Every finding on record at San Joaquin Nursing Center and Rehabilitation Cent

Based on interview and record review, the facility failed to implement their policy and procedure on room change for one of three sampled residents (Resident 1). This failure resulted in Resident 1's responsible party (RP - is the person designated by the resident often a family member or legal representative who agrees to certain obligations related to the resident's care and payment) to not be aware of Resident 1 being moved.Findings:During a review of Resident 1's admission RECORD (AR), dated 8/5/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of encephalopathy (a condition where your brain isn't working properly, causing confusion, memory problems, or changes in behavior), altered mental status (a noticeable change in how a person thinks, acts, or responds compared to their usual self), and Alzheimer's disease (a brain disorder that slowly destroys memory, thinking, and the ability to do everyday tasks).During a review of Resident 1's BIMS [Brief interview for mental status - a tool used to determine resident cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) status.], dated 7/27/26, the BIMS indicated, Resident 1 had a score of 11(A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment).During a concurrent interview and record review on 8/4/26 at 1:43 p.m. with admission Coordinator (AC), Resident 1's Notice of Room Change (NRC), dated 7/24/26 was reviewed. The NRC indicated, Resident 1 was moved from his room to another room in a different area of the facility. The NRC indicated Resident 1's RP was not informed of the room change. AC stated she had not been familiar with the room change process and had not informed Resident 1's RP about the room change on 7/24/26.During a review of the facility's policy and procedure (P&P) titled, Room Change/Roommate Assignment, dated 3/2021, the P&P indicated, Changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives) are given a written notice of such change.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in a sanitary manner when: 1. Sheet pans and dry storage bins were stored upside down while wet, with food debris and sticky residue adhered to their surfaces. 2. A dirty dining cart was stored in the walk-in refrigerator, not cleaned and disinfected. 3. Label on a container used to store garlic bread in the walk-in refrigerator had the wrong use-by date. 4. A (Brand) floor mixer had black residue buildup underneath the splash guard and splashes of light brown residue in mixing bowl. 5. A commercial can opener had black residue buildup on the cutting blade. 6. A meal slip (paper ticket that goes onto residents' food tray to ensure the correct food is served based on their needs and preferences) fell and the corner of the slip touched the edge of the gravy pan. 7. Fruit salad was left at room temperature for 37 minutes, then returned to its original container and refrigerated. The temperature of the fruit salad was 43 degrees Fahrenheit (43 F). These failures posed the risk of foodborne illness in a medically fragile resident population of 88 facility residents who received food prepared in the kitchen. Findings: 1. During a concurrent observation and interview on 3/9/2026 at 2 p.m. with the Dietary Director (DD), in the kitchen, 14 sheet pans of various sizes were stacked and stored upside down. The pans had large water stains and were stored wet. Food debris and/or sticky residue were observed on five of the 14 sheet pans that were stored for use. The DD confirmed the pans were wet and unclean. The DD stated the pans needed to be rewashed due to the risk for bacteria [germs] growth. During a concurrent observation and interview on 3/9/2026 at 2:45 p.m. with the DD, in the kitchen, plastic storage bins were stacked and stored upside down. Nine bins had residual moisture inside the bins, two bins had black speckles and sticky residue adhered to their surfaces. The DD stated the bins needed to be rewashed and fully air dried before storage. The DD stated the moisture could foster bacterial growth and residents can get sick. During a review of the P&P titled Sanitization dated 11/2022, the P&P indicated, . All utensils, counters, shelves and equipment are kept clean .All equipment, food contact surfaces and utensils are cleaned and sanitized . food preparation equipment and utensils that are manually washed are allowed to air dry . 2. During a concurrent observation and interview on 3/9/2026 at 2:15 p.m. with the DD and Certified Dietary Manager (CDM), in the walk-in refrigerator, a food cart was sticky and had dust and food particles on its surface. The DD confirmed the cart was not clean and stated staff should have wiped down the cart before storing it in the walk-in refrigerator. The DD stated it was not sanitary to store dirty food carts in the walk-in refrigerator next to food items. During a review of the P&P titled Food Receiving and Storage dated 11/2022, the P&P indicated, . Foods shall be received and stored in a manner that complies with safe food handling practices . During a review of the P&P titled Sanitization dated 11/2022, the P&P indicated, . All utensils, counters, shelves and equipment are kept clean . 3. During a concurrent observation and interview on 3/9/2026 at 2:15 p.m. with the DD and CDM, in the walk-in refrigerator, one plastic bin containing slices of bread was labeled Garlic Bread .Prepared date 2/26/2026 .Use by 6/26/2026. The CDM pulled the bread off the shelf and stated bread was stored in the walk-in refrigerator for up to three months. The CDM stated the incorrect use-by date could result in the bread being used past expiration. During a review of the P&P titled Food Receiving and Storage dated 11/2022, the P&P indicated, . Foods shall be received and stored in a manner that complies with safe food handling practices . refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded . During review of a facility document titled Dry Food Storage Guidelines undated, the document indicated, .Bread .Unopened on Shelf .5-7 days .Opened on Shelf .5-7 days .Opened Refrigerated .3 months, frozen . 4. During a concurrent observation and interview on 3/9/2026 at 2:18 p.m. with the DD and CDM, in the kitchen, one large food mixer the CDM referred to as [Brand] floor mixer had thick black residue at the attachment hub where the splash guard set. The mixing bowl had light brown food residue adhered to the inside of metal bowel. The DD confirmed the mixer was not thoroughly cleaned and stated staff did not remove the splash guard as part of staff's daily routine cleaning. During a review of the P&P titled Sanitization dated 11/2022, the P&P indicated, .When cleaning fixed equipment (e.g., mixers .the removable parts are . Washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air dried and sprayed with a sanitizing solution (at the effective concentration) . 5. During a concurrent observation and interview on 3/9/2026 at 2:35 p.m. with the DD, in the kitchen, the commercial can opener's cutting blade had thick black buildup adhered to it. The DD stated the condition of the can opener was unclean and had the potential to contaminate food items opened by the can opener. During a review of the P&P titled Sanitization dated 11/2022, the P&P indicated, . All equipment, food contact surfaces and utensils are cleaned and sanitized . 6. During an observation on 3/10/2026 at 11:55 a.m. in the kitchen, the DC plated hot foods held on the steam table during tray line (a fast-paced assembly line used to prepare resident food). The DC dropped a meal slip, and the corner of the slip contacted the edge of the gravy pan. The DC immediately removed the meal slip from the side of the gravy pan, then continued to plate the gravy. During an interview on 3/10/2026 at 12:45 p.m. with the DD, the DD stated the DC should have discarded the gravy after the meal slip fell near the gravy pan. The DD stated it was unsanitary and potentially posed a risk to the residents. During a review of the P&P titled Food Preparation and Service dated 11/2022, the P&P indicated, . Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices . appropriate measures are used to prevent cross contamination [transfer of germs from on surface, food, or person to another] . 7. During an observation on 3/10/2026 at 12:03 p.m. in the kitchen, Dietary Aid (DA) 1, removed fruit salad from the refrigerator. During a concurrent observation and interview on 3/10/2026 at 12:29 p.m. with DA 1, in the kitchen, DA 1 used a 1/3 cup scoop to plate the fruit salad into small bowls in preparation for dinner service. DA 1 plated eight bowls then rechecked the menu. DA 1 stopped plating the fruit salad and stated he used the incorrect scoop size. Eight bowls of fruit salad and original container were left on the preparation table. During an observation on 3/10/2026 at 12:40 p.m. in the kitchen, with the DD, DA 1 returned the fruit salad plated earlier to the original container. DA 1 took the fruit salad's temperature which registered at 43 F. DA 1 covered the container with foil and placed it back into the refrigerator. During an interview on 3/10/2026 at 12:45 p.m. with the DD, the DD stated the fruit salad sat out for too long and came up to temperature, therefore should not be refrigerated again. The DD stated there was a risk for bacteria to grow and the fruit salad and was discarded for resident safety. During a review of the P&P titled Food Preparation and Service dated 11/2022, the P&P indicated, . Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices . the danger zone for food temperature is above 41 Fahrenheit and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms [germs] that cause foodborne illness . the longer foods remain in the danger zone the greater the risk for growth of harmful pathogens [germs]. Therefore, PHF [potentially hazardous foods]must be maintained at or below 41 F or at above 135 degrees Fahrenheit . During a review of the P&P titled Food receiving and Storage dated 11/2022, the P&P indicated, . Foods shall be received and stored in a manner that complies with safe food handling practices . PHF/TCS [temperature control for safety- must be kept out of the 41 F to 135 F danger zone] foods are stored at or below 41 F, unless otherwise specified by law .

Based on observation, interview, and record review, the facility failed to follow infection control practices for two unsampled residents (Residents 22 and 128) when: 1.CNA (Certified Nursing Assistant) 1 did not perform hand hygiene and wore a gown while providing care to Resident 22 who was on Enhanced Barrier Precautions (EBP, infection control intervention designed to reduce the spread of multidrug-resistant organism, MDROs - a germ that is resistant to many antibiotics). 2.CNA 1 did not perform hand hygiene before and after repositioning Resident 128. 3. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene in accordance with facility policy and procedure and infection prevention and control guidelines for Clostridioides Difficile (C. difficile- contagious bacteria that causes diarrhea and inflammation of the colon). 4. LVN 1 used a medication tray in Resident 66's room who was on transmission-based precautions (a measure used to prevent the spread of a suspected or known infection) for C. difficile, then reused the tray without disinfecting it in Resident 121's room who was on enhanced barrier precautions (EBP- an infection control intervention to reduce the spread of germs). These failures placed residents at risk for cross contamination and infection and could result in health-related disease. Findings:Findings: 1.During a review of Resident 22's admission Record (AR), dated 3/12/2026, the AR indicated Resident 22 was admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). During an observation on 3/11/2026 at 2:59 p.m., outside of Resident 22's room, an EBP sign was posted next to Resident 22's name. The EBP sign indicated, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities . Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting . Further observation indicated CNA 1 went inside Resident 22's room without performing hand hygiene, grabbed and wore new pair of gloves, and proceeded with changing Resident 22's brief and bed sheets. CNA 1's clothes touched Resident 22's bed sheets. CNA 1 placed the dirty bed sheets into a dirty linen containers outside Resident 22's room. CNA 1 removed her and did not perform hand hygiene. During an interview on 3/11/2026 at 3:13 p.m. with CNA 1, outside the Resident 22's room, CNA 1 stated she did not wear any gown and wearing gloves was enough. CNA 1 stated she should had worn gloves and gowns when changing linen and providing hygiene to EBP residents to protect residents from infection. During interviews on 3/11/2026 at 4:20 p.m. and on 3/12/2026 at 2 p.m. with the Infection Preventionist (IP), the IP stated, Gown and gloves had to be worn during changing adult brief and bed sheets in EBP residents to prevent the spread of MDRO . It was imperative to practice hand hygiene before, after and in between caring ofr any resident. It is the most important thing to prevent transmittal of disease. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated February 2025, the P&P indicated, . Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the trasmission of multi-drug resistant organisms (MDROs) to residents . Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing . d. providing hygiene; e. changing linens; f. changing briefs . During a review of facility's P&P titled, Handwashing/Hand Hygiene, dated October 2023, the P&P indicated, . Hand hygiene is indicated: a. immediately before touching a resident . d. after touching a resident . 2. During an observation on 3/11/2026 at 3:14 p.m. inside of Resident 128's room, CNA 1 observed not performing any hand hygiene before and after repositioning Resident 128's legs. During an interview on 3/11/2026 at 3:16 p.m. with CNA 1, outside Resident 128's room, CNA 1 stated she was not doing hand hygiene before and after Resident 128's care. During a review of Resident 128's admission Record (AR), dated 3/12/2026, the AR indicated Resident 128 was admitted to the facility on [DATE] with a diagnosis of muscle wasting (the loss of muscle tissue, causing muscles to shrink and weaken). During an interview on 3/12/2026 at 2 PM with the IP, the IP stated, It is imperative to practice hand hygiene before, after and in between caring for any resident. It is the most important thing to prevent transmittal of disease. During a review of facility's P&P titled, Handwashing/Hand Hygiene, dated October 2023, the P&P indicated, . Hand hygiene is indicated: a. immediately before touching a resident . d. after touching a resident . 3. During an interview on 3/9/2026 at 4:25 p.m. with LVN 1, LVN 1 stated Resident 66 was on transmission-based precautions for C. difficile. During an observation on 3/9/2026 at 4:33 p.m. LVN 1 donned (put on) PPE and entered Resident 66's room to check his blood sugar. LVN 1 completed her task and removed her PPE. LVN 1 performed hand hygiene using alcohol- based hand rub (ABHR) placed outside Resident 66's room. During an interview on 3/9/2026 at 4:40 p.m. with LVN 1, LVN 1 acknowledged she did not wash her hands after care to Resident 66 was provided. LVN 1 stated facility policy required staff to wash hands with soap and water after staff cared for residents infected with C. difficile to prevent C. difficile from spreading. LVN 1 stated she should have washed her hands with soap and water immediately after she exited Resident 66's room. During an interview on 3/12/2026 at 3:15 p.m. with the Infection Preventionist (IP), the IP stated LVN 1 did not perform proper hand hygiene during the provision of care to Resident 66. The IP stated C. difficile was a contagious infection and washing hands with soap and water was the most effective way to prevent the transmission (spread) of C. difficile. The IP stated LVN 1 did not follow policy and procedure for proper hand hygiene and C. difficile. During a review of the facility policy and procedure (P&P) titled Handwashing/ Hand Hygiene dated 10/2023, the P&P indicated, .The facility considers Hand hygiene the primary means to prevent the spread of healthcare associated infections .all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors .hand hygiene is indicated .immediately after glove removal .Wash hands with soap and water .after contact with the resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile . During a review of the facility's P&P titled Clostridioides (Clostridium) Difficile dated 12/2024, the P&P indicated, .The primary reservoirs for C. difficile are infected people and surfaces .when caring for residents with CDI [C. difficile infection], staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR for the mechanical removal of C. difficile spores [bacteria cell with hard wall that can reproduce under harsh conditions] from hands . 4. During an interview on 3/9/2026 at 4:25 p.m. with LVN 1, LVN 1 stated Resident 66 was on transmission-based precautions for C. difficile. During an observation on 3/9/2026 at 4:36 p.m. outside Resident 66's room, LVN 1 exited the room holding a blue medication tray and placed the tray on a personal protective equipment (PPE) cart. LVN 1 did not disinfect the tray. LVN 1 then placed the contaminated medication tray on her medication cart. During an observation on 3/9/2026 at 4:38 p.m. in Resident 121's room, LVN 1 donned PPE and placed the contaminated medication tray on Resident 121's bedside table upon entrance to the room. Signage posted next to Resident 121's name indicated Resident 121 was on EBP. During an interview on 3/9/2026 at 4:40 p.m. with LVN 1, LVN 1 stated Resident 121 was placed on EBP because Resident 121 had a peripherally inserted central catheter (PICC- a tube inserted into a major vein above the heart) and wounds. LVN 1 acknowledged she did not disinfect the medication tray. LVN 1 stated I should have disinfected it to prevent cross-contamination (transfer of germs from one surface to another) of both carts (PPE and medication) and Resident 121's bedside table with C. difficile. During an interview on 3/12/2026 at 12:30 p.m. with the Director of Nursing (DON), the DON stated LVN 1 potentially spread C. difficile by cross contaminating multiple surfaces with the medication tray. The DON stated LVN 1 failed to follow infection control guidelines for C. difficile. During an interview on 3/12/2026 at 3:15 p.m. with the IP, the IP confirmed LVN 1's actions potentially caused the cross contamination of C. difficile and placed Resident 121 at risk for C. difficile infection. During a review of the facility's P&P titled Clostridioides (Clostridium) Difficile dated 12/2024, the P&P indicated, . Residents considered at high risk of developing symptoms associated with C difficile include .serious underlying illness . antibiotic [medicine to treat infections] .the primary reservoirs for C difficile are infected people and surfaces .Steps toward prevention and early intervention include .disinfection of items with potential fecal soiling . During a review of the facility's P&P titled Enhanced Barrier Precautions dated 2/2025, the P&P indicated, . Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention .for residents with wounds and/ or indwelling medical devices . indwelling medical devices include central lines [catheter] .

Based on observation, interview, and record review, the facility failed to maintain professional standards for three of 18 sampled residents (Resident 1, 106 and 121) and two unsampled residents (Resident 70 and 118) when: 1.Registered Nurse (RN) 1 did not verify identity before giving intravenous medication (IV, medication administered directly into the vein), did not label IV medication and tubing to Resident 121. This failure had the potential to cause harm to the resident.2.Peripherally inserted central catheter (PICC line, a long, thin flexible tube inserted into upper arm's vein and guided into a large vein above the heart, to administer medication) dressing was not changed for Resident 121. This failure had the potential to cause harm to the residents. 3.Resident 70's Medication Administration Record (MAR) was signed by LVN 5 without the medication being given. This failure placed Resident 70 at risk for seizures. 4. Resident 106 received the necessary respiratory (the process of breathing) care (respiratory treatment/ therapy, oxygen therapy) and services with a current physician's order. This placed Resident 106 at risk for being given too low or too high oxygen which could lead to respiratory failure. 5. Oxygen tubing was not labeled for Resident 118. This failure had the potential to result in the use of outdated or contaminated tubing, and negative health outcomes for Resident 118.6. Measurements for the peripherally inserted catheter (PICC line- a flexible tube inserted into a large vein near the heart ) were not done for Resident 121. This failure had the potential to result in the inability to properly monitor PICC line placement and compromised the safe administration of intravenous (IV- in a vein) therapy. 7. A Registered Nurse (RN) did not assess Resident 1 during Resident 1's stay at the facility from 1/21/2026 through 3/10/2026. This failure had the potential to result in inaccurate or incomplete assessments of Resident 1's condition and lead to inappropriate care planning services and treatments. Findings: 1.During a review of Resident 121's admission Record (AR), dated 3/12/2026, the AR indicated, Resident 121 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy (a condition where many nerves outside the brain and spinal cord are damaged), local infection of the skin and acute osteomyelitis (bone infection). During an observation on 3/10/2026 at 7:55 a.m. in Resident 121's room, RN 1 was observed walking into Resident 121's room, cleaning Resident 121's PICC line, connecting the IV tubing to the PICC line, and hanging IV medication. The IV medication and the IV tubing did not have any label. During an interview on 3/10/2026 at 8:07 a.m. outside Resident 121's room, RN 1 stated she did not identify the right patient and the right medication. RN 1 further stated she administered the IV medication without the resident's label (pharmacy label) and she did not label the IV tubing. RN 1 stated it was wrong practice because labeling and checking the identifier was expected to ensure medication was administered to the right patient at the right time and to communicate with other staff when IV tubing needed to be changed. During an interview on 3/12/2026 at 2:30 p.m. with the Director of Nursing (DON), DON stated the expectation was for all IV medications to be verified prior to administration by checking residents' pictures that were attached to their electronic medical records. DON further stated all IV medications and tubings were expected to be labeled. DON stated these practices were expected as a professional standard of practice to ensure six medication rights and prevent medication errors. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, the P&P indicated, . The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: . checking photograph attached to medical record . During a review of the facility's P&P titled, Intravenous Therapy, [undated], the P&P indicated, . All IV tubing is to be labeled with date, time and initials. 2.During a review of Resident 121's admission Record (AR), dated 3/12/2026, the AR indicated, Resident 121 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy (a condition where many nerves outside the brain and spinal cord are damaged), local infection of the skin and acute osteomyelitis (bone infection). During a concurrent observation and interview on 3/10/2026 at 9:20 a.m. with RN 1 in Resident 121's room, Resident 121's PICC line dressing was dated 2/23/26. Changed 3/1/26. The PICC line dressing was not changed in nine days. RN 1 stated it must had been overlooked and it was important to change the dressing every 7 days and as needed because it followed MD order and facility's policy and procedure (P&P) to prevent infection. During an interview on 3/12/2026 at 2:30 p.m. with the Director of Nursing (DON), DON stated the expectation was for all PICC line dressing to be changed every 7 days or as needed to prevent infection. During a review of the facility's P&P titled, Central Venous Catheter Dressing Change, [undated], the P&P indicated, . Change transparent semi-permeable membrane (TSM) dressing at least every 5-7 days and PRN (when wet, soiled, or not intact) . 3. During a concurrent observation, interview and record review on 3/11/2026 at 2:42 p.m. with Licensed Vocational Nurse (LVN) 4 in the B-Wing Hallway, there was a medication cart with a locked drawer and on top of it was a Controlled Drug Record binder. Scheduled medications (medications with high potential for abuse and/or addiction) and antibiotics bubble packs (a form of tamper -evident packaging where an individual pushes individual sealed tablets though the foil to take the medication) were inside. There was a bubble pack for Lacosamide with 9 tablets taken. The pharmacy label indicated one tablet to be taken twice a day (9am and 9pm). The record for Lacosamide was reviewed. The record indicated nine signatures for March 6th at 2100 (9pm, 2nd dose for the day) to March 11th at 2100. Only one dose was given on 3/8/2026 at 2100. LVN 4 stated the 9am dose for Lacosamide for Resident 70 was not given. Resident 70's MAR was reviewed. The MAR indicated on 3/8/2026, the Lacosamide was given to Resident 70 at 0900 (9am) and 2100. The 9am schedule was signed by LVN 5 but the medication was not given. During a concurrent interview and record review on 3/12/2026 at 9:05 a.m. with LVN 5, Resident 70's MAR was reviewed. The MAR indicated the 9am and 9pm doses on 3/8/2026 were given. LVN 5 stated the 9am dose of the Lacosamide was not given to Resident 70. LVN 5 stated, Only 1 was given. I do not remember why I did not get to give the medication and I signed it. LVN 5 stated the medication (Lacosamide) should have been given then the MAR signed. LVN 5 stated the MAR should reflect what was actually given to the resident to be able to monitor the effect of the medication and patient's safety. During an interview on 3/12/2026 at 2:29 p.m. with the Director of Nursing (DON), the DON stated the LVN should not have signed the MAR if the medication was not given to Resident 70. The DON stated the MAR should accurately reflect if the Resident 70 received or refused his medication for resident safety. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed . 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving the medication . 4. During a concurrent observation and interview on 3/9/2026 at 2:10 pm. with Resident 106 in her room, Resident 106 was lying in bed with head elevated. Resident 106 had a nasal cannula (NC) connected to an oxygen concentrator (a medical device that pulls ambient air and delivers pure oxygen) @ 4L/min (Liters per minute – unit of measure). Resident 106 stated she had been on oxygen therapy due to shortness of breath. During a concurrent observation and interview on 3/9/2026 at 3:45 pm. with Restorative Nursing Assistant (RNA) in Resident 106's room, RNA checked Resident 106's oxygen concentrator. RNA stated, It's [oxygen flow rate] at 4L/min. RNA stated Resident 106 had been on oxygen for some time. During a concurrent observation, interview and record review on 3/11/2026 at 2:57 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 106's room. Resident 106 had oxygen via nasal cannula. LVN 2 stated, It's at 3L/min. Resident 106's Physician's Orders was reviewed. LVN 2 stated there was no order for oxygen therapy. LVN 2 stated there should have been an order since Resident 106 had been on oxygen for a long time. LVN 2 stated, Without any orders we should not be giving anything [medication/treatment]. LVN 2 stated the physician order was needed to let staff know how much oxygen was safe to give to the resident. During an interview on 3/12/2026 at 2:35 p.m. with the Director on Nursing (DON), the DON stated there should have been an order for oxygen therapy for Resident 106. DON stated, So that we give the O2 [oxygen] rate as prescribed by the doctor, provide the proper care. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, the P&P indicated, Verify that there is a physician's order . 5. During an observation on 3/9/2026 at 3:15 p.m. in Resident 118's room, Resident 118 was connected to an oxygen concentrator (a medical device that supplies oxygen). The tubing and humidifier (medical device to add moisture) used for the supplemental oxygen were not labeled with the date and time. During a concurrent observation and interview on 3/9/2026 at 3:19 p.m. with MDS Coordinator (MDSC), in Resident 118's room, the MDSC inspected the humidifier device and oxygen tubing and confirmed the tubing and humidifier were not labeled. The MDSC stated Resident 118 was admitted to the facility yesterday and a label should have been affixed to the tubing upon admission. The MDSC stated facility process was to change oxygen tubing and humidifier weekly and as needed. During an interview on 3/12/2026 at 12:31 p.m. with the Director of Nursing (DON), the DON stated oxygen tubing and humidifier should be labeled with the date and time to ensure the tubing and humidifier were changed every seven days. The DON stated that weekly changes were necessary to prevent respiratory complications. The DON confirmed the facility's policy and procedure (P&P) titled Oxygen Administration did not address the labeling of tubing; however facility practice was to label tubing with date and time and Resident 118's tubing should have been labeled. 6. During a concurrent observation and interview on 3/9/2026 at 3:32 p.m. in Resident 121's room, Resident 121 stated he was recently admitted to the facility for wounds and pointed to a vascular access device (tube inserted in a vein) inserted into his right upper arm. During review of Resident 121's admission Record (AR- a document that contains essential information about a resident), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of infection following a procedure. During review of Resident 121's Admission/ readmission Evaluation/Assessment (AA) dated 3/1/2026, the AA indicated Resident 121's vascular access device was a PICC line to the right upper arm that was free of redness or drainage (fluid oozing). The AA did not indicate PICC line measurements or when the transparent dressing was last changed. During review of Resident 121's IV Administration Record (IVR) dated 3/1/2026 through 3/31/2026, the IVR indicated Resident 121's PICC line dressing was changed and catheter length measured on 3/3/2026 and 3/10/2026. During a concurrent interview and record review on 3/12/2026 at 12:03 p.m. with the DON, the DON reviewed Resident 121's medical record for the PICC line measurements. The DON stated that the record indicated Resident 121's PICC line dressing was changed on 3/3/2026 and 3/10/2026. The DON stated the record did not indicate the catheter's length was measured on 3/10/2026. During an interview on 3/12/2026 at 12:20 p.m. with Registered Nurse (RN) 1, RN 1 stated she changed Resident 121's PICC line dressing on 3/10/2026 but forgot to document the catheter's measurements. RN 1 validated it was important to document PICC line measurements to ensure the PICC line was working properly and Resident 121 was tolerating IV medications. During a review of Resident 121's Order Summary Report (OSR) dated 3/2/2026, the OSR indicated, PICC (all types) Measure catheter length with each dressing change. 7. During review of Resident 1's admission Record (AR- a document that contains essential information about a resident), undated, the AR indicated Resident 1 was admitted to the facility on [DATE]. During review of Resident 1's History and Physical (HP- a comprehensive document that records medical history and detailed physical examination) dated 1/22/2026, the HP indicated, .medical history significant for hypertension [high blood pressure], aortic stenosis [stiff heart valve-right] .heart failure [weak heart] .peripheral arterial disease [stiff or blocked veins and arteries], diabetes [high sugar in blood] .COPD [Chronic Obstructive Pulmonary Disease, lung disease] .septic shock [life threatening infection in body] secondary to UTI [urine infection] .admitted to the [facility] for strengthening and endurance training .as well as management of underlying comorbidities . During review of Resident 1's Admission/ readmission Evaluation/Assessment (AA) dated 1/21/2026, the AA indicated the assessment was completed by Licensed Vocational Nurse (LVN) 3. During a concurrent interview and record review on 3/12/2026 at 9:08 a.m. with the MDS Coordinator (MDSC- a licensed nurse who manages the minimum data set [MDS]- a clinical assessment tool used to evaluate the health, functional status, and care needs of residents), the MDSC reviewed Resident 1's medical record. The MDSC stated she completed Resident 1's MDS assessment on 2/3/2026. The MDSC stated no RN reviewed the MDS upon its completion. The MDSC stated Resident 1's record did not indicate a RN assessed and coordinated care for Resident 1 when admitted . The MDSC stated she was an LVN. During a concurrent interview and record review on 3/12/2026 at 12:03 p.m. with the Director of Nursing (DON), the DON reviewed Resident 1's assessment, including admission and discharge assessments, and care plan. The DON stated there was no indication a RN evaluated the care provided to Resident 1. The DON stated Resident 1 should have been assessed by an RN due to the complexity of Resident 1's condition. The DON acknowledged the importance of RN oversight for accurate and safe provision of care to the residents. During a review of the facility's document titled Job Description: Registered Nurse (RN) undated, the job description indicated, . Admit, transfer, and discharge residents as required .Ensure that direct nursing care be provided by a licensed nurse, a certified nursing assistant, and or a nurse aid trainee qualified to perform the procedure . review nurses notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the residents response to the care, and that such care is provided in accordance with the residents wishes .Review medication cards for completeness of information, accuracy in the transcription of physician orders, and adherence to stop order policies . Participate in the development of written preliminary and comprehensive assessments of the nursing needs of each resident as necessary . Ensure that all personnel involved in providing care to the resident are aware of the residents care plan. Ensure that nursing personnel refer to the residents care plan prior to administering daily care to the resident .

Based on observation, interview, and record review, the facility failed to ensure two of 12 ointment medications in the treatment cart had pharmacy labels. This failure had the potential to result in the wrong medication ointment to be given to another resident.Findings: During a concurrent observation and interview on 3/11/2026 at 3:11 p.m. with Treatment Licensed Nurse (TLN) by the nurses' station hallway was a treatment cart. The second drawer contained ointment medications in clear bags with resident labels (pharmacy label). There were two tubes without labels. One medication was collagenase (brand) ointment (medication that helps remove dead tissue from a wound) 250 u/gm (units per gram - unit of measure) and the other one silver sulfadiazine (medication used to prevent and treat infections) Cream USP 1% 50 gm (grams - unit of measure). TLN stated, It [medications] is for residents. I don't see a resident label. I don't know whose it is. TLN stated the residents' ointments should have been labeled with a resident label. TLN stated medications without resident label could be used on a different resident. During an interview on 3/12/2026 at 2:26 p.m. with the Director of Nursing (DON), DON stated if the medication was resident specific it should have a pharmacy label. The DON stated an ointment medication without a resident label could be used on a different resident. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated, . Labelling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and accepted pharmaceutical practices . The medication label includes . medication name . resident's name .

Based on interview, and record review, the facility failed to ensure a care plan for Anticoagulant (medication that prevent or reduce the formation of blood clot) was reviewed and updated for one of five sampled residents (Resident 3). This failure had the potential to result in Resident 3 not receiving care that is aligned with his current needs. Findings: During a concurrent interview and record review on 3/12/2026 at 9:57 p.m. with the Director of Staff Development (DSD), Resident 3's physician's orders and care plan was reviewed. Resident 3's care plan indicated, . [Resident 3] is on Anticoagulant therapy (apixaban) . DSD stated, I am not seeing an order [Apixaban brand - a blood thinner used to reduce the risk of stroke] . Resident does not take [Apixaban brand] . He [Resident 3] has a care plan for [Apixaban brand] . He should not have that care plan anymore. DSD stated a medication use care plan should have been resolved once the resident was not on the medication anymore. DSD stated an updated care plan allowed for the residents' care to be current and appropriate. During an interview on 3/12/2026 at 2:38 p.m. with the Director of Nursing (DON), DON stated, The [Apixaban brand] care plan should have been resolved, care plan closed. Since resident [Resident 3] is not taking it anymore. DON stated the care plan should have been updated and current so staff could provide the appropriate care to the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, . Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 106), received the necessary respiratory (the process of breathing) care (respiratory treatment/ therapy, oxygen therapy) and services with a current physician's order. This failure had a potential to result in respiratory complications for Resident 106.Findings: During a concurrent observation and interview on 3/9/2026 at 2:10 pm. with Resident 106 in her room, Resident 106 was lying in bed with head elevated. Resident 106 had a nasal cannula (NC) connected to an oxygen concentrator (a medical device that pulls ambient air and delivers pure oxygen) @ 4L/min (Liters per minute - unit of measure). Resident 106 stated she had been on oxygen therapy due to shortness of breath. During a concurrent observation and interview on 3/9/2026 at 3:45 pm. with Restorative Nursing Assistant (RNA) in Resident 106's room, RNA checked Resident 106's oxygen concentrator. RNA stated, It's [oxygen flow rate] at 4L/min. RNA stated Resident 106 had been on oxygen for some time. During a review of Resident 106's Minimum Data Set Assessment (MDS - a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents), dated 12/23/2025, the MDS indicated, . Section O - Special Treatments . C1. Oxygen Therapy . b. While a Resident . [marked X] . During a review of Resident 106's Care Plan, dated 12/23/2025, the Care Plan indicated, . at risk for changes in respiratory status . O2 @ 3L/min via NC Continuously . Date Initiated: 08/20/2023 . During a concurrent observation, interview and record review on 3/11/2026 at 2:57 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 106's room. Resident 106 had oxygen via nasal cannula. LVN 2 stated, It's at 3L/min. Resident 106's Physician's Orders was reviewed. LVN 2 stated there was no order for oxygen therapy. LVN 2 stated there should have been an order since Resident 106 had been on oxygen for a long time. LVN 2 stated the physician order was needed to let staff know how much oxygen was safe to give to the resident. During an interview on 3/12/2026 at 2:35 p.m. with the Director of Nursing (DON), the DON stated there should have been an order for oxygen therapy for Resident 106. DON stated, So that we give the O2 rate as prescribed by the doctor, provide the proper care. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, the P&P indicated, Verify that there is a physician's order . Review the resident's care plan to assess for any special needs of the resident .

Based on observation, interview, and record review, the facility failed to document on the daily Census and Nursing Hour Posting the facility name, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides. This failure resulted in the public not knowing the correct number of staff working per shift.During a concurrent interview and record review on 3/11/2026 at 2:20 p.m. with Director of Staff Development (DSD), the Census and Nursing Hour Posting, dated Wednesday, March 11, 2026 was reviewed. The census did not have the name of the facility or the correct number of staff or staffing hours for AM (morning shift), PM (afternoon shift), and NOC (night shift) shifts posted. DSD stated, the facility name is not on the posting, also the correct number of staff and hours for each shift (AM, PM & NOC) is not correct.

Based on interview and record review, the facility failed to ensure the Ombudsman (person who represents or protects the interest of another) was notified of resident transfer to the hospital for one of 18 residents (Resident 1) per Federal notification requirements. This failure had the potential to limit advocacy oversight and protection of Resident 1's rights during the transfer process. Findings:During a concurrent interview and record review on 3/12/26 at 9:08 a.m., with the MDS Coordinator (MDSC- a licensed nurse who manages the minimum data set [MDS]- a clinical assessment tool used to evaluate the health, functional status, and care needs of residents), the MDSC reviewed Resident 1's medical record. The MDSC stated Resident 1 was transferred to the hospital on [DATE] due to respiratory complications. The MDSC stated the record did not indicate the Ombudsman was notified of Resident 1's transfer to the hospital. During an interview on 3/12/26 at 9:26 a.m., with Social Services (SS), SS stated she was responsible for notifying the Ombudsman of resident transfers and discharges. SS stated her process was to notify the Ombudsman of all facility transfers and discharges on a monthly basis. SS stated notification of Resident 1's transfer to the hospital on [DATE] should have been recorded in Resident 1's medical record. During an interview on 3/12/26 at 3:30 p.m., with SS, SS stated the facility did not have a record of notifying the Ombudsman of Resident 1's transfer to the hospital in October 2025. During a review of the facility's policy and procedure (P&P) titled Transfer or Discharge Notice version 2.1, the P&P indicated, . Residents are permitted to stay in the facility and not be transferred or discharged unless . the transfer or discharge is necessary for the residents welfare and the residence needs cannot be met by the facility . The resident and representative are notified in writing of the following information . the specific reason for the transfer . The effective date of the transfer .the location to which the resident is being transferred . a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer .

Based on observation, interview, and record review, the facility failed to ensure one unsampled resident's (Resident 70), Medication Administration Record (MAR) for Lacosamide (medication used to treat seizures) on 3/8/2026 was accurate. This failure resulted to an inaccurate clinical record and placed Resident 70 at risk for seizures. Findings: During a concurrent observation, interview and record review on 3/11/2026 at 2:42 p.m. with Licensed Vocational Nurse (LVN) 4 in the B-Wing Hallway, there was a medication cart with a locked drawer and on top of it was a Controlled Drug Record binder. Scheduled medications (medications with high potential for abuse and/or addiction) and antibiotics bubble packs (a form of tamper -evident packaging where an individual pushes individual sealed tablets though the foil to take the medication) were inside. There was a bubble pack of Lacosamide with nine tablets taken. The pharmacy label indicated one tablet to be taken twice a day (9am and 9pm). The record for Lacosamide was reviewed. The record indicated nine signatures for March 6th at 2100 (9pm, 2nd dose for the day) to March 11th at 2100. Only one dose was given on 3/8/2026 at 2100. LVN 4 stated the 9am dose for Lacosamide for Resident 70 was not given. Resident 70's MAR was reviewed. The MAR indicated on 3/8/2026, the Lacosamide was given to Resident 70 at 0900 (9am) and 2100. The 9am schedule was signed by LVN 5 but the medication was not given. During a concurrent interview and record review on 3/12/2026 at 9:05 a.m. with LVN 5, Resident 70's MAR was reviewed. The MAR indicated the 9 am and 9 pm doses on 3/8/2026 were given. LVN 5 stated the 9 am dose of the Lacosamide was not given to Resident 70. LVN 5 stated, It [MAR] is not accurate since only one [pm dose] was given. I do not remember why I did not get to give the medication and I signed it. LVN 5 stated the resident's clinical record should have accurately reflected what was given to the resident to be able to monitor the medication effectiveness. During an interview on 3/12/2026 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the MAR should not have been signed if the medication was not given. The DON stated the MAR should accurately reflect if Resident 70 received or refused his medication for clinical record accuracy and resident safety. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, . The individual administering the medication initials the resident's MAR on the appropriate line after giving the medication . During a review of the facility's policy and procedure (P&P) titled, Documentation Accuracy in the Health Record, dated 11/2023, the P&P indicated, . Clinical records should accurately reflect the care given by each member of the health care team . Accurate records are vital to the individual, and to the staff . serves as proof of work done .

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan that included anticoagulation therapy (use of blood thinning medications) for one of 18 sampled residents (Resident 123). This failure had the potential to result in the lack of appropriate monitoring and increased the risk for bleeding complications for Resident 123. Findings:During review of Resident 123's admission Record (AR- a document that contains essential information about a resident), undated, the AR indicated Resident 123 was admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction (disrupted blood flow to the brain due to blockage). During a review of Resident 123's Order Summary Report (OSR) dated 3/6/26, the OSR indicated, .Rivaroxaban [blood thinner] 20 mg [milligrams- unit of measure] Give 1 tablet by mouth one time a day for Atrial Fibrillation [irregular heartbeat]. The order included a black box warning (a serious safety warning given for drugs or drug classes that may cause serious harm or death). During a concurrent interview and record review on 3/12/26 at 12:03 p.m., with the Director of Nursing (DON), the DON reviewed Resident 123's medication orders and care plan. The DON confirmed the black box warning symbol indicated Rivaroxaban was a high-risk medication that could cause bleeding. The DON stated Resident 123's care plan did not address Resident 123's use of the high-risk medication and anticoagulation therapy. The DON stated it should have been care planned to help establish interventions to monitor and prevent bleeding with the goal of safe anticoagulation therapy for Resident 123. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person- Centered dated 3/2022, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan . describes the services that are to be furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being .reflects currently recognized standards of practice for problem areas and conditions .

Based on observation, interview, and record review, the facility failed to ensure environment was free of accident hazards when the pavement in the facility's designated smoking area had a gap that three of three sampled residents (Resident 1, Resident 2 and Resident 3) reported causing their wheelchairs to get stuck. This failure had the potential to place residents at risk for falls and accidents. Findings:During a concurrent observation of the facility's designated smoking area and interview on 1/15/26 at 9:15 a.m. with Resident 1 and Resident 2, there was a gap in the pavement in the smoking area. Resident 1, who was alert and oriented and was on a wheelchair, stated the gap catches your wheelchair potentially causing residents to fall from their wheelchairs. Resident 1 called the gap a speed bump. Resident 2, also alert and oriented and on a wheelchair, corroborated the statements of Resident 1.During a concurrent observation and interview with the Director of Maintenance (DM) at the smoking area on 1/15/26 at 9:45 a.m., DM measured the gap in the pavement and stated it measured 0.75 inches wide.During a concurrent observation of the smoking area and interview on 1/15/26 at 9:15 a.m. with Resident 3, Resident 3, who was alert and oriented and on a wheelchair, stated his wheelchair had gotten stuck on the pavement gap. Resident 3 stated the gap was a fall hazard for residents on wheelchairs.During an interview on 1/15/26 at 11:30 a.m. with Activities Director (AD), AD stated she was responsible for monitoring residents on the smoking area and stated she would ensure residents using wheelchairs are not caught in the pavement gap.During a review of facility policy and procedure (P&P) titled Safety and Supervision of Residents , dated July 2017, the P&P indicated: Our facility strives to make the environment as free from accident hazards as possible.

Based on interview and record review the facility failed to follow its policy and procedure (P&P) titled, Referrals, Social Services, when the facility failed to schedule a follow-up surgeon's (a doctor who removes or repairs a part of the body by operating on the patient) appointment for one of four sampled residents (Resident 1). This failure had the potential for a delay in follow-up care for Resident 1 after surgery (the branch of medical practice that treats injuries, diseases, and deformities by the physical removal, repair, or readjustment of organs and tissues, often involving cutting into the body). Findings:During a review of Resident 1's History and Physical Reports (HPR), dated 7/5/25, the HPR indicated, [Resident 1] who is direct transfer back after suffering a fall resulting in C5-6 fracture [broken neck bone] requiring discectomy [removal] and fusion [joining] as well as R V2 vertebral artery stenosis [artery blockage] at injury site.f/u [follow up] w/ [with] their surgeon in 2 weeks. During a concurrent interview and record review on 8/27/25 at 9:41 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's clinical records were reviewed. There was no documentation of follow-up appointment scheduled with the surgeon. LVN 1 stated, I don't see any follow up appointments. LVN 1 stated when a resident is admitted , the admission nurse reviews the transfer paperwork, which included the history and physical, and if a follow-up appointment is needed the information is sent to social services to schedule the appointment. During a concurrent interview and record review on 8/27/25 at 9:50 a.m. with Director of Nursing (DON), Resident 1's Social Service Notes (SSN), undated were reviewed. The SSN indicated Resident 1 did not have a scheduled follow-up appointment with the surgeon. DON stated there was no follow-up appointment with the surgeon for Resident 1. During an interview on 8/27/25 at 10:05 a.m. with Resident 1, Resident 1 stated he had a neck surgery in (name of city) around June 30th (2025). Resident 1 stated after the surgery he was transferred to a hospital in (name of city) for recovery. Resident 1 stated he was then admitted to this facility for physical therapy. Resident 1 stated there were no follow up appointments since his admission (to the skilled nursing facility). Resident 1 stated he spoke with social services inquiring (seeking knowledge) about a follow-up appointment with the surgeon. Resident 1 stated no appointment has been scheduled. During a concurrent interview and record review on 8/28/25 at 8:51 a.m. with Social Services Director (SSD), Resident 1's HPR dated 7/2/25 was reviewed. Resident 1's HPR indicated, . f/u [follow-up] w/their surgeons in 2 weeks. SSD stated she spoke to Resident 1 approximately two weeks ago as Resident 1 inquired (seeking information) about a follow-up appointment with his surgeon. SSD stated she was unable to find any information in Resident 1's chart to schedule a follow-up appointment. SSD stated she asked Resident 1 to contact family to see if they had the information to the surgeon. SSD stated when a resident is admitted to the facility her responsibility is to review the hospital paperwork, which was uploaded into the resident's medical record, and note any follow up appointments which need to be scheduled. SSD stated she reviewed Resident 1's HPR but did not see the follow up appointment. SSD stated after further review of Resident 1's HPR, she should have had a follow-up appointment two weeks after surgery. SSD stated the information needed to schedule a follow-up appointment was in the HPR, which was placed in Resident 1's clinical record on 7/6/25. During a review of Resident 1's Care Plan (CP), dated 7/7/25, the CP indicated, Surgical Incision [a cut or wound made in the body during surgery]: Resident [1] has a surgical incision at the C5-6 spine. Interventions: .follow up with surgeon as indicate.During a concurrent interview and record review on 9/2/25 at 11:34 a.m. with DON, Resident 1's HPR, dated 7/2/25 was reviewed. The HPR indicated the name of the surgeon and the hospital where Resident 1 had a surgery. DON stated the information for the surgeon and facility were in this (HPR) document. DON stated social services could have used this information to schedule a follow up appointment for Resident 1. DON stated this was a delay in care. During a review of the facility's P&P titled, Referrals, Social Services, dated 12/2008, the P&P indicated, Policy statement: Social Services personnel shall coordinate most resident referrals with outside agencies.Referrals for medical services must be based on physician evaluation of resident need.Social services will document the referral in the resident's medical record.Social services will help arrange transportation to outside agencies, clinic appointment, etc. as appropriate.

Based on observation, interview, and record review, the facility failed to ensure fingernails were kept clean and trimmed for one of four sampled residents (Resident 1). This failure had the potential to result in Resident 1 developing infection and skin injury.Findings:During a review of Resident 1's admission Record (AR), dated 8/18/25, the AR indicated, DIAGNOSIS. NEED FOR ASSISTANCE WITH PERSONAL CARE.During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendations), dated 7/31/25, the SBAR indicated, Change in skin color or condition. Other relevant information: Resident (1) has history of picking at himself and scratching. Nurses noted old scratches over body. Bleeding noted. Resident (1) states he is itching.During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 5/15/25, the MDS indicated on section C (Cognitive Patterns), Resident 1 had a BIMS (Brief Interview for Mental Status) score of 10 (score of 8 - 12 indicates moderately impaired cognition). The MDS indicated on section GG (Functional Abilities), Resident 1 required substantial/maximal assist (staff does more than half the effort) with personal hygiene.During a concurrent observation and interview on 8/18/25 at 1:45 p.m. with Resident 1 in Resident 1's room, Resident 1's fingernails on both hands were long and had dark debris underneath. Resident 1 had multiple scratches and open skin areas on both arms and abdomen. Resident 1 stated he would scratch his skin because it would itch a lot. Resident 1 stated he wanted his fingernails trimmed.During a concurrent observation and interview on 8/18/25 at 2:00 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, CNA 1 stated Resident 1's fingernails on both hands were supposed to be cleaned and trimmed because they were long and had black dirt underneath. CNA 1 stated Resident 1 would be at risk for developing infection because he has been scratching and he had long and dirty fingernails.During a concurrent interview and record review on 8/18/25 at 2:49 p.m. with Infection Control Preventionist (ICP), Resident 1's care plan (CP), dated 6/18/25 was reviewed. The CP indicated, Resident has impaired skin integrity as evidenced by skin tear/abrasion/scratches to Left upper abdomen related to trauma and is at risk for infection. Interventions. Nails are to be kept short to reduce the risk of scratching or injury from picking at skin. ICP stated the CP was not followed. ICP stated Resident 1's nails were supposed to be kept short and clean to prevent infection and injury to the skin from scratching.During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, dated February 2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) on Urinary Catheter (a tube placed in the body to drain and collect urine from the bladder) Care for two of five sampled residents (Resident 1 and Resident 2) when:1. The facility did not monitor placement of urinary catheter for Resident 1.2. The facility did not document urine output according to the plan of care for Resident 2.These failures had the potential for Resident 1 and Resident 2 developing UTI (Urinary Tract Infection - bladder infection).Findings:1. During a review of Resident 1's admission Record (AR), dated 7/10/25, the AR indicated, Resident 1 is a [AGE] year-old male with a diagnosis of OBSTRUCTIVE AND REFLUX UROPATHY (blockage of flow of urine from the kidneys to the bladder and backward flow of urine from the bladder into the ureters and potentially back to the kidneys).During a review of Resident 1's Order Summary Report (OSR), dated 7/10/25, the OSR indicated, Suprapubic catheter:_16_F [French (refers to the size of the urinary catheter)]/ [per] 10cc [unit of measurement in cubic centimeter] for: obstructive uropathy [a condition where urine flow is blocked, causing it to back up and potentially damage the kidneys]. Change PRN [as needed] for accidental removal or blockage every shift. Order Date. 01/10/2025. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation), dated 6/25/25, the SBAR indicated, Resident [1] told nurse its [sic] burning when he urinates, nurse noticed residents [sic] catheter bag and tubing is empty, and urine and blood are coming from residents [sic] penis and catheter site. to send resident to ER [Emergency Room] for suprapubic catheter complications.During a concurrent interview and record review on 7/10/25 at 12:47 p.m. with Minimum Data Set Coordinator (MDSC), Resident 1's Care Plan (CP), dated 1/19/25 was reviewed, the CP indicated, [Resident 1] has a suprapubic catheter and is at risk for complications with urinary system. Change PRN for accidental removal or blockage. Goal. [Resident 1] will be/(or) remain free from (suprapubic) catheter-related trauma. Interventions. Check [Resident 1's] tubing [urinary catheter] for kinks [bend or twist] (#[number] TIMES) each shift. Monitor and document intake and output as per facility policy. MDSC stated, I don't see that it's [checking the tubing for kinks and urine output] being monitored. During a concurrent interview and record review on 7/10/25 at 12:47 p.m. with MDSC, Resident 1's Task: Bladder Continence (TBC), dated 6/11/25-7/10/25 was reviewed. The TBC indicated there was no documentation of urine output on 6/11/25-6/22/25. The TBC, dated 6/14/25 indicated, HIS [Resident 1] CATHETER CLOGGED AND HE USED THE RESTROOM TO URINATE. The TBC dated 6/15/25 indicated, catheter has been blocked, and he uses the restroom. MDSC stated there was no documentation of interventions to address when Resident 1's suprapubic catheter was clogged or blocked. MDSC stated when it was first noted there was no urine output, the licensed nurse and the physician should have been notified.During an interview on 7/31/25 at 3:33 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she did not document Resident 1's suprapubic catheter was clogged on 6/25/25. CNA 2 stated if it (clogged suprapubic catheter) was not documented, it did not happen. 2. During a review of Resident 2's AR, dated 7/10/25, the AR indicated, Resident 2 is an [AGE] year-old male with a diagnosis of INFECTION AND INFLAMMATORY (body's natural response to injury or infection) REACTION DUE TO INDWELLING URETHRAL CATHETER (tube inserted through the urethra into the bladder to drain urine).During a review of Resident 2's OSR, dated 4/22/25, the OSR indicated, Foley Catheter (tube inserted into the bladder through the urethra to drain urine): 18F/10cc for: obstructive uropathy. Change PRN for accidental removal or blockage.During a review of Resident 2's SBAR, dated 6/4/25, the SBAR indicated, The patient [Resident 2] complained about pressure at the lower abdominal area and blood in urine. The UA [Urinalysis (lab test that examines the urine)] with C&S [Culture and Sensitivity (identifies the germs causing the infection) results was notified to MD [Medical Doctor] and the new order received. Omnicef [antibiotic medicine that fight bacterial infections].During a review Resident 2's Nurse's Note (NN), dated 6/21/25, the NN indicated, pt [patient/Resident 1] was c/o [complained of] severe pain r/t [related to] foley catheter and unable to have [urine] output. Pt stated his bladder feels full but unable to urinate. pain and bleeding in penile [relating to or affecting the penis] area. MD made aware and gave order to send out to ER for further eval [evaluation].During a review of Resident 2's hospital's History and Physical (H&P), dated 6/21/25, the H&P indicated, The patient's [Resident 1] daughter reports that the patient was complaining of nausea [feeling of sickness in the stomach that may come with an urge to vomit], decreased appetite, and suprapubic discomfort for a few days. They noticed the decreased urine output today. The patient had significant increase in the pain after changing the Foley catheter and blood clots [clumps of blood that forms that form in response to a cut or other injury] were coming out. The patient was having more pain, hence he was routed into the ED [Emergency Department] for evaluation. We changed the Foley catheter here and pus [fluid produced in infected issue] was coming out. IMPRESSION: 1. Complicated urinary tract infection secondary to catheter associated.During a concurrent interview and record review on 7/10/25 at 1:32 p.m. with MDSC, Resident 2's CP, dated 6/10/25 was reviewed. The CP indicated, Resident Catheter Care. Interventions. Monitor urine output. note the placement of [urinary] catheter. During a concurrent interview and record review on 7/10/25 at 1:32 p.m. with MDSC, Resident 2's Intake & Output MAR (Medication Administration Record), dated April 2025, May 2025, and June 2025 was reviewed. The Intake & Output MAR indicated there were no documentation of urine output on 4/16/25-6/21/25.During a concurrent interview and record review on 7/10/25 at 1:32 p.m. with MDSC, Resident 2's TBC, dated 6/11/25-7/10/25 was reviewed. TBC indicated there were no documentation of urine output on 6/12/25-6/16/25, and 6/18/25. On 6/17/25, the TBC indicated, No out put in catheter. Nurse informed. MDSC stated there was no documentation of interventions addressing Resident 2's lack of urine output.During an interview on 7/10/25 at 1:45 p.m. with MDSC, MDSC stated on 6/25/25, Resident 2 came back from the acute hospital with UTI. MDSC stated Resident 2's catheter care (monitoring urine output and monitoring catheter placement) was not being done and had potentially resulted in UTI. MDSC stated the risks of developing infection could have been minimized if the facility monitored urine output and monitored catheter placement according to the plan of care.During a review of the facility's P&P titled, Catheter Care, Urinary, dated August 2022, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Input/Output 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor. Maintaining Unobstructed Urine Flow 1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.

Based on observation, interview, and record review, the facility failed to ensure:A Certified Nursing Assistant (CNA) 2 was wearing proper personal protective equipment (PPE) when entering one of nine sampled residents' (Resident 6) room on contact precautions (to use PPE before entering residents' room with residents known or suspected to be infected with germs that can be spread by direct contact). This failure had the potential to result in spread of infection to other residents, staff, and visitors.2. A Licensed Vocational Nurse (LVN) performed hand hygiene after removing used gloves during a suprapubic catheter (a tube that drains urine from the bladder through a small opening in the lower abdomen) care for one of five sampled residents (Resident 3). This failure had the potential to result in Resident 3 developing urinary tract infection (bladder infection). Findings:1. During a review of Resident 6's admission Record (AR), dated 7/10/25, the AR indicated, Diagnosis. EXTENDED SPECTRUM BETA LACTAMASE (ESBL) RESISTANCE [bacteria that is resistant to common antibiotics (medication that treats bacterial infection].During a review of Resident 6's Order Summary Report (OSR), dated 7/10/25, the OSR indicated, Contact Isolation due to VRE [Vancomycin-Resistant Enterococci-bacteria that is resistant to the antibiotic Vancomycin] and ESBL in urine.During a concurrent observation and interview on 7/10/25 at 3:38 p.m. with Certified Nursing Assistant (CNA) 2 in Hallway 1. Resident 6's room had a Contact Precautions sign on her door. The Contact Precautions sign indicated staff should wear gown and gloves when entering resident's room. CNA 2 was not wearing a gown while transferring Resident 6 from the bed to the wheelchair. CNA 2 stated she did not know Resident 6 was on contact precautions. CNA 2 stated she was supposed to wear gown and gloves in Resident 6's room to protect herself, and to not spread microorganisms to other residents.During a concurrent observation and interview on 7/10/25 at 3:40 p.m. with Infection Control Preventionist (ICP) in Hallway 1. Housekeeping (HSK) was not wearing a gown while cleaning the bed in Resident 6's room. ICP stated HSK was supposed to wear gown in Resident 6's room because Resident 6 was on contact precautions. During a concurrent interview and record review on 7/10/25 at 3:56 p.m. with ICP, the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission-Based Precautions, dated September 2022 was reviewed. The P&P indicated, Contact Precautions. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. ICP stated the P&P was not followed.2. During a review of Resident 3's Order Summary (OS), dated 12/20/23, the OS indicated, Suprapubic Foley catheter care q [every] shift.During a concurrent observation and interview on 7/11/25 at 10:57 a.m. with LVN 2 in Resident 3's room, LVN 2 performed suprapubic catheter care for Resident 3. LVN 2 cleaned Resident 3's suprapubic catheter insertion site then LVN 2 removed her gloves and wore new gloves without performing hand hygiene in between glove changes. LVN 2 stated she should have washed her hands after cleaning the insertion site and after removing her used gloves.During a concurrent interview and record review on 7/11/25 at 11:42 a.m. with ICP, the facility's P&P on Suprapubic Catheter Care, dated October 2010 was reviewed. The P&P indicated, The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Wash around the catheter site with soap and water. Wash the outer part of the catheter tube with soap and water. Remove gloves and discard in designated container. Wash and dry your hands thoroughly. ICP stated the P&P was not followed.

Based on interview and record review, the facility failed to follow their policy and procedures (P&P) titled, Prevention of Pressure Injuries (PI -localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), Wound Care, and admission Assessment and Follow Up: Role of the Nurse, for one of three sampled residents (Resident 1) when the physician was not notified and treatment orders obtained, a care plan was not developed and implemented, wound measurements were not completed, and an individualized turning/repositioning schedule was not determined, when the resident was admitted with a coccyx (tailbone) PI. These failures resulted in Resident 1 not being provided wound care for nine days and the worsening of Resident 1's pressure injury.Finding:During a review of Resident 1's Admission/readmission Evaluation/Assessment (AREA), (AREA - document used by the facility when a resident is admitted /readmitted to document the assessment including skin assessment) dated 5/7/25 (admission date), the AREA indicated, Reason for admission: Skilled needs, wound care. The AREA indicated Resident 1 was incontinent of bladder and required assistance with activities of daily living (ADLs - refers to basic self-care tasks): bathing, dressing, toileting, and bed mobility. The AREA indicated Resident 1 had a pressure injury to the coccyx (tailbone). There was no documentation measurements or a description of Resident 1's pressure injury to the coccyx.During a review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation, (Braden Scale is risk assessment tool used to predict the likelihood of a resident developing pressure injuries with the scores ranging from 6 - 23, with the lower the score the higher the risk for developing a pressure injury) dated 5/7/25, Resident 1's Braden score was 14 (score of 13-14 indicates a moderate risk for developing a pressure injury).During a review of Resident 1's care plan (comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided/interventions, and the goals of the care) initiated 5/8/25, with the focus on Skin: [Resident 1] is at risk for skin breakdown related to edema (swelling of the body tissue), impaired mobility, pain, Braden Score :14. The care plan interventions included, Assist to turn and reposition as indicated/tolerated. Keep skin clean and dry to the extent possible. The care plan did not include an individualized turning/repositioning schedule. During a review of Resident 1's Minimum Data Set, (MDS - a comprehensive assessment tool to evaluate the functional capabilities and health needs of residents) dated 5/12/25, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status- standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn, and remember) score was 11 (score between 8 to 12 indicates moderately impaired cognition). The MDS indicated Resident 1 was dependent (helper does all the effort) for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), and required substantial/maximal assistance (helper does more than half the effort) with rolling to the left and to the right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated Resident 1 had one or more unhealed pressure injuries, one unstageable pressure injury (obscured full - thickness skin and tissue loss. Full - thickness skin and tissue loss in which the extent of tissue damage within the PI cannot be confirmed because it is obscured by slough [yellow or white material consisting of dead cells which attaches to the wound bed] or eschar [dead tissue that forms over healthy skin]. If slough or eschar is removed, a Stage 3 [Full-thickness loss of skin, in which adipose (fat) is visible] or Stage 4 [Full-thickness skin and tissue loss with exposed muscle, tendon (flexible tissue, similar to a rope), ligament [a band of tissue that connects bones, joints or organs], cartilage [a strong, flexible connective tissue that protects joints and bones] or bone are visible in the pressure injury] are revealed) presenting as a deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable [the skin does not turn white when touched with a finger] deep red, maroon, purple discoloration or epidermal [outer layer of skin] separation revealing a dark wound bed or blood-filled blister [raised skin filled with fluid]) present on admission.During a review of Resident 1's Skin & Wound Evaluation (SWE - document used by the facility to document the resident's skin condition), dated 5/15/25, the SWE indicated Resident 1 had a stage 4 pressure injury present on admission. There was no documentation of the location of the PI. The SWE indicated the wound measured: area 16.8 centimeters squared (cm2 - unit of measurement), length 8.2 centimeters (cm - unit of measurement), and width 5.2 cm. No depth of the wound was documented. During a review of Resident 1's SWE, dated 5/21/25, the SWE indicated Resident 1 had a stage 4 pressure injury to the coccyx, present on admission. The SWE indicated the wound measured: area 9.0 cm2, length 4.8 cm, and width 3.0 cm. No depth of the wound was documented. During a review of Resident 1's SWE, dated 5/30/25, the SWE indicated Resident 1 had a stage 4 pressure injury to the coccyx, present on admission. The SWE indicated the wound measured: area 35.8 cm2, length 8.6 cm, width 7.3 cm, and depth 1.0 cm. The SWE indicated Resident 1's pressure injury was deteriorating and infection was suspected. No depth of the wound was documented. During a review of Resident 1's care plan initiated 5/27/25, with the focus on Skin: (Resident 1) has a pressure ulcer to (coccyx) and is at risk for further breakdown and or slow, delayed healing related to, the care plan interventions included: Pressure reduction cushion for chair. and Pressure reduction mattress for bed. There was no care plan interventions to turn reposition the resident. During a review of Resident 1's care plan with the focus on Skin: (Resident 1) has a pressure ulcer to coccyx and is at risk for further breakdown and or slow, delayed healing related to Diabetes (medical condition that leads to high blood sugar levels), incontinence of bladder incontinence of bowel, initiated 5/28/25. The care plan interventions included: Pressure reduction cushion for chair. and Air mattress No care plan interventions were added to turn and reposition at a specific frequency. During a review of Resident 1 Task Turn and Reposition, (TTR - document used by the facility to document when the staff reposition a resident) for dates 5/7/25 to 5/29/25, the following was noted:On 5/8/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/9/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/10/25, the TTR indicated Resident 1 was turned or repositioned four times within that 24-hour period On 5/11/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/12/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/13/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/14/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/15/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/16/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/17/25, the TTR indicated Resident 1 was turned or repositioned four times within that 24-hour period On 5/18/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/19/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/20/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/21/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/22/25, the TTR indicated Resident 1 was turned or repositioned four times within that 24-hour period On 5/23/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/24/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period On 5/25/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/26/25, the TTR indicated Resident 1 was turned or repositioned four times within that 24-hour period On 5/27/25, the TTR indicated Resident 1 was turned or repositioned two times within that 24-hour period On 5/28/25, the TTR indicated Resident 1 was turned or repositioned three times within that 24-hour period During a concurrent interview and record review, on 5/28/25 at 4:05 p.m. with Director of Nursing (DON). Resident 1's AREA dated 5/7/25, the AREA indicated Resident 1 had a pressure injury to coccyx. The licensed nurse did not document measurements or that staging (system used to classify the severity of the PI based on the depth of the tissue damage) of the PI was done. Resident 1's Treatment Administration Record (TAR) (TAR) dated May 2025 was reviewed. After reviewing the physician's orders, DON stated there were no physician's orders to treat the coccyx PI and therefore no treatment of Resident 1's pressure injury was performed from 5/7/25 to 5/15/25 (9 days). DON stated the admissions nurse did not obtain treatment orders from the medical doctor to perform treatments to the coccyx PI. DON stated, If it (treatment) is not documented it (treatment) is not done. Resident 1's care plans were reviewed. DON stated no actual pressure injury care plan was developed when the PI to the coccyx was first identified on 5/7/25. The care plan for the coccyx PI was not developed until 5/27/25. During a concurrent interview and record review, on 6/23/25 at 11:44 a.m. with DON, DON stated a resident's skin should be assessed and wounds should be measured and documented upon admission. DON stated measurements should be taken when identified to monitor if the wound is improving or worsening. DON stated the resident's physician should be notified of the wounds and treatment orders should be obtained and placed in the resident's medical record to be implemented. DON stated a resident with wounds should be placed on the wound doctor (a healthcare professional with specialized training and experience in the care and treatment of acute, chronic, and non-healing wounds) services to be evaluated weekly. DON stated a care plan should be created and implemented. DON stated a resident with pressure injuries on the coccyx should have care plan interventions including, turning and repositioning every 2 hours and as needed, keep the resident clean and dry, air mattress and specialized cushion while up in chair. DON stated Resident 1's pressure injury was not measured upon admission. DON stated a care plan for Resident 1's pressure injury was not created upon admission. DON confirmed the care plan for the coccyx PI was created on 5/27/25. DON stated wound care orders were not placed in Resident 1's medical record until 5/16/25 (9 days after admission) DON stated there was no documentation the nurses treated Resident 1's pressure injury on 5/7/25, 5/8/25, 5/9/25, 5/10/25, 5/11/25, 5/12/25, 5/13/25, 5/14/25, 5/15/25. Nurses documented treatment to the coccyx wound on 5/16/25. During a review of the facility's P&P titled, Prevention of Pressure Injuries, revised April 2020, the P&P indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Risk Assessment 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any change of condition. Skin Assessment 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). Inspect pressure points (sacrum, heels, buttocks, coccyx, .); . e. Reposition resident as indicated on the care plan. Prevention Skin Care 1. Keep the skin clean and hydrated. 2. Clean promptly after episodes of incontinence. Mobility/repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. 3. Teach resident who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Monitoring 1. Evaluate, report and document potential changes in skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.During a review of the facility's P&P titled, Wound Care, revised October 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. Documentation The following information should be recorded in the resident medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 10. The signature and title of the person recording the data. Reporting . 2. Report other information in accordance with facility policy and professional standards of practice.During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, lasted revised September 2012, the P&P indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessments . e. Skin assessment . 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. Documentation The following information should be recorded in the resident's medical record: . 5. Orders obtained from the physician.

Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Wound Care, for one of three sampled residents (Resident 1) when wound care orders were not obtained and care plan interventions were not developed and implemented for Resident 1's right and left heel wounds. These failures resulted in Resident 1 not being provided wound care for nine days and had the potential for worsening of Resident 1's right and left heel wounds.Findings:During a review of Resident 1's Admission/readmission Evaluation/Assessment, (AREA) dated 5/7/25, the AREA indicated, Reason for admission: Skilled needs, wound care, the AREA indicated Resident 1 required assistance with activities of daily living: bathing, dressing, toileting, and bed mobility. The AREA indicated, Resident 1 had a wound to the right heel and a closed blister to the left heel (no measurement or description documented of the wound to the right heel or the blister to the left heel).During a review of Resident 1's Baseline Care Plan (BCP - a foundational document in skilled nursing facilities, the BCP provides initial instructions for providing effective and person-centered care to a newly admitted resident), dated 5/7/25, the BCP indicated under the section titled, Skin Integrity (Prior and Current Concerns), there was no documentation Resident 1 had any current or past skin integrity concerns.During a review of Resident 1's Admissions Minimum Data Set, (MDS - a standardized assessment tool used in healthcare settings to collect comprehensive information about residents) dated 5/12/25, the MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS- standardized assessment tool used to evaluate the cognition [mental processes that allow individuals to think, learn, and remember] with scores ranging from 0 - 15 with the higher the score the more intact the resident's cognition is) score was 11 (represents moderately impaired cognition). The MDS assessment indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS assessment indicated Resident 1 had diabetic foot ulcers (an open sore or wound on the foot that occurs in people with diabetes [a diseases that affect how the body uses blood sugar], often due to nerve damage and poor blood circulation).During a review of Resident 1's Skin & Wound Evaluation, (SWE) dated 5/15/25, the SWE indicated Resident 1 had a diabetic wound to the right heel which was present on admission. The SWE indicated the right heel wound measured: area 5.0 centimeter squared (cm 2 - unit of measure), length 3.6 centimeter (cm - unit of measure), and width 1.9 cm.During a review of Resident 1's SWE, dated 5/15/25, the SWE indicated Resident 1 had a diabetic left heel wound that was present on admission. The SWE indicated the left heel wound measured: area 11.5 cm2, length 4.9 cm, and width 3.4 cm.During a review of Resident 1's care plan (is a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided/interventions, and the goals of the care) initiated 5/8/25, with the focus on Skin: [Resident 1] has diabetic ulcer(s) R (right) heel and is at risk for complications related to decreased mobility, delayed healing.further skin breakdown.infection. There were no interventions added to assist Resident 1's diabetic ulcers in the healing process on 5/8/25. Interventions were not added until 5/28/25 (21 days after Resident 1's wounds were first identified).During a concurrent interview and record review, on 5/28/25 at 4:05 p.m. with Director of Nursing (DON). Resident 1's AREA, dated 5/7/25 was reviewed. DON confirmed Resident 1 had a wound to the right heel and a closed blister to the left heel which were present upon admission with no measurement or description documented. Resident 1's Treatment Administration Record, (TAR) dated May 2025 was reviewed. After reviewing the TAR, DON stated no treatments were performed for Resident 1's right heel or left heel wounds from 5/7/25 to 5/16/25 (9 days). DON reviewed Resident 1's physicians' orders. DON stated the admissions nurse did not obtain treatment orders from the physician to treat the resident right heel and left heel. DON stated no treatments to the right and left heel were documented as being performed from 5/7/25 to 5/16/25 . DON stated, if it [treatment] is not documented it [treatment] is not done. Resident 1's care plans initiated 5/8/25 were reviewed. DON stated no wound care interventions were developed for the wounds to Resident 1's right heel or left heel on the day the care plan was developed. During a concurrent interview and record review, on 6/23/25 at 11:44 a.m. with DON, DON stated a resident's skin should be assessed and wounds should be measured and documented upon admission. DON stated measurements of wounds should be taken when identified to monitor if the wound is worsening. DON stated the resident physician should be notified of the wounds and treatment orders should be obtained and placed in the medical record to be implemented. DON stated a resident with wounds should be placed on the wound doctor (a healthcare professional with specialized training and experience in the care and treatment of acute, chronic, and non-healing wounds) services to be evaluated by the wound doctor weekly. DON stated a care plan should be created and implemented when residents have wounds. DON stated a resident with diabetic wounds to the heels would have interventions including placing a hi-lift boot (heel offloading boot meant to protect and care for bony prominence) while in bed, wound consult, treatments as order, and monitoring for signs and symptoms of infection. DON stated Resident 1's right and left heel wounds were not measured upon admission. DON stated a care plan for Resident 1's right and left heel wounds were not created upon admission, DON confirmed care plan interventions were created on 5/28/25 (21 days after wounds were identified). DON stated wound care orders were not placed in Resident 1's medical record until 5/16/25 (9 days after admission) DON stated there was no documentation of Resident 1's right or left heel wound treatments being performed until 5/16/25, 9 days after admission. During a review of the facility's P&P titled, Wound Care, revised October 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for this procedure. 2. Review the resident's care plan to assess for any special needs of the resident. Documentation The following information should be recorded in the resident medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 10. The signature and title of the person recording the data. Reporting .2. Report other information in accordance with facility policy and professional standards of practice.During a review of the facility's P&P titled, admission Assessment and Follow Up: Role of the Nurse, lasted revised September 2012, the P&P indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessments . e. Skin assessment . 12. Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings. Documentation The following information should be recorded in the resident's medical record: . 5. Orders obtained from the physician.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for one of three sampled residents (Resident 2 ) when:1. A low air loss mattress (a specialized medical mattress designed to prevent and treat pressure injuries [PI - localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction] by providing a combination of air circulation and pressure redistribution) was improperly installed. This failure resulted in Resident 2 hitting his head.2. The wheelchair was not maintained and could not be properly cleaned and sanitized. This failure had the potential for Resident 2 to be exposed the infection and bacteria.Findings:1. During a review of Resident 2's Minimum Data Set, (MDS - a comprehensive assessment tool to evaluate the functional capabilities and health needs of residents) dated 5/18/25, the MDS indicated, Resident 2's BIMS (Brief Interview for Mental Status - standardized assessment tool used to evaluate the mental processes that allow individuals to think, learn and remember) score was 12 (a score of 8 to 12 indicates moderately impaired cognition).During a concurrent observation and interview, on 5/28/25 at 1:46 p.m. with Resident 2 in Resident 2's room, Resident 2 stated his low air loss mattress was installed wrong and the machine has hit him in the head a few times. The machine (the air hose connectors) was observed at the head of the bed on the floor. Resident 2 stated he has been here for two weeks and the bed has been like this. Resident 2 stated he made a certified nursing assistant (CNA) aware and the CNA said he would change it but the CNA never changed the set up of the low air loss mattress.During a concurrent observation and interview, on 5/28/25 at 2:20.p.m. with Maintenance Director (MD), in Resident 2's room. MD stated he does assist in installing the low air loss mattresses when a nurse asks. MD stated he helps strap the mattress to the bed frame and plugs it in. MD confirmed Resident 2's low air loss mattress and the air hose connectors were located at the head of the bed and resting on the floor. During an interview on 5/28/25 at 3:54 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated low air loss mattress' air hose connectors should be placed at the foot of the bed. During a review of the facility provide manual titled, A10, Low Air-Loss Mattress Replacement System With Alternating Pressure, undated, the manual indicated, Installation 1. Place the mattress directly on the bed frame, with the air hose connectors positioned at the footboard. 2. Hang the pump onto the bed board (footboard side) .2. During a concurrent observation and interview, on 5/28/25 at 1:46 p.m. with Resident 2 in Resident 2's room, Resident 2 stated the facility provide him with his current wheelchair. Resident 2 stated he received the wheelchair with cracks and a right arm rest peeling. Resident 2 stated he put the hot pink duct tape on the left arm rest. During a concurrent observation and interview, on 5/28/25 at 2:20.p.m. with MD, in Resident 2's room, MD confirmed Resident 2's wheelchair right arm rest was cracked and peeling and the left arm rest had hot pink duct tape on more than half of the arm rest. DM stated he could not say if Resident 2's wheelchair arm rest could be sanitized. During an interview on 5/28/25 at 3:54 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents with cracked or peeling arm rest on wheelchairs, should have the arm rest replaced. LVN 1 stated cracked and peeling arm rest could not be sanitized.During a review of the facility policy and procedure (P&P) titled, Infection Prevention and Control Program, revised October 2018, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 11. Prevention of Infection . (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).

Based on interview and record review, the facility failed to ensure: 1. Wound treatments were completed as ordered by the physician for three of three sampled residents (Resident 1, Resident 2, and Resident 3). 2. Weekly wound assessments were completed for two of three sampled residents (Resident 2 and Resident 3). These failures had the potential for delayed wound healing, worsening of wounds, and infection for Resident 1, Resident 2, and Resident 3. Findings: 1. a) During a review of Resident 1's Order Summary Report (OSR), dated 3/17/25, the OSR indicated, Cleanse Wounds to R [right] upper arm, R Forearm [the part of the arm between the elbow and the wrist] and R hand with Dakins [a diluted solution, often used for wound care]. then cut holes for suction and turn wound vac [vacuum] on Q [every] Mon [Monday], Wed [Wednesday], Fri [Friday] & [and] PRN [as needed]. start date 3/17/25. During a concurrent interview and record review on 4/1/25 at 2:39 p.m. with Director of Staff Development (DSD), Resident 1's Treatment Administration Record (TAR), dated 3/2025 was reviewed. The TAR indicated the wound treatments were not completed on 3/28/25 and 3/31/25. DSD stated Resident 1's TAR was blank for all wounds on 3/28/25 and 3/31/25 indicating wound treatments were not performed. b) During a review of Resident 2's OSR, dated 3/17/25, the OSR indicated, Medihoney [wound treatment medication] Wound/Burn Dressing External Gel (wound dressing): Apply to L [left] iliac Crest [bone in the pelvis] topically every day shift for Stage III [involves full-thickness skin loss] pressure injury for 21 days . start date 3/13/25. Medihoney Wound/Burn Dressing External Gel: Apply to R Gluteus [buttocks] topically every day shift for Stage II [open wound with a red or pink wound bed] pressure injury for 21 days . start date 3/13/25. Medihoney Wound/Burn Dressing External Gel: Apply to R Iliac Crest [pelvis] topically every day shift for Stage III [full-thickness skin loss, meaning the injury extends through the skin into deeper tissue and fat] pressure injury for 21 days . start date 3/13/25. During a concurrent interview and record review on 4/1/25 at 1:50 p.m. with DSD, Resident 2's TAR, dated 3/2025 was reviewed. The TAR indicated the wound treatments were not completed on 3/15/25, 3/16/25, 3/28/25, 3/29/25 and 3/30/25. DSD stated Resident 2's TAR was blank for all wounds on 3/15/25, 3/16/25, 3/28/25, 3/29/25 and 3/30/25 which indicated wound treatments were not performed. c) During a review of Resident 3's OSR, dated 2/20/25, the OSR indicated, Betadine [a solution to help clean wounds] External Solution 10% Apply to L Lateral [side] Heel topically every day shift for Fluid Filled Blister for 21 days. start date 2/21/25. Medihoney Wound/Burn Dressing External Gel (wound dressings) Apply to L Ischium [bone in the pelvis] topically every day shift for stage III pressure injury for 21 days. start date: 2/21/25. Medihoney Wound/Burn Dressing External Gel (wound dressing) apply to R medial [middle] thigh topically every day shift for stage III pressure injury for 21 days. stat date: 2/21/25. During a concurrent interview and record review on 4/1/25 at 2:13 p.m. with DSD, Resident 3's TAR, dated 2/2025 was reviewed. The TAR indicated the wound treatment was not completed on 2/22/25. DSD stated Resident 3's TAR was blank for the wound treatment on 2/22/25 which means the wound treatment was not performed on 2/22/25. During a concurrent interview and record review on 4/1/25 at 2:13 p.m. with DSD, Resident 3's TAR, dated 3/2025 was reviewed. The TAR indicated the wound treatments were not completed on the left heel on 3/28/25 and 3/131/25. The TAR indicated wound care were not completed for R [right] medial [middle] thigh & L [left] ischium [hip] from 3/14/25 through 3/31/25. DSD stated Resident 3's TAR was blank on 3/14/25 through 3/31/25 which means wound care was not performed. During an interview on 4/1/25 at 3:48 p.m. with Director of Nursing (DON), DON stated the expectation is for staff to sign the TAR when wound treatment is completed. During an interview on 4/29/25 at 10:14 a.m. with DON, DON stated when the wound nurse is not scheduled to work, the nurse on the floor is responsible to complete the wound treatment and if the wound treatment was not documented then the wound treatment was not completed. 2. a) During a concurrent interview and record review on 4/1/25 at 1:50 p.m. with DSD, Resident 2's Skin & Wound Evaluation (SWE) dated 3/19/25 was reviewed. The SWE indicated there were no wound measurements for left iliac crest wound on 3/19/25. DSD stated there are no wound measurements and the rest of the assessment is blank. DSD stated, This is not a complete assessment. During an interview on 4/1/25 at 1:50 p.m. with DSD, DSD stated Resident 2's SWE, dated 3/19/25 for R Gluteus was missing. DSD stated there should have been a wound assessment on the R Gluteus. During a concurrent interview and record review on 4/1/25 at 1:50 p.m. with DSD, Resident 2's SWE dated 3/27/25 was reviewed. The SWE indicated there were no wound measurements on 3/27/25 on the R Iliac Crest. DSD stated, This is not a complete assessment. During a concurrent interview and record review on 4/1/25 at 2:13 p.m. with DSD, Resident 2's SWE dated 3/27/25 was reviewed. The SWE indicated the wound assessment for R Gluteus (buttock muscle) on 3/27/25 was left blank. DSD stated, This is not a complete assessment because the fields are missing responses. b) During a concurrent interview and record review on 4/1/25 at 2:13 p.m. with DSD, Resident 3's Admission/readmission Evaluation/Assessment (AA), dated 2/20/25, indicated for L [left] medial proximal [near the center of the body] calf venous [vein] stasis [lack of movement] ulcer, L medial distal [further away] calf venous stasis, L lateral heal fluid filled blister, L ischium stage III pressure injury, and R medial thigh stage III pressure injury was reviewed. The AA indicated there were no wound measurements completed on all of the five wounds on 2/20/25, . DSD stated, There are no measurements for the wounds upon admission which means these are incomplete assessments. During a concurrent interview and record review on 4/1/25 at 2:13 p.m. with DSD, Resident 3's SWE dated 2/26/25 was reviewed. The SWE indicated the assessment was partially completed on 2/26/25 for L medial calf (back of the shin) distal (farther area). DSD stated, The only part of the assessment that is complete are wound measurements everything else is left blank and not a complete assessment. During an interview on 4/1/25 at 2:13 p.m. with DSD, DSD stated there are no weekly wound assessments of the L medial proximal calf venous stasis ulcer, L medial distal calf venous stasis, L lateral heal fluid filled blister, L ischium stage III pressure injury and R medial thigh stage III pressure injury dated 2/26/25 for Resident 3. DSD stated these assessments should have been completed. During an interview on 4/1/25 at 2:13 p.m. with DSD, DSD stated, There are no assessments for resident's [3] wounds for the week of 3/3/25. Wounds should be assessed weekly. During a concurrent interview and record review on 4/1/25 at 2:13 p.m. with DSD, Resident 3's SE, dated 3/12/25 was reviewed. The SE indicated there were no wound measurements for L medial calf, proximal were completed on 3/12/25. DSD stated, There are no wound measurements, and most of the assessment is left blank. This is an incomplete assessment. During an interview on 4/1/25 at 2:13 p.m. with DSD, DSD stated there are no weekly wound assessments completed on 3/12/25 for Resident 3's wounds. During a concurrent interview and record review on 4/1/25 at 2:13 p.m. with DSD, Resident 3's SE, dated 3/18/25 was reviewed. The SE indicated there were no wound measurements for L lateral heel are completed on 3/18/25. DSD stated wound measurements were not completed. During a concurrent interview and record review on 4/1/25 at 2:13 p.m. with DSD, Resident 3's SE, dated 3/18/25 was reviewed. The SE indicated there were no wound assessment for Left Ischium on 3/18/25. DSD stated, This is an incomplete assessment. During a concurrent interview and record review on 4/1/25 at 2:13 p.m. with DSD, Resident 3's SE, dated 3/18/25 was reviewed. The SE indicated there was no wound assessment for Right Medial thigh on 3/18/25. DSD stated, This is not a complete assessment. During an interview on 4/1/25 at 4:09 p.m. with DON, DON stated the expectation of staff is to complete weekly wound assessments for all wounds. During an interview on 4/29/25 at 10:14 a.m. with DON, DON stated previously, all wound treatments and weekly wound assessments were overseen by LVN 1 who is no longer working at [facility]. During an interview on 5/1/25 at 9:48 a.m. with DON, DON stated she oversees LVN 1's wound treatments and she did not review the TAR daily for wound treatment completion. During a review of the facility's policy and procedure (P&P) titled, Wound Care, dated 10/2010, the P&P indicated, Documentation: The following information should be recorded in the resident's medical record: 2. The date and time the wound care was given. 4. The name and title of the individual performing the wound care. 6. all assessment date i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 10. The signature and title of the person recording the data. During a review of the facility's P&P titled, Prevention of Pressure Injuries, dated 4/2020, the P&P indicated, Risk Assessment: 1. Assess the resident on admission (within eight hours) for exiting pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was discharged home safely when Resident 1 needed assistance with personal care but was sent home alone without a caregiver or family member in an unsafe living condition and without discharge instructions. This failure resulted in Resident 1 being admitted to the hospital for 12 days with diagnoses of failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments), pulmonary edema (too much fluid in the lungs), elevated troponin (type of protein found in the muscles of the heart - indicator for impending heart attack) after only six hours from being discharged from the skilled nursing facility (SNF) and 12 days later, was referred to hospice care (end of life care). Findings: During an interview on 7/25/23 at 10:10 a.m. with Case Manager (CM), CM stated Resident 1 was brought to the emergency room because he passed out on his couch (after being discharged home on 7/22/23 from the SNF). CM stated the SNF verified the discharge plan for Resident 1 was to have a caregiver at home, but he (Resident 1) had no caregiver at home and was discharged home alone. CM stated she spoke with Resident 1's Caregiver (CG) but she stated she (CG) no longer was his (Resident 1) caregiver. CM stated Resident 1 did not have a caregiver at home when he [Resident 1] was discharged . During an interview on 7/27/23 at 2:20 p.m. with Director of Social Services (DSS), DSS stated she was unable to contact Resident 1's caregiver (CG) on the number that they (facility) had for him as an emergency contact but still Resident 1 was discharged home without a caregiver. DSS stated Resident 1 was discharged home alone. During a review of Resident 1's Discharge Note, dated July 22, 2023 at 12 p.m., the Discharge Note indicated, Patient [Resident 1] was discharged approximately at 12 p.m. via facility transport. The Discharge Note was reviewed. There was no documentation of discharge instructions provided to Resident 1 and no documentation if Resident 1 understood the discharge instructions. During an interview on 7/27/23 at 2:45 p.m. with Director of Nursing (DON), DON stated the facility had given Resident 1 the NOMNC (Notice of Medicare Non-Coverage - informs beneficiaries [Resident 1] of their discharge when their Medicare, government national health insurance covered services are ending). DON stated Resident 1 needed a caregiver but did not have one at home. During a review of Resident 1's Emergency Documentation (ED), dated July 22, 2023 at 6:05 p.m. (six hours later from being discharged from the SNF and alone at home), the ED indicated, Chief Complaint: BIBA [brought in by ambulance] for 5150 [emergency 72-hour hold for mental health crisis] GD [grave disability - a condition in which a person is unable to provide for his or her basic personal needs for food, clothing, or shelter], failure to thrive, presents hypotensive [low blood pressure], and bradycardic [low heart rate] (7/22/23 6:02 p.m.). History of Present illness: Patient [Resident 1] is [AGE] years old male with history of hypertension [high blood pressure], diabetes [disease where sugar levels are not regulated], hyperlipidemia [high concentration of fats in blood], HFrEF [Heart Failure reduced Ejection Fraction - measurement of how much blood is pumped through the heart] 40% [30-40% Moderately Abnormal], and tobacco use who presents for altered mental status, hypotension, and bradycardia. Per EMS [Emergency Medical Services], law enforcement was called by neighbors for a wellness check. Found on his couch hypotensive SBP [systolic blood pressure - measures the pressure in your arteries when your heart beats] 90s and bradycardic HR [heart rate] 50s [normal heart rate is 60 - 100] with intermittent bouts of somnolence [feeling sleepy]. He [Resident 1] was also hypoxic [low oxygen level in the blood] on scene saturating high 70 to 80% [normal level is above 90%] and was placed on nasal cannula [tube which is placed in the nostrils to deliver oxygen for breathing]. Currently on 4 L [liters - unit of measurement], saturating 89%. 5150 GD was placed due to lack of food and air conditioning in his home. Diagnosis: Failure to thrive, pulmonary edema and increased troponin. During a review of Resident 1's Care Plan (CP), dated June 2023, the CP indicated, Discharge Plan is: Short-term care Resident [Resident 1] wished to return home when all rehabilitation goals met and medically stable. Interventions: Assess for appropriate level of care and make recommendations. Caregiver and/or resident care training. Discuss & Assess Resident [Resident 1] and/or responsible party attitude regarding d/c [discharge] plan. Encourage relevant involvement with d/c plans. Provide adequate written and/or oral notice of all d/c plans. During a review of Resident 1's Final Summary of the Resident's Status - Rehab (Rehabilitation) Services (FSRSRS), dated 7/25/23, the FSRSRS indicated, Rehabilitation Potential: Poor. Assistive Devices: Wheelchair. Additional Rehab Notes: Poor participation with therapy [rehabilitation goals not met]. During a review of Resident 1's Admission Record, dated July 27, 2023, the Admission Record indicated, Resident 1 had diagnoses of: Need for Assistance with Personal Care, Abnormalities of Gait (manner of walking) and Mobility, Chronic Congestive Heart Failure (a serious condition in which the heart does not pump blood efficiently), Chronic Respiratory Failure (severe breathing problem), Chronic Obstructive Pulmonary Disease (COPD - severe breathing problem caused by airflow blockage). During a review of Resident 1's Order Summary Report (OSR), dated July 2023, the OSR indicated, Monitor Pulse Oximetry [method of measuring the level of oxygen in a person's blood] q [every] shift: Keep SPO2 [serum pressure oxygen - measurement of oxygen level in the blood] >90% .O2 [oxygen] at 5L/min [liters per minute] via NC [nasal cannula], Continuously for COPD every shift. Resident to discharge home 7/22/23. During an interview on 8/2/23 at 12:28 p.m. with CG, CG stated she has not been his (Resident 1) caregiver since she broke her (CG) hip in 2019. During an interview on 8/3/23 at 11:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse who discharged Resident 1. LVN 1 stated she gave him his [Resident 1] medication in the bubble packs, everything that was sent from the pharmacy, she stated she was not aware of the contents of the medication bag, and she stated she did not open it. LVN 1 stated Resident 1 was alone and had no caregiver. LVN 1 verified there were no documentation of discharge instruction was provided and if Resident 1 understood the discharge instructions. During an interview on 8/8/23 at 3:03 p.m. with DSS, DSS stated, [CG] had not been answering her phone and I am not aware that [CG] had not been his caregiver since 2019. We did not check the house, I was informed by my DON that the resident [1] was admitted to the hospital, and she [DON] said he [Resident 1] did not have an AC [air conditioning] in his house, and he had a heat stroke [heat-related illness - the body temperature rises] or something like that [sic]. During a review of Resident 1's Minimum Data Set (MDS - comprehensive assessment tool), dated 6/21/23, the MDS indicated, Resident 1's BIMS (Brief Interview for Mental Status - screening tool for cognition, ability of the brain to think) was 10 (score of 8-12 means moderate cognitive impairment). The MDS Section G Functional Status indicated, Resident 1 needed one-person physical assist for bed mobility, transfer, and dressing. During a review of Resident 1's hospital Progress Notes, dated July 31, 2023, the Progress Notes indicated, Patient [Resident 1] is not able to care for himself and it would be unsafe to discharge him home without someone caring for him, plan is Hospice. During a review of Resident 1's hospital Discharge Summary (DS), dated August 2, 2023 (Resident 1 stayed 12 days in the hospital), the DS indicated, Discharge Plan: Patient [Resident 1] discharge to SNF, on Hospice. During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, dated October 2022, the P&P indicated, The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: d. The degree of caregiver/support person availability, capacity, and capability to perform required care. f. What factors may make the resident vulnerable to preventable readmissions, and g. How those factors will be addressed.

Based on interview and record review, the facility failed to ensure four of four residents (Resident 1, Resident 2, Resident 3, and Resident 4) were provided nursing care when the nursing care unit they were in (a single, 4-bed isolation room known as the red zone, where Covid-19 positive residents were housed) went unstaffed for a period at least sixty (60) minutes. 1. This failure had the potential to result in Resident 1's fall to the floor, and, 2. The failure had the actual result of no staff responding to Resident 1 as she laid on the floor, for approximately 30 minutes, which required Emergency Medical Services (EMS) to be summoned by her roommate, Resident 2, due to no facility staff being aware of the fall, and, the actual result of untimely incontinent care provided to four of four residents (Resident 1, Resident 2, Resident 3, and Resident 4) as they lay in urine-soaked incontinent briefs and bed linens while the red zone went unstaffed. Findings: 1. During a review of a facility document, dated 8/29/21, titled Investigation Alleged Abandonment of Post [IAAP], the IAAP indicated, that The administrator. was made aware that a [Licensed Vocational Nurse (LVN) 1] in the red zone had left her post sometime after 7am on [8/29/21]. Her replacement took over around 8am. The document was written by the Administrator. A follow-up facility document, dated 9/2/21, titled Investigation Alleged Abandonment of Post [IAAP], the IAAP indicated, LVN 1 . had left her post shortly after 7am on 8/29 [8/29/21]. The document was written by the Administrator. During a review of Resident 1's Admission Record (AR), (undated), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 8/24/21, the MDS indicated, Resident 1's cognitive skills (cognition refers to conscious mental activities and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS indicated Resident 1 required extensive assistance to move about in bed and for toileting, and required the physical assistance of one person. During a review of the facility document titled, Detail Time Report, dated 8/28-29/21, for LVN 1, it indicated LVN 1's In Time was at 6 PM on 6/28/21, and Out Time was at 7:30 AM on 8/29/21. During a phone interview, on 9/17/21, at 4:20 PM, with LVN 1, LVN 1 hung up the phone when asked to give her account of the events of 8/29/21. During an interview, on 9/23/21, at 12:40 PM, with Resident 2, Resident 2 stated that on 8/29/21, she heard Resident 1 fall, and saw that the bed across from her, belonging to Resident 1, was empty. Resident 2 stated that she tried to ring her call bell and call for the nurse but nobody came. Resident 2 stated that after fifteen (15) minutes of continuously calling the nurse, she decided to call 911 herself. This activated EMS, which dispatched an ambulance to the facility. During a review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 1's cognitive skills for daily decision making were intact. During an interview, on 9/23/21, at 12:47 PM, with Resident 4, Resident 4 stated that she saw Resident 1 walk towards the window and fall to the floor with a bedside table on top of her. Resident 4 stated that she called the nurses for help but nobody came. During a review of Resident 4's MDS, dated [DATE], the MDS indicated, Resident 4's cognitive skills for daily decision making were intact. During an interview, on 9/23/21, at 1:12 PM, with the Administrator, the Administrator stated that there was no Certified Nursing Assistant (CNA) assigned in the red zone nursing unit with LVN 1 to assist her with the four residents (Resident 1, Resident 2, Resident 3, and Resident 4). The Administrator stated that after LVN 1 had left the red zone, there were no staff left in there to care for the four residents. The Administrator stated the outcome of this was that Resident 1 fell . The Administrator stated that he did not care that LVN 1 had another job to go to, and that LVN 1 was not supposed to leave, that's not how we run things here. The Administrator stated when Resident 1 fell , it was a negative outcome. During an interview, on 9/23/21, at 3:22 PM, with LVN 2, LVN 2 stated that on 8/29/21 she started her shift at 7 AM. LVN 2 stated she was instructed to take over the care of the four residents in the red zone on 8/29/21, at 8:30 AM. LVN 2 stated that when she arrived in the red zone, she witnessed ambulance personnel with Resident 1 on the gurney (a wheeled stretcher used for transporting hospital patients). LVN 2 stated, Resident 1 would not have fallen if she and Certified Nursing Assistant (CNA) 1 were there. During an interview with CNA 1, on 9/23/21, at 3:29 PM, CNA 1 stated that on the morning of 8/29/21, the charge nurse told her to go to the red zone at 8:30 AM. CNA 1 stated when she got in the room, Resident 1 was in a gurney, and the paramedics where there already. During a review of the Ambulance Service Record (ASR), from EMS, dated 8/29/21, the ASR indicated, Per roommates on scene, pt [patient, Resident 1] had a fall approx 30 mins ago, roommates state no staff has been in to check on her or help. The ASR indicated, pt found lying on the floor in water in room, there is electrical around pt with water covering the floor. pt is cold to touch and seeming lethargic [slow to respond]. pts vitals taken and bp [blood pressure] noted to be low. all others wnl [within normal limits]. pt transported to the hospital . The ASR indicated that call received at 8:04 AM, and was Requested by [a] bystander. The ASR indicated EMS was at patient [at] 8:08 AM, and Depart[ed] Scene [at] 8:29 AM. During a review of Resident 1's clinical record, the Progress Notes, dated 8/29/21, at 9:15 AM, indicated, . received call to report to red zone, upon arrival to red zone CNA [Certified Nursing Assistant] and ems were present resident was strapped to gurney. ems stated they were called because a patient had fallen and needed assistance. The Progress Note was written by LVN 2. During a review of facility's policy and procedure (P&P) titled, Staffing, dated 10/1/17, the P&P indicated, The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans and facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. During a review of Resident 1's Admission Record (AR), (undated), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's MDS, dated [DATE], the MDS indicated, Resident 1's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 1 required extensive assistance to move about in bed and for toileting, and required the physical assistance of one person. During a review of Resident 2's AR, (undated), the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 2 required extensive assistance with bed mobility, transfers and toileting. During a review of Resident 3's AR, (undated), the AR indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's MDS, dated [DATE], the MDS indicated, Resident 3's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 3 required extensive assistance with toileting. During a review of Resident 4's AR, (undated), the AR indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 4's MDS, dated [DATE], the MDS indicated, Resident 4's cognitive skills for daily decision making were intact. The MDS indicated Resident 4 required limited assistance with toileting. During an interview, on 9/23/21, at 1:12 PM, with the Administrator, the Administrator stated that there was no Certified Nursing Assistant (CNA) assigned in the red zone with LVN 1 to assist her with the four residents (Resident 1, Resident 2, Resident 3, and Resident 4). The Administrator stated that after LVN 1 had left the red zone, there were no staff left in there to care for the four residents. During an interview with LVN 2 on 10/18/21, at 12:30 PM, LVN 2 stated that when she arrived in the red zone at 8:30 AM, on 8/29/21, the three (Resident 2, Resident 3, and Resident 4) remaining residents of the red zone were incontinent and needed to be changed. LVN 2 stated that Resident 3 and Resident 4's bed linens were also wet, as urine has soaked through the adult incontinent briefs they were wearing. LVN 2 stated that after the paramedics had left with Resident 1, she noted that her bed was also wet with urine. During a review of facility's policy and procedure (P&P) titled, Staffing, dated 10/1/17, the P&P indicated, The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans and facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services.

(Note: Mechanical lifts are assistive devices used in healthcare facilities that allow caregivers to lift a resident and transfer them with a minimum of physical effort. Commonly used brands are Arjo, Medline, and Hoyer. Each operate by hooking onto and lifting a sling that is positioned under the resident. In the below deficiency, the brand-name Hoyer is used by facility staff to describe mechanical lifts in general, regardless of the actual manufacturer.) Based on observation, interview, and record review, the facility failed to safely transfer one of one residents (Resident 1) from her bed to her wheelchair, when the wrong sling was used on a mechanical lift. This failure resulted in Resident 1 falling to the floor and fracturing her right hip, leading to pain and surgical repair. Findings: During a review of Resident 1's Progress Note, dated 11/5/20, at 2:53 PM, the Progress Note indicated during transfer from bed to (wheelchair) with Hoyer lift . resident had a fall. four staff members in room at time of fall. cna (Certified Nursing Assistant) and nurse transferring resident to chair via Hoyer. while pulling Hoyer away from bed to (wheelchair) resident fell hitting the floor with her bottom. sling hooks unhooked from Hoyer's center hook. resident slid out of sling from the bottom. hooks still connected to the top hooks. stated her bottom hurt with pain 6/10. new orders for x-ray. Licensed Vocational Nurse (LVN) 1 wrote the Progress Note. During an interview on 11/24/20, at 9:36 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated that staff was rushing to try and get Resident 1 ready for her [MEDICAL TREATMENT] (process that filters the blood) appointment, when Resident 1 fell from a lift. CNA 1 stated that while Resident 1 was on the lift, Resident 1 was placed in a sitting position and the sling straps slipped off, causing Resident 1 to fall to the floor. CNA 1 stated that Resident 1 needed to be on a special [MEDICAL TREATMENT] sling that has loop straps on the top and bottom, because the [MEDICAL TREATMENT] sling is compatible with the [MEDICAL TREATMENT] center's Hoyer lift. CNA 1 stated that Resident 1 was on the correct sling that she needed for [MEDICAL TREATMENT], but stated, It was the wrong machine, I'm not gonna lie. The [MEDICAL TREATMENT] sling goes with a specific machine. During an interview on 11/24/20, at 9:57 AM, with CNA 2, CNA 2 stated that she oversaw the mechanical lift controls during Resident 1's transfer. CNA 2 stated that when Resident 1 was placed in the sitting position, the sling slipped and Resident 1 fell to the floor, next to the bed. CNA 2 stated, everyone was rushing because transportation was waiting and nobody paid attention to their part. At that time we were only using one kind of machine. Now we have a new Hoyer lift. CNA 2 stated that she was not sure if the sling was applied the proper way. During a concurrent observation and interview on 11/24/20, at 10:07 AM, with CNA 2, in a resident hallway, two of the facility's mechanical lifts were noted. One was a Medline brand, model MDS700EL; the second was an Arjo brand, model Maxi Move. No Hoyer branded mechanical lift was observed. CNA 2 stated that the facility's Arjo Maxi Move was the lift that was used on the day of Resident 1's fall (not a Hoyer brand lift, as previously described by LVN 1 and CNA 1). CNA 2 stated that they used the Arjo Maxi Move with the dark blue [MEDICAL TREATMENT] sling to transfer Resident 1 to the wheelchair. CNA 2 demonstrated how the dark blue [MEDICAL TREATMENT] sling was attached to the Arjo Maxi Move. CNA 2 draped the top two sling loops over the top positioning handles of the Arjo Maxi Move, and then slid the bottom two loops of the sling onto a straight bar that was positioned below the positioning handles. No fasteners were noted to keep the [MEDICAL TREATMENT] sling loops in place. CNA 2 then demonstrated how the bottom sling loops slid from the Arjo lift bar when the Arjo lift was put into a sitting position. CNA 2 demonstrated how the teal-colored Arjo sling attaches to the Arjo Maxi Move with a special plastic clip, that slides over a small metal lug, for the sling to be properly secured. The Arjo Maxi Move was observed to have Plastic Snap Slings Only! written on it with Sharpie marker. CNA 2 stated that this was written after Resident 1's fall. The second mechanical lift observed was from Medline, model MDS700EL. CNA 2 stated that this is the correct lift that is to be used with the dark blue [MEDICAL TREATMENT] sling. The Medline lift was observed to have four hooks that can securely hook the loops from the [MEDICAL TREATMENT] sling. The Medline mechanical lift was also noted to have writing on it from a Sharpie marker that read, [MEDICAL TREATMENT] and Blue Slings Only. CNA 2 stated that this was written on the Medline lift after Resident 1's fall. During an interview on 12/4/20, at 2:10 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that there were 2 LVN's (LVN 1 and MDS 1) and 2 CNA's (CNA 1 and CNA 2) assisting Resident 1 at the time of Resident 1's fall on 11/5/20 at approximately 2:53 PM. LVN 1 stated that Resident 1 was in the sling when the hooks from the bottom slipped off' and Resident 1 fell and hit her bottom. LVN 1 stated that Resident 1 fell from the Arjo lift due to the use of an improper sling. LVN 1 stated that she had never used this type of sling with the Arjo Maxi Move lift before. LVN 1 stated that after Resident 1's fall she assessed Resident 1 and called Resident 1's physician to obtain orders. During an interview on 12/4/20, at 2:15 PM, with Minimum Data Set Nurse (MDS) 1, MDS 1 stated that she was walking down the hall when she noticed that staff needed help with Resident 1. MDS 1 stated that the staff was trying to quickly get Resident 1 onto her wheelchair because Resident 1's ride to the [MEDICAL TREATMENT] center was waiting outside. MDS 1 stated that she helped get Resident 1 on the sling and then proceeded to get the wheelchair. MDS 1 stated that Resident 1 was in the sling when it slipped off the middle part of the Hoyer. MDS 1 stated that the incorrect sling was used. During a review of Resident 1's Progress Note, dated 11/9/20, at 7:18 PM, the Progress Note indicated that Resident 1 was having pain to her right side while turning in bed, and that Resident 1 stated that she only had this pain since the fall on 11/5/20. Pain reducing medication was administered. LVN 1 wrote the Progress Note. During a review of Resident 1's Progress Note, dated 11/11/20, at 1:32 PM, the Progress Note indicated that Resident 1 was complaining of pain to her legs and that pain medication was ineffective. Physician was made aware and ordered x-ray of pelvis and knees. During a review of Resident 1's Radiology Results Report (RRR), dated 11/12/20, the RRR indicated that an x-ray of Resident 1's pelvis (hips) were obtained. This report indicated that Resident 1 had a fracture to her right hip. During a review of Resident 1's History and Physical (H&P) from a local acute care hospital, dated 11/13/20, the H&P indicated that Resident 1 presented to the emergency department with complaints of pain to her right hip, worsening with movement. Medical Doctor (MD) 1 concluded that Resident 1 had a right [MEDICAL CONDITION] and ordered for Resident 1 to have a consult with MD 2, a bone surgeon. During a review of Resident 1's Consultation from a local acute care hospital, dated 11/13/20, the Consultation indicated that MD 2 assessed Resident 1 and recommended that she have a right hip hemiarthroplasty (a surgical procedure that restores hip function). During a review of Resident 1's Operative Report (OP) from a local acute care hospital, dated 11/17/20, the OP indicated that Resident 1 was taken to the operating room for a surgical procedure to repair her right [MEDICAL CONDITION]. The OP indicated MD 2 inserted a metal rod with a ball on one end into Resident 1's thigh bone and reconnected it to her hip. During a review of the facility's policy and procedure (P&P) titled, Lifting Machine, Using a Mechanical, dated 2001, the P&P indicated, in the section steps and procedures line 12. Attach sling straps to sling bar according to manufacturer's instructions. 13. Lift the resident two inches from the surface to check stability of attachments. During a review of the Arjo lift manufacturer's instructions (MI) titled, Maxi Move Instructions for Use, dated January 2014, the (MI) indicated in the Safety Instruction section to Use only ArjoHuntleigh slings and stretchers that have been specifically designed for the Maxi Move. In the section Product Description/Function there is a Warning that states Only use ArjoHuntleigh supplied slings and stretchers that are designed to be used with MAXI MOVE to prevent fall risk and injuries. During a review of the Medline mechanical lift website, at punchout/medline.com/products/Powered-Base-Patient-Lifts/Lifts/Z05-PF #mrkDocumentation, an instructional video indicated, Always use only Medline slings with Medline lifting equipment. Mixing slings and equipment from different manufacturers creates an untested , unproven combination. This is a liability risk should an accident occur.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan to reflect the care needs and level of assistance for Activities of Daily Living (ADL) for one of two sampled residents (1) when one certified nursing assistant (CNA 1) transferred Resident 1 alone without the assistance of other staff members. This resulted in Resident 1 sustaining fractures (broken bones) to both lower legs. Findings: During a review of the clinical record for Resident 1, the Progress Notes for Resident 1 dated 4/12/17, at 4:08 PM, indicated Resident (Resident 1) complaining of extreme severe pain on BLE (both lower extremities) .Resident informed the nurse that during transfer last night (4/11/17) she stated her legs got tangled and when staff (Certified Nursing Assistant 1-CNA 1) put her to bed she heard both legs pop. The Progress Notes dated 4/13/17, at 5:25 AM, indicated Resident 1 was admitted to the hospital with [REDACTED]. The hospital progress note for Resident 1 dated 4/12/17, indicated Resident 1's left and right legs had proximal tibia fractures and a non-displaced proximal fibular fractures (bone fractures occurring at the shinbone area that included both bones of the lower leg called the tibia and fibula which affect the knee joint, stability, and motion). Another Progress Notes dated 4/14/17, indicated under RADIOGRAPHS .She (Resident 1) has minimally displaced bilateral tibial plateau fractures with significant osteopenia (a condition that occurs when the body does not make new bones as quickly as it reabsorbs the bone) of the bone. The Minimum Data Set (MDS-a comprehensive assessment tool) dated 2/17/17, indicated under Functional Status, Resident 1 needed two or more persons physical assistance with transfers (transfers such as from wheelchair to bed) because Resident 1 had impaired movement to both of her legs which put her at risk for injury. The CNA-ADL TRACKING FORM (ADL-Activities of Daily Living-any daily activity performed for self-care such as feeding ourselves, bathing, dressing, grooming, work, homemaking, and leisure. The ability or inability to perform ADLs can be used as a very practical measure of ability/disability in many disorders. The tracker is a record of ADLs and other services performed for the resident by the staff.) for Resident 1 from the dates of 4/1/17- 4/11/17, indicated Resident 1 was totally dependent on staff and required two or more persons to physically assist her with transfers. The care plan for FUNCTIONAL MOBILITY/ADL'S for Resident 1 revised 12/12/15, indicated Resident 1 had impaired physical mobility, had a limitation in independent purposeful physical movement of her legs, and required extensive assistance to total dependence with ADL's. However, the care plan did not reflect the MDS comprehensive assessment which indicated the level of assistance required for Resident 1's transfers included two or more staff members to physically assist Resident 1 with transfers. During an interview with the Director of Nursing (DON), on 4/24/17, at 1:26 PM, she stated Resident 1 was alert and oriented, had a [DIAGNOSES REDACTED]. The DON stated CNA 1 was transferring Resident 1 from the wheelchair to the bed when Resident 1's legs became tangled together because of her contractures and CNA 1 untangled Resident 1's legs. The DON stated Resident 1 complained of pain and the facility transferred the resident to a local acute hospital. The DON stated the facility was informed Resident 1 sustained fractures to both her legs. During a concurrent observation and interview with Resident 1, on 4/24/17, at 1:50 PM, with Licensed Nurse 1, Resident 1 was lying in bed and was noted with braces (braces are medical equipment used to support the leg, hip, knee, ankle or foot and can be used for a range of needs from stability to immobilization) to both her lower legs. Resident 1 stated she sustained broken bones to both of her legs and she was having a lot of pain. During an interview with CNA 2, on 4/24/17, at 2:58 PM, he stated that before the incident (with CNA 1 and Resident 1 on 4/11/17), the CNAs were transferring Resident 1 with two persons physical assist and using a Hoyer lift (device used to transfer residents). During an interview with the MDS Nurse (MDSN) and review of Resident 1's clinical record, on 4/24/17, at 3 PM, the MDSN was informed when the incident happened, CNA 1 transferred Resident 1 from the wheelchair to the bed by herself. However, the MDS and the CNA-ADL tracking form, indicated Resident 1 needed two or more persons physical assist with transfers. The MDSN was also informed the care plan for Functional mobility/ADL's did not indicate the level of assistance required for Resident 1's transfers, to guide the staff caring for Resident 1 and avoid confusion over Resident 1's level of assistance with transfers. The MDSN reviewed the clinical record and verified the findings. The MDSN was also asked what was the facility's process regarding care planning Resident 1's ADL's and how would the nurses communicate Resident 1's level of assistance with transfers to the CNAs. The MDSN did not provide any further information. During an interview with CNA 1, on 4/27/17, at 4 PM, CNA 1 stated she transferred Resident 1 from the wheelchair to the bed by herself. CNA 1 stated she sat Resident 1 on the side of the bed and Resident 1's legs became tangled together. CNA 1 stated she placed Resident 1 in a lying position and untangled the resident's legs. During an interview with CNA 1, on 5/16/17, at 12:52 PM, she stated before the incident happened, she was transferring Resident 1 by herself. CNA 1 was asked if she was aware of Resident 1's care plan for ADL's. CNA 1 stated before the incident she was not reading Resident 1's ADL care plan. CNA 1 stated It's my fault, I didn't read. The facility undated policy and procedures titled RESIDENT ASSESSMENT AND CARE PLANNING indicated under Purpose To identify resident needs and to provide a data base to be used in planning the comprehensive nursing care to meet the resident's individual needs and to assist the resident in reaching the highest level of independence possible. Indicated under Policy .The assessment information will be used to develop a comprehensive resident care plan to allow the resident to reach his or her highest practicable level of physical, mental and psychological functioning.

Based on observation, interview, and record review, the facility failed to provide effective pain medication in a timely manner for two random residents (21 and 22). This failure resulted in unrelieved pain for Resident 21 and Resident 22. Findings: 1. During the initial tour on 2/16/16, at 7:05 AM, in Hallway A, Resident 21 was observed lying in bed, with a grimacing facial expression. A black splint was observed on her right wrist area and a black orthotic device (boot) was on her left foot and lower leg. During an interview with Resident 21, on 2/16/16, at 7:05 AM, she stated she was dumped here (at the facility) the previous night and had not received any medication that relieved her pain. She stated she had just had an open lung biopsy (surgery) and was at this facility for post-operative rehabilitation care. Resident 21 stated she had fallen prior to admission and fractured (broke) her right wrist. She stated the boot to her left foot and leg was related to her diabetes (a serious medical life-long disease that affects the way the body handles sugar in the blood and has many complications). Resident 21 stated the facility staff had been unable to obtain the pain relief medication ordered by her physician and she had been in pain all night. She stated the facility gave her some (non-narcotic) pain medication around 9 PM last night (three hours after she was admitted ), but that it did not come close to relieving her pain. She stated the facility informed her they were trying to obtain the narcotic pain medication but were having difficulty getting the order or obtaining it from the pharmacy. During a review of the clinical record for Resident 21, the [MEDICAL CONDITION] and Critical Care Consultation Report transcribed 2/10/16, at 3:32 PM, indicated Resident 21 had a past medical history of [REDACTED]. The Progress Notes dated 2/15/16, at 6:30 PM indicated Resident 21 was admitted to the facility and had no complaints of pain at that time. The Progress Notes dated 2/16/16, at 8:57 AM, General Note, indicated the resident stated she was in .pain on admission. During a review of the clinical record for Resident 21, the Order Summary Report dated 2/15/16, at 10:25 PM, indicated the following pain medication orders [REDACTED]. During a review of the clinical record for Resident 21, the Medication Administration Record [REDACTED]. One tablet of [MEDICATION NAME] 800 mg was documented as given at 9:24 PM, for moderate pain, and was noted as ineffective for pain relief. No other actions were taken to relieve the resident's pain at that time. On 2/16/16, at 8:12 AM, she received [MEDICATION NAME] 800 mg for a pain level of five out of ten, which was indicated as effective on the MAR. She did not receive the prescribed narcotic pain medication for severe pain (six out of ten level) until 2/16/16, at 4 PM, 10 hours after her admission to the facility. During an interview with Licensed Vocational Nurse (LVN) 2, on 2/18/16, at 3:30 PM, she stated when a resident is admitted from a hospital and in pain, the facility will request the transferring hospital to give pain medication prior to coming and would need to obtain a prescription (physician order) from the doctor. LVN 2 stated the facility must fax a prescription for a narcotic pain reliever to the pharmacy, who must contact the ordering physician to confirm the order before the pharmacist can provide the medication for the resident. LVN 2 did not indicate whether Resident 21 had received medication from the hospital prior to her transfer to this facility. During an interview with LVN 3, on 2/18/16, at 3:48 PM, he stated when a resident was admitted in pain the facility would fax the narcotic pain medication prescription to the pharmacy. If there was no prescription the facility would call the pharmacy who must contact the physician. LVN 3 stated at night there can often be an issue when the facility or pharmacy was unable to contact the physician to confirm the order. LVN 3 stated he was on duty when Resident 21 was admitted and the resident's [MEDICATION NAME] had not been received by the time his shift was over. LVN 3 stated I do know they got a hold of the doctor eventually and I know her medications came in the next day. He stated he remembered giving the resident an [MEDICATION NAME] as a standing order for pain, as they had not received the approval from the pharmacy to provide the [MEDICATION NAME]. He did not indicate any other actions were taken to relieve the resident's pain when the [MEDICATION NAME] was ineffective. Resident 21 did not receive the prescribed [MEDICATION NAME] 5-325 mg two tablets as indicated for severe pain until the late afternoon following her admission day (2/16/16 at 4 PM). During an interview with the Director of Nursing Services (DNS), on 2/19/16, at 9:45 AM, she stated when a resident is admitted with a narcotic order, barriers can occur based on day of the week or time of day. The DNS stated We prefer a hard script (paper prescription rather than electronic) so we can fax (the prescription) to the pharmacy . sometimes we fax and then call the pharmacy, and they say they don't have it in their system, we have to re-fax the order. The DNS stated There is not really a policy for this and additional inservice will need to be provided to the nursing staff (to ensure residents receive their pain medications as ordered). 2. During the Quality of Life Group Interview, on 2/17/16, at 2 PM, Resident 22 stated that she had been in pain for two days about 1.5 weeks ago because the facility did not have her regular pain medication ([MEDICATION NAME] - a narcotic pain medication) available. During an interview with Resident 22, on 2/18/16, at 10:05 AM, she stated about 1.5 weeks ago, she requested her regular pain medication, [MEDICATION NAME]. The resident stated she was told the facility did not have the medication and they had been faxing requests to the doctor with no response. Resident 22 stated she waited two days until her regular pain medication was available and her pain resolved. She stated she was unable to sleep due to pain until she received her regular pain medication ([MEDICATION NAME]). During an interview with Registered Nurse (RN) 1, on 2/18/16, at 3:30 PM, RN 1 stated the facility's process to obtain a narcotic pain medication for a resident included the following: .if we don't have the order the Pharmacy has to call the doctor to OK. It can take a long time to get .a day or a few hours .mostly weekends or holidays are hard. We can call the facility doctor for an order if the other doctor does not call back .I have done that (called the facility doctor). There is no policy on how long to wait .it depends on how much pain the person is in. We can give them Tylenol if they are not allergic. During an interview with LVN 1 and a clinical record review for Resident 22, on 2/19/16, at 9:45 AM, the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Tylenol 325 mg, two tablets for mild pain with a pain scale of 1-3, was given to Resident 22 on 2/12/16, at 8:16 PM, for a pain level of six out of ten and again on 2/13/16, at 7:49 AM for a pain level of 10 out of 10 (severe pain) and was documented as ineffective on 2/13/16. No other action was indicated to relieve Resident 22's pain on 2/12/16 and 2/13/16. On 2/13/16, at 10:42 AM, [MEDICATION NAME] 10-325 mg, one tablet was given to Resident 22 for her pain level assessed at a nine out of ten pain level, as a one time dose taken from the facility's E-kit (a facility's medication kit that contains medications to be used on an emergency or urgent basis). The MAR indicated [REDACTED]. Resident 22 had not received [MEDICATION NAME] for her effective pain relief for a 42 hour period. LVN 1 stated there had been delays in authorizations to refill medications at times . especially on the weekends and holidays (2/13/16 was a Saturday). During a review of the clinical record for Resident 22, the Progress Notes, dated 2/12/16, at 11:46 PM indicated Resident 22's as needed medication .[MEDICATION NAME] for pain .still awaiting for valid from MD . The progress note dated 2/13/16, at 2 PM, indicated NOC (night) shift charge nurse informed nurse that [MEDICATION NAME] has not come in from pharmacy. At approx. 7:45 AM resident (22) complaining of pain 10/10 (worst pain imaginable/very severe or horrible) given Tylenol PRN (as needed) via md (physician) order with little effectiveness. Writer call pharmacy and was informed waiting for written prescription. During an interview with the DNS, on 2/19/16 at 9:45 AM, the DNS stated one of the facility's barriers to obtain narcotic pain medication was the time of day an order was received. After hours orders could be more difficult to obtain. She stated the facility preferred to receive a prescription from the transferring hospital for a new resident. The DNS stated it was easier to obtain (the narcotic) if the prescription came from an acute care hospital. She stated the facility had to fax medical orders to the pharmacy by 8 PM, and follow-up with telephone calls. If the pharmacy indicated they did not have the prescription, the facility would have to refax the prescription. The DNS stated the facility does not document when the staff called the Pharmacy .it's just verbal. She stated We call the facility doctor between two to four hours (of not receiving the medication) .there is no policy .it is education with my nurses .I am very sorry .it is additional training for my nurses. The facility policy and procedure titled Pain Management Guideline, undated, indicated under Guideline: Functions of appropriate pain management include .Intervening to treat pain before the pain becomes severe . The pain rating scale is indicated as Numeric Rating Scale: The patient/resident identifies pain on a 0-10 scale, 0=no pain and 10=worst pain imaginable (very severe or horrible).

Based on observation, interview, and record review, the facility failed to ensure an effective infection control program was established when the facility failed to: 1. Investigate, prevent and control the spread of scabies (according to Center for Disease Control (CDC) human scabies is caused by an infestation of the skin by the human itch mite. The tiny scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Scabies can spread rapidly under crowded conditions where close body contact is frequent. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks) in the facility for four of four sampled residents (1, 2, 3, and 4) and four of four facility staff (Licensed Nurse (LN) 1, Certified Nursing Assistants (CNA) 1, 2, and 3). 2. Develop a care plan for four of four sampled residents residents (1, 2, 3, and 4) who were receiving treatment for [REDACTED]. 3. Ensure one of one housekeepers (HS) and one of one laundry staff (LS) were properly trained and knowledgeable about their roles in scabies prevention and control for four sampled residents (1, 2, 3, and 4) being treated for [REDACTED]. 4. Report the case of suspected scabies to the County of Public Health. These systemic failures placed all ninety two residents in the facility at risk of acquiring scabies. Immediate Jeopardy (IJ) was called with the Administrator and Director of Nursing (DON), on 12/17/14, at 11:45 AM, due to the facility's failure to investigate, prevent and control the spread of scabies in the facility. On 12/22/14, at 4:25 PM, with an acceptable plan of correction, the IJ was abated with the Administrator, Director of Nursing, Director of Education and Training, and Area Vice President. Findings: According to the document written by the California Department of Public Health Division of Communicable Disease Control, dated 3/2008, it indicated for the "PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA LONG-TERM CARE FACILITIES", under the subheading for the development of a "SCABIES PREVENTION PROGRAM," it read in part, "Long term care facilities should have a scabies prevention program...When scabies is suspected, an immediate search for additional cases should be initiated." Under the subheading for developing a "SCABIES CONTROL PROGRAM," it read in part, "A scabies control program should be developed and approved by the infection control committee. The program should designate a physician such as the medical director who will act as the program coordinator. The physician should be given the authority to notify attending physicians, perform diagnostic procedures such as skin scrapings and to order [MEDICATION NAME] and therapeutic treatments on exposed residents. The infection control practitioner should be responsible for (1) identification of contacts of symptomatic case(S). (2) prevention of transmission, (3) treatment of [REDACTED]." 1a. During a concurrent observation and interview with Resident 1, on 12/16/14, at 2:15 PM, there was no Personal Protective Equipment ((PPE)-specialized clothing including gowns, gloves, masks or equipment worn by an employee for protection against infectious materials) noted outside the room. CNA 1 was also in the room and provided privacy by pulling the privacy curtain. Resident 1 stated she could just show the rash while sitting in her motorized wheelchair. Resident 1 exposed the areas with the rash while sitting in her motorized wheelchair and there was a reddish/brownish raised rash area extending from her abdomen, underneath both breast, and under both arms. Resident 1 stated, the rash started months ago, when there were five residents playing Bingo and making statements they had a rash with severe itching. Resident 1 also stated, after a few days she started having itchiness and a rash, and her roommate (Resident 2) also has the same rash and "Her rash is really bad." 1b. During a concurrent observation and interview with Resident 2, on 12/16/14, at 2:25 PM, she was observed laying in her bed, scratching her neck and face aggressively. Resident 2 stated, "It's very itchy." She was noted with a reddish raised and crusted rash extending from her face, neck, ears, upper and lower body, both upper and lower extremities. When Resident 2 was asked about the rash she stated, she has had the rash for months and the staff applied some cream, "I wish they put more (referring to the application of the cream) because I'm scratching my skin off my bones." During a concurrent observation and interview with CNA 1, on 12/16/14, at 2:35 PM, outside of Resident 1 and Resident 2's room; CNA 1, CNA 4, and CNA 5, were noted coming in and out of the room, without wearing PPE. CNA 1 was asked if Resident 1 and Resident 2's room was on contact isolation precautions. CNA 1 stated, "No". The facility policy and procedures titled "Isolation-Initiating Transmission-Based Precautions" revised 8/2012, indicated under the subheading for Policy Interpretation and Implementation "...5. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall: a. Ensure that protective equipment (i.e., gloves gowns, masks, etc.) is maintained outside the resident's room so that everyone entering the room can access what they need; b. Post the appropriate notice on the room entrance door, so that all personnel and staff will be aware of precautions, or be aware that they must see a nurse to obtain additional information about the situation before entering the room. c. Ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room..." During an interview with the DON, on 12/16/14, at 2:09 PM, outside of Resident 1 and Resident 2's room, the DON was asked if Resident 1 and Resident 2's room was on contact isolation precautions. The DON stated "No" because Resident 1 just had the [MEDICATION NAME] cream (a topical agent for the treatment of [REDACTED]. The DON also stated Resident 1, had a skin scraping (to examine under a microscope for mites, eggs, or mite fecal matter) performed and the facility was waiting for the results. She was asked what procedures the facility implemented to prevent and control a scabies infestation. The DON could not provide any further information that the facility had taken actions to prevent the spread of scabies. During an interview with the DON, on 12/16/14, at 2:40 PM, in regards to Resident 1 and 2's rashes, the DON stated she did not assess Resident 1 nor Resident 2's rash, but was aware these two residents were treated with [MEDICATION NAME]. She also stated Treatment Nurse (TN) 1, had been updating her in regards to the residents' rashes. The DON was asked about the facility's policy and procedures for Infection Control (IC) to prevent and control a scabies outbreak, the DON stated she did not know. No further information regarding prevention and control of scabies was provided. The DON was asked again what policies and procedures did the facility have in place to prevent the spread of scabies. The DON stated, the nurses were calling the physician to obtain orders for a cream. No further information was provided. During an interview with the Infection Control Nurse (ICN), on 12/16/14, at 4 PM, she stated she was aware Resident 1 and Resident 2 had the [MEDICATION NAME] treatment; however, when she asked the nurse about the residents' skin condition, the nurse told her there was no confirmed [DIAGNOSES REDACTED]. During an interview with CNA 2, on 12/16/14, at 4:25 PM, she stated she was one of the CNAs taking care of Resident 2. She was aware Resident 2 had been treated with [MEDICATION NAME]. CNA 2 added whenever they have residents treated with [MEDICATION NAME] cream, the protocol is to get the resident's linens and clothes and place them in a red bag. Then endorse to the laundry staff that these items were infectious. If the laundry staff were not in the laundry room, staff would return the bag back to the resident's room and place the bag in the bathroom. The facility policy and procedures titled "Scabies", effective date 12/1/14, indicated under Pre-Treatment Procedure, "1. While the resident is being treated, remove four (4) sets of clothing from the resident's room. Bag the clothing in a bag, and send the bag to the laundry for processing. 2. Place all remaining clothes of the infected resident into a bag. Seal the bag and label "Do not open until___" (date 14 days from storage date). Take to designated storage area. Note: Coordinate these procedures between nursing and environmental services." 1c. During a review of the clinical record for Resident 3, a physician's order dated 11/29/14, read to apply "[MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to body topically at bedtime for rash until 11/30/14 at 23:59 (11:59 PM), apply from neck to toes at bedtime. Shower in the am. Clean bed and wash all linens AND apply to body topically at bedtime for rash until 12/14/14, 23:59 (11:59 PM) apply from neck to toes at bedtime. Shower in the am. Clean bed and wash all linens." During an interview with LN 2, on 12/16/14, at 4:35 PM, she stated, when she applied the [MEDICATION NAME] cream on Resident 3, she did not wear any PPE. LN 2 only wore PPE when the physician ordered isolation precautions. LN 2 stated, there was no physician's order for isolation for Resident 3; therefore, she did not wear any PPE. LN 2 also stated the facility did not treat Resident 3's roommate, because Resident 3's roommate did not complain of any rash. According to California Department of Public Health, Management of Scabies Outbreak in California Health Care Facilities, dated 3/2008, under "Controlling the Outbreak," it read: "Control of an outbreak involves a choice between treating only symptomatic cases and their known contacts or treating possible contacts including asymptomatic patients, healthcare workers, volunteers, and visitors (mass [MEDICATION NAME])... treatment of [REDACTED]. As a result, retreatment of [REDACTED]." 1d. During a review of the clinical record for Resident 4, a physician's order dated 12/7/14, indicated, "[MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to rash all over body topically one time only to rash on body and leave for 12 hours related to Rash and OTHER NONSPECIFIC SKIN ERUPTION for 1 Day give shower after 12 hours and remove [MEDICATION NAME] (sic)." Resident 4 was in a room with four other roommates. There was no documentation that Resident 4 was placed on isolation or separated from the other three roommates. During an interview with TN 1, on 12/16/14, at 3:40 PM, TN 1 stated she currently had approximately nine residents with treatments for rash and had several residents that had received [MEDICATION NAME] treatment. TN 1 was asked for the policy and procedures for IC to prevent and control a scabies outbreak. She stated she had not read it. When TN 1 was asked about the process followed when residents develop unexplained rashes, TN 1 replied, "I don't know." She also stated, she was not wearing PPE, with residents who were treated for [REDACTED]. The facility policy and procedures titled "INFECTIOUS -CLINICAL PROTOCOL" revised 10/2013, indicated under "C. Skin/Soft Tissue Infection (SSTI)...(5) Consider scabies in any resident with unexplained generalized rash. It may be helpful to consult a dermatologist (branch of medicine dealing with the hair, nails, skin and its diseases) and/or obtain scrapings for evaluation of mites, eggs, or mite feces." 1e. During an interview with LN 1, on 12/17/14, at 10:30 AM, he stated, he started seeing residents with skin rashes in 6/2014. He notified the acting DON at the time. He stated the Administrator was aware of the residents with rashes; however, the facility did not want to acknowledge there was suspected scabies in the facility. LN 1 also stated, he currently had a rash and was treated for [REDACTED]. 1f. During an interview with CNA 1, on 12/16/14, at 2:28 PM, she stated, after she gave Resident 2 a shower (cannot remember the date), two days later she developed a rash on her stomach and she treated herself with [MEDICATION NAME] cream. She also stated, she informed the nurses and administration about her rash "But they keep saying it's not scabies." 1g. During an interview with CNA 2, on 12/16/14, at 4:27 PM, she stated she also had a rash and she treated herself with [MEDICATION NAME] (another medication used to treat scabies). She had scabies in the past and she knew she had scabies and this medication ([MEDICATION NAME]) would resolve it. CNA 2 stated about two weeks ago she told the Administrator about the rash and that it might be scabies. The Administrator told her he would investigate. During an interview with the Administrator, on 12/16/14, at 4:50 PM, he stated CNA 2 did notify him of her skin rash. Administrator stated, he did not do the investigation at the time when CNA 2 reported the rash to him. 1h. During an interview with CNA 3, on 12/17/14, at 11:37 AM, she stated on 12/4/14, she had to go to a local acute hospital due to her worsening skin rash and itchiness, the hospital told her she had scabies. CNA 3 also stated, she notified the ICN on 12/4/14, that she could not come to work because she had scabies. During an interview with the ICN, on 12/17/14, at 11:30 AM, the ICN verified that CNA 3 did inform her that she was diagnosed and treated for [REDACTED]. According to California Department of Public Health Division of Communicable Disease Control dated 3/2008' indicated under "PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA LONG-TERM CARE facilities" under the subheading Identification of Contacts of Symptomatic Case(s) "As soon as a possible case of scabies is identified, the infection control practitioner should develop a contact identification list. This list should identify every resident, health care worker, visitor and volunteer who may have had a direct, physical contact with the case within the previous month. If more than one symptomatic case is identified, a separate contact list for each case may be required." The facility policy and procedures titled "Scabies," effective date 12/1/14, under "General Guidelines," it read, "7. Staff members who may have been exposed should report any rashes developing on their bodies to the Infection Preventionist or Director of Nursing Services." 2a. During a review of the clinical record for Resident 1, a physician's order dated 12/1/14, indicated "[MEDICATION NAME] Cream 5% topically, apply to skin from neck down in pm, and wash off in am repeat in 1 week 2 weeks." There was no care plan noted in the clinical record to direct the staff on appropriate interventions to prevent and control the possible spread of the infection. TN 1 verified the findings. 2b. During a review of the clinical record for Resident 2, a physician's order dated 10/26/14, indicated "[MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to entire body topically one time only related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION until 10/27/14 at 23:59 (11:59 PM)." There was no care plan noted in the clinical record to direct the staff on appropriate interventions to prevent and control the possible spread of infection. TN 1 verified the findings. 2c. During a review of the clinical record for Resident 3, a physician's order dated 11/29/14, indicated "[MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to body topically at bedtime for rash until 11/30/14 at 23:59, apply from neck to toes at bedtime. Shower in the am. Clean bed and wash all linens AND apply to body topically at bedtime for rash until 12/14/14, 23:59 (11:59 PM) apply from neck to toes at bedtime. Shower in the am. Clean bed and wash all linens." There was no care plan noted in the clinical record to direct the staff on appropriate interventions to prevent and control possible spread of infection. TN 1 verified the findings. 2d. During a review of the clinical record for Resident 4, a physician's order dated 12/7/14, indicated "[MEDICATION NAME] Cream 5% ([MEDICATION NAME]) Apply to rash all over body topically one time only to rash on body and leave for 12 hours related to Rash and OTHER NONSPECIFIC SKIN ERUPTION for 1 Day give shower after 12 hours and remove [MEDICATION NAME]." There was no care plan noted in the clinical record to direct the staff on appropriate interventions to prevent and control possible spread of infection. TN 1 verified the findings. 3a. During an interview with the Housekeeping Supervisor (HS), on 12/17/14, at 10:35 AM, he was asked if nursing staff had informed him to clean the following rooms: Resident 1's room on 12/2/14, after Resident 1 received [MEDICATION NAME] treatment, Resident 2's room, on 10/27/14, after Resident 2 received [MEDICATION NAME] treatment, Resident 3's room, on 11/30/14, after Resident 3 received [MEDICATION NAME] treatment, and Resident 4's room, on 12/8/14, after Resident 4 received [MEDICATION NAME] treatment. The HS stated, those rooms were cleaned daily with no special instructions from the nursing department and no special precautions were taken by the housekeeping department. When the HS was asked how the housekeeping department was informed if residents had infectious diseases such as scabies, he stated, "No one tells me." No further information was provided. The facility policy and procedures titled, "Scabies", effective date 12/1/14, indicated under Environmental Services: "1. Clean lobbies, lounges, etc., before resident bathing and treatment times so that "treated" residents do not use unclean areas. 2. Clean and disinfect shower rooms after all residents have received their treatment. 3. Vacuum furniture made of fabric in the residents room. Wrap the furniture in plastic and store for two (2) weeks..." The facility policy and procedures titled "HEALTHCARE SERVICES GROUP, INC. JOB TO BE DONE: CONTAMINATED ISOLATION ROOM CLEANING," dated 5/11/05, under "Steps to do Job," it read, "Before entering the room: 1) Scrub hands and arms for 3 minutes with disinfectant soap. 2) Dress on Isolation clothes: 1st- Booties 2nd- Cap 3rd- Mask 4th- Gown 5th- Gloves..." 3b. During a concurrent observation and interview with a Laundry Staff (LS), on 12/19/14, at 1:40 PM, the LS was asked if she received inservice training about scabies prevention and control, she replied, "Yes". The LS stated, the CNAs would place the dirty laundry in the soiled laundry room barrels or on the floor. When the LS was asked about her role in scabies control and prevention and how she would know if the dirty laundry was infectious or not, the LS stated, "I don't' know." The facility policy and procedures titled "Scabies," effective date 12/1/14, indicated under Laundry Department: "1. Wash four (4) changes of clothing for each affected resident and place the clothing in a plastic bag. Label it with the resident's name and store it in the clean laundry area until treatment has ended (8 to 14 hours). 2. Upon completion of treatment, return these 4 changes of clothing to the resident's room. 3. Store the resident's remaining clothing in a storage area for 14 days, without laundering it. 4. Upon completion of 14 day storage, launder and return clothing to the resident's room. 5. Wear gloves and gowns when handling contaminated laundry..." 4. During an interview with the ICN regarding scabies reporting to the local health department, on 12/16/14, at 4:10 PM, she stated the facility did not report the scabies outbreak to the County Department of Public Health. The facility policy and procedures titled "Isolation-Initiating Transmission-Based Precautions" revised 8/2012, indicated under Authority in Emergency Situations, "In an emergency, the Infection Preventionist, Administrator and/or Medical Director shall have the administrative authority, accountability and responsibility to:...b. Notify the health department of reportable diseases, as appropriate:.." According to the document written by the California Department of Public Health Division of Communicable Disease, dated 3/2008, it indicated under Outbreak Definition "a scabies outbreak can be defined as two or more patients, healthcare workers, volunteers, and/or visitors with at least one confirmed positive skin scrapings within two week period; one confirmed (positive skin scarping) and at least two clinically suspect cases identified in patients, health care workers, volunteers, and/or visitors during a two week period or at least one clinically suspect of scabies identified in patients, healthcare workers, volunteers and/or visitors within a two week period." The facility was aware that one of its healthcare workers (CNA 3) was confirmed and treated with scabies on 12/4/14 and four suspected cases (Resident 1, 2, 3, and 4) within a two-week period. The facility administration did not report the scabies outbreak to the county health department.

Based on observation, interview, and record review, the facility failed to develop a plan of care to ensure adequate supervision and monitoring for one of two sampled residents (2) who had a history of [REDACTED]. This failure resulted in a physical altercation between Resident 1 and Resident 2 on 4/19/14, requiring Resident 1 to be transferred to the acute care hospital for treatment of [REDACTED]. Findings: During a review of the "FACILITY REPORTED EVENT", dated 4/19/14, indicated that at approximately 2:20 AM, Resident 2 got up to use the restroom and when he came out of the restroom he went into the room across the hall instead of returning to his bed. A confrontation then ensued between Resident 2 and Resident 1. Both residents struck out at each other causing Resident 1 to fall and hit his left rib cage on the footboard of his bed. Resident 1 had x-rays ordered and it was identified that Resident 1 had sustained the fracture to his 7th and 8th ribs. During an observation and interview on 5/1/14, at 4:05 PM, in Resident 2's room, Resident 2 was dressed, awake, and lying in his bed. Resident 2 was asked about the altercation on 4/19/14, but he could not recall the incident with Resident 1. During an observation and interview on 5/1/14, at 4:25 PM, in Resident 1's room, Resident 1 was awake and sitting in his wheelchair. Resident 1 was observed rubbing his chest occasionally. Resident 1 was asked what happened to his chest. He stated he did not know what happened and that he only remembered that he came back from the hospital and had pain in his chest. He stated his chest was not currently painful and that it only bothers him sometimes. During an interview with the Assistant Director of Nursing (ADON), on 5/1/14, at 3:30 PM, she stated Licensed Staff (LS) 1 and LS 2 heard a commotion in the hallway on 4/19/14, at 2:20 AM. LS 1 and LS 2 went toward the direction of the noise and saw Resident 1 on the floor. The ADON further stated, the physician was notified and ordered an x-ray and the result indicated Resident 1 had fractures of the 7th and 8th ribs. Resident 1 was then sent to the acute care hospital and a police report was filed. The ADON also stated Resident 2 was placed on one to one supervision after the altercation with Resident 1. During an interview with LS 1, on 5/13/14, at 9:30 AM, LS 1 stated she and LS 2 heard a commotion on 4/19/14, around 2:15 to 2:30 AM, LS 1 stated they went to the room and found Resident 2 standing by the doorway and saying, "In my bed." Resident 1 was on the floor and his roommate (Resident 3) stated, "That man (referring to Resident 2) hit him (referring to Resident 1)." LS 1 also stated Resident 2 is confused and agitated and he hits and threatens the staff and his roommate when he is being changed. LS 1 stated, Resident 2 has acted out towards other residents before, "he thinks he owns the building and the staff are working for him." During an interview with Certified Nursing Assistant (CNA) 1, on 5/29/14, at 4:45 PM, CNA 1 stated Resident 2 can become combative when prompted to do something. He gets up and uses the restroom by himself and he will try to push me CNA 1 or "anyone". CNA 1 stated, "He wants to be independent as possible. He...requires a lot of verbal cues and he has gotten combative with me. I remember... I told him he was incontinent and he (needed) his diaper changed, he refused and pushed me away...loud and combative." During an interview with LS 3, on 5/29/14, at 4:30 PM, LS 3 stated Resident 1 is alert with confusion, "happy go lucky person." He is "very congenial, has good behavior, not seen him combative". LS 3 further stated, she has seen Resident 2 tell the CNAs to leave him alone while "making a fist". LS 3 remembered (Resident 2) was being monitored for aggressive behaviors for striking out at other residents and staff 6-8 months ago. During an interview with Resident 4, on 5/29/14, at 5:15 PM, Resident 4 has been at the facility for a year and 2 months. Resident 4 stated, "I know the resident (Resident 2)... I am concern(ed) because he is dangerous and I am a patient here for the rest of my life. It scares me..." During the review of the clinical record for Resident 4, the Brief Interview for Mental Status (BIMS) dated 3/21/14, indicated Resident 4's intact cognition with a score of 15/15. During a review of the clinical record for Resident 1, on 5/29/14, at 11:26 AM, there was no documented evidence Resident 1 had aggressive behaviors, combative or he has been physically and verbally aggressive toward anyone. During a review of the clinical record for Resident 2, the History and Physical dated 9/10/13, indicated Resident 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 11/14/13, at 12:02 PM, the Nurses Progress Notes indicated Resident 2 began yelling at the nurse and stated, "I will knock the[***]out of you and when you wake up you will tell me you are sorry." On 11/15/13, at 2:50 PM, the nurses notes indicated Resident 2 had an increase in aggression and cursing that afternoon, and hit a staff member. Resident 2 was re-directed at that time. On 11/15/13, at 4:12 PM, Resident 2 was sent to ER (emergency room ) for acts of violence and excessive aggression. On 3/3/14, at 4:12 PM, a social service note documented, "On 02/23/14 (Resident 2) was wondering (sic) into rooms. One incident he went into a room and called a gentlemen a 'n...' Staff stepped in prior to any physical altercation could take place." On 3/3/14 at 4:12 PM, a social service note indicated, "(Resident 2) is having current behavior of smearing feces on walls, putting bowle (sic) on wall, putting bowle (sic) movements in sink, etc..." On 3/7/14 at 3:16 PM, a nurse's weekly summary note indicated, "Will Refuse to be changed at times..." On 3/19/14, at 5:40 AM, a nurse's note indicated, "CNA reported to nurse that she heard resident (Resident 2) arguing with (his roommate). (Resident 2) was threatening to break (his roommate's) nose and hit him with his wooden stick... Resident (2) appeared very confused, agitated, aggressive and angry..." On 3/20/14, at 4:52 PM, a nurse's note indicated, "quarterly MDS (MDS is a comprehensive assessment of the resident to determine care needs) completed...behaviors triggered. (Resident 2) has physical behavior towards others, mostly staff but at times other residents The MDS, dated [DATE], indicated Resident 2 experiences physical and verbal behaviors directed at others at least 1-3 times a week. The MDS also indicates that Resident 2 wanders in facility approx. 1 - 3 times per week..." On 3/24/14, at 1:31 PM, an activity note indicated, "...He has a bad temper and needs to be watched during program. If he becomes aggressive toward staff or other residents activities staff will escort him to his room..." A review of the comprehensive care plan for Resident 2 was reviewed and there was no care plan developed to address the resident's physical aggression towards others to monitor and supervise the resident to ensure other residents' safety. During an interview with the MDS nurse, on 6/30/14, at 1 PM, she reviewed the clinical record and was unable to find a care plan to address Resident 2's behaviors. The facility policy and procedure titled "Behavior Management Guideline" dated 2013, read in part "Assessment/Care Planning: Licensed nursing staff completes the Plan of Care following identification... behavioral concerns... Based on review of the tracking log, a determination will be made if the resident is a danger to self or others and if so, a plan of care is developed to ensure safety and determine if the center can meet the resident/patient's needs on an ongoing basis." The facility policy and procedure titled " Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property" dated 3/1/13, read in part, "It is the policy of the Company to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property, are reported immediately... If the circumstances require it, the DNS (Director of Nursing) or ED (Executive Director)... shall remove a resident suspected of being the subject of an alleged violation to an environment where the resident's safety can be protected... If the suspected perpetrator is another resident, the DNS or ED shall separate the residents so they do not have access to each other until the circumstances of the alleged incident can be determined... The medical record should be reviewed to determine the resident's past history and condition and its relevance to the alleged violation... Appropriate steps shall be taken to prevent recurrence of the incident."

Based on observation, interview, and record review, the facility failed to: 1. Take necessary actions when one of 16 sampled residents (1) accidentally received burns from coffee being spilled on him. Such failure had the potential to allow a recurrence of a burn incident from spillage of hot beverages. 2. Ensure the back patio was free of hazardous materials, which had placed its residents and visitors at risk for preventable accidents. Findings: 1. The clinical record for Resident 1 was reviewed on at 9/25/12 at 11 AM. The "Nurses Progress Note" dated 6/27/12 indicated, ...Resident had thin and frail skin...during breakfast, resident (Resident 1) had hot coffee spilled on his left inner thigh resulting in redness and raised skin." Resident 1's physician prescribed "Silvadene Ointment, (treatment for [REDACTED]. Apply cream and cover with a dry dressing for three days." Silvadene Ointment is a topical antibiotic used to treat second and third-degree burns. Second-degree burns involved injuries to both the outer and underlying layer of the skin, causing pain, redness, swelling, and blistering. Third-degree burns destroy the outer layer of skin and the entire layer beneath. During an interview with Resident 1 on 9/26/12 at 10 AM, he stated, "Yes, I was burned by coffee, the Certified Nursing Assistant (CNA) 1 accidentally spilled it on me, it was red and hurt for a few days." During an interview with CNA 1, on 9/26/12, at 11:55 AM, she stated the resident did not spill the coffee, she further explained, "I took care of him (Resident 1) on the day of his burn. I was serving coffee from the carafe, as I pulled his (Resident 1) tray out the coffee spilled onto his lap. The Director of Staff Development told me to be more careful when serving coffee. The coffee is very hot, even when I pour it into a cup, if it splashes, I feel the burn." On 9/26/12 at 1:45 PM, the Dietary Supervisor (DS) was interviewed. She stated the facility used an institutional coffee maker that has the hot water piped into (the coffee maker from) the wall. "When we pull the coffee out of the machine it is 170 degrees (Fahrenheit F). By the time it (hot coffee) gets to a resident; it's probably about 140 degrees and that shouldn't burn them because we serve their food at that temperature." The DS stated the facility did not have a policy for beverage temperatures and it had not been a practice to check the temperatures of beverages. During an observation on 9/26/12 at 11:30 AM, in the Flower Dining Room, the DS poured coffee from a carafe into a coffee cup and checked the temperature. The temperature read 150 degrees F. During an interview with the Facility Administrator on 9/26/12 at 12 PM, she stated, "This was an isolated incident. It was an accident." When asked if the facility took any action to prevent this accident from happening again, the Facility Administrator stated the staff (CNA 1) was told to be more careful when serving coffee and there was no need to take any precautionary action. The Facility Administrator added, "We do not temp the coffee... The burn was overtreated." According to an article from the Journal of American Medicine Association (Katcher, L.K. (1981). Scald Burns from Hot Tap Water. Journal of AM Med Assoc., 246(11), 1219-1222), and Table 1 of Time and Temperature Relationship to Serious Burns (Mortiz, A.R., Henriques F.C. Jr. (1947). Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns. Am J Pathology, 23, 695-729), burns related to hot liquids may be due to spills. "Many residents in long-term facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility...decreased cognition...decreased mobility, and decreased ability to communicate." The same article indicated at a water temperature of 133 degrees F, a third degree burn can occur in 15 seconds. "Burns can occur even at water temperatures below those identified in the table depending on an individual's condition and the length of exposure." 2. During a general tour of the facility with the Maintenance Supervisor on 9/24/12 at 10 AM, the following hazardous items in the back patio were observed, which had the potential to cause tripping to its residents and visitors: A. Multiple six-foot gray plastic sheets laying on the ground. B. Four broken beds with 2 x 4 wooden planks sticking out of them. Their electrical cords were laying in the walkway which could cause tripping incidents. C. One dresser, about four feet tall, had multiple mechanical parts on top of it. These mechanical parts were within residents' reach and posed danger if they fall off the dresser. D. Two garden chairs with torn fabric seats that was unsafe for use. During an interview with CNA 2 on 9/24/12, at 10:10 AM, she stated, "Residents do go out on the back patio, that's where we have barbecues for them." During a group interview on 9/25/12 at 3 PM, several residents indicated the back patio was the area they entertained their visitors.