development of pressure injury for one of 15 sample residents (Resident 29) when: 1. The physician's treatment orders for Stage 3 pressure injury on the left ankle such as daily wound dressing change, floating both heels and keeping legs elevated at all times were not implemented; 2. There was no ongoing skin assessment to monitor the status and progress of the left ankle pressure injury; 3.a. The care plan addressing left ankle Stage 3 pressure injury/ulcer (Stage 3 pressure ulcer has full thickness tissue loss. Subcutaneous (situated under the skin) fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss) was developed on 1/29/2020, 32 days after the change of wound status was assessed on [DATE]. 3.b. The Stage 3 pressure ulcer care plan did not include person-centered wound care and treatment as indicated on the physician's order. These failures resulted in progression of left ankle skin tear to Stage 3 pressure injury for Resident 29. Findings: 1. Review of Resident 29's clinical record indicated, a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool), dated [DATE], indicated, Resident 29 required extensive assistance with two-person physical assist for bed mobility and transfers. Resident 29 was also determined to have impairment on both lower extremities and was at risk for developing pressure ulcers. Review of Resident 29's Order Summary Report, dated 2/1/20 to 2/29/20, indicated, .Float both heels on pillows at all times . Keep leg elevated at all times . left outer ankle, clean with N/S (sic) (Normal Saline - a salt and water solution) pat dry apply [MED] and TAO (Triple Antibiotic Ointment) to area cover with 4x4 secure with tape one time a day . During an observation and concurrent interview, on 2/12/20, at 10:23 AM, with Restorative Nursing Assistant 1 (RNA 1), Resident 29 was awake in bed, lying on her left side with knees bent and rubbing against each other. Resident 29 was wearing blue foam booties on both feet touching and resting on the mattress. On the resident's left outer ankle, was a pink foam dressing with 1/29/20 written on the foam. RNA 1 acknowledged Resident 29 had a wound on the left ankle and there was no pillow placed to float and elevate the feet. RNA 1 also stated, We should put pillows to elevate the feet. During a concurrent observation and interview, on 2/12/20, at 10:25 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, Resident 29 had a Stage 3 pressure ulcer. LVN 1 also explained the date on the foam dressing was the date the dressing was last changed and confirmed that the dressing was 14 days overdue to be changed. LVN 1 further stated, It should be changed every day as ordered (referring to the pink foam wound dressing) . LVN 1 acknowledged the physician's order for the daily wound dressing change was not followed. During a concurrent observation and interview, on 2/12/20, at 10:35 AM, with LVN 1, LVN 1 removed the pink foam dressing from Resident 29's left ankle. The left ankle wound had a foul smelling odor with a yellow thick and moist material sticking on the wound bed. LVN 1 stated, It smells. It's covered with slough (a layer of dead tissue, usually cream or yellow material in the wound). During an interview, on 2/12/20, at 5 PM, with the Director of Nursing (DON), DON acknowledged Resident 29's wound dressing was not changed since 1/29/20. The DON stated, The physician's treatment order should be followed, if order says daily, it should be done daily. During a review of the facility's policy and procedure titled, Prevention of Pressure Ulcers/Injuries, dated July 2017, indicated, .Risk Assessment .4. Inspect the skin on a daily basis when performing or assisting with personal care or ADL's (Activity of Daily Living). a. Identify any signs of developing pressure injuries .b. Inspect pressure points .c. Wash the skin after any episodes of incontinence .d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan . Review of the facility policy and procedure titled, Wound Care, dated October 2010, indicated, .Preparation 1. Verify 2. Review the resident's care plan to assess for any special needs of the resident . Procedure . 17. Make the resident comfortable. Use supportive devices as instructed . Review of the facility policy and procedure titled, Administering Medications indicated, .3. Medications must be administered in accordance with the orders, including any required time frame . 2. During an interview, on [DATE], at 10:53 AM, Registered Nurse 1 (RN 1) stated, on [DATE], Resident 29 had a skin tear on the left ankle. The skin tear progressed to a Stage 3 pressure ulcer after a month. During an interview, on 2/12/20, at 11:18 AM, LVN 1 stated there were two wound assessments on the record dated, 1/20/20 and [DATE]. LVN 1 stated, I don't see other assessment aside from that (1/20/20 and [DATE]). The treatment nurse was responsible for completing the wound evaluation every Monday. LVN 1 acknowledged the wound assessment evaluation was not consistently completed every week to monitor the progress of left ankle skin tear to Stage 3 pressure injury. Review of the MDS Section M (Skin Condition) dated [DATE], indicated, Resident 29 had one (1) unstageable pressure injury (Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar (tan, brown or black) in the wound bed) with suspected deep tissue injury. The MDS assessment, dated 1/18/2020, indicated, Resident 29 had one (1) Stage 3 pressure injury. Under Unstageable-Deep Tissue Injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue), it indicated 0 which meant Unstageable-Deep Tissue Injury was not present. 3.a. Review of Resident 29's Change of Condition (COC) Evaluation, dated [DATE], under Skin Status Evaluation indicated, .6a. Describe skin changes .Skin tear .Accompanied by significant pain or bleeding .Left ankle (outer) skin tear 1.5 cm (centimeter) x 1 cm) . Review of Resident 29's Weekly Wound Evaluation, dated 1/20/2020 and [DATE]20 indicated, Resident 29 had a Stage 3 pressure ulcer on the left ankle. The 1/20/20 evaluation indicated the ulcer measured 2 cm x 1.9 cm and the [DATE] indicated the ulcer measured 1.2 cm x 1.1 cm. Review of Resident 29's care plan for Stage 3 pressure ulcer, initiated on 1/29/20, under the interventions it indicated, .Assess/record/monitor wound healing q (every) week .Assess and document status of wound perimeter, wound bed, and healing progress . Review of the facility policy and procedure titled, Prevention of Pressure Ulcers/Injuries, dated July 2017, indicated, .Risk Assessment 1. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition . Review of the facility policy and procedure titled, Pressure Ulcer/Injury Risk Assessment, dated July 2017, indicated, .General Guidelines 1. The purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed and which will take time to modify .Steps in the Procedure .3. Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool. 4. Conduct a comprehensive skin assessment with every risk assessment . Review of Resident 29's Change of Condition (COC) Evaluation, dated [DATE], under Skin Status Evaluation indicated, .6a. Describe skin changes .Skin tear .Accompanied by significant pain or bleeding .Left ankle (outer) skin tear 1.5 cm (centimeter) x 1 cm) . Review of Resident 29's Weekly Wound Evaluation, dated 1/20/2020 and [DATE]20 indicated, Resident 29 had a Stage 3 pressure ulcer on the left ankle. 3.b. Review of the care plan for Resident 29 indicated, the care plan addressing Stage 3 pressure ulcer was initiated on 1/29/2020, 32 days after the change of wound status was assessed on [DATE]. There was no documented evidence a care plan was developed prior to 1/29/20. Further review of the Stage 3 pressure ulcer care plan, dated 1/29/2020, indicated the following interventions: a. Administer medications as ordered .; b. Assess/record/monitor wound healing q week. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and decline to the MD (physician); c. Educate the resident/family/caregivers as to causes of skin breakdown, including transfer/positioning requirements . d. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. e. If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team), and family .; f. Monitor nutritional status .; g. Teach resident/family the importance of changing positions .; h. Treat pain per orders prior to treatment . i. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (drainage). Review of the Order Summary Report for Resident 29, dated 2/1/20 to 2/29/20, indicated, .Float both heels on pillows at all times . Keep leg elevated at all times . left outer ankle, clean with N/S (sic) pat dry apply [MED] and TAO (Triple Antibiotic Ointment) to area cover with 4x4 secure with tape one time a day . This order was not included in the care plan dated 1/29/20. Review of the facility policy and procedure titled, Pressure Ulcer/Injury Risk Assessment, dated July 2017, indicated, .Steps in the Procedure .5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessment, the condition of the skin, the resident's overall clinical condition .a. The interventions must be based on current, recognized standards of care .c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate . Review of the facility's policy and procedure titled, Wound Care, dated October 2010, indicated, .Preparation . 2. Review the resident's care plan to assess for any special needs of the resident . Review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated December 2016, indicated, .1. The Interdisciplinary Team (IDT), in conjunction with the resident, and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan .2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .