Every finding on record at San Leandro Healthcare Center

Based on observation, interview and record review the facility failed to ensure one of three sample selected residents (Resident 1) was treated with respect and dignity, when the facility's staff talked to Resident 1 disrespectfully on two separate occasions as a reaction towards Resident 1's difficult behaviors towards direct care staff. This deficient practice resulted in Resident 1 feeling bad, disrespected and threatened.Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility in October 2021. During a review of Resident 1's Minimum Data Set (MDS, an assessment to plan and guide care) assessment dated [DATE], Section C - Cognitive Patterns indicated Resident 1's Brief Interview for Mental Status (BIMS, screening tool used by healthcare professionals to evaluate a person's memory, attention, and orientation) score was 15 of 15 (cognitive response and short-term memory are entirely intact). During an interview on 6/8/26 at 10:08 am., with Resident 1, Resident 1 stated on 04/2026, LVN 1 told him Don't act like a Devil because Resident 1 told her why LVN 1 did not answer the phone. Resident 1stated it made him feel bad when Licensed Vocational Nurse (LVN) 1 called him devil and still feels bad every time seeing LVN 1. During an interview on 6/8/26 at 10:46 a.m., Resident 1 stated on another occasional in 01/2026, Certified Nursing Assistant (CNA) 1 was cleaning him up and the water was cold. Resident 1 asked CNA 1 to change the water and called him boy because he did not remember CNA 1's name, CNA 1 got upset and called him nigger a few times. Resident 1 stated he felt threatened by CNA1, still feels bad and disrespected. During a review of Resident 1's Progress notes dated 4/29/26, indicated Resident 1 reported to staff on 4/25/26 around 6:30 p.m., Resident 1 attempted to get help to replace his low oxygen tank, but was unable to reach staff by phone and staff (Licensed Vocational Nurse - LVN 1) disrespected him by calling him Devil. During an interview on 6/9/26 at 12:17 p.m., with LVN 1, LVN 1 stated she was the assigned nurse supervisor on 4/25/26 and saw Certified Nursing Assistant (CNA) 2 was crying in the hallway. CNA 2 told LVN 1 that Resident 1 told CNA 2 bad words, and hence LVN 1 told Resident 1 don't act like a Devil on that day. LVN 1 stated Resident 1 was very mean to staff, yelled at them and used bad words all the time and she was trying to stop Resident 1 from abusing staff. During an interview on 6/9/26 at 12:50 p.m., with CNA 2, CNA 2 stated on 4/25/26, she was taking lunch break, when Resident 1 started yelling at her and wanted to go to his bed. CNA 2 told Resident 1 that she still had 5 minutes, when CNA 2 went back to Resident 1's room, Resident 1 started to yell at her and told her, crybaby and fat. CNA 2 left the room and started crying, LVN 2 saw CNA 2 and told Resident 1 don't act like a devil. During a review of Resident 1's IDT Progress Notes dated 1/27/26 indicated, Resident 1 reported to the Administrator (ADM) on 1/26/26 that Certified Nurse Assistant (CNA)1 called him Nigger during care, CNA 1 was interviewed and stated Resident 1 repeatedly called him Boy, and in responding, asked how Resident1 would feel if he was called him Nigger. During an interview on 6/9/26 at 10:42 a.m., with CNA1, CNA1 stated he was cleaning Resident 1 and Resident 1 called him Boy and CNA 1 told Resident 1 if I call you Nigger you like it? and Resident 1 start yelling. CNA 1 stated he knew that he was not supposed to have an argument with Resident 1, but Resident 1 insulted him and CNA1 responded like that. During an interview on 6/9/26 at 09:30 a.m., with the Registered Nurse (RN)1, RN1 stated, on 1/26/26 at around 5 a.m., heard Resident 1 was calling CNA 1 Boy and started yelling, Resident 1 called RN1, and told CNA 1 called him Nigger, RN1 asked CNA 1 to leave the room. During a review of the facility's undated policy and procedure (P&P) titled Resident Rights indicated .Employees shall treat all residents with kindness, respect, and dignity.

Based on interview and record review, for one of two sampled residents (Resident 2), the facility failed to ensure Resident 2 was afforded the right to participate in the care planning process when care conference meeting was not scheduled despite repeated requests from Resident 2's representative.This failure had the potential to result in Resident 2 being uninformed about treatment objectives and care plan.During a review of Resident 2's admission Record (AR), the AR indicated Resident 2 was admitted to the facility in March 2025 with diagnoses that included cognitive communication deficit (a difficulty with communication caused by impairments in cognitive functions like memory, attention, and problem-solving, rather than by problems with speech or language), age-related cognitive decline (a natural slowdown in thinking and memory that occurs with aging), and epilepsy (a brain disorder characterized by recurrent seizures, which are temporary disruptions in brain activity). The AR also indicated Resident Representative (RR) 1 was responsible for Resident 2's care.During a concurrent interview and review of Resident 2's Social Service Notes on 11/18/25 at 10:47 a.m. with Social Worker (SW), SW stated Long Term Care Ombudsman (LTCO) 1 requested a care plan meeting with RR 1 and Resident 2 via email. SW stated the meeting was initially scheduled for 10/28/25 at 10 am but was postponed to 11/3/25 because Resident 2 was hospitalized from [DATE] to 10/30/25. Although Resident 2 returned to the facility on [DATE] and RR 1 informed SW of Resident 2's return on 11/1/25, no confirmation or discussion about the rescheduled care plan meeting occurred. Resident 2 remained in the facility from 10/30/25 until being taken to the hospital again on 11/12/25, without a care plan meeting being held. There was no documentation of any coordination for setting up the meeting in the clinical record.During a telephone interview on 11/19/25 at 10:14 a.m. with LTCO, LTCO stated sending SW an email to request a care plan meeting with RR 1 and Resident 2. LTCO stated SW did not reply until the morning of 10/30/25, informing LTCO that Resident 2 was still in the hospital. LTCO stated reaching out again on 11/3/25 to ask if any care plan meetings had been scheduled. LTCO stated on 11/17/25, RR 1 informed LTCO that no meeting had been scheduled. LTCO stated the facility was trying to discharge Resident 2 and RR 1 wanted updates on the discharge plan and process. During a follow-up interview on 11/18/25 at 12:33 p.m. with SW, SW stated the receptionist on duty will call the resident's family to arrange a care plan meeting upon admission. SW could not show any documentation in the clinical record of any scheduled care plan meeting in the clinical record.During an interview on 11/19/25 at 10:42 a.m. with Receptionist (REC) 1, REC 1 stated, initial care conferences are scheduled by the receptionist on duty for newly admitted residents. For Resident 2, who was not a newly admitted resident, and was only returning from the hospital, it was the responsibility of SW to schedule the subsequent care conference meeting.During a review of the facility's policy and procedure (P&P) titled Resident Participation-Assessment/Care Plans last revised February 2021, the P&P indicated: The residents and any legal representative are encouraged to attend and participate in the development of the person-centered care plan . The resident and the resident's representative's right to participate includes the right to request meetings . The facility provides sufficient notice in advance of the meeting.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 was treated with respect and dignity when Certified Nursing Assistant (CNA) 1 loudly argued with Resident 1.This failure had resulted in Resident 1's emotional distress. During a review of Resident 1's admission Record (AR) dated 11/18/25, the AR indicated Resident 1 was admitted to the facility in August 2025 with diagnoses that included major depressive disorder (a mental health condition causing persistent sadness, hopelessness, and loss of interest in activities, significantly impacting daily life) and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event, such as combat, assault, or a natural disaster).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE], the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A BIMS score of 13-15 is an indication of intact cognitive status.During a telephone interview on 11/19/25 at 11:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated hearing loud arguing around midnight on 9/17/25. LVN 1 stated she separated Resident 1 and CNA 1, who were arguing. Resident 1 said he requested CNA 1 to unlock the bathroom door, but CNA 1 did not assist. LVN 1 stated both Resident 1 and CNA 1 became somewhat aggressive, and she heard CNA 1 tell Resident 1 to go to his room and return to sleep in a loud manner. However, Resident 1 calmed down after being separated.During a telephone interview on 11/18/25 at 3:36 p.m. with CNA 1, CNA 1 repeatedly stated during the interview that Resident 1 refused to listen after CNA 1 explained that the bathroom door was not locked.During a review of Resident 1's Interdisciplinary Team (IDT, a group composed of individuals from different departments of the facility) Note dated 9/17/25, the IDT Note indicated Resident 1 had a verbal altercation with CNA 1, resulting in Resident 1 feeling threatened and unable to sleep through the night.During a review of the facility's policy and procedure (P&P) titled Dignity last revised February 2021, the P&P indicated that each resident shall be cared for in a manner that promotes feelings of self-worth and self-esteem and sense of well-being. Staff are required to always speak to residents respectfully.

Based on observation, interview, and record review, the facility failed to verify that residents understood binding arbitration agreements (a formal method of dispute resolution where a third party makes a decision instead of the dispute going to court) and/or that they were aware they could rescind the agreement within 30 days for 3 of 3 sampled residents (Resident 18, Resident 13, and Resident 49). This failure had the potential for residents to enter into an agreement without understanding their rights. Findings: During a review of the arbitration agreement made between the facility and three randomly selected residents (Resident 18, Resident 13, and Resident 49), the arbitration agreements included three boxes stating prior to signing this agreement the resident reviewed the voluntary arbitration program guide, the resident received a copy of this agreement after it's execution, and the resident is aware that he/she may rescind the agreement in writing at any time within thirty (30) days of the date of its execution. The boxes to indicate that these steps were completed were blank for all three residents. During a review of resident 13's admission record, Resident 13 was initially admitted to the facility in August 2024 with multiple diagnoses, including End Stage Renal Disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body's needs.), Myocardial Infarction (heart attack), and Difficulty in Walking. During a review of Resident 13's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information.), dated 8/8/24, Resident 13 had a BIMS of 15, indicating intact cognitive status. During a concurrent interview and record review on 11/6/24 at 11:38 a.m. with Resident 13, Resident 13's binding arbitration agreement, dated 8/7/24, was reviewed. Resident 13 stated he remembers being given paperwork on admission and signing the documents. Resident 13 stated he does not remember having the arbitration agreement explained to him. During a review of Resident 49's admission record, Resident 49 was initially admitted to the facility in August 20204 with multiple diagnoses, including Hypertension (high blood pressure) and Difficulty in Walking. During a review of Resident 49's BIMS score, dated 8/28/24, Resident 49 had a BIMS score of 15, indicating intact cognitive status. During a concurrent interview and record review on 11/6/24 at 11:46 a.m. with Resident 49, Resident 49's arbitration agreement, dated 9/28/24, was reviewed. Resident 49 stated he signed a lot of papers during the admission process and doesn't remember anyone explaining that it was voluntary and/or if anyone checked if he understood the agreement. During a review of Resident 18's admission record, Resident 18 was initially admitted to the facility in [DATE] with multiple diagnoses, including Hypertension and Surgical Aftercare (care while recovering from surgery). During a review of Resident 18's BIMS score, dated 9/25/24, Resident 18 had a BIMS score of 15, indicating intact cognitive status. During a concurrent interview and record review on 11/6/24 at 11:17 a.m. with Resident 18, Resident 18's arbitration agreement, dated 9/24/24, was reviewed. Resident 18 stated she does not remember anyone explaining the document to her. Resident 18 stated she was under stress when she got to the facility and signed all the papers she was given. During a concurrent interview and record review on 11/5/24 at 2:32 p.m. with Patient Care Coordinator1 (PCC1), Resident 49's arbitration agreement, dated 9/28/24, was reviewed. PCC1 stated she co-signed the arbitration agreement with Resident 49. PCC1 stated that she is not very familiar with the arbitration agreement and if the resident has questions, she would get another staff member. PCC1 stated she is not certain if residents can rescind the agreement after signing. During an interview on 11/6/24 at 12:29 p.m. with PCC3, PCC3 stated there are three boxes on the arbitration agreement and the process is to check the boxes on the arbitration agreement to verify that the information was reviewed with the residents. During a concurrent interview and record review on 11/6/24 at 1:55 p.m. with Administrator (ADM), Resident 49's arbitration agreement, dated 9/28/24, Resident 18's arbitration agreement, dated 9/24/24, and Resident 13's arbitration agreement, dated 8/7/24, were reviewed. ADM stated the documents have boxes that should be checked to verify that the resident reviewed the Voluntary Arbitration Program Guide, the resident received a copy of the agreement, and the resident is aware that the resident may rescind the agreement within thirty days. ADM stated the box yes was not checked on any of the documents and should have been. ADM stated the boxes should be checked to verify that the resident received and reviewed the document and if they are not checked, there is a chance that the information could not have been reviewed, resulting in the residents not understanding their rights.

Based on observation, interview, and record review, the facility failed to provide a binding arbitration agreement (a formal method of dispute resolution where a third party makes a decision instead of the dispute going to court) that met the regulations. This failure had the potential for residents to enter into an agreement that did not protect their rights. Findings: During a review of the arbitration agreement made between the facility and three randomly selected residents (Resident 18, Resident 13, and Resident 49), the arbitration agreement for all three residents did not provide for the selection of a neutral arbitrator agreed upon by both parties and/or provide for the selection of a venue that is convenient to both parties. During a concurrent interview and record review on 11/6/24 at 1:55 p.m. with Administrator (ADM), Resident 49's arbitration agreement, dated 9/28/24, Resident 18's arbitration agreement, dated 9/24/24, and Resident 13's arbitration agreement, dated 8/7/24, were reviewed. ADM stated the documents do not have a section that provides for the selection of a venue that is convenient to both the resident and the facility. ADM stated the arbitration agreement does not provide for the selection of a neutral arbitrator agreed upon by both parties. ADM stated there is a risk that residents could not understand their rights.

Based on observation and interview, the facility failed to provide clean and comfortable home like environment for 4 residents residing in two of 25 rooms in the facility when the shared bathroom in these 2 rooms had a towel on the floor and the toilet seat was dirty with brown particles on the toilet seat. This failure placed all 4 residents residing in these rooms at increased risk for healthcare-associated infections (HAIs), which could result in longer recovery times, additional medical treatments, and even hospitalization s and negatively impact the residents' overall well-being and quality of life. Findings: During a concurrent observation and interview on 11/4/24 at 10:14 a.m. with the Social Worker (SW), the shared bathroom between room [ROOM NUMBER] and 21 was observed. A towel was on the floor and the toilet seat was dirty with brown particles on the toilet seat. SW confirmed the toilet seat was not clean, with brown particles and towel on the floor, and stated the bathroom should always kept clean to prevent of risk of infection. During a review of the facility's policy and procedure (P and P) titled, Homelike Environment, revised on February 2021, the P & P indicated, . The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include a. clean, sanitary, and orderly environment .).

Based on the observation, interview and record review, the facility failed to safely administer and provide adequate supervision to one of 21 sampled residents (Resident 18) while using a hot water bag (a rubber container designed to hold hot water to apply warmth to specific areas of the body) on her body to keep herself warm for over 24 hours. This failure placed Resident 18 at risk for skin burns. Findings: During a review of Resident 18's Admission Record (a record with residents' basic information) printed on 11/4/24, the record indicated Resident 18 was admitted to the facility in Septembet 2024. During a record review of Resident 18's Minimum Data Set (MDS, an assessment used to guide care) dated 9/30/24, the assessment indicated Resident 18 had an active diagnosis of Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). The assessment indicated Resident 18's Brief Interview for Mental Status (BIMS, an assessment tool used to screen and identify memory, orientation, and judgement status of the resident) score was 15 out of 15, indicating Resident 18's mental status was intact. During a concurrent observation and interview on 11/4/24 at 9:58 a.m. with Resident 18, Resident 18 was lying in bed, awake, with hot water bottle filled with hot water on her right side of the chest. Resident 18 stated one of the Certified Nursing Assistant (CNA 1) helped to fill it up with hot water that morning. Resident 18 stated her room was cold, so she needed the hot water bottle in addition to the blanket, to keep herself warm. Resident 18 stated she used it frequently since she purchased it online about three days ago. Resident 18 stated her nursing assistants were aware, they helped to fill up the water bottle with hot water. During an interview on 11/4/24 at 10:15 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated he filled up the hot water bag and gave it to Resident 18 during the start of his shift (usual start time for morning shift is 7:00 am). CNA 1 stated he was not the assigned nursing assistant for Resident 18, neither he told Resident 18's nurse, nor supervised Resident 18 while she used hot water bag. CNA 1 stated the hot water bag could cause skin burns if Resident 18 remained unsupervised. During an interview on 11/4/24 at 1:03 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated she was the assigned nursing assistant for Resident 18 on 11/3/24 morning shift (7am to 3:30pm). CNA 3 stated she saw Resident 18 using a hot water bag but did not communicate with Resident 18's charge nurse about it. CNA 3 stated she filled up Resident 18' hot water bag with hot water on 11/3/24, but was unsure if the water temperature was appropriate. CNA 3 stated she used her own skin to test the water temperature. During a phone interview on 11/6/24 at 4:14 p.m. with Certified Nursing Assistant (CNA) 6, CNA 6 stated she was the assigned nursing assistant for Resident 18 during the 11/3/24 afternoon shift (3pm-11:30pm). CNA 6 stated she saw Resident 18 using the hot water bag on her body. CNA 6 stated she also filled up with hot water from the janitor closet on 11/3/24 but was not sure if the water temperature was appropriate. CNA 6 stated she had not received any training regarding the use of hot water bags. During an interview and record review on 11/4/24 at 2:22 p.m. with Licensed Vocation Nurse (LVN) 2 , Resident 18's physician orders and progress notes dated November 2024 were reviewed. LVN 2 stated she noticed Resident 18 using the hot water bag that day only. LVN 2 stated there were no written physician orders and progress notes pertaining to the use of the hot water bag. LVN 2 stated Resident 18 could suffer skin burns if unsupervised. During an interview on 11/6/24 at 12:32 p.m. with the Director of Nursing (DON), the DON stated a hot water bag could not be used in the facility as it increased the risk for burn injuries and other skin issues. The DON stated communication among staff, from licensed nurses to nurse managers and including herself was essential. During a record review of the facility's Policy and Procedure (P&P) revised 7/2017, titled, Safety and Supervision of Residents, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on observation and record review the facility failed to provide Activities of Daily Living (ADL) for one of 17 sample selected residents (Resident 157), when Resident 157 was observed with long, broken finger nails and black particles under nails. This failure placed Resident 157 at risk for skin damage and infection and also affect his comfort and dignity, contributing to a lower quality of life and possible emotional distress. Findings: A review of Resident 157's Admission Record indicated, Resident 157 was admitted to the facility with multiple disease including Cerebral Palsy (a group of neurological disorders that affect a person's ability to move, balance, and maintain posture). During an observation on 11/4/24 at 12:00 p.m. inside Resident 157's room, Resident 157 was observed with long finger nails, with broken and black particles under the nails. During an interview on 11/4/24 at 2:30 p.m. with Certified Nurse Assistant (CNA) 2, CNA 2 confirmed the long , broken and black particles under Resident 157's finger nails and stated the licensed nurses did not ask him to cut the nails. During an interview on 11/04/24 at 02:35 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that he did not know Resident 157 had long nails and its important to keep the nails short and clean because of infection prevention and risk for skin injury. A review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of Revised February 2018, the P &P indicated . Nail care includes daily cleaning and regular trimming .

Based on interview and record review, for one of five sampled residents (Resident 17) reviewed for activities of daily living (ADL) care, the facility failed to implement a comprehensive-centered ADL plan of care. This failure had the potential to result in delayed provision of care. Findings: During a review of Resident 17's Admission Record, the Admission Record indicated, Resident 17 was admitted to the facility in February 2024 with diagnoses that included morbid obesity, acute and chronic respiratory failure (acute or chronic impairment of gas exchange between the lungs and the blood), chronic pain syndrome, paraplegia (the loss of muscle function in the lower part of the body including both legs), and pain in left knee. During a review of Resident 17's Minimum Data Set (MDS, an assessment tool used to direct resident care) assessment dated [DATE] indicated Resident 17 had impairment on both lower extremities and totally dependent on staff for toileting hygiene (ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement), and lower body dressing. The MDS also indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15 (A BIMS score of 13-15 is an indication of intact cognitive status). During an interview on 11/4/24 at 10:15 a.m. with Resident 17, Resident 17 stated the staff had said there was no assigned CNA for the night shift on 10/21/24. Resident 17 stated only after calling the cops to the facility he got get the help for personal hygiene. During an interview on 11/5/24 at 1:08 p.m. with Director of Nursing (DON), DON stated, on 10/21/24, Certified Nursing Assistant (CNA) 7 was assigned to Resident 17 but CNA 7 had refused to enter Resident 17's room. DON stated being aware of a prior incident when CNA 7 became uncomfortable after Resident 17 hurled curses and racial insults at CNA 7. DON stated also being aware of several incidents of being rude and racist toward staff especially CNAs. DON stated, although the staff assignment indicated CNA 7 was assigned to Resident 17, CNA 7 routinely switched assignment with another CNA to avoid having to go to Resident 17's room, an arrangement that the facility management was not aware of. During a telephone interview on 11/6/24 at 10:44 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated CNA 7 was assigned to Resident 17, but CNA 7 refused to go to Resident 17's room to help with ADLs. LVN 3 stated the other two CNAs from the other station also refused to go to Resident 17's room. During a review of Resident 17's ADL care plan dated 4/22/24, the care plan indicated Resident 17 required staff assistance to turn and reposition in bed, with dressing and personal hygiene and oral care. During a review of Resident 17's care plan to address verbal aggression to staff during ADLs revised on 9/2/24, the care plan indicated for staff to always go Resident 17's room in pairs. During an interview on 11/7/24 at 12:06 p.m. with Patient Care Coordinator (PCC) 3, PCC 3 stated was making the staffing schedule but was not aware CNA 7 could not be assigned to Resident 17. During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADLs), Supporting last revised March 2018, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, in accordance with the plan of care, including appropriate support and assistance with, hygiene, mobility, elimination, dining, and communication. During a review of another P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program last revised April 2021, the P&P indicated to ensure adequate staffing and oversight/support to prevent burn out and stressful working situations, adequately prepare staff for caregiving responsibilities, Provide staff with opportunities to express challenges related to their job and work environment .help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts.

Based on observation, interview and record review, the facility failed to accurately assess and code active diagnosis for one of 21 sampled residents (Resident 31) in the Admission Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) assessment when Resident 31's admission MDS assessment was inaccurately coded with a Yes for diagnoses of Pneumonia (an infection of one or both lungs caused by bacteria, viruses or fungi causing difficulty in breathing, cough, fever, and chills) and Septicemia (a life-threatening blood infection) during the look back period). During this period, Resident 31 did not have active Pneumonia and Septicemia. This failure resulted in an outdated and inaccurate reflection of Resident 31's medical/clinical status. Findings: During a review of Resident 31's Admission Record (a record with residents' basic information) printed on 11/6/24, the record indicated Resident 31 was admitted to the facility in October 2024. During a record review of Resident 31's Admission MDS assessment dated [DATE], the assessment indicated Resident 31 had active diagnoses of Pneumonia and Septicemia. The assessment indicated Resident 31's Brief Interview for Mental Status (BIMS, an assessment tool used to screen and identify memory, orientation, and judgement status of the resident) score was 15 out of 15, indicating Resident 31 has little to no cognitive impairment. During a concurrent observation and interview with Resident 31 on 11/4/24 at 10:58 a.m., Resident 31 was lying in bed, with the head of the bed slightly elevated, awake, and able to communicate needs. Resident 31 showed no signs and symptoms of respiratory distress and was breathing comfortably. Resident 31 stated she had no current infections and was not taking any antibiotics to treat any infection. During an interview with Certified Nursing Assistant (CNA) 4 on 11/4/24 at 11:10 a.m., CNA 4 stated she was the assigned nursing assistant for Resident 31 and did not observe any signs of infections, such as fever, shortness of breath or coughing. CNA 4 also stated she did not receive any report from the Charge Nurse if Resident 31 had an infection. During a concurrent interview and record review on 11/5/24 at 8:19 a.m. with the Licensed Vocation Nurse (LVN) 2, Resident 31's Electronic Health Record (EHR) for physician's orders and progress notes was reviewed. LVN 2 stated she was a regular charge nurse for Resident 31 and did not observe any signs and symptoms of infections related to Pneumonia and Septicemia since Resident 31's admission to the facility in October 2024. LVN 2 stated Resident 31's vital signs were normal and had no difficulty breathing since admission. LVN 2 also stated there were no progress notes and records of any antibiotic ordered by a physician to treat such infections. During a concurrent interview and record review on 11/6/24 at 11:46 a.m. with the MDS Coordinator (MDSC), Resident 31's EHR for clinical record was reviewed. MDSC stated she could not locate any documentation indicating Resident 31 had active diagnosis of Pneumonia and Septicemia in the History and Physical, Progress Notes, Medication Administration Record, Xray and Lab results within the look back period (a time period over which the resident's condition or status is captured in the MDS assessment and ends at 11:59 p.m. on the day of the Assessment Reference Date (ARD), from 10/15/24 through 10/21/24. MDSC stated the MDS was important assessment tool as it provided an overview of a resident's health condition for developing care plans, and incorrect coding could impact the care provided to the resident. During a record review of the facility's Policy and Procedure (P&P) dated 10/2020, titled, Resident Assessments, the P&P indicated, Information in the MDS assessment will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Based on interview and record review, the facility failed to complete and transmit Discharge Minimum Data Set (MDS, an assessment tool to guide patient care) for one of one sampled resident (Resident 11) to Centers of Medicare and Medicaid Services (CMS) for over 120 days. This failure resulted in reflecting Resident 11 as an active resident while he was already discharged from the facility. Findings: During a review of Resident 11's Admission Record (a record with residents' basic information) printed on 11/6/24, the record indicated Resident 11 was admitted to the facility in June 2024. During a concurrent interview and record review on 11/6/24 at 12:53 p.m. with the MDS Coordinator (MDSC), Resident 11's progress notes dated 7/12/24 was reviewed. The MDSC stated Resident 11 was discharged from the facility on 7/12/24. MDSC stated facility was required to complete a Discharge MDS Assessment upon residents' discharge from the facility. The MDSC stated, Resident 11's discharge MDS was not completed and/or transmitted to CMS till date. A review of the CMS guide,Resident Assessment Instrument (RAI) Version 3.0 User Manual 10/2023, showed the discharge MDS required completion within 14 calendar days of discharge, and transmission date within 14 days following completion date.

Based on observation, interview and record review, the facility failed to establish a system of disposition of controlled drugs for accurate reconciliation when blister packs (also called a bubble pack, blister pack, a card that packages doses of medication within small, clear, or light-resistant, amber-colored plastic bubbles [or blisters] and each pack is secured by a strong, paper-backed foil that protects the pills until dispensed) of controlled medications with popped and taped shut blisters were stored. This failure had the potential to result in inaccurate reconciliation of controlled medications. Findings: 1. During an observation and concurrent interview and review on 11/4/24 between 1:41 p.m. and 2:19 p.m. with Licensed Vocational Nurse (LVN) 2, Station 1 medication cart was observed. Inside the medication cart narcotic (controlled) box was a blister pack of oxycodone hydrochloride (controlled pain medication/narcotic) 5 milligrams (mg) had two blisters, individual blister #7 count and # 8, that were popped and taped shut with a paper tape. The blister pack was inside Station 1 medication cart where medications ready for administration were stored. The Controlled Drug Record-Individual Patient's Narcotic Record (CDR-IPNR) for oxycodone 5 mg, the CDR-IPNR indicated #7 did not have any signature, while #8 indicated, a date and time that was crossed out with a single horizontal line and indicated one signature. Inside the two individual plastic blisters were half of a white round tablet. LVN 2 stated, the popped (punctured) medications were supposed to be signed by two licensed nurses but were not. 2. During an observation and concurrent interview on 11/4/24 at 2:20 p.m. with Director of Nursing (DON), contents of the narcotic file cabinet were observed. There was a blister pack of MS Contin (controlled/narcotic pain medication) that had one individual blister popped and taped shut. DON stated the medication was for a resident who has been discharged from the facility. DON also stated the blister pack that was taped shut should have been destroyed and signed by two licensed nurses, and not replaced in the blister pack because one would not know if it was the same medication as the one that was removed/popped. During a review of the CDR-IPNR for MS Contin, the CDR-IPNR indicated individual blister # 25 was popped and taped shut with a white paper tape. There was a date and time written that was crossed out with a single horizontal line and one signature. During a review of the facility's policy and procedure (P&P) titled Discarding and Destroying Medications last revised November 2022, the P&P indicated, Disposal of controlled and non-controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. A controlled medication policy and procedure that addressed popped blister packs was requested and was not provided during the entire survey.

Based on observation and interview, the facility had 18 rooms (Rooms 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25) with multiple beds that provided less than 80 square feet (sq. ft.) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver. Findings: During an interview with the Administrator (ADM) on 11/06/24 at 12:50 p.m., the following rooms and corresponding square footage per bed were identified: Room Activity Room Size Floor Area 7 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 8 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 9 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 10 Bedroom [ROOM NUMBER] sq ft 70 sq.ft/bed 11 Bedroom [ROOM NUMBER] sq ft 72 sq.ft/bed 12 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 14 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 15 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 16 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 17 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 18 Bedroom [ROOM NUMBER] sq ft 73 sq.ft/bed 19 Bedroom [ROOM NUMBER] sq ft 72 sq.ft/bed 20 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 21 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 22 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 23 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 24 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed 25 Bedroom [ROOM NUMBER] sq ft 71 sq.ft/bed During random observations of care and services from 11/4/24 through 11/7/24, there was sufficient space for the provision of care for the residents in all 18 rooms. Each resident had adequate personal space and privacy. Resident 49 was observed being able to ambulate in the room without difficulty. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the 18 rooms.

Based on interview and record review, the facility failed to ensure one of three discharged residents (Resident 1) had a safe and appropriate discharge location based on his medical needs when Resident 1 who was legally blind was discharged to an independent living facility where resident sustained falls. This failure placed Resident 1 at risk for adverse health outcomes that had the potential to cause serious complications and psychosocial harm. Findings: During a review of Resident 1's Admission record, printed on 9/12/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and has a medical diagnosis including history of cerebral infarction (a condition which occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) without residual deficits, generalized muscle weakness and need for assistance with personal care. During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 12/27/22, the MDS assessment section B indicated Resident 1's vision was severely impaired. MDS section G also indicated that Resident 1 needed staff assistance for toilet use, transfers, personal hygiene, dressing and bathing. The MDS assessment section C indicated Resident 1's Brief Interview of Mental Status (BIMS- an assessment for mental status) score was 14 out of 15 which indicated intact mental status. During a review of Resident 1's Care Plan, printed on 9/12/23, the care plan indicated Resident 1 has self-care performance deficit related to impaired balance, limited mobility and being legally blind. The care plan interventions included assistance from staff for showering, dressing, mobility, personal hygiene, toileting, and transfers. During an interview on 9/11/23 at 1:30 pm., with Resident representative (RP), RP stated, when she visited the facility with her father prior to discharge, she was not aware that the facility was an independent living facility and thought it was assisted living facility. RP also stated they only found out that the facility was independent living facility after the discharge. RP stated after the discharge Resident 1 fell a couple of times at the independent living facility and they had to call 911 for help. During a concurrent interview and record review on 9/12/23 at 11:24 a.m., Resident 1's Interdisciplinary discharge summary was reviewed. The Interdisciplinary discharge summary section G1 indicated that Resident 1 was discharged to an assisted living facility. Social Worker (SW) stated Resident 1 was discharged to a Board and Care facility and not assisted living facility. SW stated resident 1 and resident representative visited the facility prior to discharge to confirm to discharge the resident. SW stated the facility was referred from a placement agency and no one from the facility visited or verified if it was a board and care facility other than verbal confirmation from the owner of the facility. During an interview on 9/12/23 at 12:18 pm., with owner of the independent living facility, the owner stated the facility is a licensed independent living facility in which residents needed to provide for their own care. Owner also stated they accepted Resident 1 because they were provided information that the resident was independent with most of his ADL and care and only needed some assistance with care. Owner also stated they can help with medications and food but Resident 1 needed constant supervision and assistance with ADL all the time which they could not provide, and the facility was not a right fit for the resident's needs. During an interview on 9/12/23 at 12:38 p.m. with SW, SW stated it was the facilities responsibility to ensure Resident 1 was discharged to a safe place. SW also stated they did not know that Resident 1 was discharged to an independent living facility. SW also stated it was important to make sure it was the right place for Resident 1 to ensure if the residents medical care needs and accessibility would be met.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1)'s medical records are in accordance with accepted professional standards and practices, when Resident 1's ADL (Activities of Daily Living)'s documents (nutrition and fluid) were not completed by the facility's staff. This failure resulted in Resident 1 not having accurate documents in his medical file. Findings: A review of Resident 1's face sheet indicated; Resident 1 was admitted to the facility with multiple diagnosis including urinary tract infection. A review of Resident 1's ADLs (Documentation Survey Report v2, Sep-22 and Aug-22) are missing staff initial/signature on the following dates: Nutrition-Amount Eaten section: on 9/4/22 all shifts (Hours 0700, 1200 and 1700), and on 8/16/22, 8/23/22 and 8/28/22 all shifts (Hours 0700, 1200 and 1700) Nutrition-Fluid: 9/4/22 and 9/10/22 all shifts (Hours 0700-1500, 1500-2300, 2300-0700) and on 8/16/22, 8/23/22 and 8/28/22 all shifts (Hours 0700-1500, 1500-2300, 2300-0700). During an interview on 2/8/23 at 10:00 a.m., with the Complainant, Complainant stated Resident 1 was at the facility for a few weeks. He was hospitalized , and the facility did not notify the family about him not eating and drinking while he was resided at the facility. During an interview and record review on 2/8/23 at 12:53 p.m., with the Director of Nursing Assistant ([NAME]), [NAME] reviewed the ADLs documents and confirmed the missing documentations and stated the Certified Nurse Assistant (CNA) was supposed to document the amount of the food and fluid that residents eat and drink and if residents were refusing CNAs must document and report to the charge nurses. [NAME] stated if CNAs did not document it means they did not do the tasks. During an interview on 2/8/23 at 1:05 p.m., with CNA 1, CNA 1 stated all the CNAs must document the percentage of and fluid that residents are eating and drinking for the nurses to know if residents were losing weight and if residents were refusing CNAs must document and report to the charge nurses. CNA 1 stated if CNAs don't document on ADLs sheet it means they did not do those tasks. During an interview on 2/16/23 at 10:44 p.m., with CNA 2, CNA 2 stated he did not remember Resident 1, but he always must report to the nurses if residents were not eating or drinking and, chart on ADL sheets. A review of the facility's policy and procedure Charting and Documentation , revised April 2008, indicated . All services provided to the resident, or any changes in the resident's medical condition shall be documented in the resident's medical record .

Based on observation, interview and record review, the facility failed to ensure 37 out of 37 residents with regular diet received enough protein on a regular basis. This practice failure had a potential of malnutrition and protein deficiency for 37 residents on regular diet who were residing at the facility. Findings: During a concurrent observation and interview on 11/15/22 at 11:30 a.m., in the kitchen with Dietary Manager (DM), staff prepared dishes to serve residents with regular diet, fish was measured by the facility's scale and the weight of the fish was 2.1 oz (ounce, measurement) instead of 3 oz for regular diet. DM stated it was important to follow the protein measurements in the recipes because residents could have malnutrition or lose weight. DM stated she had no idea she had to follow the recipe for cooking size. DM confirmed 37 residents were on a regular diet at that time. During an interview and record review on 11/16/22 at 9:30 a.m., with Dietitian (D), D reviewed the recipe and stated kitchen staff had to use 4 oz fish for cooking and serving size should be 3 oz. D stated if residents do not receive enough protein, they could end up with malnutrition and other complications related to it. A review of Fall Menus dated 11/15/22 indicated the fish fillet was supposed to be serve in size of 3 oz for regular diet. A review of Recipe: fish fillet with garlic sauce indicated . Fish fillet 2 lb (pounds) for serving 8 (4 oz per person) . A review of the facility's policy and procedure Menu Planning dated 2020, indicated . One serving is three ounces of cooked meat, fish, or poultry without bone or fat . A review of the facility's policy and procedure Food Preparation dated 2018, indicated . To be sure portions served equal portion size listed on the menu .

Based on observation, interview and record review, the facility failed to obtain contracts, memorandum of understanding, or other agreements with third parties to provide dialysis services for three of four sampled residents (Resident 4, 43, 28) who were receiving dialysis treatments (the process of removing excess water, impurities from the blood of people whose kidneys could no longer perform these functions normally). This failure had the potential for Resident 4, 43, and 28 to receive inadequate or inappropriate dialysis care. Findings: A review of Resident 4's admission record dated 11/15/22 indicated Resident 4 was admitted to the facility on [DATE] with end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis, leading to the need for dialysis or a kidney transplant), and dependence on renal dialysis. A review of Resident 4's order summary report dated 11/16/22 indicated Resident 4 was scheduled for dialysis at Dialysis Center 1 on Monday, Wednesday, and Friday from 9:30 a.m. to 1:30 p.m. A review of Resident 43's admission record dated 11/15/22 indicated Resident 43 was admitted to the facility on [DATE] with end stage renal disease, and dependence on renal dialysis. A review of Resident 43's order summary report dated 11/26/22 indicated Resident 43 was scheduled for dialysis at Dialysis Center 2 from 7:30 a.m. to 11:00 a.m. every Monday, Wednesday, and Friday. A review of Resident 28's admission record dated 11/15/20 indicated Resident 28 was admitted to the facility on [DATE] with end stage renal disease, and dependence on renal dialysis. A review of Resident 28's order summary report dated 11/16/22 indicated Resident 28 was scheduled for dialysis at Dialysis Center 3 from 12:30 p.m. to 4:00 p.m. every Tuesday, Thursday, and Saturday. During an interview with Assistant Administrator (AA) 2 on 11/16/22, at 8:45 a.m., AA 2 stated the facility did not have any agreements with Dialysis Center 1, 2, and 3 because it was not the facility's practice to enter into agreements with dialysis centers.

Based on observation, interview and record review, the facility failed to ensure pharmacy medication cart storage were clean and orderly, when various items were found in the narcotic box of Medication Cart (Med Cart) 1 and 2, and loose pills were found in Med Cart 1. This deficiency had the potential to result in medication diversion. Findings: During an inspection of Med Cart 2 on 11/16/22 at 11:20 a.m., the narcotic box had a plastic container which had a dirty wallet labeled with a resident's name, several loose coins, keys in a key ring, dollar bills, a cell phone, hearing aids and batteries, two wrist watches and a bag with 22 empty small medicine bottles. During an interview on 11/16/22 at 11:35 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated only narcotic medications were supposed to be in the narcotic box. During a concurrent inspection of Med Cart 1 on 11/16/22 at 12:50 p.m. and interview with LVN 3, the narcotic box had a plastic container with three pairs of hearing aids, a ring, a necklace, coins, and several letter envelopes which contained dollar bills. LVN 3 stated the narcotic box should be clean and not be used to secure personal items of residents. During an inspection of Med Cart 1 at 1:20 p.m. on 11/16/22, with LVN 3, 17 loose pills were found at the bottom of the left third drawer. LVN 3 state Med Cart 1 drawers had to have a cleaning schedule with a designated staff. During an interview with the Director of Nursing (DON) on 11/16/22 at 2:05 p.m., DON stated a cleaning schedule had to be set up for the medication carts, and no personal resident items should be kept in any area of the medication carts. The facility's policy and procedure titled, Preparation for Medication Administration, dated 2007 indicated, The nurse or authorized staff member on duty ensures equipment and supplies relating to medication storage and use are clean and orderly.

Based on observation, interview and record review, the facility failed to follow its policies and procedures for oxygen administration and ensure oxygen supplies were maintained according to the operator's manual for three (Resident 39, 5, and 20) of four sampled residents receiving oxygen therapy, when staff did not document oxygen flow and rationale of Resident 39's oxygen therapy and Resident 39, 5, and 20's oxygen concentrator (an electronically operated device that separates oxygen from room air and provides high concentration of oxygen directly through a nasal cannula, a lightweight tube with one end split into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) filter was covered with a thick layer of gray, fluffy matter. This deficient practice had the potential for Resident 39, 5 and 20 to receive ineffective and inadequate oxygen therapy. Findings: A review of Resident 39's Admission Record dated 11/17/22 indicated Resident 39 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood causing low levels of oxygen in your body tissues). A review of Resident 39's Minimum Data Set (MDS, a tool to guide resident care) indicated Resident 39 was cognitively intact and received oxygen while a resident. A review of Resident 39's doctor's orders indicated an order on 12/24/21 for oxygen at 3 liters per minute via nasal cannula as needed for shortness of breath and/or to maintain oxygen saturation (amount of oxygen in the blood) greater than or equal to 92%. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2 on 11/17/22 at 8:35 a.m., Resident 39 received oxygen at 5 liters per minute. LVN 2 confirmed Resident 39 received oxygen at 5 liters per minute (LPM). LVN 2 stated Resident 39's oxygen should be at 3 LPM. LVN 2 stated he does not know when Resident 39's oxygen was increased to 5 LPM because there was no documentation. During a concurrent record review and interview on 11/17/22 at 9:00 a.m., Resident 39's November 2022 Medication Administration Record (MAR) was reviewed with Director of Nursing (DON). Resident 39's November 2022 MAR did not indicate how many LPM of oxygen Resident 39 was receiving. DON confirmed there was no documentation from the staff to indicate how much LPM of oxygen Resident 39 was receiving. The facility document titled, Oxygen Administration, revised October 2022, indicated After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: . 3. The rate of oxygen flow, route, and rationale. 42922 During a concurrent initial tour and interview with Maintenance Supervisor (MS) on 11/14/22 at 12:40 p.m., at Resident 5's bedside Resident 5 was observed using an oxygen concentrator. The concentrator had a filter on its side which was covered with a thick layer of gray, fluffy matter. MS stated Resident 5's concentrator filter was covered with a thick layer of dust, and it should be washed regularly. During a concurrent observation and interview with LVN 1 on 11/15/22 at 10:15 a.m., Resident 39 was observed using a concentrator. Resident 39's concentrator filter was covered with a thick layer of gray, fluffy matter. LVN 1 stated the filter was filthy, and there should be a schedule for cleaning the filters. During an observation on 11/15/22 at 11:25 a.m., at Resident 20's bedside, Resident 20 was observed using an oxygen concentrator. The concentrator had a filter which was covered with a thick layer of gray, fluffy matter. During an interview with Assistant Administrator (AA) 1 on 11/15/22 at 11:50 a.m., AA 1 stated there should be a written cleaning schedule for the concentrators, including the filters. Review of the oxygen concentrator's Operator's Manual recommended cleaning the air filter every 7 days with mild dish soap (2 tablespoons) and warm water.

Based on observation, interview and record review, the facility failed to ensure two of two sample selected non-English speaking residents (Resident 108 and 110) had an appropriate communication system in place when Residents 108 and 110 did not have a written translation of vital information (communication board) at the bed side. This failed practice resulted in Residents 108 and 110 not being able to communicate effectively with staff and to express their needs. Findings: A review of Resident 108's Admission Record indicated Resident 108 was admitted to the facility with diagnosis of Hepatic encephalopathy (syndrome of impaired brain function occurring in patients with advanced liver diseases). During an observation and interview on 11/14/22 at 2:00 p.m., at Resident 108's room with Certified Nurse Assistant (CNA) 2, Resident 108 was observed not able to talk in English with the surveyor. CNA 2 confirmed Resident 108 was Spanish speaking and staff used sign language to communicate with Resident 108. CNA 2 was not able to find a communication board at Resident 108's bedside and did not know if the facility had a translation system in place or not. A review of Resident 110's Admission Record indicated Resident 110 was admitted to the facility with diagnosis of heart failure (heart muscle does not pump blood as well as it should). During a concurrent observation and interview on 11/14/22 at 11:43 a.m., in Resident 110's room with CNA 3, Resident 110 was observed trying to talk to CNA 3, but CNA 3 was not able to understand. CNA 3 used sign language with Resident 110. CNA 3 stated she used sign language to communicate with non-English speaking residents and had no idea what other way is available to staff. CNA 3 further stated it is important to be able to communicate with residents to know about their needs. During an interview on 11/14/22 at 02:05 p.m., with Social Worker (SW) 1, SW 1 confirmed Residents 108 and 110 did not have a communication board in their own language at bedside. SW 1 was not able to communicate with Resident 110 and 108. SW 1 further stated it was important for the residents to be able to communicate with staff for their needs using their own language. A review of the facility's policy and procedure, Translation and/or Interpretation of Facility Services, revised May 2017, indicated, . 6. This facility shall provide Written translation of vital information pertaining to health services . 17. Staff shall be trained upon hire and at least annually on how to provide language access services to LEP (limited English proficiency) residents .