Every finding on record at San Pablo Healthcare & Wellness Center

Based on observation, interviews and record reviews, the facility failed to prevent the elopement (a resident leaving the facility unsupervised or without permission) of one of two sampled residents (Resident 1), when staff did not relock the front main door at 6:30 a.m. after letting kitchen staff enter the facility.This failure resulted in Resident 1 leaving the facility unsupervised and without permission and placed the resident at risk for exposure to unfavorable weather conditions and possible injuries. During a review of Resident 1's admission record, printed 1/29/2026, the admission record indicated the resident was admitted to the facility in November 2025 11/26/25 with a diagnosis of encephalopathy (any disease, damage or malfunction that affects the brain's structure or function, resulting in an altered mental status), traumatic brain injury (a disruption in brain function caused by a blow, jolt or penetrating head injury) without loss of consciousness, unsteadiness of feet and type 2 diabetes mellitus (a disorder characterized by high blood sugar) with kidney disease.During a review of Resident's 1 Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 11/3/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) summary score of 11 out of 15. A score of eleven (11) indicated moderate cognitive decline: may include forgetting daily routines or making minor errors. Section E of the MDS evaluated Resident 1's behaviors and indicated the resident had not exhibited any wandering behaviors. Section GG of the MDS for functional abilities indicated the resident required supervision, verbal cues and touching assistance as the resident completed activities and range of motion for upper or lower extremity without limitations. Resident 1's Minimum Data Set, dated [DATE] indicated Resident1 had memory problems and was moderately impaired when making decisions regarding tasks of daily life. Section GG of the MDS indicated no changes in functional abilities.During a concurrent interview and record review on 1/29/26, at 12:00 p.m., with the Director of Nursing (DON), the facility investigative summary dated 11/27/25 was reviewed. The Investigative summary indicated that the resident had removed his wander guard and exited the facility through the unlocked front door without supervision or authorization. The DON stated the front door was unmanned and facility staff were busy with other resident care activities. The DON stated, during his interview of the kitchen staff, that the kitchen staff stated they unlocked the front door to allow another kitchen staff in and forgot to relock the door as it was almost 7:00 a.m. The resident returned to the facility on [DATE].During a review of Resident's 1 Situation, Background, Assessment, Recommendation communication form (SBAR), dated 10/31/25, the SBAR form indicated around 9:05 p.m. on 10/31/25, Resident 1, unattended, exited the facility through an emergency door. The SBAR indicated Resident 1 was observed walking away from the facility, where three staff followed and attempted to redirect Resident 1 back to the facility.During a review of Resident 1's elopement evaluation, dated 10/31/25, the elopement evaluation indicated Resident 1 had a history of elopement or attempted leaving the facility without informing staff, the resident wandered, the resident had expressed the desire to go home, wandering behavior was goal directed and the wandering was likely to affect safety of self and others.During a review of the care plan for risk of wandering/elopement, initiated on 10/31/25 and reviewed on 12/02/25, the care plan did not include the wander guard as an intervention.During a review of the Interdisciplinary (IDT) note, dated 11/25/25, the IDT note indicated at approximately 6:30 a.m. the staff noted Resident 1 was not present on the unit during routine rounding. There was no witness to the departure. The resident elopement was confirmed by reviewing the close circuit television footage.During a review of Resident 1's elopement evaluation, dated 11/27/25, the elopement evaluation indicated the resident had a history of elopement or attempted leaving the facility without informing staff, the resident wandered, the resident had expressed the desire to go home, wandering behavior was goal directed and the wandering was likely to affect safety of self and others.During a review of Resident 1's progress note, dated 11/28/25, the progress note indicated the resident continued to demonstrate noncompliance with wearing the assigned wander guard. Resident was assessed as a high elopement risk, with a pattern of attempts to leave the unit and exit seeking behaviors.During an interview on 2/6/26, at 12:24 p.m., with the DON, the DON stated staff unlocked the front main door on 11/25/25 to allow the kitchen staff to enter and forgot to relock the door as it was almost 7:00 a.m. DON stated he did interview the staff who unlocked the door, but the investigation summary lacked the written interviews. Other attempts to interview the staff who unlocked the main front door was unsuccessful.During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, dated 1/31/23, the P&P indicated elopement is a behavior that leads to a resident leaving the facility unsupervised or without permission. If the resident exits the facility despite efforts to stop them, a staff member may accompany or follow the resident.During a review of the facility's P&P titled, Unusual Occurrence reporting, dated 5/30/24, the P&P indicated, the investigation and documentation should include but is not limited to interviews with residents, staff and any other witnesses.

Based on interviews and record review, the facility failed to implement its policy and procedure for injuries of unknown origin to thoroughly investigate an unexplained injury of unknown source for one (Resident 1) of three sampled residents when facility did not know how Resident 1's right great toenail fell off exposing the nail bed. This failure had the potential to cause pain and placed Resident 1 at risk for emotional distress, mistreatment or abuse, and further injury.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/21/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status) score was 11 and indicated mild cognitive impairment. The MDS indicated Resident 1 was not able to recall the day of the week. MDS indicated Resident 1 had difficulty communicating some words or finish thoughts but able if prompted or given time. MDS indicated Resident 1 had diagnoses that included seizure disorder or epilepsy. During a review of progress notes titled, Change in Condition Evaluation (COC), dated 2/13/26, COC indicated Certified Nursing Assistant (CNA) 1 reported a complete nail avulsion (the partial or complete tearing away of toenail from nail bed) on Resident 1's right foot, dry, red in appearance. Resident 1 was aphasic and could not describe what happened. During an observation on 2/19/26, at 11:33 a.m., Resident 1 laid in bed on her back asleep. Observed bed in lower position. Resident 1's right great toe was covered with a dressing. Resident 1's feet were close to footboard. Further review of COC, dated 2/13/26, indicated that Resident 1 often dangled her feet outside her bed at times hitting the hard parts of the bed and nearby table, causing damage on her skin and nails. During an interview on 2/19/26, at 11:45 a.m., with Certified Nursing Assistant (CNA1), CNA1 stated she found Resident 1's right great toe without nail and reported to Licensed Vocational Nurse (LVN 1). CNA1 stated she did not know how the nail fell off. During an interview on 2/19/26, at 11:55 a.m., with LVN 1, LVN 1 stated that CNA 1 informed LVN 1 that Resident 1's right great toenail fell off and CNA 1 did not know what happened. LVN 1 stated he asked other nurses, and no one knew how Resident 1's right great toenail fell off. During a concurrent interview and record review on 2/19/26, at 12:20 p.m., with LVN 1 and Director of Nursing (DON), Resident 1's COC and right great toenail avulsion care plan dated 2/13/26 were reviewed. LVN 1 stated staff did not know what happened with Resident 1's right great toenail avulsion. LVN 1 stated he assumed it may be because Resident 1 dangled feet outside of bed. During a concurrent interview and record review on 2/19/29, at 12:50 p.m., with DON, Resident 1's care plan was reviewed. DON stated facility did not investigate the source of the injury to Resident 1's right great toenail that fell off because there was an assumption that Resident 1 at times hit leg on the hard parts of bed. DON stated that the interdisciplinary team (IDT-a professional discipline that works together to provide the greatest benefit to the resident which included the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically and appropriate and person - centered.) did not review Resident 1's injury to right great toenail. During a review of the facility's policy and procedure (P&P), titled, Injury of Unknown Origin-Investigation, revised November 18, 2015, P&P indicated, To protect the health and safety of residents by ensuring that all unexplained injuries are promptly and thoroughly investigated and addressed .An injury of unknown source is defined as an injury that meets both of the following conditions: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; andThe injury is suspicious because of the extent of the injury; the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma; the number of injuries observed at one particular point in time; or the incidence of injury over time.

Based on observation, interview, and record review, the facility failed to ensure one (Resident 1) of three sampled residents' behavior of dangling feet outside bed at times hitting the hard parts of the bed and nearby table were addressed on care plan with appropriate interventions. This failure had the potential to place Resident 1 at risk for pain and injuries.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/21/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status) score was 11 and indicated mild cognitive impairment. The MDS indicated Resident 1 was not able to recall the day of the week. MDS indicated Resident 1 had difficulty communicating some words or finish thoughts but able if prompted or given time. MDS indicated Resident 1 had diagnoses that included seizure disorder or epilepsy. During a review of progress notes titled, Change in Condition Evaluation (COC), dated 2/13/26, COC indicated Certified Nursing Assistant (CNA) 1 reported a complete nail avulsion the partial or complete tearing away of toenail from nail bed) on Resident 1's right foot, dry, red in appearance. Resident 1 was aphasic and could not describe what happened. During an observation on 2/19/26, at 11:33 a.m., Resident 1 laid in bed on her back asleep. Observed bed in lower position. Resident 1 right great toe covered with a dressing. Resident 1's feet were close to the footboard, and there were no devices noted to prevent Resident 1's foot from kicking the foot board. Further review of COC, dated 2/13/26, indicated that Resident 1 often dangled her feet outside her bed, at times hitting the hard parts of the bed and nearby table, causing damage on her skin and nails. During an interview on 2/19/26, at 11:45 a.m., with Certified Nursing Assistant (CNA 1), CNA1 stated she found Resident 1's right great toe without nail and reported to Licensed Vocational Nurse (LVN 1). CNA1 stated she did not know how the nail fell off. During an interview on 2/19/26, at 11:55 a.m., with LVN 1, LVN 1 stated that CNA 1 informed LVN1 that Resident 1 right great toenail fell off, and CNA 1 did not know what happened. LVN 1 stated he asked other nurses, and no one knew how Resident 1's right great toenail fell off. During a concurrent interview and record review on 2/19/26, at 12:20 p.m., with LVN1 and Director of Nursing (DON), Resident 1's COC and right great toenail avulsion care plan, dated 2/13/26, were reviewed. LVN 1 stated staff did not know what happened with Resident 1's right great toenail avulsion. LVN 1 stated he assumed it may be because Resident 1 dangled feet outside the bed. During a concurrent interview and record review on 2/19/29, at 12:50 p.m., with DON, DON stated there was an assumption that Resident 1 at times hit leg on the hard parts of bed. DON stated facility's interdisciplinary team (IDT-a professional discipline that worked together to provide the greatest benefit to the resident which included the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically and appropriate and person - centered) had not addressed Resident 1's behavior of dangling feet outside the bed and at times hitting legs on hard parts of bed, with care plan interventions.

Based on interview and record review, the facility failed to implement its abuse prevention policy and procedure to not employ or continue to employ anyone found guilty of abuse when: Facility employed one Certified Nursing Assistant (CNA 1) who had a finding of patient abuse record on background screening report conducted prior to employment. Facility did not check information from previous and/or current employers and make reasonable efforts to uncover information about any past criminal prosecutions for CNA 1 prior to employment. Finding is defined as a determination made by the state that validates allegation, mistreatment of residents, or misappropriation of their property. This failure had the potential to place residents at risk for emotional distress, mistreatment, or abuse. During a review of Resident 1's progress note, titled SBAR, dated 1/20/26, the SBAR (a communication tool used by licensed nurses to document residents' condition).indicated Resident 1 reported that CNA 1 verbally and physically abused Resident 1. SBAR indicated Resident 1 appeared anxious, intimidated, and uncomfortable with care. During a concurrent observation and interview on 1/26/26, at 10:15 a.m., with Resident 1, Resident 1 stated he asked CNA 1 to help with his clothes and drinking water. Resident 1 stated CNA 1 told him to stand up and help himself. Resident 1 stated CNA 1 spilled water on his wheelchair and damaged items in his wallet. Resident 1 was upset and anxious when he recited what happened with CNA 1. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems), dated 9/10/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact cognition. The MDS indicated Resident 1 had clear speech, made self understood and understood others. MDS indicated Resident 1 had diagnoses that included paraplegia (partial or complete paralysis of the lower half of the body, including both legs and sometimes the abdomen). During a telephone interview on 1/26/26, at 11:02 p.m., with CNA 1, CNA 1 stated Resident 1 was upset that his roommate wore his clothes and screamed. CNA 1 stated while trying to move Resident 1's bedside table to the side, a bottle of hot sauce and water slid from the table, broke and slipped on the floor. During a concurrent interview and record review on 1/26/26, at 11:26 a.m., with Director of Nursing (DON), CNA 1's Employee File (EF) was reviewed. The EF indicated facility employed CNA 1 on 2/17/22. Further review of CNA 1's EF indicated the background screening report (BGSR) for employment, dated 2/15/22, indicated CNA 1 had a finding in state nurse aide registry concerning abuse of patient. CNA1's BGSR indicated CNA1 was on the Office of Inspector General (OIG)/Medical exclusion and State Board list. (Background screening for employment is the process of verifying a job candidate's educational, professional, and personal history to assess their qualifications, safety, and integrity). Further review of EF indicated facility did not check references for CNA 1 from previous and/or current employers and make reasonable efforts to uncover information about any past criminal prosecutions prior to employment. DON stated there were no reference checks completed for CNA 1 on file. DON stated she had checked with payroll department and could not provide documentation of CNA 1's reference checks. During a concurrent interview and record review on 1/26/26, at 12:10 p.m., with the Administrator (Admin) and Director of Nursing (DON), CNA1's BGSR dated 2/15/22 was reviewed. The BGSR indicated, CNA 1 had a finding of Patient Abuse on record. Admin stated he was not aware of CNA 1's BGSR finding of patient abuse and was not involved in the hiring decision. Admin said facility does not hire nursing staff with patient abuse findings. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 2022, the P&P indicated, a. The facility will screen potential employees for history of abuse, neglect, or mistreating residents, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries.b. The facility does not knowingly employ or continue to employ anyone found guilty of abuse, neglect, exploitation, .

Based on interview and record review, the facility failed to implement its policy and procedure to report an allegation of financial abuse and misappropriation of resident property as required by law and regulations to the appropriate agencies for one (Resident 1) of three sampled residents when Administrator did not notify law enforcement and report to the department when it was suspected that Certified Nursing Assistant/Customer Relations (CNA 1) used Resident 1's bank card with online purchases. Misappropriation of resident property and Financial Abuse- defined as the deliberate displacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.This failure had the potential to place Resident 1 at risk for emotional distress, mistreatment, or abuse.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 9/10/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 11 and indicated mild cognitive impairment. The MDS indicated Resident 1 was not able to recall the day of the week. MDS indicated Resident 1 had clear speech, difficulty communicating some words or finish thoughts but able if prompted or given time. MDS indicated Resident 1 had adequate vision see fine detail, such as regular print in newspapers/books and does not use corrective lenses. MDS indicated Resident 1 had diagnoses that included anxiety disorder (a mental condition characterized by excessive and persistent feelings of anxiety and fear that interfere with daily life).During a review of Resident 1's progress notes titled, Social Services, dated 10/29/25, the social services notes indicated Resident 1 stated he believed that someone was using his bank card and online store account. The social services notes indicated facility assisted Resident 1 to replace debit card and change password for online store account and online bank account. The social services notes indicated facility informed Resident 1 that if he needed assistance with purchasing items from an online store to inform social services for assistance.During an interview on 12/4/25, at 10:28 a.m., with Resident 1, Resident 1 stated he believed that a staff that had assisted him with purchases online used his debit card on his online store account. Resident 1 stated facility was aware of his concern and the staff that had assisted Resident 1 with purchases. Resident 1 stated he did not want to talk about the staff anymore. Resident 1 stated facility had assisted him to change his password to his bank and online store account. During an interview on 12/4/25, at 11:15 a.m., with Social Services Director (SSD), SSD stated Resident 1 suspected that CNA 1 used his bank card to make purchases online. SSD stated Resident 1 asked CNA 1 to assist with purchases online. SSD stated facility asked the bank to replace Resident 1's bank card. SSD stated initially facility did not take it seriously when implementing intervention to replace Resident 1's bank card. During an interview on 12/4/25, at 11:30 a.m., with Administrator (Admin) and SSD, Admin stated Resident 1 complained to the department head that there were missing items regarding use of Resident 1's bank card. Admin stated the incident was assigned to social services with expectation to do a search and check inventory. Admin stated he did not report incident to appropriate agencies, i.e., Police and Licensing and Certification department.During an interview on 12/4/25, at 12:18 p.m., with CNA 1, CNA 1 stated Resident 1 asked for help with purchases online. CNA 1 stated, in Resident 1's presence, that he helped Resident 1 enter Resident 1's bank card number online while Resident 1 picked items to be purchased. CNA 1 stated Resident 1 had vision problems so CNA 1 helped Resident 1 in case Resident 1 could not see well. CNA 1 stated he helped Resident 1 return some of the items purchased. CNA 1 stated he received the purchases at the facility for Resident 1 and updated Resident 1's inventory list. CNA 1 stated SSD asked CNA 1 to stop assisting Resident 1 with online purchases because Resident 1 may allege theft of properties or money.During a review of Resident 1's Resident Inventory List dated 7/20/25, 8/30/25, 8/31/25, 9/16/25, 10/11/25, 9/12/23, and 9/18/25, Resident 1's inventory list indicated duplicate personal items on records i.e. shoes, shirts, sunglasses, watch, magnetic bracelet, short sleeves, long sleeve shirts etc.During an interview on 12/4/25, at 1:08 p.m., with Admin and DON, Admin stated facility did not report to appropriate agencies as required by law because there was no missing money from Resident 1's bank account.During a review of the facility's policy and procedure, titled, Abuse Prevention and Management, dated 2022 indicated, The facility will report all allegations of abuse and criminal activity as required by law and regulations to the appropriate agencies.

Based on observation, interview, and record review, the facility failed to ensure the ice supply was stored and prepared under sanitary conditions when there was reddish-brown matter inside the residents' ice machine and around the ice chute dispenser. These failures had potential to put residents at risk for food borne illness (an illness that comes from eating contaminated food and infection) and cross-contamination (transfer of bacteria or other microorganisms from one substance to another) that could have resulted in infection or spread of infection. Findings: During an observation and interview on 6/24/25 at 2:10 p.m. with the Maintenance Director (MD) and Registered Dietician (RD). MD opened the ice machine, and it showed a reddish-brown matter inside the back part of the ice container and around the ice chute dispenser. Using a paper towel, RD wiped the visible reddish-brown matter. RD showed the reddish-brown matter was transferred to the paper towel she used. RD stated she did not know what it was or where it came from. MD stated the reddish-brown matter looked like a residue that could have been left from the last time the machine was cleaned. MD stated the ice machine should have been maintained and cleaned and not have any residues at all. MD stated the dirty ice machine had the potential to contaminate the ice that was supplied to the residents. During an interview on 6/24/25 at 2:16 p.m. with the Director of Nursing (DON), the DON stated the ice machine should have been always cleaned and free from any dirt to prevent any food borne illnesses. The DON stated the residue that was found in the ice machine could have caused food poisoning to the residents. During a record review of the facility's policy and procedure (P&P), titled, Ice Machine - Operation and Cleaning, revised on October 1, 2014, the P&P indicated, The dietary staff will operate the ice machine according to the manufacturer's guidelines. The ice machine will be cleaned routinely .II. Sanitation of Equipment .F. On no less than a monthly basis, remove ice to wash inside of the machine .H. Sanitize the inside of the machine using a sanitizing solution and a clean cloth . During a record review of the Food and Drug Administration (FDA) Federal Food Code 2022, the food code indicated, 4-601.11 .Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils .Equipment food-contact surfaces and Utensils shall be clean to sight and touch.

Based on observation, interview, and record review, the facility failed to serve food for four of 12 sampled residents (Residents 22, 56, 38 and 254) that was palatable when food was bland (lacked flavor). This failure had the potential to result in a negative dining experience that could lead to poor dietary intake, compromising the health and nutritional status of Residents 22, 56, 38 and 254 who received food from the kitchen. Findings: During an observation and interview on 6/23/25, at 10:41 a.m. with Resident 22, Resident 22 stated the facility's food always tasted bland and lacked flavor. Resident 22 stated, Look at those salt and pepper I have on my table. That's how terrible their food is. Resident 22's tray table had plastic cups that contained multiple packets of salt and pepper. Resident 22 also had a personal small saltshaker. Resident 22 stated the facility's food had no flavor at all. During an interview on 6/23/25, at 11:45 a.m., with Resident 56, Resident 56 stated the facility's food could have been better because the food they served did not have a taste at all. During an interview on 6/23/25, at 11:51 a.m., with Resident 38, Resident 38 stated the facility's food was awful and did not taste good. Resident 38 stated most entrees served by the kitchen were always bland and lacked taste. During a dining observation and interview on 6/23/25, at 12:36 p.m., in the dining room with Resident 254, Resident 254 was having lunch and observed complaining about his food to a staff. Resident 254 stated the meal that was served during lunch did not have a taste at all and it needed more flavor and seasoning. Resident 254 stated, I thought this place was meant to provide healthy and tasty food. They always mess up with my food. During a record review of the daily menu, dated 6/25/25, the lunch menu indicated the residents received fish, tartar sauce, scalloped potatoes, and Italian herb vegetables. During a concurrent observation an interview on 6/25/25, at 1:00 p.m., with Registered Dietician (RD) and Dietary Services Supervisor (DSS), a test tray was conducted. The test tray contained the same regular texture and pureed food served to residents for lunch. The food was tasted by three surveyors, RD, and DSS. All three surveyors agreed that the regular fish and the scalloped potatoes were bland and lacked flavors. DSS stated she could only taste the oregano seasoning in the fish. During a follow up interview on 6/26/25, at 10:34 a.m., with DSS, DSS stated it was important for the residents to receive flavorful meals for residents to enjoy their food preference and promote dignity. During a record review of the facility's P&P, titled, Standard Recipes, dated 7/1/14, the P&P indicated, Recipe accuracy concerns will be reported to the Dietician for evaluation and modification as necessary.

Based on observation, interview, and record review, the facility failed to ensure standards of professional practice were maintained during medication administration for four of four sampled residents (Residents 52, 253, 56 and 93) when licensed nurse pre-poured (generally refers to medications that have been prepared in advance and are ready for administration, rather than being prepared immediately before use) Residents 52, 253, 56 and 93's medication. This failure had the potential for a significant medication error that can lead to serious harm or even death. Findings: During a record review of Resident 52's admission Record (AR), printed on 6/25/25, the AR indicated Resident 52 was admitted to the facility in March 2025 with diagnoses of chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause airflow blockage and breathing problems) and anxiety disorder (a group of mental health conditions characterized by excessive, persistent fear and worry that can significantly interfere with daily life). During a record review of Resident 253's AR, printed on 6/25/25, the AR indicated Resident 253 was admitted to the facility in June 2025 with diagnoses of multiple fractures (broken bone) of ribs and senile degeneration of the brain (neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior). During a record review of Resident 56's AR, printed on 6/25/25, the AR indicated Resident 56 was admitted to the facility in May 2025 with diagnoses of end stage renal disease (the final stage of chronic kidney disease where the kidneys have severely reduced or completely stopped functioning) and congestive heart failure (a condition where the heart doesn't pump blood as efficiently as it should, leading to a buildup of fluid in the body). During a record review of Resident 93's AR, printed on 6/25/25, the AR indicated Resident 93 was admitted to the facility in June 2025 with diagnoses of Fournier's gangrene (a severe and rapidly progressing necrotizing fasciitis, or flesh-eating disease, affecting the genitals, perineum, and surrounding areas) and type 2 diabetes mellitus (a chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels). During an observation and interview on 6/25/25, at 11:10 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 was inside Resident 56's room talking to Resident 56's roommate while she was holding a medication tray and the portable vital signs machine was right next to her. After talking to Resident 56's roommate, LVN 1 came out of the room while rolling the portable vital signs machine and carrying a medication tray that had multiple plastic cups of water and multiple medication cups with orals pills inside. LVN 1 proceeded to the nurse's station and sanitized the vital signs machine, while she was still holding the medication tray with her other hand. LVN 1 pushed the portable rolling vital signs machine back to the hallway and entered Resident 52 and Resident 93's room. LVN 1 placed the same medication tray she was carrying inside Resident 56's room on top of a tray table. LVN 1 assessed Resident 52's vital signs. LVN 1 asked Resident 52 if he was having anxiety because Resdient 52's heart rate was elevated. Resident 52 replied, yes to LVN 1. LVN 1 informed Resident 52 that the antianxiety medication was ready for administration. After taking Resident 52's vital signs, LVN 1 took one medication cup from the medication tray. The medication cup had a label that showed Resident 52's room number. LVN 1 admistered the oral medication to Resident 56. LVN 1 stated the medication cups in the medication tray were pre-poured for Residents 52, 253, 56 and 93. During a follow up interview on 6/25/25, at 11:23 a.m., with LVN 1, LVN 1 stated she prepared the medications ahead of time because it always made her medication pass and administration a lot faster. LVN 1 stated she left the medication cart by the nurse's station because she did not like pushing it because it was hard for her to move it around the hallway. LVN 1 stated she did not know what the facility's policies were for medication administration and that she was trained by her preceptor to perform pre-pour technique when passing the medications. LVN 1 stated she did not think there were any risks for medication errors with pre-poured medications. LVN 1 stated she memorized all the medications that she prepared for her residents. LVN 1 further stated if she accidentally knocked the medication cups and the tablets or capsules were mixed, LVN 1 stated she would just have to waste (medications that are discarded or thrown away) the medications and start over again in preparing them. During an interview on 6/25/25, at 11:28 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses were supposed to give medications to one resident at a time. The DON stated the licensed nurses were expected to bring their medication carts and prepare medications right before they administer them to a resident. The DON stated the licensed nurses were also expected to verify the resident through the electronic health record before entering a resident's room. The DON stated LVN 1 should never have prepared the medications for Residents 52, 253, 56 and 93 ahead of time because it had a great risk of medication errors and break in infection control. The DON further stated there was no way LVN 1 could have memorized all the medications she prepared. The DON stated some residents were not able to identify their medications and they could have taken the medications that were not meant for them. During a record review of the facility's policy and procedure (P&P), titled, Medication Administration-General Guidelines, effective October 2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices .Procedures .B. Administration .4. Medications are administered at the time they are prepared. Medications are not pre-poured .7. Residents are identified before medication is administered. Methods of identification include .b. Checking photograph attached to medical record .C. Documentation .1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given .

Based on observation, interview, and record review, the facility failed to treat one of two sampled residents (Resident 72) with dignity and respect when a staff member discussed Resident 72's diagnosis and condition while having lunch in front of another resident. This failure had the potential to affect Residents 72's privacy and psychosocial well-being. Findings: During a record review of Resident 72's admission Record (AR), printed on 6/24/25, the AR indicated Resident 72 was admitted to the facility in May 2024 with diagnoses of Parkinsonism (a group of neurological conditions that share similar motor symptoms with Parkinson's disease, such as tremors, stiffness, and slow movement) and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.) During a dining observation and interview on 6/23/25 at 12:20 p.m. with Activity Assistant (AA), without being asked, AA stated she was going to help Resident 72 during lunch because Resident 72 had Parkinson's disease (a progressive neurological disorder that primarily affects movement, causing symptoms like tremors, stiffness, and slow movement) and Resident 72's hands were shaking. During a dining observation on 6/23/25 at 12:28 p.m., Resident 72 and another resident were seated right in front of AA during lunch. AA was feeding Resident 72 pureed meat and vegetables. Without being asked again, AA suddenly stated out loud, She has Parkinson's. Look, her hands are shaking. She's deaf. She cannot hear. while the other resident was in front of them and other residents were close by. During a follow up interview on 6/23/25 at 12:48 p.m. with AA, AA stated she wanted to share Resident 72's conditions because she was assisting Resident 72. AA stated she got nervous and stated Resident 72's condition twice even if she was not asked for such information. AA stated she should not have said Resident 72's diagnosis and condition out loud because it was a Health Insurance Portability and Accountability Act (HIPAA, is a federal law that sets national standards for protecting sensitive patient health information. It aims to ensure patient privacy and security while also allowing for the flow of health information needed for patient care and public health.) violation. During an interview on 6/24/25 at 10:13 a.m. with the Director of Nursing (DON), the DON stated the staff who were assigned in the dining room during mealtimes were not supposed to disclose residents' diagnosis or personal information to others for privacy and dignity. The DON stated Resident 72's dignity and self esteem could have been affected when AA discussed Resident 72's information in front of the other resident. During a record review of the facility's policy and procedure (P&P), titled, Resident Rights - Quality of Life, revised in March 2017, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, individuality and receives in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her practicable well-being .Facility staff shall maintain an environment in which is confidential clinical information is protected .communication is conducted outside the hearing range of residents and public .Facility staff treats cognitively impaired residents with dignity and sensitivity

Based on interview and record review the facility failed to ensure to refer the resident to the appropriate state-designated authority for level II PASARR evaluation for one of two sample selected resident (Resident 37) when Resident 37 was positive for level I PASARR (the preliminary screening process has identified a potential mental illness or intellectual/developmental disability), and did not refer for PASARR II evaluation. This failure could result in placement in an inappropriate facility, lack of needed mental health services and increase of behavioral issues or hospitalizations. Findings: A review of Resident 37's admission Record indicated Resident 37 was admitted to the facility with diagnosis of Depression and Post Traumatic Stress Disorder (PTSD [a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event]). During a review of Preadmission Screening and Resident Review (PASARR) Level one Screening dated 2024 indicated . Result of Level Screening: Level I- Positive . During a concurrent interview and record review on 6/25/25 at 11:00 a.m., with the Minimum Data Set's coordinator (MDSC), MDSC stated that MDSC is responsible to review the residents PASARR and follow up with level II as needed, and when resident has PASARR level one positive it means resident can have serious mental illnesses and need level II evaluation to see if resident needs higher level of care. MDSC confirmed that they did not do PASARR II evaluation for Resident 37 and stated, they missed it. A review of the facility's policy and procedure Pre-admission Screening Level II Resident Review NP-104B (PASARR Level II) revised July 2018, indicated . The facility staff will coordinate the recommendations from the level II PASARR determination and PASARR evaluation report with the resident's assessment, care planning and .

Based on observation, interview, and record review, the facility failed to provide appropriate care and services related to enteral feeding (also referred to as tube feeding, is the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) nutrition for one sampled resident (Resident 252) on a feeding tube when Resident 252 did not receive the calculated amount of tube feeding formula (designed to provide nutrition to individuals who cannot consume adequate food orally) per physician's order. This failure had the potential to cause dehydration, weight loss, and gastrointestinal (GI, relating to stomach and intestines) problems such as abdominal pain and diarrhea. Findings: During a record review of Resident 252's admission Record (AR), printed on 6/25/25, the AR indicated Resident 252 was admitted to the facility in April 2025 with diagnoses of traumatic subarachnoid hemorrhage (bleeding into the space surrounding the brain caused by head trauma) and gastrostomy status (refers to the presence of a gastrostomy tube, a surgically placed tube into the stomach for feeding or medication administration). During record review of Resident 252's Order Summary Report, dated 6/25/25, the record indicated Resident 252 had an active physician order with a start date on 5/23/25 to provide Resident 252 the formula of Jevity 1.5 (calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) at 75 millimeters (ml, a unit of volume)/hour for 20 hours to provide a total of 1550 ml formula. The order also showed Resident 252's enteral feeding should have been off from 8:00 a.m. to 12:00 p.m. everyday. During an observation and interview on 6/25/25, at 8:20 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 252 was sleeping in the bed while the tube feeding was being administered. Resident 252's feeding formula bottle that was half full and the feeding pump machine showed Resident 252 was receiving a volume rate of 60 ml/hour. When asked about the physician's orders including the total volume of formula per day and the time the tube feeding pump had to be stopped, LVN 1 stated Resident 252's enteral feeding was continuous for 24 hours every day. During a follow up interview on 6/25/25, at 11:22 a.m., with LVN 1, LVN 1 confirmed that she did not know Resident 252 had an order to receive 75 ml/hour of enteral feeding for 20 hours a day. LVN 1 stated she thought Resident 252's feeding amount per hour had always been 60 ml/hour. LVN 1 also stated she did not know that Resident 252's enteral feeding had to be off at 8:00 a.m. and start the daily feeding at 12:00 p.m. everyday. LVN 1 stated she only replaced Resident 252's formula bottle whenever it was almost empty. LVN 1 stated the correct enteral feeding nutrition order should have been followed because Resident 252 could have had malnutrition and dehydration. During an interview on 6/25/25, at 11: 29 a.m., with the Registered Dietician (RD), the RD stated when her recommendations were approved by the physician, she would have expected the licensed nurse to carry out the order. RD stated Resident 252 was at risk for weight loss because Resident 252 received less amount of the enteral nutrition than what she had recommended. During an interview on 6/25/25, at 11:35 a.m., with the Director of Nursing (DON), the DON stated the licensed nurses were responsible in making sure enteral feeding orders were verified every shift. The DON stated LVN 1 should have assessed Resident 252 and verified the enteral feeding orders every time she was assigned to Resident 252. The DON stated he expected the licensed nurses to follow the correct orders when providing enteral nutrition to the residents. The DON stated residents who did not receive enough nutrition were also at risk for infections and delayed healing because they were not getting enough nutrients. During a record review of the facility's policy and procedure (P&P), titled, Enteral Feeding - Closed, dated 1/1/12, the P&P indicated, Enteral feeding will be administered via pump as ordered by the attending physician .Review order for feeding .Calculate the amount of formula to be given per shift per attending physician's order of volume per hour .

Based on observation and interview, the facility had 12 residents (Rt)'s rooms (room [ROOM NUMBER],10, 11, 15, 16, 17, 22, 25, 26, 29, 30, and 40) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had potential to result in inadequate space for delivery of care to each of the residents in each room, or for storage of the resident's belongings. Findings: During an observation on 6/23/25, at 11;00 a.m., the following rooms and corresponding square footage per bed were identified: Room Activity Room size Floor area 3 Rt room [ROOM NUMBER] in x 227 in 78 sq. ft per bed 10 Rt room [ROOM NUMBER].5 in x 155.5 in 71.54 sq. ft per bed 11 Rt room [ROOM NUMBER].5 in x 227 in 79.6 sq. ft per bed 15 Rt room [ROOM NUMBER] in x 156 in 72.58 sq. ft per bed 16 Rt room [ROOM NUMBER] in x 156 in 79.08 sq. ft per bed 17 Rt room [ROOM NUMBER] in x156 in 79.08 sq. ft per bed 22 Rt room [ROOM NUMBER] in x 156 in 77.66 sq. ft per bed 25 Rt room [ROOM NUMBER] in x 224.5 in 79 sq. ft per bed 26 Rt room [ROOM NUMBER] in x 224.5 in 79.51 sq. ft per bed 29 Rt room [ROOM NUMBER].5 in x 226.5 in 79.43 sq. ft per bed 30 Rt room [ROOM NUMBER] in x 156 in 75.02 sq. ft per bed 40 Rt room [ROOM NUMBER] in x 227 in 79.34 sq. ft per bed During random observations of care and services from 6/23/25 to 6/26/25, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care and each resident had adequate personal space and privacy. 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 five rooms. Granting of room size waiver recommended.

Based on observation, interview, and record review, the facility failed to ensure two out of six residents (Resident 1 and Resident 3) were free from physical abuse when: 1) Resident 1 was hit in the head by Resident 2, 2) Resident 3 had lemonade thrown at her by Resident 4. This failure resulted in Resident 1 and Resident 3 being the recipient of physical abuse which affected their physical and psychosocial well-being. Findings: 1) A review of Resident 1 ' s Face Sheet, printed 3/4/25, indicated Resident 1 ' s diagnoses of heart failure (heart not able to pump enough blood to meet body ' s needs) and generalized weakness. A review of Change in Condition Evaluation, written on 12/8/24 at 9:42 a.m., the Change in Condition Evaluation noted Resident 1 was in the room waiting for Resident 2 to come out of the bathroom. Resident 1 stated when Resident 2 came out of the bathroom, Resident 2 hit her twice in the head. In the Pain Assessment section, Resident 1 reported a pain level of 4 (0 being the lowest pain level and 10 being the highest pain level). During an interview on 3/4/25, at 11:35 a.m., with Licensed Vocational Nurse (LVN), LVN stated Resident 1 was in her wheelchair by her room door, gesturing and pointing to the back of the head along with facial grimacing. Per Change in Condition Evaluation, Resident 2 was transferred to another room with no roommate. During an interview on 3/4/25, at 1:45 p.m., with Registered Nurse (RN), RN stated Resident 2 did not have a sitter (staff assigned to a resident to monitor actions and behaviors) on night shift. During an interview on 3/4/25, at 2:10 p.m., with the Director of Nursing (DON), the DON stated Resident 2 had been on 1:1 (designated staff who monitors a resident) for about six months prior to this incident. Per DON, Resident 2 was weaned off 1:1 observation status. The DON added 1:1 observation is guaranteed on AM (7:00 a.m. – 3:30 p.m.) and PM (3:00 p.m. to 11:30 p.m.) shifts but not guaranteed on night (11:00 p.m. to 7:30 a.m.) shifts. The DON confirmed Resident 2 did not have an assigned sitter on the night shift of the incident. The incident occurred on 12/8/24 between 6:30 a.m. and 7:00 a.m. During an interview on 6/17/25, at 11:30 a.m., with the DON, the DON stated Resident 2 was on staff supervision on AM and PM shifts due to facility activities and multiple interactions with staff and other residents. Resident 2 was not on staff observation status on night shifts because there were no facility activities. A review of the facility ' s Summary of Investigation, completed on 12/13/24, the Administrator (ADM) concluded the incident as a negative interaction between residents. The investigation summary further noted Resident 1 verbalized she will feel safe and not threatened if Resident 2 will not come back to her room again. 2) A review of Resident 3 ' s Face Sheet, printed 6/17/25, indicated Res 3 ' s diagnoses of respiratory failure (lungs cannot properly exchange gases between oxygen and carbon dioxide) and chronic pain syndrome (persistent pain that lasts weeks to years). A review of Resident 3 ' s SBAR (situation, background, appearance, review) Communication Form, written on 12/9/24, the SBAR Communication Form noted on 12/9/24 at around 2:00 p.m., Resident 4 threw lemonade at roommate Resident 3. A review of Resident 4 ' s SBAR Communication Form, written on 12/9/24, the SBAR Communication Form noted in the Behavioral Evaluation section, Resident 4 displayed verbal and physical aggression. Noted on the form, Resident 4 said she threw lemonade at Resident 3 due to Resident 3 lying about her own medical conditions. Both residents were separated and reassigned to other rooms. A review of Progress Notes, written on 12/9/25 at 11:47 p.m., Resident 4 was noted getting irritated with aggressive behaviors towards sitter and nurse. Progress Notes written on 12/10/24 at 2:13 p.m. noted Resident 4 getting irritated late afternoon, grabbing wheelchair and hitting the wall. Progress Notes written on 12/11/24 at 2:42 p.m. noted Resident 4 continued to have aggressive behavior, noncompliance of smoking schedule breaks and became angry and frustrated. A review of Resident 4 ' s SBAR Communication Form, written on 12/18/24, the SBAR Communication Form noted in the Behavioral Evaluation section, Resident 4 was a danger to self or others, had verbal and physical aggression. Resident 4 was placed on 5150 (involuntary 72-hour hold of an individual for psychiatric evaluation) and was taken to a psychiatric emergency hospital. During an interview on 6/17/25, at 4:22 p.m., with Certified Nursing Assistant (CNA), CNA stated she heard screaming from the room of Resident 3 and Resident 4. Per CNA, when she arrived at the room, she saw both residents screaming at each other. CNA called for staff assistance and residents were separated. A review of the facility ' s Summary of Investigation, completed on 12/14/24, the Administrator (ADM) concluded the incident as a negative interaction between residents. A review of the facility ' s policy and procedure (P&P) titled, Abuse – Prevention, Screening, & Training Program, dated July 2018, the P&P indicated, The Facility establishes a safe environment that reasonably supports resident to the extent possible . The facility identifies, corrects, and intervenes in situations in which abuse . is more likely to occur.

Based on interview and record review, the facility failed to implement their policy and procedure to thoroughly investigate an allegation of abuse for one (Resident 1) of three sampled residents. Resident 1 alleged that a Certified Nursing Assistant (CNA1) hit him on the right leg because he refused to wear a sock. Facility designee/Director of Nursing (DON) did not interview alleged CNA, staff member assigned to provide care for Resident 1 and/or implement care plan to suspend alleged abuser while incident was under investigation. This failure had the potential to place Resident 1 at risk for emotional distress, mistreatment, or abuse. Findings: During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 3/11/25, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 1 ' s score was 9 meaning mild cognition. Resident 1 had clear speech, difficulty communicating some words or finishing thoughts, misses some part or intent of message. Resident 1 was dependent on helper does all task to put on and take off socks. Resident 1 ' s diagnoses included cerebrovascular accident (CVA) or stroke. During a concurrent observation and interview on 4/1/25 at 10:20 a.m. with Resident 1 in his room. Resident 1 stated he did not want to talk about the allegation. During a review of Resident 1 ' s care plan dated 3/16/25, the care plan indicated Resident 1 alleged physical abuse from facility ' s CNA, interventions included to suspend alleged abuser while incident is under investigation. During an interview on 4/1/25 at 11:01 a.m. with Certified Nursing Assistant (CNA1) , CNA1 stated she was not aware that Resident 1 alleged physical abuse by a CNA. CNA1 stated she was not informed of any allegation of abuse and was not suspended. CNA 1 stated she continued to assist Resident 1 with care as needed. During a concurrent interview and record review on 4/1/25 at 1:56 p.m., with Director of Nursing (DON), the investigation summary completed 3/21/25 was reviewed. The investigation summary did not include documentation that alleged CNA 1 and or Resident 1 ' s care givers were interviewed. DON stated facility process was to interview staff when the allegation involved staff member. DON stated alleged CNA1, and Resident 1 assigned care giver were not interviewed or suspended because Resident 1 was a poor historian. During a review of the facility's policy and procedure (P&P) titled, Reporting Abuse, revised January 08, 2014, the P&P indicated, Upon an allegation of abuse by facility staff member, the facility staff member will be suspended and removed from the premises during the investigation.

Based on observation, interview, and record review the facility failed to ensure necessary treatment and care services was provided for one (Resident 2) of three sampled residents in accordance with professional standards of practice when, rehabilitation referral for restorative nursing (RNA) for Resident 1 was not followed up. This failure had the potential for Resident 1 to not receive the necessary care and services to ensure mobility and muscle strength. Findings: During a review of Resident 2's Minimum Data Set (MDS - Resident assessment and care guide tool), dated 2/26/25, the MDS indicated Resident 2's Basic Interview of Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. The MDS indicated Resident 2 was able to recall the correct year, month, and day of the week. MDS indicated Resident 2 need partial assistance from another person with walking from room to room. The MDS indicated Resident 2 had diagnoses that included morbid obesity. During a concurrent observation and interview on 4/1/25 at 11:15 a.m. Resident 2 sat up in bed in his room, awake and verbally responsive. Resident 2 stated he was not able to walk. Resident 2 stated Restorative Nursing Assistance (RNA) had not provided him treatment to help him to walk. During a concurrent interview and record review on 4/1.25 at 12:32 p.m. with Director of Rehabilitation (DOR1), Resident 1 ' s Occupational Therapy (OT) discharge summary dated 3/13/25 was reviewed. OT and (PT) Physical therapy discharge recommendation indicated RNA for bilateral upper extremities (BUE) treatment and standing with front wheel walker (FWW) to facility maintenance of mobility and bilateral upper extremities (BUE) strength. DOR 1 stated Resident 1 was discharge from PT/OT therapy into RNA for functional maintenance of mobility and strength. During an interview on 4/1/25 at 12:30 p.m. with Restorative Nursing Assistant (RNA1), accompanied by RNA2 and RNA3, RNA1 stated Resident 1 was not on RNA services. RNA 1 stated facility process was when resident was discharged from PT/OT, RNA referral is given to nursing department. RNA1 stated she was not aware Resident 1 had an RNA referral. During a concurrent interview and record review on 4/1/25 at 12:48 p.m. with Licensed Vocational Nurse/Director of Staff Development (LVN1), Resident 1 ' s Restorative Program description dated 3/13/25 was reviewed. Resident 1 ' s restorative program description indicated cable exercises as tolerated three times a week, walking in hallway with front wheel walker. LVN1 stated she was responsible to follow up with Resident 1 ' s RNA referral. LVN1 stated she was sick for two weeks and did not follow up on Resident 1 ' s RNA referral. During a concurrent interview and record review on 4/1/25 at 2:10 p.m. with Director of Nursing (DON), Resident 1 ' s Restorative Program description dated 3/13/25 was reviewed. DON stated he will investigate what happened and why Resident 1 ' s referral for RNA was not followed up. During a review of the facility ' s policy and procedure (P&P) titled, Restorative Nursing Program Guidelines, revised September 19, 2019, the P&P indicated, The Director of Nursing Services (DON), or their licensed nurse designee, manages and directs the Restorative Nursing Program.

Based on observation, interview and record review, the facility failed to provide choice based on resident preferences for one of two sampled residents (Resident 1) when Resident 1 was not changed to his hospital gown upon request and was left in street clothes overnight. This failure had the potential to cause physical discomfort and emotional distress to Resident 1. Findings: During a record review of Resident 1 ' s Admission Record, printed 12/31/24, the Admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1 ' s Care Plan, dated 1/26/24, the Care Plan indicated Resident 1 had decreased ability to perform self-care related to impaired activity tolerance, impaired balance/safety, pain limiting function, weakness . During an observation and interview on 12/27/24, at 8:55 a.m., with Resident 1, Resident 1 wore a jacket, t-shirt and pants that were halfway down his thighs. Resident 1 stated he requested a Certified Nurse Assistant (CNA), from the night shift, change him to his gown before going to bed the other night because he wore the same clothes the whole day. Resident 1 stated the CNA did not assist him and told him he would be more comfortable wearing his street clothes because it was cold. Resident 1 stated it was not the first time a CNA refused to assist him with changing clothes at night. Resident 1 stated he reported it to the Long-Term Care Ombudsman in the past. Resident 1 stated he felt he was treated differently when the CNA did not assist him, and it affected his self-esteem and dignity. During an interview on 12/27/24, at 10:15 a.m., with CNA 1, CNA 1 stated when she arrived, Resident 1 was wearing street clothes. CNA 1 stated Resident 1 should have been assisted by the night shift CNA if Resident 1 had requested to have his clothes changed to hospital gown. CNA 1 stated Resident 1 could have been more comfortable when sleeping. CNA 1 further stated Resident 1 ' s skin could also have been checked for any skin issues. During an interview on 12/27/24, at 10:36 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 1 should have been assisted before going to bed so he could be comfortable at night. RN 1 stated if Resident 1 refused to be changed, CNAs should document the refusal. RN 1 stated Resident 1 did not have behaviors of refusing Activities of Daily Living (ADLs: Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). During an interview on 12/27/24, at 12:40 p.m., with the Director of Nursing (DON), the DON stated changing residents to hospitals gowns at bedtime was a preference. The DON stated if a resident refused to be provided ADLs at night, there should be documentation and care plan about the refusals. The DON stated if Resident 1 preferred to wear his hospital gown, Resident 1 should have been assisted. The DON stated Resident 1 ' s dignity could have been affected and must have been disappointed. During a follow up interview on 1/2/25, at 10:08 a.m., with the DON, the DON stated there was no documentation from the nursing staff that Resident 1 refused ADLs which included changing clothes before going to bed. During a record review of the facility ' s policy and procedure (P&P) titled, Residents Rights - Quality of Life, revised in March 2017, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being . Residents are groomed as they wish, including bathing, dressing and oral care. Based on observation, interview and record review, the facility failed to provide choice based on resident preferences for one of two sampled residents (Resident 1) when Resident 1 was not changed to his hospital gown upon request and was left in street clothes overnight. This failure had the potential to cause physical discomfort and emotional distress to Resident 1. Findings: During a record review of Resident 1's Admission Record, printed 12/31/24, the Admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1's Care Plan, dated 1/26/24, the Care Plan indicated Resident 1 had decreased ability to perform self-care related to impaired activity tolerance, impaired balance/safety, pain limiting function, weakness . During an observation and interview on 12/27/24, at 8:55 a.m., with Resident 1, Resident 1 wore a jacket, t-shirt and pants that were halfway down his thighs. Resident 1 stated he requested a Certified Nurse Assistant (CNA), from the night shift, change him to his gown before going to bed the other night because he wore the same clothes the whole day. Resident 1 stated the CNA did not assist him and told him he would be more comfortable wearing his street clothes because it was cold. Resident 1 stated it was not the first time a CNA refused to assist him with changing clothes at night. Resident 1 stated he reported it to the Long-Term Care Ombudsman in the past. Resident 1 stated he felt he was treated differently when the CNA did not assist him, and it affected his self-esteem and dignity. During an interview on 12/27/24, at 10:15 a.m., with CNA 1, CNA 1 stated when she arrived, Resident 1 was wearing street clothes. CNA 1 stated Resident 1 should have been assisted by the night shift CNA if Resident 1 had requested to have his clothes changed to hospital gown. CNA 1 stated Resident 1 could have been more comfortable when sleeping. CNA 1 further stated Resident 1's skin could also have been checked for any skin issues. During an interview on 12/27/24, at 10:36 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 1 should have been assisted before going to bed so he could be comfortable at night. RN 1 stated if Resident 1 refused to be changed, CNAs should document the refusal. RN 1 stated Resident 1 did not have behaviors of refusing Activities of Daily Living (ADLs: Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). During an interview on 12/27/24, at 12:40 p.m., with the Director of Nursing (DON), the DON stated changing residents to hospitals gowns at bedtime was a preference. The DON stated if a resident refused to be provided ADLs at night, there should be documentation and care plan about the refusals. The DON stated if Resident 1 preferred to wear his hospital gown, Resident 1 should have been assisted. The DON stated Resident 1's dignity could have been affected and must have been disappointed. During a follow up interview on 1/2/25, at 10:08 a.m., with the DON, the DON stated there was no documentation from the nursing staff that Resident 1 refused ADLs which included changing clothes before going to bed. During a record review of the facility's policy and procedure (P&P) titled, Residents Rights - Quality of Life , revised in March 2017, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being . Residents are groomed as they wish, including bathing, dressing and oral care. Based on observation, interview and record review, the facility failed to provide choice based on resident preferences for one of two sampled residents (Resident 1) when Resident 1 was not changed to his hospital gown upon request and was left in street clothes overnight. This failure had the potential to cause physical discomfort and emotional distress to Resident 1. Findings: During a record review of Resident 1's Admission Record, printed 12/31/24, the Admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1's Care Plan, dated 1/26/24, the Care Plan indicated Resident 1 had decreased ability to perform self-care related to impaired activity tolerance, impaired balance/safety, pain limiting function, weakness . During an observation and interview on 12/27/24, at 8:55 a.m., with Resident 1, Resident 1 wore a jacket, t-shirt and pants that were halfway down his thighs. Resident 1 stated he requested a Certified Nurse Assistant (CNA), from the night shift, change him to his gown before going to bed the other night because he wore the same clothes the whole day. Resident 1 stated the CNA did not assist him and told him he would be more comfortable wearing his street clothes because it was cold. Resident 1 stated it was not the first time a CNA refused to assist him with changing clothes at night. Resident 1 stated he reported it to the Long-Term Care Ombudsman in the past. Resident 1 stated he felt he was treated differently when the CNA did not assist him, and it affected his self-esteem and dignity. During an interview on 12/27/24, at 10:15 a.m., with CNA 1, CNA 1 stated when she arrived, Resident 1 was wearing street clothes. CNA 1 stated Resident 1 should have been assisted by the night shift CNA if Resident 1 had requested to have his clothes changed to hospital gown. CNA 1 stated Resident 1 could have been more comfortable when sleeping. CNA 1 further stated Resident 1's skin could also have been checked for any skin issues. During an interview on 12/27/24, at 10:36 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 1 should have been assisted before going to bed so he could be comfortable at night. RN 1 stated if Resident 1 refused to be changed, CNAs should document the refusal. RN 1 stated Resident 1 did not have behaviors of refusing Activities of Daily Living (ADLs: Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). During an interview on 12/27/24, at 12:40 p.m., with the Director of Nursing (DON), the DON stated changing residents to hospitals gowns at bedtime was a preference. The DON stated if a resident refused to be provided ADLs at night, there should be documentation and care plan about the refusals. The DON stated if Resident 1 preferred to wear his hospital gown, Resident 1 should have been assisted. The DON stated Resident 1's dignity could have been affected and must have been disappointed. During a follow up interview on 1/2/25, at 10:08 a.m., with the DON, the DON stated there was no documentation from the nursing staff that Resident 1 refused ADLs which included changing clothes before going to bed. During a record review of the facility's policy and procedure (P&P) titled, Residents Rights - Quality of Life , revised in March 2017, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being . Residents are groomed as they wish, including bathing, dressing and oral care.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 1) when Resident 1 ' s call light was not answered in a timely manner. This failure had the potential to cause physical discomfort and emotional distress to Resident 1. Findings: During a record review of Resident 1 ' s Admission Record, printed 12/31/24, the Admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1 ' s Care Plan, dated 1/26/24, the Care Plan indicated Resident 1 had decreased ability to perform self-care related to impaired activity tolerance, impaired balance/safety, pain limiting function, weakness . During an observation and interview on 12/27/24, at 9:00 a.m., with Resident 1, Resident 1 ' s room was located across the nurse ' s station. Resident 1 ' s call light was within Resident 1 ' s reach and located on the right side of his bed. Resident 1 stated the facility was always slow to answer the call lights. Resident 1 stated there were multiple occasions that he had to call the front desk because no one responded to his call light. Resident 1 stated the front desk paged the nursing staff assigned to him, but the nursing staff still took a long time until they arrived. Resident 1 stated there were times that he had to wait for hours for a CNA or a licensed nurse to assist him especially during the PM shift (3:00 p.m.-11:00 p.m.). Resident 1 stated the staff were just passing by even if his call light was on. Resident 1 stated he required staff ' s assistance in his ADL care because he was a fall risk. Resident 1 stated he felt he was being neglected and treated differently when the facility did not answer his call light promptly. During an observation on 12/27/24, at 9:52 a.m., in Resident 1 ' s room, Resident 1 pressed his call light button. Resident 1 ' s call light on indicator was lit inside Resident 1 ' s room and at the nurse ' s station. A beeping sound was also heard while Resident 1 ' s call light was continuously on. During an observation on 12/27/24, at 10:06 a.m., no staff entered the room to check on Resident 1. Multiple staff were observed passing by Resident 1 ' s room while the call light was on. A licensed nurse was also observed stationed in the hallway, near Resident 1 ' s room, working on the medication cart. The licensed nurse did not respond to Resident 1 ' s call light. During an observation and interview on 12/27/24, at 10:12 a.m., with CNA 1, CNA 1 entered Resident 1 ' s room after 20 minutes had passed. CNA 1 stated she was assisting another resident. CNA 1 stated nobody had informed her the call light was on in Resident 1 ' s room. CNA 1 stated any staff from the facility could answer the call light. CNA 1 stated it was important for the call lights to be answered promptly to assess the residents' needs. During a follow up interview on 12/27/24, at 10:36 a.m., with RN 1, RN 1 stated the call light for Resident 1 should be answered promptly to check on Resident 1's needs. RN 1 stated waiting for 20 minutes for a staff to answer the call light was too long and could have been an emergency for Resident 1. During an interview on 12/27/24, at 12:38 p.m., with the DON, the DON stated the facility call light policy was to promptly check a resident when they pressed their call light button and not have a resident wait for more than 15 minutes. The DON stated anybody from the facility ' s staff could respond to the call light. The DON stated Resident 1 should not have to wait 20 minutes for nursing staff to arrive. The DON stated the licensed nurse who was in the hallway while Resident 1 ' s call light indicator was on should have checked Resident 1. The DON stated the call light must be answered to avoid situations such as an emergency or worsening of conditions. During a record review of the facility ' s policy and procedure (P&P) titled, Residents Rights - Quality of Life, revised in March 2017, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being . Residents are groomed as they wish, including bathing, dressing and oral care. During a record review of the facility ' s P&P, titled, Communication Call System, dated 1/1/12, the P&P indicated, The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities . III. Nursing Staff will answer call bells promptly, in a courteous manner . V. In answering to request, Nursing Staff will return to resident with the item or reply promptly .A. Assistance will be offered before leaving. Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 1) when Resident 1's call light was not answered in a timely manner. This failure had the potential to cause physical discomfort and emotional distress to Resident 1. Findings: During a record review of Resident 1's Admission Record, printed 12/31/24, the Admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1's Care Plan, dated 1/26/24, the Care Plan indicated Resident 1 had decreased ability to perform self-care related to impaired activity tolerance, impaired balance/safety, pain limiting function, weakness . During an observation and interview on 12/27/24, at 9:00 a.m., with Resident 1, Resident 1's room was located across the nurse's station. Resident 1's call light was within Resident 1's reach and located on the right side of his bed. Resident 1 stated the facility was always slow to answer the call lights. Resident 1 stated there were multiple occasions that he had to call the front desk because no one responded to his call light. Resident 1 stated the front desk paged the nursing staff assigned to him, but the nursing staff still took a long time until they arrived. Resident 1 stated there were times that he had to wait for hours for a CNA or a licensed nurse to assist him especially during the PM shift (3:00 p.m.-11:00 p.m.). Resident 1 stated the staff were just passing by even if his call light was on. Resident 1 stated he required staff's assistance in his ADL care because he was a fall risk. Resident 1 stated he felt he was being neglected and treated differently when the facility did not answer his call light promptly. During an observation on 12/27/24, at 9:52 a.m., in Resident 1's room, Resident 1 pressed his call light button. Resident 1's call light on indicator was lit inside Resident 1's room and at the nurse's station. A beeping sound was also heard while Resident 1's call light was continuously on. During an observation on 12/27/24, at 10:06 a.m., no staff entered the room to check on Resident 1. Multiple staff were observed passing by Resident 1's room while the call light was on. A licensed nurse was also observed stationed in the hallway, near Resident 1's room, working on the medication cart. The licensed nurse did not respond to Resident 1's call light. During an observation and interview on 12/27/24, at 10:12 a.m., with CNA 1, CNA 1 entered Resident 1's room after 20 minutes had passed. CNA 1 stated she was assisting another resident. CNA 1 stated nobody had informed her the call light was on in Resident 1's room. CNA 1 stated any staff from the facility could answer the call light. CNA 1 stated it was important for the call lights to be answered promptly to assess the residents' needs. During a follow up interview on 12/27/24, at 10:36 a.m., with RN 1, RN 1 stated the call light for Resident 1 should be answered promptly to check on Resident 1's needs. RN 1 stated waiting for 20 minutes for a staff to answer the call light was too long and could have been an emergency for Resident 1. During an interview on 12/27/24, at 12:38 p.m., with the DON, the DON stated the facility call light policy was to promptly check a resident when they pressed their call light button and not have a resident wait for more than 15 minutes. The DON stated anybody from the facility's staff could respond to the call light. The DON stated Resident 1 should not have to wait 20 minutes for nursing staff to arrive. The DON stated the licensed nurse who was in the hallway while Resident 1's call light indicator was on should have checked Resident 1. The DON stated the call light must be answered to avoid situations such as an emergency or worsening of conditions. During a record review of the facility's policy and procedure (P&P) titled, Residents Rights - Quality of Life , revised in March 2017, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being . Residents are groomed as they wish, including bathing, dressing and oral care. During a record review of the facility's P&P, titled, Communication Call System, dated 1/1/12, the P&P indicated, The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities . III. Nursing Staff will answer call bells promptly, in a courteous manner . V. In answering to request, Nursing Staff will return to resident with the item or reply promptly .A. Assistance will be offered before leaving. Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 1) when Resident 1's call light was not answered in a timely manner. This failure had the potential to cause physical discomfort and emotional distress to Resident 1. Findings: During a record review of Resident 1's Admission Record, printed 12/31/24, the Admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1's Care Plan, dated 1/26/24, the Care Plan indicated Resident 1 had decreased ability to perform self-care related to impaired activity tolerance, impaired balance/safety, pain limiting function, weakness . During an observation and interview on 12/27/24, at 9:00 a.m., with Resident 1, Resident 1's room was located across the nurse's station. Resident 1's call light was within Resident 1's reach and located on the right side of his bed. Resident 1 stated the facility was always slow to answer the call lights. Resident 1 stated there were multiple occasions that he had to call the front desk because no one responded to his call light. Resident 1 stated the front desk paged the nursing staff assigned to him, but the nursing staff still took a long time until they arrived. Resident 1 stated there were times that he had to wait for hours for a CNA or a licensed nurse to assist him especially during the PM shift (3:00 p.m.-11:00 p.m.). Resident 1 stated the staff were just passing by even if his call light was on. Resident 1 stated he required staff's assistance in his ADL care because he was a fall risk. Resident 1 stated he felt he was being neglected and treated differently when the facility did not answer his call light promptly. During an observation on 12/27/24, at 9:52 a.m., in Resident 1's room, Resident 1 pressed his call light button. Resident 1's call light on indicator was lit inside Resident 1's room and at the nurse's station. A beeping sound was also heard while Resident 1's call light was continuously on. During an observation on 12/27/24, at 10:06 a.m., no staff entered the room to check on Resident 1. Multiple staff were observed passing by Resident 1's room while the call light was on. A licensed nurse was also observed stationed in the hallway, near Resident 1's room, working on the medication cart. The licensed nurse did not respond to Resident 1's call light. During an observation and interview on 12/27/24, at 10:12 a.m., with CNA 1, CNA 1 entered Resident 1's room after 20 minutes had passed. CNA 1 stated she was assisting another resident. CNA 1 stated nobody had informed her the call light was on in Resident 1's room. CNA 1 stated any staff from the facility could answer the call light. CNA 1 stated it was important for the call lights to be answered promptly to assess the residents' needs. During a follow up interview on 12/27/24, at 10:36 a.m., with RN 1, RN 1 stated the call light for Resident 1 should be answered promptly to check on Resident 1's needs. RN 1 stated waiting for 20 minutes for a staff to answer the call light was too long and could have been an emergency for Resident 1. During an interview on 12/27/24, at 12:38 p.m., with the DON, the DON stated the facility call light policy was to promptly check a resident when they pressed their call light button and not have a resident wait for more than 15 minutes. The DON stated anybody from the facility's staff could respond to the call light. The DON stated Resident 1 should not have to wait 20 minutes for nursing staff to arrive. The DON stated the licensed nurse who was in the hallway while Resident 1's call light indicator was on should have checked Resident 1. The DON stated the call light must be answered to avoid situations such as an emergency or worsening of conditions. During a record review of the facility's policy and procedure (P&P) titled, Residents Rights - Quality of Life , revised in March 2017, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being . Residents are groomed as they wish, including bathing, dressing and oral care. During a record review of the facility's P&P, titled, Communication Call System, dated 1/1/12, the P&P indicated, The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities . III. Nursing Staff will answer call bells promptly, in a courteous manner . V. In answering to request, Nursing Staff will return to resident with the item or reply promptly .A. Assistance will be offered before leaving.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for one of two sampled residents (Resident 1) when Resident 1 ' s room had: 1. Uncovered trash bin which contained an overflow of soiled diapers and dirty gloves. 2. Resident 1 ' s clothing stored in a mesh bag which was on the floor right next to the overflowing trash. This deficient practice had the potential to cause an unsanitary environment and spread of infection. Findings: During a record review of Resident 1 ' s Admission Record, printed on 12/31/24, the Admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During an observation and interview on 12/27/24, at 8:55 a.m., with Resident 1, Resident 1 was sitting on his bed. Under Resident 1 ' s edge of the bed, there was a small trash bin with no covering which was overflowing with soiled diapers and dirty gloves. Right next to the uncovered trash bin, a pair of dirty gloves and a mesh bag with clothes inside were found on the floor. Resident 1 stated the mesh bag contained his dirty laundry. Resident 1 stated he did not know his laundry was still there because he had asked his Certified Nurse Assistant (CNA) from the previous shift to take it to the laundry. Resident 1 stated he did not know the uncovered trash bin was placed under the edge of his bed. Resident 1 stated it made him sick to his stomach to know that the trash bin with overflowing soiled diapers was close to his bed. Resident 1 stated he felt upset because the facility was not following the procedure in maintaining proper sanitary and clean rooms. During an interview on 12/27/24, at 9:40 a.m., with CNA 1, CNA 1 stated the uncovered overflowing trash with soiled diapers and the clothes in a mesh bag were already present when she arrived. CNA 1 stated the CNAs from the previous shift must have left them in Resident 1 ' s room. CNA 1 stated the trash bin should not have been left exposed and overflowing. CNA 1 stated the trash with soiled diapers should have been disposed of immediately after providing care to Resident 1. CNA 1 further stated Resident 1 ' s clothes in a mesh bag should have been placed in a plastic bag and brought to the laundry room. CNA 1 stated exposed and overflowing trash with soiled diapers and laundry with no plastic covering on the floor could cause the spread of infection. During an interview on 12/27/24, at 12:34 p.m., with the Director of Nursing (DON), the DON stated the CNAs were responsible for making sure the rooms were clean and sanitary. The DON stated the CNA who was assigned to Resident 1 should have thrown away the bag of trash with soiled diapers before leaving Resident 1 ' s room. The DON stated the CNAs should have placed Resident 1 ' s laundry in a plastic bag instead of leaving it on the floor. The DON stated these practices had risk of infection. During a record review of the facility ' s policy and procedure (P&P), titled, Resident Rooms and Environment, dated 1/1/12, the P&P indicated, The facility provides resident with a safe, clean, comfortable, and homelike environment .Facility staff aim to create a personalized, homelike atmosphere, paying close attention to .A. Cleanliness and order Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for one of two sampled residents (Resident 1) when Resident 1's room had: 1. Uncovered trash bin which contained an overflow of soiled diapers and dirty gloves. 2. Resident 1's clothing stored in a mesh bag which was on the floor right next to the overflowing trash. This deficient practice had the potential to cause an unsanitary environment and spread of infection. Findings: During a record review of Resident 1's Admission Record, printed on 12/31/24, the Admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During an observation and interview on 12/27/24, at 8:55 a.m., with Resident 1, Resident 1 was sitting on his bed. Under Resident 1's edge of the bed, there was a small trash bin with no covering which was overflowing with soiled diapers and dirty gloves. Right next to the uncovered trash bin, a pair of dirty gloves and a mesh bag with clothes inside were found on the floor. Resident 1 stated the mesh bag contained his dirty laundry. Resident 1 stated he did not know his laundry was still there because he had asked his Certified Nurse Assistant (CNA) from the previous shift to take it to the laundry. Resident 1 stated he did not know the uncovered trash bin was placed under the edge of his bed. Resident 1 stated it made him sick to his stomach to know that the trash bin with overflowing soiled diapers was close to his bed. Resident 1 stated he felt upset because the facility was not following the procedure in maintaining proper sanitary and clean rooms. During an interview on 12/27/24, at 9:40 a.m., with CNA 1, CNA 1 stated the uncovered overflowing trash with soiled diapers and the clothes in a mesh bag were already present when she arrived. CNA 1 stated the CNAs from the previous shift must have left them in Resident 1's room. CNA 1 stated the trash bin should not have been left exposed and overflowing. CNA 1 stated the trash with soiled diapers should have been disposed of immediately after providing care to Resident 1. CNA 1 further stated Resident 1's clothes in a mesh bag should have been placed in a plastic bag and brought to the laundry room. CNA 1 stated exposed and overflowing trash with soiled diapers and laundry with no plastic covering on the floor could cause the spread of infection. During an interview on 12/27/24, at 12:34 p.m., with the Director of Nursing (DON), the DON stated the CNAs were responsible for making sure the rooms were clean and sanitary. The DON stated the CNA who was assigned to Resident 1 should have thrown away the bag of trash with soiled diapers before leaving Resident 1's room. The DON stated the CNAs should have placed Resident 1's laundry in a plastic bag instead of leaving it on the floor. The DON stated these practices had risk of infection. During a record review of the facility's policy and procedure (P&P), titled, Resident Rooms and Environment , dated 1/1/12, the P&P indicated, The facility provides resident with a safe, clean, comfortable, and homelike environment .Facility staff aim to create a personalized, homelike atmosphere, paying close attention to .A. Cleanliness and order Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for one of two sampled residents (Resident 1) when Resident 1's room had: 1. Uncovered trash bin which contained an overflow of soiled diapers and dirty gloves. 2. Resident 1's clothing stored in a mesh bag which was on the floor right next to the overflowing trash. This deficient practice had the potential to cause an unsanitary environment and spread of infection. Findings: During a record review of Resident 1's Admission Record, printed on 12/31/24, the Admission Record indicated Resident 1 was admitted to the facility in May 2024 with multiple diagnoses that included congestive heart failure (a chronic condition where the heart can't pump blood efficiently) and type 2 diabetes (a long-term disease in which the body cannot regulate the amount of sugar in the blood). During an observation and interview on 12/27/24, at 8:55 a.m., with Resident 1, Resident 1 was sitting on his bed. Under Resident 1's edge of the bed, there was a small trash bin with no covering which was overflowing with soiled diapers and dirty gloves. Right next to the uncovered trash bin, a pair of dirty gloves and a mesh bag with clothes inside were found on the floor. Resident 1 stated the mesh bag contained his dirty laundry. Resident 1 stated he did not know his laundry was still there because he had asked his Certified Nurse Assistant (CNA) from the previous shift to take it to the laundry. Resident 1 stated he did not know the uncovered trash bin was placed under the edge of his bed. Resident 1 stated it made him sick to his stomach to know that the trash bin with overflowing soiled diapers was close to his bed. Resident 1 stated he felt upset because the facility was not following the procedure in maintaining proper sanitary and clean rooms. During an interview on 12/27/24, at 9:40 a.m., with CNA 1, CNA 1 stated the uncovered overflowing trash with soiled diapers and the clothes in a mesh bag were already present when she arrived. CNA 1 stated the CNAs from the previous shift must have left them in Resident 1's room. CNA 1 stated the trash bin should not have been left exposed and overflowing. CNA 1 stated the trash with soiled diapers should have been disposed of immediately after providing care to Resident 1. CNA 1 further stated Resident 1's clothes in a mesh bag should have been placed in a plastic bag and brought to the laundry room. CNA 1 stated exposed and overflowing trash with soiled diapers and laundry with no plastic covering on the floor could cause the spread of infection. During an interview on 12/27/24, at 12:34 p.m., with the Director of Nursing (DON), the DON stated the CNAs were responsible for making sure the rooms were clean and sanitary. The DON stated the CNA who was assigned to Resident 1 should have thrown away the bag of trash with soiled diapers before leaving Resident 1's room. The DON stated the CNAs should have placed Resident 1's laundry in a plastic bag instead of leaving it on the floor. The DON stated these practices had risk of infection. During a record review of the facility's policy and procedure (P&P), titled, Resident Rooms and Environment , dated 1/1/12, the P&P indicated, The facility provides resident with a safe, clean, comfortable, and homelike environment .Facility staff aim to create a personalized, homelike atmosphere, paying close attention to .A. Cleanliness and order

Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 3), received the necessary services to maintain good grooming, and personal hygiene when they were not receiving showers consistently and as scheduled. This failure resulted in these residents being unhappy and facility not meeting their physical, mental, and psychological needs. Findings: During a review of Resident 1's face sheet, the face sheet indicated, Resident 1 was admitted to the facility with diagnoses that included Diabetes (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood), severe obesity, generalized weakness, and depression. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 7/21/24, the MDS indicated, a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 15 indicating no cognitive impairment. The MDS also indicated, Resident 1 required substantial/maximal assistance from staff for showers/bathing. During a review of Resident 2's face sheet, the face sheet indicated, Resident 2 was admitted to the facility with diagnoses that included paraplegia (leg paralysis), muscle weakness, and sepsis (the body's extreme response to an infection). During a review of Resident 2's MDS dated [DATE], the MDS indicated, a BIMS score of 15 indicating no cognitive impairment. The MDS also indicated, Resident 1 required staff supervision or touching assistance for showers/bathing. During an interview on 10/9/24 at 11:30 a.m., with Resident 1, Resident 1 stated he was supposed to be getting a shower twice a week (Mondays and Thursdays) but getting it once every three weeks and that is so upsetting to him and he had to fight staff before he could get one, and before he could get a basin for bath. During an interview on 10/9/24 at 11:36 a.m., with Resident 3, Resident 3 stated he needed to remind staff multiple times before he could get his showers. During an interview on 10/9/24 at 12 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated all residents have a sponge bath every day and showers twice a week. CNA 1 stated they have a shower schedule that they follow. CNA 1 stated they chart the showers and the bed baths in the computer that is attached on the wall and have the shower book for those staff who do not have an ID for the computer access such as new CNA or orientee. During a review of facility's shower schedule document, the shower schedule indicated Resident 1's shower days are Mondays and Thursdays. During a review of the facility's shower flowsheet record for Resident 1 titled, Bathing: Type dated look back 30 days, from 9/1/24 to 10/3/24, the shower flowsheet indicated, checkmarks indicating Resident 1 had a shower on 9/12/24(Thursday) indicating once in that week, 9/16/24(Monday) indicating once in that week; and no indication of a shower for the last two weeks in September until 10/3/24 (Thursday) when he had shower indicating once in that week. No indication for showers on 9/19/24(Thursday), 9/23/24(Monday), and 9/26 /24(Thursday or other days of those weeks. The flowsheet did not indicate any check mark for Resident refused or Resident not available and the spaces were blank. During a review of facility's shower schedule document, the shower schedule indicated, Resident 3's shower days are Tuesdays and Fridays. During a review of Resident 3's shower flowsheet record, look back 30 days from 9/11/24 to 10/6/24, the shower flowsheet indicated checkmarks for 9/25/24(Wednesday) once for that week, and for 10/4/24(Friday) once for that week, indicating Resident 2 only received shower on those two times in 30 days. The shower flowsheet did not indicate any checkmarks for the weeks from 9/11/24 to 9/23/24 and no checkmarks indicated that Resident 2 refused or unavailable. During a telephone interview on 10/10/24 at 2:15 p.m., with the Director of Nursing (DON), the DON stated they always follow the schedule for showers unless the resident refuses. DON stated for showers, it didn't matter if showers are done in AM (morning) or PM (evening), no specific shift and sometimes the scheduled days may change but each resident should have their shower twice a week. DON was unable to state the reason or provide any documents that indicated a refusal or other reasons for the missed shower days for Resident 1 and 3. During a review of the facility's policy and procedure (P&P) titled,Showering and Bathing, dated January 1, 2012, the P& P indicated, Purpose: A tub or shower bath is given to the residents to provide cleanliness, comfort and to prevent body odors . A review of the facility's P&P titled Resident Rights - Quality of Life, dated March 2017 indicated, Purpose: To ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to maintain the physical environment in accordance with standards of practice, when one resident room and the bathroom used by five residents was not clean. This failure did not ensure residents were provided with a clean, sanitary, and comfortable environment. Findings: During an observation on 10/9/24 at 11 a.m., in Resident 1 and 3 ' s bathroom, the bathroom appeared dirty. Over the toilet bowl a raised toilet seat with arms was placed. Inside the toilet bowl, there were dried scattered brown/black substance around its upper surface and some around the raised toilet seat over it. The toilet bowl had yellowish liquid inside which appeared like urine still sitting there not flushed. There was trash can with no trash liner and looked dirty inside. The bathroom floor appeared dirty. During an interview on 10/9/24 at 11:05 a.m., with Resident 2, Resident 2 stated, they don ' t clean the bathroom unless you call them. Resident 2 stated the bathroom is always like that unless they call the housekeeping to clean it. During an observation on 10/9/24 at 11:11 a.m. in residents 1 & 3 ' s room, the room floor appeared dirty, not swept, and with scratches/marks on the floor. During an interview on 10/9/24 at 11:36 a.m., with Resident 3, Resident 3 stated they don ' t clean the bathroom and anytime he used it, he had to clean it himself because it is always dirty. Resident 3 stated the room is always dirty as well. During a concurrent observation and interview on 10/9/24 at 12:12 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 acknowledged the bathroom is dirty. CNA stated the dirt around the toilet bowl looked old and did not look new. CNA 1 wore gloves and flushed the toilet, and stated she was flushing off the urine. During an interview on 10/9/24 at around 12:40 p.m., Housekeeping Supervisor (HKS) confirmed that the bathroom was not clean and did not look good. HKS confirmed room was not yet mopped. During an interview on 10/9/24 at 2:30 p.m., with the Infection Preventionist (IP), the IP stated the bathrooms need to be cleaned and sanitized 24 hrs. seven days a week, and the rooms and bathrooms are expected to be clean all the time. During an interview on 10/9/24 at 3:05 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated six residents in the two rooms shared the bathroom, and five out of the six residents did go to the bathroom to use it. During a telephone interview on 10/10/24 at 10:42 a.m., with the Director of Nursing (DON), the DON stated it is expected of all staff disciplines to ensure residents ' rooms and bathrooms are always clean and not pose any threat or risk to patients. DON stated if it is dirty and needed to be cleaned immediately. During a review of the facility ' s policy and procedure (P&P) titled, Resident Rooms and Environment and Housekeeping - Restrooms and Showers dated January 1, 2012, the P&P indicated, to provide residents with a safe, clean, comfortable and homelike environment .to promote the health of residents and staff by maintaining clean and sanitary conditions .Restrooms: empty, clean, and reline wastebaskets, clean thoroughly all surfaces of toilet .make sure all rust or other stains are removed .sweep and mop floor The P&P dated September 2016 titled Housekeeping - Resident rooms indicated, .The floor is swept or vacuumed. The floor is damp mopped with disinfectant solution .

Based on interview and record review, the facility failed to provide supervision to assure a safe transfer with two staff for one (Resident 1) of four sampled residents. As a result Resident 1 fell on [DATE] and sustained a severely fractured hip which was not recognized for three days. Findings: Review of the clinical record indicated Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. (progressive disease that destroys memory and other mental functions). A review of the Minimum Data Set Assessment (an assessment tool to guide care), dated 3/17/17, indicted Functional Status During Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair): Assistance needed was, Total dependence-full staff performance every time during entire 7-day period. The Support provided for transfer was assessed as, Two plus persons physical assist. That meant that Resident 1 needed at least two staff members to transfer her from the bed to the wheelchair. Review of the Fall Risk Assessment, date 6/19/17, Resident 1's rating for fall risk was 15. On the Total Score line at the bottom of the form was written, A total score of 10 or above represents HIGH RISK. A review of the care plan, revised on 3/16/17, indicated Resident 1's Problem/Need list included, At risk for fall, limited mobility, poor balance, lack of awareness, forgets to call/wait for assistance . and had a history of [REDACTED]. During an interview on 8/29/17 at 11:10 a.m., Certified Nurse Assistant (CNA) 1 stated (when the fall happened), Basically, I had got her dressed. Resident was supposed to be transferred to a chair. It was a two person transfer. As I went to go pull the wheelchair close to the bed for her to get her up, as I went to grab the wheelchair, she (Resident 1) was sitting on the side of the bed. To my knowledge, I thought she could hold herself up on bed. I guess not. I tried to catch her. I definitely approached her from the back. When I ran she was already pretty much was on the ground. It was something that happened fast. It was an instant type thing. I remember holding her from her back under her arm. I knew I needed to leave her there. The other CNA (CNA 2) went to get help. She came after the fall. She (Resident 1) seemed as though she could hold herself up. I thought I could take a few steps and grab the chair. I had worked with the resident before and was able to transfer the resident. CNA 1 stated, Resident 1,Cried a little bit. She did not yell. She was grabbing onto her leg or thigh. She always cried and complained. It seemed she was saying she was in pain. CNA 1 stated, I was told to make her feel as comfortable as possible in the chair and put her in the day room after the incident. During an interview on 8/29/17 at 3:30 p.m., with Licensed Vocational Nurse (LVN) 1, who was the charge nurse on the day of Resident 1's accident, LVN 1 stated, It always takes one person to get her (Resident 1) out of bed, or they would ask the RNA (Restorative Nurse Assistant) to do it. During an interview on 8/30/17 at 3:15 p.m., the Assistant Director of Nursing (ADON) stated we should have assessed in more detail, where the pain was coming from. When I assessed her, the CNA did not report to me that she said, pain. The fall happened on Friday. It was on Monday that she was really complaining of pain. The hip was tender and there was some heat. A review of the SBAR Communication form, dated 8/14/17, indicated Resident 1 had, Left hip pain and swelling and left cheek discoloration. Rt (resident) complains of pain when moved. An x-ray was done on 8/15/17 at the facility. The x-ray results showed Resident 1 had a severely comminuted (multiple fragments) fracture of the left hip. On 8/15/17 at 2:30 p.m. Resident 1 was sent to an acute hospital for treatment. The ED (Emergency Department) Provider Notes indicated Resident 1 had a fractured right hip, abrasions (top layer of skin damaged from friction) of both lower legs, bruising on the right leg and delirium (decline from a previous baseline state of mental function), probably from pneumonia. On 8/17/17 surgery was done to repair the fracture.

Based on observation, record and document review and staff interviews, the facility failed to ensure that food served to one (Resident 8) of 21 sampled residents was appropriate to meet her individual needs. Resident 8 was served whole grapes for lunch, when a mechanical soft diet (chopped, blended or ground food prescribed for difficulty chewing or swallowing) was ordered. This deficient practice had the potential to result in choking and could lead to death. On 4/27/15 at 3:55 p.m. the facility administrator was informed of the immediate jeopardy situation (IJs). The facility provided an acceptable immediate plan of action on 4/27/15 at 5:45 p.m. The corrections for the abatement of the IJs included: training of dietary staff by the RD on the diet textures; training of licensed nursing staff by the Registered Dietitian (RD) and Quality Assurance (QA) Nurse Consultant regarding checking trays for diet accuracy before delivery to residents. The facility will reassess all residents on a mechanical soft diet for signs and symptoms of aspiration (inhaling food/fluid into the lungs). Other components of the immediate plan of action included the Dietary Supervisor (DS) and/or designee performing checks on trays of mechanically altered diets for accuracy, five times a week. Also the RD will perform tray accuracy checks during weekly visits and report findings to the administrator. Immediate jeopardy situation ended on 4/28/15 at 2:15 p.m after discussions with the Administrator. Findings: During lunch meal service in the kitchen on 4/27/15 at 12:20 p.m. Resident 8's tray had a bowl of grapes in addition to Spaghetti and roast turkey with Alfredo sauce. Review of the lunch menu showed the following items were to be served: Roast turkey with Alfredo sauce, parslied Herb penne (pasta), green beans with dill, wheat roll, margarine, Apple crisp and Milk. For residents on the Ground/Mechanical soft diets, the changes were noted as follows: roast turkey was to be ground, green beans and penne pasta, soft and the apple crisp, diced apples. There were no grapes on the menu. The cart with Resident 8's tray was wheeled to the Restorative Dining Room at 12:35 p.m. During an observation on 4/27/15 at 2:00 p.m. Certified Nursing Assistant (CNA) 1 brought a lunch tray with food items which included a bowl of unpeeled, whole grapes to Resident 8. CNA 1 removed the cellophane wrap from the bowl of grapes and served them to Resident 8. CNA 1 was prevented from offering the bowl of grapes to Resident 8 and told that she should not have grapes as the order was for a mechanical soft diet. During an observation and concurrent interview on 4/27/15 at 2:35 p.m. in the dining room Resident 8 was sitting in her wheelchair in front of the dining table and Restorative Nursing Assistant (RNA) 1. On the table was an unwrapped bowl of unpeeled whole red grapes and under the bowl was Resident 8's meal ticket (piece of paper showing the resident's dietary information. When asked why the bowl of (unpeeled whole red) grapes was back on the table, RNA 1 stated that she would ask the nurse why the grapes were on Resident 8's tray because it was, "A choking hazard." RNA 1 stated that when she came in the nurses had already checked the trays, so she thought the lunch trays were ready to be passed. RNA 1 stated that she was assigned to supervise/assist Resident 8 during meals. RNA 1 stated that Resident 8 liked fresh fruits and had had grapes before. In an interview on 4/27/15 at 2:53 p.m. with dietary aide (DA) 2, she acknowledged she was responsible for putting fresh fruits on the trays of residents who have expressed a preference for fresh fruits and she made this determination from a list. When asked if she knew that whole grapes could be a choking hazard for residents on mechanical soft diet she said, " They can't have grapes? " In an interview on 4/27/15 at 3:15 p.m., registered nurse (RN) 4 stated it was the nurse's responsibility to check the trays before they were served to the residents. During an interview on 4/27/15 at 3:18 p.m. with the Registered Dietitian (RD) in the presence of the DS, RN 4 and RN 5, RD stated residents on mechanical soft diet can only have bananas and canned fruits. DS stated that was the first she heard that resident on mechanical soft diet can only have banana or canned fruits. In an interview on 4/28/15 at 2:30 p.m., the Director of Staff Development (DSD) stated she was the one who checked the meal cart for the lunch meal on 4/27/15. She provided no additional information on the presence of grapes on the tray of the resident who was ordered a mechanical soft diet. Review of the record on 4/27/15 showed Resident 8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. On 4/28/15, review of the speech therapy evaluation and plan of treatment, dated 3/11/13-4/7/13, showed Resident 8 presented with oral phase dysphagia (difficulty swallowing), prolonged chewing and inability to control a small mass of chewed food. Clearing of the oral cavity required multiple verbal prompts. During an interview with Speech Therapist (SP) 1 on 4/29/15 at 1:25 p.m., she said that a mechanical soft diet did not include unpeeled whole grapes. SP 1 said, "The skin of the grape is difficult to chew." SP 1 further stated that there is a risk associated with eating unpeeled whole grapes for individuals with oral phase dysphagia. If the individual is unable to control chewed food or to clear her airway a grape can become aspirated into the respiratory track, interfering with breathing and possibly resulting in death. Review of the facility's diet manual titled, "Mechanical Soft Diet," on 4/27/15 at 3:00 p.m., showed a list of foods to avoid: "Whole grapes (may use skinless grapes which are cut in half) or plums." Under the list of foods allowed were: "Ripe, soft and chopped 1/2 inch-no skins. May serve whole ripe banana."

Definitions: Center for Disease Control (CDC) - US agency charged with tracking and investigating public health trends. A part of the US Public Health Services (PHS) under the Department of Health and Human Services (HHS), the CDC is based in Atlanta, Georgia. It publishes key health information, including weekly data on all deaths and diseases reported in the US and [MEDICATION NAME]' health advisories. The CDC also fields special rapid-response teams to halt epidemic diseases. C.diff (Clostridium difficile or C.difficile) - A spore-forming, gram-positive anaerobic bacteria that produces two exotoxins. It is shed in feces, unstable and is contagious. Any surface, device, or material that becomes contaminated can serve as a reservoir for the C.diff spores. Usual symptoms include: watery diarrhea/loose stools, fever, loss of appetite, nausea, and abdominal pain/tenderness. C.diff colonization means that the patient exhibits no clinical symptoms and tests positive for the C.diff organism and/or toxin. C.diff infection means that the patient does exhibit symptoms (active infection) and tests positive for the C.diff organism and/or toxin. Maintaining adequate cleaning and disinfection of environmental surfaces and preventing contamination is needed in order to prevent transmission. www.cdc.gov Personal Protective Equipment (PPE) - Specialized clothing and equipment used by employees for protection against health and safety hazards. PPE is designed to protect many parts of the body i.e.; eyes, head, face, hands, arms, feet, ears, etc. Contact Isolation Precautions - Applied to patients with stool incontinence, draining wounds, uncontrolled secretions, pressure ulcers, or presence of draining body fluids, and presence of generalized rashes. Placement of patients in private rooms or if private room not available, patients are in room with other patients with C.diff infection. Use of PPE to prevent spread of infection is necessary along with Hand Hygiene. www.cdc.gov Universal/Standard Precautions - a set of basic infection prevention practices intended to prevent transmission of infectious diseases from one person to another. These practices are applied to every person every time to assure that transmission of disease does not occur. The term "standard precautions" is now used instead of the former " universal precautions. " Use of handwashing and alcohol based hand sanitizer is the practice in standard/universal precautions. Co-hort - a group of people who share a common characteristic or experience within a defined period. www.wikipedia.org Based on observation, interview and record review, the facility failed to establish and maintain an Infection Control Program that helped to prevent the transmission of disease and infection when one (Resident 4) of 21 sampled residents had a transmittable disease and proper infection control practices were not followed throughout the facility. This failure had the potential to cause all residents to be unnecessarily exposed to unsafe, unsanitary, harmful transmittable disease processes. An Immediate Jeopardy situation was communicated to the facility's Executive Director and declared on 9/30/14 at 2:15 p.m. The facility's Executive Director provided an acceptable plan of action and he was informed that the Immediate Jeopardy was abated on 9/30/14 at 7:55 p.m. The facility's immediate plan of action included: ? Inservice education to the Occupational Therapist who allowed the potential spread of infection to occur. ? Meeting of the Interdisiplianry team for discussion and assessment of the resident's needs, implementation of care plan. Education of the resident regarding infection and prevention of spread of infection. ? Inservice of all in house staff by members of the Infection Control Committee to re-educate all regarding contact precautions. ? Consultation with the Medical Director for additional direction. ? Disinfection of the Rehabilitation Room and equipment with prescribed bleach solution. ? Review of all residents for the symptoms of infection. ? Education of staff licensed nurses regarding the collection of data, completion of the infection surveillance form and policies and procedures regarding infection control. Findings: 1. During a concurrent observation and interview on 9/29/14 at 1:50 p.m. with Registered Nurse 2 (RN 2), Resident 4's room had a plain white paper sign on the door of room with the following instructions, "Stop, visitors report to charge nurse before entering the room, staff follow instructions." Resident 4's room had PPE stored in a plastic three drawer container outside of the room. Resident 4 was not in her room. When asked what the PPE and a sign on the door were for, RN 2 stated, "Resident 4 has C.diff." When asked if Resident 4 had an active case for C.diff, RN 2 stated that she would go check the chart and return. During an observation on 9/29/14 at 1:52 p.m., Occupational Therapist 1 (OT 1)walked along with Resident 2 in the hallway near Resident 4's room. OT 1 walked into Resident 4's room behind Resident 2 assisting her with a walker. OT 1 entered the room without doning PPE; no gloves, gown or mask. OT 1 assisted Resident 2 back into bed, bumping against the bed of Resident 4, and exited the room without washing her hands. In a concurrent observation and interview with RN 2 on 9/29/14 at 1:58 p.m., RN 2 stated, "Yes, Resident 4 still has the C.diff infection and had two loose stools this morning and is on [MEDICATION NAME] (used in some cases to treat C.diff)." When asked whether Resident 2 (Roommate of Resident 4) also had C.diff, RN 2 stated, " No, she is here for rehabilitation." When asked where Resident 4 was currently, RN 2 stated that she believed that Resident 4 was in the Physical Therapy (PT) room. RN 2 walked to the PT room and identified Resident 4 from the doorway. By observation on 9/29/14 at 2 p.m., Resident 4 was in the PT room exercising while Occupational Therapist 2 (OT 2) assisted her. OT 2 wore gloves but had no gown or mask donned. Resident 4 had on her street clothing and nothing between her and the seat of the PT equipment. There were two other residents in the PT room during Resident 4's session with OT 2. In an interview with OT 1 on 9/30/14 at 2:05 p.m. regarding Resident 4's current contact isolation precautions, OT 1 stated, "Yes, she's on precautions. It could be contact, I think we have to wear gowns, gloves, and a mask only if we come in contact with her loose stool." "No, I don't know about indirect versus direct contact." When asked about Resident 4 currently being in the PT room exercising, OT 1 stated while pointing to OT 2, "At least he's wearing gloves." In a concurrent observation and interview with the Director of Staff Development/Infection Control Coordinator (DSD/ICC) on 9/29/14 at 2:20 p.m., the DSD/ICC stated that she "instructs staff to wear PPE, gown, gloves and mask when a resident has C.diff and is on contact isolation precautions." "We co-hort residents when not active (versus active C.diff infection), but although Resident 2 doesn't have C.diff, she doesn't have any open skin sores." When asked if Resident 4 was still actively exhibiting signs and symptoms of C.diff, the DSD/ICC stated, "Yes." When asked whether she would be allowed to participate in physical therapy during an active case of C.diff, the DSD/ICC stated, "No." When asked to confirm Resident 4's presence in the PT room working with OT 2, the DSD/ICC stated, "I'm gonna have to speak with him." Review of the Vanderbilt University Medical Center Department of Infection Prevention, "Isolation Basics; Isolation Frequently Asked Questions" document copyright 2014; www.vanderbilt.edu/infection control, shows that "90 percent of the time healthcare workers enter room of patient on isolation precautions, and they touch either the patient or objects in the patient's environment. This may be due to unexpected issues that arise once in the room, thus "gowning up" is recommended regardless of how much contact with either the patient or the patients's environment is anticipated." Review of CDC guidelines for C.diff updated on March 6, 2012, shows to "Use Contact Precautions for patients with known or suspected Clostridium difficile infection: Place these patients in private rooms, if private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with Clostridium difficile infection. Use gloves when entering patients' room and during patient care. Perform Hand Hygiene after removing gloves. Use gowns when entering patients' rooms and during patient care. Continue these precautions until diarrhea ceases because C.diff infected patients continue to shed organism for a number of days following cessation of diarrhea, continue contact precautions beyond symptom resolution or until discharge depending on average length of stay at facility." In an interview with OT 2 on 9/29/14 at 2:30 p.m., OT 2 stated, "She's on universal precautions because of her C.diff. She said she wanted to exercise, so I checked my schedule today." "Obviously you wear the gloves with universal precautions, but we check the sign and ask the nurse whether to wear mask and gowns." "Obviously with C.diff you just have to wear your gloves." "I disinfected the equipment with the Super-Sani Cloth Disinfectant before and after she sat down." Review of the copied label of the "Super Sani-Cloth Germicidal Disposable Wipe" disinfectant used on 9/29/14 by OT 2, showed that it was "suitable for use on equipment requiring alcohol-based products" and that it contains 55 percent [MEDICATION NAME] alcohol and is bleach free." Review of the Centers for Disease Control and Prevention (CDC), "Guideline for Disinfection and Sterilization in Health care Facilities" dated 2008 showed the following: "Because C.diff spore production can increase when exposed to nonchlorine-based cleaning agents and the spores are more resistant than vegetative cells to commonly used surface disinfectants, some investigators have recommended use of dilute solutions of hypochlorite (1,600 parts per million available chlorine) for routine environmental disinfection of rooms of patients with C.diff associated diarrhea or colitis, to reduce the incidence of C.diff diarrhea, or in units with high C.diff rates. C.diff associated diarrhea rates were shown to have decreased markedly during a period of bleach disinfection (1:10 dilution) of environmental surfaces compared with cleaning with a quarternary ammonium compound. Because no EPA-registered products exist that are specific for inactivating C.diff spores, use of diluted hypochlorite should be considered. However, studies have shown that asymptomatic patients constitute an important reservoir within the health-care facility and that person-to-person transmission is the principal means of transmission." "Exposure time for 1000 ppm available chlorine achieved lower reduction of C.diff spores at 10 minutes when disinfecting." Review of the clinical record on 9/29/14 showed that Resident 4 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The clinical record showed that Resident 4 began exhibiting symptoms of C.diff on 9/2/14. Resident 4 was confirmed on 9/5/14 to have a positive/active lab report for C.diff. A nursing note dated on 9/5/14 showed "contact precautions initiated and maintained," three days after symptoms began. A physician's note dated on 9/5/14 showed, "patient's stool for C.diff is positive." The nursing care plan dated on 9/17/14 showed "contact precautions" dated 12 days after Resident 4 had a positive lab for C.diff. A nursing note dated on 9/27/14 at 3:00 p.m., showed that Resident 4 was "up in wheelchair propelling self around" and had two loose mucous like stool with slight characteristic of foul odor." Another nursing note dated for 9/28/14 at 3:10 p.m., showed that Resident 4 was "up on wheelchair, propels self, no isolation." A nursing note dated for 9/29/14 at 3:00 p.m., showed that Resident 4 had "three loose moderate amount stool with distinct foul smell." Continued review of the clinical record showed that Resident 4 also had positive/active lab report for C.diff on 9/6/14, 9/19/14, 9/21/14 and 9/22/14. By observation on 9/30/14 at 8:30 a.m., Resident 4 was lying in her bed with a visitor sitting at her bedside. The visitor for Resident 4 did not have on PPE. A bedside commode was sitting near the foot of Resident 4's bed. There were two trash receptacles in Resident 4's room without identifiable hazardous waste trash liners (red bags). Resident 4's roommate Resident 2 was not in the room. Review of the facility's "Infection Control Surveillance" document on 9/30/14 dated for the month of September 2014, showed that each listed resident including Resident 4, did not have information documenting signs and symptoms of their infection, did not have what type if any isolation precautions were initiated if needed, and did not show a date of when the infection was cleared. The facility's "Surveillance Data Collection Form" for Resident 4 showed a date of 9/4/14 for onset of her symptoms which was two days after nursing staff first documented symptoms for Resident 4 in the clinical record. In an interview on 9/30/14 at 11:50 a.m. with the DSD/ICC regarding the facility's infection control tracking and surveillance, the DSD/ICC stated, "I use my information on the 24 hour nursing report and the 72 hour charting and if a change of condition sheet is completed, but I don't put them on the surveillance grid unless they are on a antibiotic." When asked how the facility determines that there may be a facility wide issue with a specific infectious disease process if symptoms are not tracked on the grid, and are not documented when cleared, the DSD/ICC could not state how this would be accomplished. In an interview on 9/30/14 at 10:30 a.m. with Resident 2, (roommate of Resident 4) Resident 2 stated, "If she has something (infection) going on, why didn't they put her in a room by herself?" "She (Resident 4) has been in and out of the room since I came 2 weeks ago." In an interview on 9/30/14 at 7:20 p.m. with the Maintenance/Environmental Services Supervisor (MS/ESS), stated that he had used a 1:10 bleach solution for sanitizing all common areas (PT room, hallway, floor, resident room) where Resident 4 was known to have been present. "We sprayed and wiped after 20 seconds approximately of leaving it on." When asked about the amount of time needed to leave the bleach solution wet before wiping, the MS/ESS was unaware that the solution needed to sit for 10 minutes. Review of the facility's Policy and Procedure on 9/30/14 entitled, "Care of Residents with Active C.diff infections; dated January 2011, showed that "Residents with active C.diff infections will receive appropriate treatment. Other residents will be protected from spread of infection." The facility would "provide whenever possible residents with active C.diff having diarrhea with a private room. If cohorting is necessary, the resident with C.diff would be given a bedside commode and resident will not share a toilet, if possible, resident should be cohorted with other resident with C.diff. Isolation/Barrier precautions are to be used when caring for the resident with C.diff including but not limited to gloves and gowns. Barrier precautions will continue until diarrhea is resolved. All caregivers should use soap and water for decontamination of hands after giving care. Room, bed, sink and commode should be cleaned with 10% bleach solution. Residents with active C.diff should be encouraged to remain in their rooms until the diarrhea has resolved. Residents with active C.diff should be educated not to use other bathrooms in the facility. In an interview on 10/2/14 at 11:25 a.m. with the DSD/ICC while in the presence of the Quality Assurance Nurse Consultant (QA NC) regarding the facility's Infection Control Program's tracking and surveillance of infectious disease processes, the DSD/ICC stated that the facility was now tracking symptoms of infectious diseases rather that just when a resident is placed on antibiotic treatment. According to the DSD/ICC the facility subcommittee for the Infection Control Program was meeting daily instead of the monthly meetings that were previously occurring. 2. In an observation during initial tour on 9/29/14 at 1:52 p.m., there was one pink basin and one pink bed pan on top of the toilet tank in room [ROOM NUMBER] and 32's shared bathroom. In an observation and concurrent joint interview on 9/29/14 at 1:57 p.m., when asked if the pink basin and pink bedpan should be on top of the toilet tank, Certified Nurse Assistant 2 (CNA 2) and CNA 3 both stated that the basin and bedpan should have been placed in a plastic bag and stored inside the resident's bedside stand. CNA 2 proceeded to remove the basin and bedpan from the toilet tank and disposed of both of them. In an interview on 10/2/14 at 2:30 p.m., when asked where a resident's basin and bedpan be stored, the Staff Development Coordinator/Infection Control Coordinator (DSD/ICC) stated that they should be stored in the resident's bedside stand. DSD/ICC also stated that the basin and bedpan do not need a plastic bag if they are dry enough. Review of the facility's policy titled, "Urinal and Bedpan - Offering and Removing", revised on 1/1/12 indicated that, "Store the bedpan or urinal; do not leave it in the bathroom or on the floor."

Based on observation, staff interview, and record review, the facility failed to provide adequate supervision and assistance for three of 21 sampled residents (18, 32, 44). 1. Resident 18 was left alone in the room while he was in bed, restless and attempting to get up by himself. This resulted in the potential for Resident 18 to attempt to get out of bed, falling and injuring himself. 2. The facility did not ensure that Residents 32 and 44 had a safe smoking area. The residents sought a place to smoke that was out of wind and sat between parked cars or behind dumpsters where they were not visible for supervision. This resulted in the potential for injury due to lack of visibility. Findings: 1. Review of the medical record showed that the facility admitted Resident 18 on 6/14/13. Resident 18's [DIAGNOSES REDACTED]. Review of the Transfer Summary from the hospital, dated 6/14/13, showed that Resident 18 had a history of [REDACTED]. Observations of facility staff as they attempted to provide care to Resident 18 showed that the assessment did not adequately reflect Resident 18's condition and the care plan was inadequate to keep him safe from an accident. Observations were as follows: During an observation on 6/17/13 at 8:45 a.m. Resident 18 was bent over at the waist, almost coming out of the wheelchair. Due to Resident 18's posturing, agitation, straining against a restraint and trying to get up, it took three CNAs to keep Resident 18 from falling and to get him into bed. During an observation and interview on 6/18/13 at 8:40 a.m., Resident 18 was in bed and the Activity Assistant (AA) said she was the sitter for Resident 18 that day. The AA said that she was only there to watch Resident 18 and to call for help if needed, but that she could not touch the resident. Resident 18 was moving around in bed lifting his head , leaning towards the foot of the bed with his eyes closed, mumbling and trying to hold onto the side rails. When the AA asked if Resident 18 if he wanted to get up, he said, "Yes." The AA did not use the call light to call for help, but walked to the door and back to the bedside. When asked what was happening, the AA stated, I am looking for a CNA (Certified Nurse Assistant) to help him get up." On 6/18/13 at 8:47 a.m. Resident 18 continued to frown, mumble agitatedly and attempted to get out of bed. AA walked back to the door again, saying she was looking for help, stepped outside the room leaving Resident 18 alone for 14 seconds. In a concurrent interview AA was asked, "Can you take care of this Resident?", AA stated, "I am not comfortable in taking care of the Resident." AA explained her job description by saying that she would not touch him, but would only watch Resident 18 and call for help when the resident needed to get up or change position. During the observation from 8:40 a.m. to 8:47 a.m. the AA did not offer any comfort or help, leaving Resident 18 at risk for attempting to get out of bed and falling. On 6/18/13 when asked what the facility measures were to keep Resident 18 safe, the DON stated, "This Resident gets aggressive and tries to get up. The AA is a sitter and an AA cannot give care, but is there to provide activity for the Resident and see that he does not fall. She can only sit and watch the Resident in bed and in the wheelchair. The AA will use the call light to call a nurse or CNA for help. A CNA is assigned for the care of this Resident but this CNA has other residents too." The DON also stated, "(Resident 18) is a high risk for falls and injury." During observations on 6/18/13 at 10:40 a.m., 11:30 a.m. and 2:13 p.m., Resident 18 was sitting in a wheelchair accompanied by the AA, who could not provide any care to Resident 18. During an interview on 6/18/13 at 11:55 a.m., with the psychiatrist, she stated, "(Resident 18) has a high risk for falls, due to his posturing (bending at the waist, uncontrollably). The psychiatrist stated the posturing was related to the psychotropic medication given at the acute hospital. The psychiatrist further stated, "I am worried he is going to fall." 2. During an observation on 6/19/13 at 6:15 p.m., two residents were sitting outside in electric wheelchairs smoking in the parking lot adjacent to the designated smoking area. The designated smoking area was a grassy area under a tree with a curb. There were cars parked next to the curb. One of the residents (32) had a contracture of his right arm and there was no observed movement of the right extremities . On 6/19/13 at 6:25 p.m., during an interview, the Director of Nursing (DON) stated that randomly sampled Resident 32 was safe to smoke independently. DON said there was an assessment and care plan in the chart. DON said there were smoking aprons if the resident requested one. During an observation and interview on 7/2/13 at 10:40 a.m., Resident 32 said he wanted to go outside to smoke. Resident 32 went to the parking area near the designated smoking area, via his electric wheelchair. Resident 32 said he couldn't get the electric wheelchair over the curb where the designated smoking was so he smoked in the parking lot. Resident 32 then went inside a concrete barrier and went behind one of two large garbage bins in the concrete structure. Resident 32 said he smoked there when it was windy. By observation Resident 32 dangled the cigarette in his mouth. He used a lighter to light the cigarette with his left hand. Once lit he put away the lighter in his pocket and then secured the cigarette with his left hand. Resident 32 said if an ash fell and started to burn his clothing he believed he could put it out. He pointed to a burn hole in his jacket as an indication he could put out a fire. Resident 32 said the burn hole was from a time when the jacket hung over the side of the wheel chair and he accidentally flicked an ash over the side, burning the jacket. Resident 32 said he usually smoked with another resident and he was never offered a smoking apron. Resident 32 wasn't visible to anyone outside the concrete structure. Review of the Discharge Summary from the hospital, dated 4/9/12, showed that Resident 32 had a past medical history which included two strokes which left him paralyzed on the right side. The MDS (Minimum Data Set) for a Comprehensive assessment dated [DATE] showed that Resident 32 was cognitively intact and had functional limitation of range of motion of both extremities on one side. There was a "Safe Smoking Assessment," dated 4/25/13, and signed by three Interdisciplinary Team (IDT) members. The paralysis of the right side was not considered in the smoking assessment. One of the pre-printed assessment items was, "...7. Are there any concerns about the resident's ability to smoke independently?" The column for "No" was checked. The "Smoking" resident care plan, dated 12/1/12, showed a check mark next to "Resident is safe to smoke independently." Other preprinted items on the care plan which were not checked were "Resident is at risk for smoking related injury due to: "Range of motion limitation," and "Impaired manual dexterity." Approaches which were checked for Resident 32 were "Supervise resident per Facility policy while smoking" and "Assist resident to and from designated smoking area..." There were no staff members with Resident 32. Review of the policy "Smoking by Residents" dated as revised on 1/1/12, had the following purpose: "To provide safe smoking areas for residents who wish to smoke." The policy included: "The Facility has designated specific outdoor areas as safe smoking areas. The procedure included the following: "Residents who are assessed as "safe smokers" by IDT may smoke independently in the designated smoking area(s)." The procedure did not have direction to staff on the items to consider when performing a safe smoking assessment. 3. During an observation on 6/16/13 at 8:50 a.m., prior to entering the facility two residents, one in a wheelchair and one ambulatory approached the designated area to smoke adjacent to a (red line) fire curb without wheelchair access that connected to the facility parking lot. Under a tree was one plastic off white colored chair and a few feet from the chair was the smoke container (beige). During a second observation, concurrent with an interview on 6/20/13 at approximately 11:45 a.m. to 1:30 p.m. accompanied by the Maintenance Supervisor and FOSS surveyor for the environmental tour the MS when asked where the designated smoking area was (pointed) to the area under the tree. When questioned the MS said that the smoking apron and fire extinguishers were located inside the building and that some residents that come out can smoke independently. He also said that resident's don't like to smoke in the elements and sit where Resident 44 was to get out of the wind. Observed Resident 44 sitting between two metal dumpster's to get out of the windy area. The designated smoke area was adjacent to a (red line) fire curb and the facility parking lot. The smoking area was not accessible with two parked vehicles along the fire curb in the designated smoke area in which motorists have the right of way. During a second observation on 7/2/13 at approximately 7:00 a.m. a noticeable change occurred where the aforementioned fire curb was no longer colored red. Two vehicles were parked in the designated smoking area once again, and the designated smoke area was not accessible. This was unsafe due to vehicle traffic. When questioned at approximately 5:30 p.m. the MS stated, the County " Paints the fire curbs", and said he had nothing to do with it. During an observation, concurrent with an interview on 7/2/13 at 1:30 p.m. Resident 44 was observed smoking between parked vehicles (Physician's Parking lot) then moved toward the area where the metal carts are located to get away from the windy area. Resident 44 stated he smokes between parked vehicles and that he is aware of the motorist driving and knows he has to get out of there path when he goes to the smoking designated area. He said he tries to get out of the wind and "I know it is unsafe". During a review of the Policy and Procedure, "Smoking by Residents", indicated that the facility will provide safe smoking areas for residents who smoke. "The Facility provides designated outdoor areas as safe smoking areas. Residents who smoke will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas.