Every finding on record at Sonoma Post Acute

Based on observation, interview, and record review, the facility failed to protect one of five sampled residents (Resident 1) from abuse when Resident 2 punched Resident 1 in the face and chest while he was in his bed. This failure caused Resident 1's lip to bleed and redness to his chest when Resident 1, who was bed-bound, was unable to get away from Resident 2 when he approached him and began to punch him with his fist.Review of a document from the county sheriff's department titled, Incident/Investigation Report, dated 6/16/26 at 8:13 p.m., indicated an officer responded to a report of an assault that had occurred between two residents who were roommates. The report indicated, The victim was punched twice, once in the chest and once in the lip causing a minor laceration to his lower lip. The report further indicated the offender was Resident 2, the victim was Resident 1, and the reportee was Licensed Nurse (LN) C. During an observation and concurrent interview on 6/24/26 at 2:30 p.m., Resident 2 was seated on the couch in a common area with his head in his hands and his eyes closed. When this surveyor greeted Resident 2 and introduced herself, Resident 2 opened his eyes and responded with nonsensical statements and was not able to give any meaningful answers to questions. During an observation and concurrent interview on 6/24/26 at 2:52 p.m., Resident 1 was seated in a wheelchair. Resident 1 stated with difficulty due to his aphasia (impaired ability to speak) that he needed to talk to this surveyor. Resident 1 took his right fist and moved it quickly toward his mouth and then pointed at his mouth. When asked if he had been punched in the mouth, Resident 1 nodded yes. Resident 1 was not able to state the name of who punched him. Resident 1 stated he needed help to get out of the facility. During an interview on 6/25/26 at 2:05 p.m., LN A stated she was regularly assigned to care for Resident 2. LN A stated Resident 2 had aggressive behaviors. LN A stated Resident 2 had recently lashed out and tried to hit the PM shift nurse when he tried to give Resident 2 his pills. LN A stated Resident 2 had angry outbursts at staff, he called her names, yelled at other residents, and he recently punched Resident 1. During an interview on 6/25/26 at 2:10 p.m., Certified Nursing Assistant (CNA) B stated he regularly was assigned to care for Resident 2. CNA B stated Resident 2 had aggressive behaviors such as getting upset during care and yelling, Leave me alone! Don't touch me! CNA B stated he had to have another CNA with him to help during care, such as brief changes, due to Resident 2's aggression. During an interview on 6/25/26 at 2:43 p.m., LN C verified she responded to the incident on 6/16/26 between Resident 1 and Resident 2. LN C stated that around 7:30 p.m., CNA D and CNA E heard yelling in Resident 1 and 2's room. LN C stated CNA D entered the room and saw Resident 2 standing very close to Resident 1. LN C stated CNA D redirected Resident 2 out of the room and LN C did a thorough assessment of Resident 1. LN C stated she noted Resident 2's lower lip was bleeding and he had redness to his right chest. LN C stated Resident 1 told her he was punched by Resident 2. LN C stated she called the administrator, law enforcement, and sent the required form to the long-term care ombudsman. LN C stated Resident 2 was not able to recall that he had punched Resident 1. LN C stated Resident 2 had had behavior like this before. During an interview on 6/25/26 at 3 p.m., CNA E stated she recalled the incident between Residents 1 and 2 on 6/16/26. CNA E stated her coworker CNA D was assigned to care for Residents 1 and 2 that evening. CNA E stated she was in a room down the hall when she heard yelling and CNA D came and got her and took her to the room where Residents 1 and 2 resided. CNA E verified Residents 1 and 2 were roommates. CNA E stated Resident 2 was already walking towards the nurses' station by this time. CNA E stated she tried to talk to Resident 1, he was having a hard time saying what he wanted to say, but he kept saying, He punched me, he punched me. CNA E stated she put on gloves and looked at the inside of Resident 1's lower lip which looked like he had been punched. CNA E stated she also noted redness on Resident 1's chest and asked him if Resident 2 had punched him in his chest, too, and Resident 1 responded, Yes. CNA E stated she reported this to LN C at the nurses' station. CNA E stated Resident 1 did not have any injuries at the beginning of her shift. CNA E stated Resident 1 was in his bed laying down at the time of the incident. CNA E stated Resident 1 could not get up on his own so he could not get away from the situation. CNA E stated Resident 2 had aggressive behaviors, such as if he heard something he did not like he would start yelling and cussing, and he also would get in people's faces. During a phone interview on 6/25/26 at 3:08 p.m., CNA D stated she recalled that on the evening of 6/16/26 she saw Resident 2 walk into his room and close the door behind him. CNA D stated that about 10 seconds later she could hear Resident 2 yelling at Resident 1, she heard Resident 2 call Resident 1 an asshole and a bitch, so she walked in and separated them. CNA D stated she told Resident 2 to follow her out of the room and then she told CNA E to go check on Resident 1. CNA D stated CNA E told her that Resident 1 was bleeding and she was going to get the nurse. CNA D verified Resident 1 did not have any injuries before the incident occurred. CNA D stated Resident 2 had aggressive behaviors, and stated Resident 2 had grabbed her by her arm and tried to bite her when she was changing his brief. CNA D stated Resident 2 also called her an asshole when she tried to encourage him to eat, and he had grabbed the nurses' hands when they were providing care. CNA D stated Resident 2 generally stayed away from people when he was out of his room, but when he was in a room with people, that was when he targeted people. CNA D stated Resident 2 thought people were saying things about him that were not true, and all you have to do is look at him to get him riled up. CNA D stated Resident 2's new roommate told her yesterday (6/24/26) that he woke up and Resident 2 was staring at him watching him sleep, so he told Resident 2 to go away, and Resident 2 told him he was going to punch him in the face. Review of Resident 1's facesheet (demographics) indicated an admission date of 3/20/25, age of eighty years old, and multiple medical diagnoses including but not limited to amyotrophic lateral sclerosis (ALS, commonly known as Lou Gehrigsdisease, destroys motor neurons in the brain and spinal cord, which causes muscles to weaken, twitch, and waste away, leading to loss of movement, speech, swallowing, and breathing) and left-sided paralysis following a stroke. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/11/26 indicated Resident 1 had a moderate cognitive impairment, had difficulty making himself understood when speaking, and needed extensive assistance from staff for most activities of daily living (eating, dressing, bathing, etc) and mobility. Review of Resident 2's facesheet indicated an admission date of 5/16/26, age of eighty-one years old, and multiple medical diagnoses including but not limited to metabolic encephalopathy (altered brain function caused by an underlying systemic, chemical, or organ problem rather than a direct brain injury) and dementia (a decline in cognitive abilities-such as memory, reasoning, and communication-that is severe enough to interfere with daily life). Review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a severe cognitive impairment and was able to walk at least 50 feet with supervision. Further review of Resident 2's MDS indicated that he had displayed verbal and physical behaviors that significantly interfered with his care and activities on one to three of the past seven days, and that the behaviors put others at risk of injury. Review of Resident 2's care plan indicated a focus area, dated 5/18/26, The resident has a behavior problem of being verbally and physically aggressive [related to] dementia. Resident peer to peer (aggressor) swiped right hand across another resident, with interventions that included, Intervene as necessary to protect the rights and safety of others. Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised 4/2021, indicated, Residents have the right to be free from abuse . This includes but is not limited to freedom from . physical abuse . The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse . by anyone including, but not necessarily limited to: . other residents .

Based on interview and record review, the facility failed to report to the Department an allegation of abuse. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.Review of a document from the county sheriff's department titled, Incident/Investigation Report, dated 6/16/26 at 8:13 p.m., indicated an officer responded to a report of an assault that had occurred between two residents who were roommates. The report indicated, The victim was punched twice, once in the chest and once in the lip causing a minor laceration to his lower lip. During a record review and concurrent interview on 6/24/26 at 3:20 p.m., the Administrator stated he was aware of the resident-to-resident incident that occurred on 6/16/26 but stated it was not reported to the Department because the resident who was the aggressor had dementia. The Administrator provided a flow sheet created by a long-term care ombudsman organization which indicated that in cases of alleged abuse where the aggressor had a dementia diagnosis, facility staff were only required to notify law enforcement and the ombudsman's office. The Administrator stated he was following the reporting guidance on the flow sheet he was given. During an interview on 6/25/26 at 2:43 p.m., Licensed Nurse (LN) C verified she responded to the resident-to-resident incident that occurred on 6/16/26. LN C stated she called the Administrator, who was the abuse coordinator, who advised her to call law enforcement to report the incident and send the form for abuse allegation reporting to the long-term care ombudsman. When queried, LN stated she was not sure when abuse allegations needed to be reported to the Department. Review of facility policy and procedure Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last revised 9/2022, indicated, All reports of resident abuse (including injuries of unknown origin) . are reported to local, state and federal agencies (as required by current regulations) . The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility .

Based on observations, interviews, and record review the facility failed to provide supervision and assistance during meals to prevent accidents for two of six sampled residents (Resident 1 and Resident 2), when staff allowed Resident 1 and Resident 2 to have access to their meal trays without the physician ordered 1:1 assistance. This failure resulted in unwitnessed choking and death for Resident 1 and placed Resident 2 at risk for aspiration (the accidental breathing in of food, liquid, saliva, or vomit into the airways and lungs instead of swallowing it down the food pipe (esophagus) to the stomach) while eating.On 4/16/26, the Department received a complaint from a Family Member (FM) alleging Resident 1 passed away on 3/11/26 after choking on food and being left unattended in the room with access to the breakfast tray. The FM reported speaking with the Medical Director (MD) on 3/11/26, who stated Resident 1 had orders for 1:1 assistance, while on 3/12/26 the Administrator stated the Speech Language Pathologist (SLP) had lifted the 1:1 order two days before the resident's death.During a phone interview on 4/20/26 at 4:25 p.m., with the FM, the FM stated Resident 1 had a known history of dysphagia, three prior strokes, dementia, and required strict 1:1 feeding assistance at home due to difficulty swallowing and a tendency to take large bites. The FM stated she informed the facility of these needs upon Resident 1's admission and observed during visits that Resident 1 continued to require close feeding assistance. The FM reiterated that on the morning of 3/11/26, the MD called and informed her Resident 1 had died and stated Resident 1 was found in bed and appeared to have choked on food. The MD again told the FM Resident 1 had physician prescribed 1:1 feeding orders and stated the event should not have happened, but did not know how Resident 1 got his hands on the food. The FM confirmed on 3/12/26, the Administrator called her and told her the SLP had discontinued the 1:1 order two days prior to the incident.A review of Resident 1's admission record, dated 1/9/26, indicated Resident 1 was admitted to the facility with multiple diagnoses including dementia (a progressive state of decline in mental abilities) and oropharyngeal dysphagia (a condition where the muscles in the mouth and throat do not work well, making it hard to start a swallow and causing food or liquid to enter the airway instead of the stomach).A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/13/26, indicated Cognitive Loss/Dementia and swallowing concerns were present.A review of Resident 1's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgment status), dated 1/14/26, showed a score of 00 (BIMS has a possible score range of 0-15, with lower scores indicating more severe cognitive impairment, a score of 00 reflects significant impairment in memory, attention, and orientation).During an interview on 4/21/26 at 9:55 a.m. with Licensed Nurse A (LN A), LN A stated based on the active orders in Resident 1's chart, [Name] (Resident 1) should have had someone with him during breakfast (on 3/11/26), as Resident 1 had an active order for 1:1 assistance with meals. LN A confirmed she was the nurse responsible for Resident 1 on 3/11/26 and reported that when she entered Resident 1's room at approximately 8:10 a.m., no nursing staff were present with the resident despite the 1:1 requirement. LN A stated she found the resident upright in bed, unresponsive, without respirations or a carotid pulse (pulse in the neck, just below the jawline), with scrambled eggs visible in the oral cavity, which she removed during her airway assessment. LN A stated she immediately requested assistance, verified Resident 1 was Full Code, initiated CPR, and directed 911 to be called.During an interview on 4/21/26 at 12:52 p.m. with the SLP, the SLP stated she did not discontinue Resident 1's physician ordered 1:1 Feeding Assistance with meals.During an interview on 4/21/26 at 2:45 p.m. with the Director of Staff Development (DSD), the DSD stated, Resident 1 should have had someone with him to help with feeding the morning of 3/11/26.During an interview on 4/29/26 at 4:21 p.m. with LN D, LN D stated a 1:1 feeding assistance order means a nursing staff member must always stay with the resident during meals.During an interview on 4/29/26 at 4:29 p.m., the MD confirmed Resident 1 had an active 1:1 feeding assistance order on 3/11/26. The MD stated a 1:1 feeding assistance order requires nursing staff to remain with the resident during the meal especially when the order is written for aspiration risk supervision.During a review of Resident 1's Speech Therapy Evaluation titled Medicare SLP Evaluation & Plan of Treatment, dated 1/12/26, Resident 1 was documented to have poor safety awareness, impulsive intake behaviors, impaired cognition limiting the ability to follow swallowing strategies, and ongoing aspiration risk, with SLP noting the need for supervision during oral intake.During a review of Resident 1's care plan titled, Care Plan Report, with entries initiated on 1/11/26 and revised on 3/12/26, the plan included *** Nursing - 1:1 ASSISTANCE @ MEALS *** and Whole pills w/ apple Sauce 1 pill at a time, identifying Resident 1 as requiring continuous assistance at meals.During a review of Resident 1's physician orders, titled Order Summary Report, covering 01/09/26 through 3/11/26, the record listed Resident 1 had an active, Prescriber Written order for Nursing - 1:1 Feeding Assistance with Meals.During a review of Resident 1's progress notes, titled Progress Notes *NEW*, dated 3/11/26, entry created by LN A at 3:43 p.m., LN A recorded at 07:47 a.m. a Certified Nursing Assistant (CNA) was notified to assist Resident 1 with breakfast. At approximately 8:10 a.m., Resident 1 was found by LN A sitting upright in bed, unresponsive, pale, and without respirations or carotid pulse (pulse in the neck, just below the jawline). Resident 1 did not respond to verbal or painful stimuli. LN A immediately requested assistance and verified the resident's Physician Orders for Life-Sustaining Treatment (POLST) indicating Full Code status. Cardiopulmonary resuscitation (CPR) was initiated at 8:11 a.m. LN C was performing chest compressions. LN D applied the Automated External Defibrillator (AED) and analysis showed a non shockable rhythm. During airway assessment by LN E, visible food material was noted in the oral cavity and removed. LN A contacted Emergency Medical Services (EMS) at 8:12 a.m. while CPR continued. CPR continued until EMS arrived at approximately 8:16 a.m. and assumed care. Resuscitative efforts continued under EMS direction. Despite all interventions, the resident was pronounced deceased by EMS at 8:44 a.m.During a review of documentation received from the Sonoma County Sheriff's Office, titled Death Investigation Report and reflecting scene observations from 3/11/26, the cause of death for Resident 1 was listed as ASPHYXIA (a dangerous condition where the body does not get enough oxygen), due to OBSTRUCTION OF AIRWAY BY FOOD BOLUS (when a lump of food gets stuck in the throat and blocks the breathing tube, making it hard or impossible to breathe), and the manner of death was Accident. The report also stated that during the morning of 3/11/26, the coroner investigator saw scrambled eggs on the sheets and pillow near the headboard of Resident 1's bed, eggs in the suction device container, and eggs on the floor near the resident's head inside the room.A review of Resident 2's admission record dated 4/17/26, indicated Resident 2 was admitted to the facility with multiple diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) and oropharyngeal dysphagia. Resident 2 was admitted with a tube feeding (when a person gets liquid food through a small tube that goes into their stomach or intestine because they cannot eat safely by mouth) in place.During an observation on 4/22/26 at 12:29 p.m., Resident 2 was in his room sitting upright in bed eating a pureed lunch (pureed ham steak, pureed pan seared potatoes, and pureed seasoned fresh broccoli) without nursing staff present to provide the physician ordered 1:1 supervision.During a concurrent observation and interview on 4/22/26 at 12:35 p.m., the surveyor was already in Resident 2's room when Licensed Nurse B entered. LN B stated Resident 2 should not have been left alone with the meal tray. LN B further stated either a licensed nurse, or a CNA was expected to remain with Resident 2 during meals because oral intake had only recently begun on 4/20/26 to transition him off tube feedings, which Resident 2 was still receiving. LN B remained in the room and provided continuous supervision until Resident 2 finished eating.During a review of Resident 2's dietary orders dated 4/20/26, Resident 2 was ordered a pureed diet and mildly thick liquids. The physician order required Resident 2 to take small bites and sips, use a chin down posture when swallowing, and have 1:1 supervision during all eating to prevent choking.During a review of Resident 2's Speech Therapy Evaluation titled Medicare SLP Evaluation & Plan of Treatment, dated 4/20/26, Resident 2 was only allowed to try small amounts of food or liquid with staff help. The review showed Resident 2 needed 1:1 supervision any time food or liquid was given because of severe swallowing problems and silent aspiration (when food, liquid, or saliva goes down and into the airway and toward the lungs - without the person coughing, choking, or showing any obvious signs) in the past.During a review of Resident 2's care plan titled, Care Plan Report, printed 4/22/26, the care plan included instructions for Resident 2 to have 1:1 supervision during all eating trials. The care plan included goals to keep Resident 2 free from aspiration.During a review of the facility policy titled Assistance with Meals Policy, revised March 2022, the policy stipulated, .Facility staff will serve resident trays and will help residents who require assistance with eating., and .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food service safety for a census of 79, when:Fish fillets, beef patties, and cookie dough stored in the freezer were not sealed and open to air.Sanitizer buckets for surface cleaning were found empty and during preparation of new sanitizing solution the ppm's ( parts per million- a measurement of concentration of sanitizer to water) were insufficient, and staff could not verbalize the correct ppm's needed for proper sanitization.A colander was found in the ready to use area with dried food stuck to the base and inside openings and 3 pans were found with peeling/flaking of cooking surfaces.10 Plastic tubs used for storage of snacks and food preparation were seen with hard water stains, visible moisture, old adhesives stuck to the outer surfaces and were stacked underneath the sink near the drainpipe which was covered in orange foam sealant. [NAME] drip spots from drainpipes were seen near plastic tubsA steel table was seen to the right of the stove top burners and was covered in dust and debris with black and brown sticky substance and old flour. A pumice stone used for cleaning stove was covered in foil on the table.Tile floors are missing tiles, tiles were seen with cracks, brown/orange/black staining and discoloration under the sinks. A mass of tangled plastic and rubber tubing and metal pipes was observed under the dishwashing sink/table near garbage disposal with brown and black staining to walls and floor.These failures created an unsanitary kitchen environment and had the potential to contribute to the spread of foodborne illnesses among an already vulnerable resident population.During a concurrent observation and interview on 4/13/26 at 10:45 a.m. while conducting the initial tour with the Director of Dietary Services (DDS), boxes of fish fillets, beef patties, and cookie dough were seen open with inner plastic bags open to air. DDS stated, this did not meet her expectation as the bags should be closed and sealed to prevent freezer burn. A review of a facility policy titled, Sanitation and Infection Control, Freezer Storage, dated 2023, indicated, All foods should be stored in an airtight, moisture resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. 2. During an observation on 4/13/26 at 9:45 a.m. while conducting the initial kitchen tour, sanitization buckets, both green and red, are seen empty. During a concurrent observation and interview on 4/13/26 at 10:28 a.m. with Dietary Aid 1, Dietary Aid 1 prepares the sanitizer solution utilizing the sanitizer from a large container under the dishwashing sink labeled, Eco-lab Oasis 146-Multi-Quat Sanitizer. Dietary Aid 1 then added hot water from the sink and tested the ppm with the test strip showing the ppm at 100. Dietary Aid 1 could not state if 100 ppm was the concentration goal. During an interview on 4/23/26 at 11:00 a.m. with the DDS in the kitchen, DDS stated the desired ppm for the sanitizer solution was 200 ppm and all kitchen staff should be aware of this. DDS had no explanation for why the buckets were empty that morning but that was not protocol and the first aid or cook who arrived should have prepared them and agreed this is not optimal or sanitary for food preparation. A review of the ECOLAB-Oasis 146 Multi-Quat Sanitizer product information, dated 2025, indicated, Oasis 146 is an effective sanitizer against Escherichia coli and Staphylococcus aureus on food contact surfaces when used at 0.26-0.68oz per 1 gallon of 400 ppm hard water (150 ppm-400 ppm active quat)Oasis 146 is an effective sanitizer against Escherichia coli, Staphylococcus aureas, Campylobactor jejuni, Escherichia coli 0157:H7, Klebsiella pneumoniae, Listeria monocytogenes, Salmonella choleraesuis, Shigellasonnei, Yersinia enterocolitica and Enterobacter sakazakii on food contact surfaces when used at 0.35 oz- 0.68 oz per gallon of 500 ppm hard water (200 ppm to 400 ppm active quat). At 1.0 oz. per 1 gallon of water, this product is an effective general disinfectant that can be used to disinfect floors, walls, woodwork, sink tops, garbage pails, telephones, restrooms, bathroom fixtures and other hard non-porous surfaces. A review of a facility policy titled, Sanitization and Infection Control; Sanitizing Equipment and Surfaces with Quaternary Ammonia (QUAT) Sanitizer, dated 2023, indicated, Staff will check for appropriate Quat levels by inserting a test strip into the bucket of solution; Test strips can range between 200-400 ppm or per manufacturers guidelines. 3. During concurrent observation and interview on 4/13/26 in the initial kitchen tour with the DDS, a colander was seen with dried food stuck to the rim of the base and in the openings, and two pans were seen with peeling/flaky cooking surfaces. The DDS confirmed the findings and stated, These should be thrown out, I would not want food that was prepared in them, it could flake off and get into the food and that is not safe. A review of a facility policy titled, Sanitization, revised 11/2022, indicated, All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from any breaks, corrosions, open seams, cracked and chipped areas that might affect their use or proper cleaning. 4. During a concurrent observation and interview on 4/13/26 at 9:45 a.m. during the initial kitchen tour with Dietary Aid 2, 10 plastic tubs were seen stacked and stored under the food preparation sink next to the drainpipe which was covered in a bright orange foam sealant. [NAME] drip spots were noted on the shelf surface the tubs were stacked on, old adhesive remained stuck to the outer surface, and moisture was visible between tubs. Dietary Aid 2 stated space was a concern but there was probably a better place to store them, and it was difficult to scrub off the adhesive from labels used. A review of a facility policy titled, Sanitization, revised 11/2022, indicated, The food service area is maintained in a clean and sanitary manner.Plastic ware, china, and glassware that cannot be sanitized or are hazardous because of chips, cracks, or loss of glaze are discarded.Food preparation equipment that is manually washed are allowed to air dry whenever practical. According to the FDA Food Code 2017, Section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: Cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored: in a clean, dry location. 5. During an observation on 4/13/26 at 9:45 a.m. during the initial kitchen tour, a steel table was seen to the right of the stove top burners near where food is prepared, the lower shelf was covered in dust and debris with black and brown sticky substance and old white flour scattered over surface. A pumice stone used for cleaning stove was covered in foil and stored on the shelf. During a concurrent observation and interview on 4/13/26 at 11:00 a.m. in the kitchen with the DDS, DDS observed the steel table to the right of the stovetop and stated, That is really not good, it doesn't look like it has been cleaned in a month, it is unsanitary. A review of a facility policy titled, Sanitization, revised 11/2022, indicated, The food service area is maintained in a clean and sanitary manner. It is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris (FDA Food Code, 2017 4-601.11). Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (FDA Food Code Annex 4-602.13).A document review of the Food and Drug Administration (FDA) Food Code 2017, 4-602.13 states Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6. During a concurrent observation and interview on 4/13/26 at 11:00 a.m. in the kitchen with the DDS, DDS confirmed the floors did not appear clean, and the areas underneath the sinks had rust, grime, and tangles of tubing. DDS stated the kitchen was old and needed work which made it difficult to determine cleanliness despite the cleaning logs and agreed the kitchen was not optimal and some areas were unsanitary which could put residents at risk for illness. During an interview on 4/15/26 at 8:35 a.m. with the Maintenance Director, he stated he had started one month ago and helped in the kitchen for deep cleaning and repairs, and felt the floors had years of wear and tear and the kitchen needed a renovation. A review of a facility policy titled, Sanitization, revised 11/2022, indicated, The food service area is maintained in a clean and sanitary manner.

Based on observation, interview and record review the facility failed to ensure a safe operating kitchen environment for a census of 79 when the kitchen space was not maintained, and equipment was not effectively repaired or replaced.This failure made it difficult for kitchen staff to maintain a sanitary environment and execute the duties of the food and nutrition services department, and affected the maintenance department's ability to maintain equipment that was in need of replacing. During an observation on 4/13/26 at 9:45 a.m. during the initial kitchen tour floor tiles were seen missing, broken and chipped, with black/brown staining and build up, kitchen cabinets were chipped with rusty hinges, near the garbage disposal was a tangled mass of plastic and rubber tubing with metal and plastic pipes with brown discoloration to tile and wall, sink drains and pipes were reinforced with bright orange spray foam sealant with visible drip marks underneath.During a concurrent observation and interview on 4/15/26 at 9:30 a.m. in the kitchen with [NAME] 1, leaking of a brown substance was seen pooling at the base of the stove with a towel covering it, and half of the stove top is covered with foil. [NAME] 1 stated kitchen staff had only 4 burners and 3 working ovens for all the cooking which made it very difficult to manage, and the cooks had to pre-cook and reheat frequently during meal preparation. [NAME] 1 stated the fourth oven had been broken for a very long time and verified the leaking from the stove. [NAME] 1 stated they had worked in the kitchen for 22 years and everything was the same, nothing had changed, small repairs were done but equipment remained a problem. [NAME] 1 became tearful and expressed frustration with not having the tools to execute their position the way they would like to.During a concurrent observation and interview on 4/13/26 at 11:00 a.m. with the Director of Dietary Services (DDS), DDS concluded the kitchen was very old with lots of wear and tear and needed updating. During an interview on 4/15/26 at 8:35 a.m. with the Maintenance Director, he stated the floors needed replacement and the kitchen needed renovation.During an interview on 4/15/26 at 10:30 a.m. with the Administrator (ADM) in his office, ADM stated he was aware that the kitchen needed attention and it was on the list of needed renovations but required more time and logistics and was last on the list.A review of a facility policy titled, Sanitization, revised 11/2022, indicated, All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners are kept in good repair.A review of a facility policy titled, Maintenance, revised 12/2009, indicated, The maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to have survey results available for all residents to review when the binder containing survey results was out of reach for wheelchair-bound residents. This failure had the potential to discourage residents in wheelchairs from reviewing survey results when they could not reach the binder without having to ask for assistance. During an observation and concurrent interview on 4/16/26 at 1:45 p.m., Administrator verified the binder that contained survey results in the wall-mounted file holder approximately 5.5 feet from the floor next to the nurses station was the only binder available for residents to review survey results. Administrator stated the binder containing the survey results could not be reached by someone in a wheelchair. Administrator stated that residents should be able to reach the binder without having to ask for help and stated he would move the binder somewhere else. Review of facility policy, Resident Rights, last revised 8/2009, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . Examine survey results .

Based on observation, interview and record review the facility failed to ensure a trauma informed care environment was provided for three sampled residents ( Resident 7, Resident 29, and Resident 41) with Post Traumatic Stress Disorder (PTSD- A mental health condition triggered by experiencing or witnessing terrifying, life-threatening, or traumatic events .PTSD occurs when symptoms-such as flashbacks, avoidance, and severe anxiety-last longer than a month and disrupt daily life.) when, social assessments were not thorough, trauma informed care plans were not present or not individualized with no personal triggers identified, and residents were not provided with behavioral health services.This failure resulted in Resident's feeling their mental health needs were dismissed, not receiving the services they needed from qualified clinicians, and an inability of staff to mitigate risk of re-traumatization and keep residents safe. A review of Resident 7's admission record indicated she was admitted on [DATE] with a readmission on [DATE] after hospitalization, with the diagnoses of Post Traumatic Stress Disorder (PTSD), Anxiety Disorder and Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 7's Minimum Data Set (MDS – a resident assessment tool) dated 3/19/26 indicated she had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 indicating no cognitive impairment. A review of Resident 7's Care Plan, last reviewed 3/23/26, indicated she had no Trauma Informed Care Plan. It further indicated Resident 7 had a mood disorder and was to be referred to behavioral health services. A review of Social Services progress notes dated 3/7/24 indicated the Social Services Director (SSD) asked Resident 7 about her PTSD and she stated she did not want to talk to him about it because she didn't want him to know about it. During an interview on 4/13/26 at 3:20 p.m. Resident 7 stated when she returned from her last hospitalization the staff treated her like a pariah due to her infection. Resident 7 stated that she had PTSD from the death of her husband, mental health institution stay, stroke, brain tumor and blood disease, and she had asked for proper mental health help as she did not want to keep talking to unqualified staff at the facility. Resident 7 stated a psychiatrist came to speak with her once and she told her whole life story and then poof, that was it, no other follow- up from psychiatrist or staff. During an interview on 4/16/26 at 12:22 p.m. with the SSD in his office, the SSD stated Resident 7 was hard to talk to and he had made no other attempts to discuss her trauma or identify triggers. SSD further stated he thought Resident 7 was referred to psychiatry, but Resident 7 did not have active mental health services. A review of Resident 29's admission record indicated he was admitted on [DATE] with a readmission on [DATE], with the initial diagnoses of PTSD, Transient Ischemic Attack (Mini-Stroke), Major Depressive Disorder, and others. A review of Resident 29's MDS, dated [DATE], indicated he had a BIMS score of 12 indicating mild cognitive impairment. A review of Resident 29's Social Services Progress Notes dated 10/22/25 indicated the Social Services Director (SSD), met with Resident 29 for his Social Assessment and Resident 29 was a veteran who served in the army. There was no indication of a trauma assessment during this visit note and there were no subsequent notes about trauma in any of the SSD's documentation. A review of Resident 29's Care Plan last reviewed 1/23/26 indicated a Psychosocial-Emotional Trauma focus initiated 11/04/25 with no mention of type of trauma, triggers, or individualized care planning goals and interventions. During an interview on 4/14/26 at 8:35 a.m. with Resident 29 in his room, Resident 29 became tearful and stated he spoke to a woman once about his trauma and she started to cry and he did not want to continue to upset her. Resident 29 stated his tears come but there is no emotion, he cannot change what happened, it is a part of war, it is a part of him now and he just had to deal with it. During an interview on 4/16/26 at 12:22 p.m. the SSD stated Resident 29 did not have any triggers for trauma and there were none in his care plan. SSD stated the Care Plan did state to refer for mental health services and Resident 29 had not received any services while at the facility or been referred to a VA (Veteran's administration) mental health provider. SSD stated triggers were important for trauma informed care so you can avoid upsetting residents and know how to keep them safe. During an interview on 4/16/26 at 3:02 p.m. with the Director of Nursing (DON), DON stated she expected trauma to be assessed by the SSD during the social assessment and any resident with the diagnosis of PTSD should have a Trauma Informed Care Plan with triggers so staff knew what to avoid, how to assist, and decrease the risk of re-traumatizing. A review of a facility policy titled, Social Assessment, revised 7/2014, indicated, Components of the Social Assessment; Cognitive Factors including residents orientation to self-identity, time, place and situations; Short term memory and recall ability; Cognitive Skills for decision making ability; signs and symptoms of delirium; and recent onset of acute changes in mental status; Mood and Behavioral factors including attitudes and feelings about; Self and Situation; Family and Others; institutional environment; Signs or Symptoms of Depression or anxiety; Personal, family and social supports; Behavioral symptoms, including; Psychosis, Wandering, Refusal of Care, Recent changes in behavior. A review of a facility policy titled, Trauma Informed Care, revised 3/2019, indicated, Trauma informed care is culturally sensitive and person centered.and caregivers are taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers. Resident #41 was admitted [DATE] with Diagnoses that included Post-Traumatic Stress Disorder (PTSD). A review of Resident #41's Minimum Data Set (MDS) section titled Brief Interview for Mental Status (BIMS) revealed a score of 7. (Scores are categorized as 13–15 (cognitively intact), 8–12 (moderate impairment), or 0–7 (severe impairment)). During an interview and record review on 4/16/2026 at 10:11 a.m. with the Social Services Director (SSD), he stated when a new resident was assessed he would assess for care planning, depression, anxiety or behaviors like depression, sadness or suicidal ideations, and then document that in the Minimum Data Set (MDS) (A standard resident assessment tool) assessment. He stated the MDS was an assessment that was unique to the resident and was used to identify and complete the resident care plan for diagnoses that included depression, anxiety, and psychiatric issues. He stated the care plan was supposed to be used to implement individual care as a communication tool between staff. The SSD stated Resident #41 was admitted [DATE] and the SSD stated, I don't know about him very much, poor cognition, poor communication. The SSD stated, I don't know anything about his diagnoses, and he was aware he had a diagnosis of PTSD. The SSD stated there was no individualized care plan for PTSD and when asked why, the SSD stated that Resident #41 had Slipped through and I missed this one. The SSD stated he should have interviewed Resident #41 to find out about the trauma, completed the care plan with specific interventions and notified the physician. The SSD stated he did not notify the physician, but other members would have found out about the diagnosis. He stated, All of us should be on top of it. He stated, Care plans should all be different and individualized for PTSD. During an interview and record review on 4/16/25 with MDS Nurse, at 11:15 a.m., she stated Resident #41 had no observed behaviors upon admission. She stated he was admitted with an information packet from the Veterans Administration (VA). She stated he had hit his roommate, and someone should have observed a link between his care plan, diagnoses of PTSD and his behavior. She stated his triggers for PTSD were not documented and she could not find any consultation for psychiatric assessment or treatment in his medical record. During an interview and record review on 4/16/25 with Director of Nursing, at 11:30 a.m., she reviewed Resident #41's medical record and stated he had a care plan for PTSD, but it was not individualized to include what the trauma was, if there were any triggers and she did not see evidence of any psychiatric consultations. She stated it was not complete. During an observation on 4/16/26 at 1 p.m. Resident #41 walked to the facility lobby with a backpack on. He was animated, talkative and was determined when speaking to a nurse who asked him where he was going. He stated very sternly he was going to catch a bus to leave and visit his daughter. He stood up and walked outside the main doors of the facility where staff continued to talk with him. A review of a document titled Care Plan Report, dated 2/9/26 indicated The resident has a behavior problem r/t (Related to) PTSD. There was no documentation of the cause of the PTSD, triggers, or individualized treatment plans documented. Review of a document titled U.S. Department of Veterans Affairs, Social work psychosocial assessment, dated 2/10/26, indicated Resident #41was a Veteran is 70%SC for PTSD.( A disability rating from the Veterans Administration(VA) that signifies occupational and social impairment with deficiencies in most areas, representing a severe level of impairment that interferes with work, school, and relationships.). Review of Resident #41's medical record document titled Progress Notes, documented by Social Services Director, dated 2/16/26 indicated This writer met with the resident today to follow up and conclude emotional support services. This visit marks the final session to conclude emotional support services with the resident. Emotional support services are concluded at this time. Review of Resident #41's medical record document titled SBAR Communication Form and Progress Note. (A documentation of a change of condition by the staff) dated 2/11/26 at 6:53 p.m. indicated A Mental Status Evaluation was not changed and a Behavioral Evaluation was not clinically applicable to the change in condition being reported. A review of a facility Policy and Procedure titled Trauma Informed Care, revised March 2019, indicated Nursing staff are trained on trauma assessment and how to identify triggers associated with re-traumatization. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. Evaluate trauma-informed practices as part of the facility assessment.: Implement universal screening of residents for trauma. Utilize trained and qualified staff members who have established a rapport with the resident to assess him or her for previous trauma. A review of facility Inservice Education Calendar indicated a document titled Trauma Informed Care Lesson Plant, dated 8/4/25, indicated the Social Service Director had attended. The attached handout included EGUIDE Trauma-Informed Care, that indicated Trauma Survivors include Military veterans. Facility must identify triggers that retraumatize residents who have a history of trauma. Realize that residents may not talk freely about trauma. A review of the facility Monthly Inservice Calendar titled ANNUAL PROPOSED INSERVICES 2025-2026, did not indicate any training for PTSD or Trauma Informed Care.

Based on observation, interview and record review, the facility did not ensure sufficient Certified Nursing Assistants (CNA) staff to provide care and respond to five resident's (Resident 48, Resident 45, Resident 19, Resident 35 and Resident 68) basic needs when Residents were not provided 1. assistance to use the bathroom, 2. showers or bed baths twice a week and 3. assistance with meals. This lack of assistance resulted in residents and their responsible party (decision makers) frustration and feeling like they were not cared for. During an observation on 4/13/26 at 10:10 a.m., hallway three was observed to have a heavy smell of urine. During an observation and interview with Resident #48 on 4/13/26 at 10:10 a.m., Resident 48 was in her wheelchair in her room facing the wall, with the curtains pulled closed. She stated there was not enough staff to give her showers. She stated she had only two showers in the last five weeks. She stated she would love to go outside for some fresh air to help her get better, but no one has taken her outside. She stated she has only been outside twice in the last five weeks. During an observation on 4/13/2026 at 12:03 p.m., Resident #48 was observed in a wheelchair facing the wall with the curtains pulled. During an observation on 4/13/2026 at 3:20 p.m. Resident #48 was observed in a wheelchair facing the wall with the curtains pulled. Review of a facility shower document for Resident #48 dated 3/18/26 to 4/16/26, indicated she received a shower on 3/21/26, 4/1/26, 4/4/26 and 4/15/26. Resident #48 was admitted [DATE] with diagnoses that included a fractured vertebra (a bone in the spine), Shortness of breath related to respiratory failure with hypoxia (Respiratory failure occurs when someone does not have enough oxygen in your blood.). A review of her Minimum Data Set (MDS)(A standardized test to determine how well a resident is functioning.) indicated a Brief Interview for Mental Status (BIMS) (An assessment of how cognitively intact a resident is.) score of 11 (A score of 00-9 indicated major cognitive impairment, 10-12 indicated moderate impairment, and 13-15 indicated no cognitive impairment.). A review of Resident 68's admission record indicated she was admitted on [DATE] with the diagnoses of Dementia (a progressive state of decline in mental abilities) and Dysphagia (difficulty swallowing). A review of Resident 68's Minimum Data Set (MDS), dated [DATE] indicated she had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 03 indicating severe cognitive impairment. A review of Resident 68's POC Response History (a task check off document for direct care staff) for shower's for the last 30 days indicated she had not received a shower for 6 days from 3/21/26 through 3/26/26 and no refusal was documented. A review of Resident 68's Care Plan last reviewed 2/6/26 indicated she required setting up assistance and cueing during meals. During an observation on 4/13/26 at 12:40 p.m. in the dining room during lunch, Resident 68 was observed eating her minced and moist (a diet with the consistency of ground beef and/or softened/pureed) lunch with her fingers. Staff did not attempt to sit and assist Resident 68 at any time during the meal. During an interview on 4/13/26 at 12:40 p.m. with Registered Nursing Assistant 1(RNA1), RNA 1 confirmed that no staff had assisted Resident 68 and allowing residents to eat with their fingers was not standard practice. During an observation on 4/13/26 at 12:22 p.m. in the dining room during lunch, 20 Residents were present at 7 tables and were observed sitting and waiting for trays for 45 minutes. There were 3 staff present at the start of lunch, 5 total assisted with passing trays. During an observation on 4/13/26 at 12:49 p.m. in the dining room during lunch, there were 4 total staff present with 4 total assist residents at two tables. Resident 18 approached this surveyor and stated he wasn't given anything to drink during his meal and he had asked staff to get him something, he is thirsty and asking this surveyors help in obtaining fluids. His tray ticket is observed and he was on a regular diet and allowed thin liquids, no drinks were seen at his place setting. During an observation on 4/14/26 at 7 a.m. hallway three was observed to have a heavy smell of urine. During an observation on 4/15/26 at 6 a.m. hallway three and hallway one were both observed to have a heavy smell of urine. During a telephone interview on 4/13/26 at 11:37 a.m., Responsible Party (RP) A stated staff did not prevent problems. She stated they waited until something happened to her family member rather than prevent issues. She stated she had to ask for help after problems with her family member had occurred. She stated she was enraged by the facility inability to be proactive about preventing problems. She stated her family member was supposed to get up and walk and the staff told her they were afraid she would fall so she was always left in the wheelchair. She stated they never have enough staff. She stated staff told her they work short because of sick calls. During an observation and interview on 4/13/26 at 3:28 p.m., Resident #45 entered the bathroom in her wheelchair without assistance. When she finished, she began to yell for help. She continued for 30 minutes to yell for help. No staff were observed to come into the room and assist her. She stated she needed help to clean herself and get off the toilet and back into her wheelchair. She stated her legs were numb. During an interview on 4/14/2026 at 10:17 a.m., Resident #19 stated there was not enough staff to take of resident needs. He stated showers were either given very late in the day or no showers at all. He stated his meals were always served late and served cold. He stated not enough staff to pass meal trays or give showers. Resident #19 was admitted [DATE], with diagnoses that included Heart Disease, Morbid Obesity, Diabetes, and an MRSA (Methicillin Resistant Staphylococcus Aureus) infection of both feet. A review of his MDS BIMS score indicated a score of 14. During an interview on 4/14/26 at 2:20 p.m. with Responsible Party B (Resident 35) Responsible Party B stated she had to be the squeaky wheel around the facility otherwise nothing got done and she came to the facility every day because there were not enough staff. Responsible Party B further stated there were not enough staff in long term care and on the weekends, it was a skeleton crew, and residents did not receive their showers. Responsible Party B stated, I worry about the residents here that do not have someone like me to fight for them. A review of Resident 35's admission record indicated he was admitted on [DATE] with diagnoses of Lewy Bodies Dementia (a progressive neurodegenerative disease characterized by abnormal protein deposits (Lewy bodies) in the brain, causing cognitive decline, hallucinations, movement issues (parkinsonism), and dramatic fluctuations in alertness). A review of Resident 35's Minimum Data Set (MDS) dated [DATE] indicated he had severe cognitive deficit. During an interview with Unlicensed Staff B on 4/16/26 at 9:19 a.m. he stated a normal assignment was 10 residents. He stated on a bad day he gets assigned 11 residents. He stated the facility was chronically short staffed. He stated he had to work harder when the facility was short staffed. He stated if the facility was fully staffed, he would have an assignment of 7 or 8 residents. He stated he would be able to have time to clean the residents, clean their rooms, give them better care, pay attention to their fingernails. He stated he consistently worked 6 days a week and even worked double shifts and had overtime. He stated when he had 11 residents, the rooms were not cleaned, and sometimes showers were not provided, or resident were not taken to the dining room for meals or activities. He stated residents were supposed to get two showers a week. During an interview on 4/16/26 at 9:34 a.m. Unlicensed Staff C stated he had an assignment of 10 residents. He stated 6 of those residents were total care and bed bound. He stated he was rushed and could not spend time doing everything he thought the residents needed like to spend time getting ready for the day or talking with the residents. He stated if he had fewer residents, he would be able to spend more quality time with residents and shave them, clean them, bring them coffee or water. He stated he worked a double shift at least once a week and always had consistent one hour of overtime every day because of sick calls and short staffing. He stated he stayed to finish helping residents get changed and help them. During an interview with Dietary Supervisor on 4/16/26 at 1:30 p.m. she stated she was responsible for scheduling the nursing staff. She stated the facility did not have enough Certified Nursing Attendants (CNA's). She stated everyday there were 2-3 sick calls, and she had used registry (an outside agency) staff, overtime and double shifts to fill the schedule. She stated we do not have enough staff, and the staff have worked short at least 75% of the time. She stated registry staff did not know the residents and residents would get better and more attentive care from regular staff. During an interview on 4/16/2026 at 1:39 p.m. the Administrator stated hiring enough CNAs was a big challenge. He stated in March 13% of overtime pay was related to double time as a result of the lack of nursing staff. A review of a Resident Council Meeting document titled Department Response Form,; Dated 4/22/25, indicated When registry CNAs are assigned to her care, she believes this affect the timeliness and overall quality of the assistance provided. Dated 3/21/25 indicated CNA's are not responding to call lights promptly. Dated 8/22/25, indicated CNA's are often hard to locate during PM shit / NOC shift. Dated 8/22/25, indicated Daughter of (Resident #45) stated that the wait time for a CNA to come assist her mom to the bathroom / put back to bed was 45 mins. She made 2 trips to nurses station (PM Shift) requesting for help and the response she got was 'We are doing change of shift.' No CNA was found in hall. RESPONSE (Response to include Residents) interview We apologize for the delay, there are times CNA's are showering or cleaning other residents. Occasionally we have call-offs or late call-offs. It depends on timing. Dated 10/16/25 indicated PM Shift are usually short CNAs weekends.RESPONSE (Response to include Resident Interview) I have spoken with staffing coordinator to appropriately I have asked her not to move pm shift workers to AM shift to assure coverage at pm shift. Typically, pm shift has less staff than AM due to tasks are less. Unfortunately late or last minute call off effects our staffing. We are doing (our) best to improve staffing.

Based on observation, interview and record review, the facility failed to prepare food in a manner that resulted in a palatable texture and flavor for 8 residents receiving a pureed diet and failed to follow therapeutic diet requirements for all 8 residents with fortified (diet enriched with extra calories) diet orders when,Pureed foods were prepared using no specifications for texture requirements and the test tray for the pureed diet was runny, gummy/sticky, and lacked seasoning. 2. Fortified diets indicated on tray tickets were not read aloud by Dietary Aide 3 to [NAME] 1 while plating the food, resulting in no added fortification. This failure resulted in residents not receiving their prescribed diets and had the potential to result in residents not consuming their meals which could cause weight loss in an already vulnerable population. A review of the facility Diet Type Report, dated 4/16/26, indicated there were 8 residents who received pureed diets. A review of the facility document titled, Diet Spreadsheet, dated 4/15/26 indicated the lunch menu was Chicken Adobo, Hawaiian rice, buttered peas and carrots, mini egg rolls with sweet and sour sauce, and apple brown [NAME]. During a concurrent observation and interview on 4/15/26 at 9:30 a.m. with [NAME] 1 in the kitchen during lunch meal prep, peas and carrots for pureed diets are already being boiled on the stove. [NAME] 1 stated due to a lack of additional burners and one broken oven, cooks must pre-cook and reheat often when preparing meals. [NAME] 1 presented commercial thickener in a pump and stated she preferred to use the pump as there was a guide on the back that indicated how much to use per ounce of food. During a concurrent observation and interview on 4/15/26 at 11:30 a.m. with [NAME] 1 in the kitchen during lunch meal prep just before tray line, pureed meat, peas and carrots, and Hawaiian rice, had just been prepared and were being spooned into serving trays. [NAME] 1 stated she used broth and added the pump thickener little by little until it reached the desired consistency. [NAME] one could not verbalize how she tested the consistency and was unaware of the spoon or fork testing method. [NAME] 2 is observed preparing the pureed egg rolls using broth and adding powdered thickener a little at a time. During an interview on 4/15/26 at 2:35 p.m. with [NAME] 2 in the kitchen after tray line, [NAME] 2 stated he started 3 months ago and could not recall is he had any IDDSI (International Dysphagia Diet Standardization Initiative, a global framework for testing and labeling food textures and drink thicknesses for people with Dysphagia) training. [NAME] 2 stated when preparing pureed foods, he used broth or other liquid that contains nutrients and added thickener powder little by little until it reached a consistency he was happy with. [NAME] 2 could not verbalize how to test for correct consistency. During a concurrent observation and interview on 4/15/26 at 1:05 p.m. with [NAME] 1 a pureed test tray was sampled. [NAME] 1 and surveyors concluded the texture of all pureed items was too thin, very gummy and stuck to the spoon, and lacked seasoning. [NAME] 1 stated the food looked and tasted like baby food. A review of Dining RD recipes for Pureed Chicken Adobo, Pureed Seasoned Rice, Pureed Buttered Peas and Carrots and Pureed Egg Rolls, dated 2026, indicated the IDDSI instructions for all pureed recipes, Pureed (PU4)-Perform appropriate IDDSI testing to ensure texture standards are met. A review of the IDDSI 2.0 Pureed Diet specifications, dated 7/2019, indicated, The pureed diet characteristics should not require chewing, show some slow movement with gravity but cannot be poured, falls off spoon in a single spoonful when tilted and holds it shape, no lumps, not sticky, and to please use the IDDSI Fork Drip Test and Spoon Tilt test. 2. A review of the facility Diet Type Report, dated 4/16/26, indicated there were 8 residents who received fortified diets. During an observation on 4/15/26 between 12:00 p.m. and 12:55 p.m. during tray line, Dietary Aide 3 reads aloud the diet type indicated on the tray ticket to [NAME] 1 who was plating the food. Dietary Aide 3 did not read aloud or relay which residents had fortified diets ordered. [NAME] 1 did not have her own tray tickets or other reference so she depended on the Dietary Aide to read off the correct diet. During an interview on 4/15/26 at 12:55 p.m. in the kitchen with Dietary Aide 3 and [NAME] 1 after the last meal cart left the kitchen, Dietary Aide 3 could not verbalize what a fortified diet was and confirmed she had not read aloud this part of the diet type. [NAME] 1 confirmed she had not plated any fortification. [NAME] 1 stated she had prepared fortified chicken soup and had not plated any of it. During a group interview on 4/15/26 at 3:45 p.m. with the Director of Dietary Services (DDS), Registered Dietician 1( RD1) and [NAME] 1, in the conference room, DDS and RD 1 stated missing fortification did not meet their expectations and could put residents at risk for weight loss and loss of nutritive value. A review of a facility policy titled, Nutrition Therapy Essentials Diet Manual, Fortified/Enhanced Foods, undated, indicated, Fortified/enhanced foods may be used for individuals with reduced oral intake to provide maximum nutrition support with the intent to increase calories and protein without a significant increase in food volume. A review of a facility policy titled, Food and Nutrition Services, revised 10/2017, indicated, Each Resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on interviews and record reviews the facility failed to ensure one of two sampled residents (Resident 39) received ongoing social services for the assistive devices needed for hearing impairment when there was no follow up after her evaluation for hearing aids over one year ago, her MDS assessment did not accurately reflect her hearing status and there was no care plan for addressing adaptive coping strategies for hearing loss.This failure resulted in ongoing hearing impairment without adaptive measures which caused Resident 39 to feel isolated, avoid participation in many activities, and struggle during communication with others.A review of Resident 39's admission record indicated she was admitted on [DATE] with the diagnoses of Paraplegia (loss of movement and/or sensation, to some degree, of the legs), Anxiety and Depression.A review of Resident 39's Minimum Data Set (MDS, an assessment tool), dated 2/24/26 indicated she had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 with no cognitive impairment. MDS Section B indicated she had no impaired hearing or need for assistive devices.A review of Social Services Progress Notes dated 1/23/25 indicated Resident 39 was seen by an ENT (ear, nose and throat specialist) on 1/7/25 and qualified for hearing aids for both, left and right ears, and a referral had been sent to [company name] to start the process of obtaining hearing aids.A review of Resident 39's Care Plan, last reviewed 2/27/26, indicated no care plan goals or interventions related to hearing loss.During an interview on 4/13/26 at 3:40 p.m. with Resident 39 stated she had been evaluated for hearing aids over a year ago and never received an update from staff. Resident 39 further stated she had to ask people to repeat themselves, felt isolated, and it was becoming more difficult to participate in activities and conversations.During an interview on 4/16/26 at 8:15 a.m. with the Minimum Data Set Nurse (MDS Nurse), she stated she only used verbal interview for MDS assessments and if a Resident did not report an issue, she did not code for it. During a concurrent interview and record review on 4/16/26 at 12:22 p.m. with Social Services Director (SSD), SSD confirmed Resident 39 had qualified for hearing aids over a year ago and no follow up was documented in his notes and there was no care plan addressing her hearing impairment. SSD further stated delays in receiving care could result in feelings of isolation and struggles in communication.During an interview on 4/16/26 at 3:02 p.m. with the Director of Nursing (DON) in her office, DON stated she expected the MDS Nurse to conduct a full assessment of the Resident during periodic assessment as this was how the team was alerted to concerns at least quarterly. DON continued, stating if Resident 39 was evaluated and qualified for hearing aids she would expect staff to facilitate any follow up needs timely and it should be reflected on the Care Plan.A review of a facility policy titled, Resident Assessments, revised 10/2023, indicated, Information in the MDS assessments will consistently reflect information in the progress notes, plan of care, and resident observations and interviews.A review of a facility policy titled, Social Assessment, revised 7/2014, indicated, Data Obtained from the social assessment shall be used to develop all relevant portions of the care plan( e.g., social services, recreational services and activities, end of life care, and ancillary services) and Components of a social assessment include physical factors with impact on function and quality of life including: Sight, Hearing, Speech;A review of a facility policy titled, Hearing Impaired Resident, Care of, revised 02/2018, indicated, Staff will assist the Resident (or representative) with locating available resources, scheduling appointments, and arranging transportation to obtain needed services. Determine the resident's awareness and adaptation to hearing loss. Evaluate residents adaptive needs and progress at regular intervals.

Based on observation, interview and record review, the facility failed to ensure dental needs and services were provided to one of two residents (Resident 31) sampled for dental concerns when Resident 31's MDS did not reflect his current dental status, and he had resided at the facility for one year without an evaluation for dental needs.This failure allowed poor dentation to go unnoticed in an already vulnerable resident with no proper evaluation of dental needs or treatments.A review of Resident 31's admission record indicated he was admitted on [DATE] with the diagnoses of Schizophrenia (a mental illness that is characterized by disturbances in thought), Dysphagia (difficulty swallowing), and need for assistance for personal care.A review of Resident 31's Minimum Data Set (MDS-a resident assessment tool) dated 4/13/26 indicated he had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 6 indicating severe cognitive impairment. MDS Section L for dental indicated he had no dental concerns.During an observation and interview on 4/14/26 at 8:47 a.m. in Resident 31's room, Resident 31 is observed to be missing almost all of his upper teeth, with nubs of brown, grey, yellow enamel and exposed root, built up tartar, dry lips and spit build up in corners of mouth.During a concurrent interview and record review on 4/16/26 at 8:15 a.m. with the MDS Nurse in her office, Resident 31's most recent MDS was reviewed. MDS Nurse confirmed Resident 31 was coded as having no dental concerns. MDS Nurse stated if a resident did not report a problem, she did not code for it, and this was the same process for residents with cognitive concerns. MDS Nurse stated she had not performed a full assessment on Resident 31 and relied on direct care staff to report concerns to her and the Social Services Director (SSD) who handled all dental referrals.During an interview with the SSD on 4/16/26 at 12:22 p.m. in his office, the SSD stated the facility had two dental providers that cycle through the census and he did not refer for services unless there was a problem reported. SSD confirmed Resident 31 had not been evaluated for dental needs by the providers that came to the facility and because he had [name of insurance provider] coverage, he had to go through the [insurance provider] for care. SSD confirmed he had not completed a referral to the [insurance provider's] dental provider. The SSD validated that Resident 31 had issues with cognition and communication and may not have been able to relay if he had concerns or problems. A review of a facility policy titled, Resident Assessments, revised 10/2023, indicated, All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.Information in the MDS assessments will consistently reflect information in the progress notes, plan of care, and resident observations and interviews.A review of a facility policy titled, Availability of Services, Dental, revised 08/2007, indicated, Oral healthcare and dental services will be provided to each resident.Social Services will be responsible for making necessary dental appointments.

Based on observation, interview, and record review, the facility failed to provide support personnel to safely and effectively carry out the functions of the food and nutrition services department for a census of 79 residents when the Director of Dietary Services (DDS) did not participate in the essential duties of day-to-day operations, staffing levels were insufficient, and dietary personnel did not demonstrate competency in specific procedures and protocols necessary to carry out the functions of food and nutrition services.This failure had the potential to affect the safety and quality of the food produced by the food and nutrition services department. During an interview with Resident #19, Resident #44 and Resident #74, on 4/13/26 at 1:02 p.m. they stated their lunches were always served last and the food was cold. Resident# 19 stated he always has to ask dietary staff to re-heat his food. He stated he hated the food because the vegetables were never fresh and always overcooked. He stated the residents that could not get out of bed were not assisted with meals. During an interview on 4/14/26 at 8 a.m., Resident #19 stated his breakfast was served cold and he had to ask staff to reheat them. During an interview on 4/16/2026 at 9:19 a.m., Unlicensed Staff B stated he had heard residents complain about the food being served cold. He stated it came out of the kitchen cold. He stated he told kitchen staff all the time, but they did not have a supervisor. A review of the kitchen staffing schedule indicated 2 full-time cooks, 3 full -time dietary aides and 3 part-time diet aids. The PM shift often had only one cook and one aide. On Sundays there was one cook for both shifts. Most AM shifts had 1 cook, and 2-3 aids and most PM shifts had 1 cook and 1-2 aids. During an interview on 4/14/26 at 1:32 p.m. with the DDS, DDS confirmed she fulfilled the role of DDS and Staffing Coordinator at the facility. DDS stated she split her time between the positions 50/50 and worked remotely and more than 40 hours a week to meet the demands. During a concurrent interview and record review on 4/14/26 at 3:00 p.m. with the Administrator (ADM), the job descriptions for both positions were reviewed and the ADM could not state how many hours a week would be needed to meet the demands of each position. ADM stated there was no way to illustrate how many hours per week the DDS devoted to the kitchen versus staffing position. ADM stated the DDS had an assistant in the kitchen who helped with DDS duties and that was [NAME] 1. During an interview on 4/15/26 at 9:30 a.m. with [NAME] 1 in the kitchen, [NAME] 1 stated she was not the DDS's assistant, and worked overtime all the time to meet the demands in the kitchen after the loss of a full-time cook. [NAME] 1 stated she trained the new cook as best she could, but this was difficult as they only had 2 full-time cooks right now and their hours were different. During an observation on 4/13/26 at 9:45 a.m. while conducting the initial kitchen tour the sanitization buckets, both green and red, were empty. During a concurrent observation and interview on 4/13/26 at 10:28 a.m. with Dietary Aid 1, Dietary Aid 1 prepared the sanitizer solution utilizing the sanitizer from a large container under the dishwashing sink labeled, Eco-lab Oasis 146-Multi-Quat Sanitizer. Dietary Aid 1 then added hot water from the sink and tested the ppm (parts per million), and the test strip shows the ppm at 100. Dietary Aid 1 could not state if 100 ppm was the concentration goal. During an interview on 4/15/26 at 12:55 p.m. in the kitchen with Dietary Aide 3 and [NAME] 1 after the last meal cart left the kitchen, Dietary Aide 3 could not verbalize what a fortified diet was and confirmed she had not read aloud this part of the diet type. [NAME] 1 confirmed she had not plated any fortification. [NAME] 1 stated she had prepared fortified chicken soup and had not plated any of it. During a concurrent observation and interview on 4/15/26 at 1:05 p.m. with [NAME] 1 and surveyor team in the conference room, a pureed test tray was sampled by surveyors and [NAME] 1. [NAME] 1 and surveyors concluded the texture of all pureed items was too thin, very gummy and stuck to the spoon, and lacked seasoning. [NAME] 1 stated it looked and tasted like baby food. During an interview on 4/15/26 at 2;35 p.m. [NAME] 2 stated he had been at the facility for 3 months and the kitchen was short staffed, and staff needed more training. [NAME] 2 relayed when he was the cook, he must do it all, the meals, snacks, dessert, tray line, alternatives, and more aids were needed. [NAME] 2 stated the DDS came into the kitchen when she had time to and staff could go and get her if she was needed for something. [NAME] 2 confirmed [NAME] 1 did all his training and he had not received any IDDSI training. During a group interview on 4/15/26 at 3:45 p.m. with the DDS, Registered Dietician 1 (RD1) and Cook1, the DDS stated she had not participated in tray line or test tray tasting this week and had been out on the floor most of the week because this was also part of her position. DDS further stated she was responsible for the training and competencies of all dietary staff. All 3 employees stated the largest obstacle in the food and nutrition services department was lack of sufficient staffing. During a review of a facility document titled, Job Description: Dietary Manager , dated 02/2024, indicated, The primary purpose of your job position is to provide supervision for the Dietary Department ensuring quality food and Nutrition is met in accordance with current federal, state, and local standards, guidelines and regulations governing our facility. Supervise staff in the day to day facility operations of assigned areas.direct and participate in food preparation and service of food that is safe, appetizing, and is of the quality and quantity to meet each residents needs in accordance with physicians orders.hires, trains, dietary employees. monitor work assignments, provide feedback, evaluate performance.ensure equipment and work areas are clean, safe. Maintain kitchen and food storage area in a safe, orderly, clean and sanitary manner. A review of a facility policy titled, Food and Nutrition Services Staff, revised 10/2017, indicated, The food and nutrition services staff, under the supervision of the dietician an/or the food and nutrition services manager, will safely and effectively carry out the functions of the food and nutrition services department.

Based on interview and record review, the facility infection preventionist failed to review three of three residents sampled for antibiotic stewardship (Residents 8, 16, and 24). This failure had the potential to result in residents receiving unnecessary antibiotics and further contribute to antibiotic resistance.During an interview and concurrent record review on 4/16/26 at 9:06 a.m., Infection Preventionist (IP) pulled up on her laptop her line list of residents who were prescribed antibiotics for the month of April 2026. IP stated her antibiotic stewardship program included using an infection screening tool built into the electronic medical record that reviewed the symptoms of the resident's suspected infection and determined if the symptoms met criteria for treatment with antibiotics. IP stated that if an antibiotic was prescribed, she did an antibiotic timeout 48 to 72 hours after the antibiotic was started to monitor for any reaction to the antibiotic and notified the doctor to see if there should be any change based on lab work or cultures. IP stated the doctor would respond to the timeout and instruct them to continue the antibiotic, discontinue, or change the course to another antibiotic. Further review of the line list indicated Resident 16 had been started on an antibiotic for symptoms of a urinary tract infection on 4/9/26 with an end date of 4/16/26. When queried, IP was not able to produce documentation that Resident 16 had an infection screening completed or an antibiotic timeout. The line list indicated Resident 8 had been started on an antibiotic for symptoms of a urinary tract infection on 4/10/26 with an end date of 7/17/26, and Resident 24 had been started on an antibiotic for symptoms of a urinary tract infection on 4/2/26 with an end date of 4/7/26. IP was not able to produce documentation that the infection screenings or antibiotic timeouts were completed for Resident 8 or Resident 24. IP verified it was her responsibility to complete these reviews for the antibiotic stewardship program and stated she had gotten a little behind. IP verified Resident 16's antibiotic was completed today, 4/16/26. IP stated the goal was to have the infection screening completed before the antibiotic was started. IP stated the purpose of antibiotic stewardship was to prevent the use of antibiotics unnecessarily and reduce antibiotic resistance. IP stated the antibiotic timeout was how they accomplished that. IP stated the risk to the resident if the antibiotic timeout was not done was they would be taking an antibiotic that was not specific to the organism causing their infection. Review of facility policy Antibiotic Stewardship, last revised 12/2016, indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents.

Based on interview and record review, the facility failed to allow one resident (Resident 1) of two sampled residents to return to the facility after completing treatment for Carbapenem-Resistant Enterobacteralus (CRE- a group of bacteria that are difficult to treat because they are resistant to carbapenems, which are a class of powerful antibiotics typically used for severe infections) at the hospital.This failure caused Resident 1 to experience an unnecessary 42-day hospitalization and anxiety over the forced eviction from her home.Findings:A review of Resident 1's admission sheet indicated admission to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (a progressive lung condition that obstructs airflow and makes breathing difficult), neutropenia (a condition with lower-than-normal neutrophils (a key white blood cell fighting infections which puts the person at risk for serious bacterial illnesses), difficulty in walking, depression (a serious mood disorder which causes persistent sadness which affects a person's thoughts, feelings, and daily activities), and anxiety disorder (a serious mental illness marked by excessive, persistent fear and worry which interferes with daily life).A review of Resident 1's nursing progress note dated [DATE] at 12 a.m. indicated, [Resident 1] unplanned discharge event.[on] [DATE].sent to emergency department from specialty office [during physician appointment] due to shortness of breath and cough.A review of Resident 1's hospital Case Manager (CM, a nurse or social worker who coordinates a patient's care, acts as their advocate, and plans for their safe discharge from the hospital)/ Social Worker (SW) notes indicated the following:-An Initial assessment dated [DATE] at 3:09 p.m. indicated, Discharge [DC] Needs Assessment.Anticipated Discharge Disposition: skilled nursing facility [SNF].Expected DC Date: [DATE].[Resident 1] has been living at [facility name] last 2 years.-On [DATE] at 1:37 p.m. indicated, .Spoke with [facility admission Director (AD)] from [facility name] she will take [Resident 1] back when medically stable.-On [DATE] at 2:11 p.m. indicated, Spoke with [AD] at [facility name], who confirmed that they can accept patient over weekend once [NAME] [outpatient parenteral antibiotic therapy, when a patient receives long-term intravenous (IV) antibiotics outside of the hospital allowing for early discharge and comfortable recovery from serious infections] is in.-On [DATE] at 11:08 a.m. indicated, Per MD [physician], [Resident 1] needs IV Avyca(R), a specialty antibiotic that is quite pricey. Needs IV abx [antibiotics] until 10/8[/25].-On [DATE] at 12:43 p.m. indicated, Will complete IV antibiotics here, then discharge after last dose on 10/8[/25].Per [AD], she has left a message.to discuss new dx [diagnosis] of CRE and facility's inability to accept [patients] with CRE.A review of an email from the facility's AD to the hospital CM, dated [DATE] at 12:28 p.m., indicated, Since [Resident 1] has had an extensive stay post-surgery her behold [sic, supposed to be bed hold] unfortunately expired and she has a new diagnosis of CRE. Typically, we will continue to hold the bed for our LTC [long-term care] patients, but in this case, we cannot accommodate CRE and its very strict needs. [The facility] does not have any single bedrooms as most are 3 patients to a room, and she is now requiring a lifetime isolation needs from here on out. A review of Resident 1's hospital records indicated the following: -A CM progress note dated [DATE] at 3:30 p.m. indicated, .Received report from bedside RN [Registered Nurse] that [Resident 1] received a phone call from [the facility] that they are not able to have her return to her LTC bed and that her belongings are being packet [sic] up, per bedside RN [Resident 1] is very upset.Placed call to [AD].at [the facility] to verify that [Resident 1] received this phone call; [AD] confirmed this.Met with [Resident 1] at bedside.[Resident 1] Stated that she is very concerned that she won't have a place to go when she is discharged from the hospital.[The facility] had cancelled their acceptance in [NAME] [Artificial Intelligence Discharge Agent], unbooked. -A CM progress note dated [DATE] at 12:07 p.m. indicated, .spoke with Ombudsman.who received verbal consent from [Resident 1] to speak with [Facility Administrator (ADM)].His concerns for readmission are there is not a single room available, staff will be required to wear face shield, and [Resident 1] will continue to smoke, causing cough and spreading of CRE. [Resident 1] is currently on Nicotine patch and not smoking at hospital. -A palliative care (specialized medical support for people with serious illness, focusing on improving quality of life) consultation dated [DATE] at 9:59 a.m. indicated, .Living situation: needs SNF. -A CM progress note dated [DATE] indicated, .consulted with [physician] who stated [Resident 1] has been previously treated for CRE and is no longer considered contagious. -A CM progress note dated [DATE] indicated, .spoke with Ombudsman who stated they spoke to [Facility ADM] and they are stating they are at 95% capacity and still consider [Resident 1] to be contagious and they will require their own room. -A psychiatry physician's note dated [DATE] at 5:57 p.m. indicated Resident 1's, Hospital Day 24.Loss of the SNF bed was also difficult because.she considered that home and had friends there. These very long hospitalizations also are difficult to cope with as patients tend to lose a fair amount of autonomy as well as control and it is difficult to know what to expect even in the short-term.Chief Complaint: Anxiety and adjustment. A review of an email from the facility's AD to the hospital CM dated [DATE] at 9:19 a.m. regarding Resident 1's discharge to the facility indicated, I saw the doctor continuously note. 'Discussed with ID [Infectious Disease] [Physician Name] on 10/14[/25].the infection was treated appropriately and resolved.'.While that may be appropriately treated at the hospital, at the skilled nursing facility level we must follow our CDPH [California Department of Public Health] infection prevention guidelines. These state that CRE colonization can persist for many months even after treatment, and that repeat testing or clearance cultures are not recommended or considered reliable for discontinuing contact precautions as the patient can be negative one week and positive the next. Because of this, we are required to continue treating the patient as CRE-positive and are unable to accept the patient under our current infection control protocols. A review of Resident 1's CM Director note dated [DATE] at 10:41 a.m. indicated, Spoke with [Facility ADM].states there is one room at [the facility] that can be utilized for isolation. This room is currently occupied and the patient within this room has equipment that needs to be able to fit in the next room in order for the isolation room to be utilized. A review of Resident 1's Skilled/Intermediate Facility instructions/Orders, dated [DATE], indicated Resident 1 was transferred from the hospital to a dedicated swing bed (a hospital room that can be used to provide intensive, immediate needs to skilled nursing needs) at an affiliated hospital for physical therapy and occupational therapy. The MD ordered Resident 1 to remain on contact isolation (precautions used to prevent the spread of infectious illness). A review of Resident 1's hospital CM/SW discharge plan progress notes indicated the following: -A note dated [DATE] at 10:37 a.m. indicated, [On] 11/13[/25] SW spoke to Ombudsman and the appeal ruled in [Resident 1's] favor. Facility has 3 days to accept [Resident 1] back or they will incur $750 per day fine until she returns. -A note dated [DATE] at 10:52 a.m. indicated, [Resident 1] is planning to DC to [the facility] today.[Resident 1] informed and agrees with plan. During an interview on [DATE] at 12:43 p.m., the Social Services Director (SSD) stated the Infection Preventionist (IP) told leadership the facility could not house the type of disease Resident 1 had been diagnosed with. During an interview on [DATE] at 1:02 p.m., the IP stated Resident 1 was diagnosed with CRE which was an organism resistant to all treatment. The IP further stated residents with CRE would require isolation for the entirety of their stay and have dedicated staff. The IP stated she was responsible for presenting in-services for staff regarding new organisms and would use CDPH and Centers for Disease Control (CDC) guidance. The IP stated the final decision to accept Resident 1 back to the facility fell to the ADM and Director of Nursing (DON) and that neither asked for her opinion. During a phone interview on [DATE] at 1:40 p.m., the ADM stated he would rather incur penalties than place other residents at risk. The ADM stated he was waiting for sputum samples to be resulted and would have accepted Resident 1 back immediately. The ADM stated he had no private rooms to place Resident 1 in which made isolation difficult. He stated, Many rooms have shared bathrooms, further complicating isolation. I also have to consider resident rights in moving rooms. Creating a private room for the CRE resident was virtually impossible. During a phone interview on [DATE] at 9:19 a.m., the CM at the hospital stated Resident 1 had been ready to return to the facility for quite some time now. The CM stated Resident 1 remained in contact isolation, but it was questionable whether or not she needed to be. The CM confirmed Resident 1 no longer on antibiotics and had finished her antibiotic course on [DATE]. The CM further stated, She is just sitting here waiting. In an interview on [DATE] at 2:32 p.m., Resident 1 stated she did not understand why she was being treated like a pariah. A review of an email sent to the surveyor from the ADM dated [DATE] at 11:36 a.m. indicated, While we technically have open beds, our facility does not have a single private room, which makes true isolation extremely difficult.We also had to consider.the need to appropriately cohort residents on C.diff [a common, potentially serious bacterial infection causing diarrhea and requiring contact isolation precautions (standard precautions enhanced with the use of a gown and gloves for all interactions)] or other precautions. When all of these factors were taken into account, creating a private room for the CRE patient became virtually impossible. During a phone interview on [DATE] at 11:24 a.m., the SW at the hospital confirmed Resident 1 was transferred back to the facility on [DATE]. A review of an email sent to the surveyor from the ADM dated [DATE] at 11:36 a.m. indicated, .We never discharged [Resident 1] from the facility/ never said we wouldn't take her back. We were either waiting for proper bed availability or directions from local resources on how we could make it work. A review of the facility's daily census dated [DATE] through [DATE] was conducted on [DATE] and indicated the facility had at least one female bed available within this time frame.A review of the facility's policy titled Transfer or Discharge, dated [DATE], indicated, Once admitted to the facility, residents have the right to remain in the facility.If the basis for the transfer or discharge is necessary.and the resident's needs cannot be met in our facility, the resident's physician.documents.the specific resident needs that cannot be met.this facility's attempt to meet those needs.Residents are permitted to return to the facility after therapeutic leave.The facility will not discharge the resident unless it has ascertained from the resident.that he or she does not wish to return.A review of the facility's policy titled Isolation- Categories of Transmission-Based Precautions dated [DATE] indicated, The three types of transmission-based precautions are contact, droplet and airborne.The decision on whether contact precautions are necessary will be evaluated on a case by case basis. The individual on contact precautions will be placed in a private room if possible. If a private room is not available, the Infection Preventionist will assess various risks associated with other resident placement options (e.g., cohorting, placing with a low risk roommate).A review of CDPH's document titled Recommendations for Infection Control for Residents with CRE in Long-Term Care Facilities dated [DATE] indicated, admission or readmission to a long-term care facility [LTCF] should not be denied based on known colonization or infection with any multidrug-resistant organism (MDRO), including CRE.LTCF medical director, infection prevention personnel, and all staff participating in antibiotic stewardship activities should be notified of the presence of CRE in a resident of the facility. If the facility does not have antimicrobial stewardship activities, a case of CRE may serve to demonstrate their need.California Senate [NAME] No. 361, passed on [DATE], requires all skilled nursing facility, by no later than [DATE], to implement an antimicrobial stewardship policy that is consistent with the antimicrobial stewardship guidelines developed by the Centers for Disease Control and Prevention, the federal Centers for Medicare and Medicaid Services, or specified professional organizations.Staff at the facility, particularly those caring for the resident, should receive education about CRE and appropriate infection prevention measures .The determination to discontinue contact precautions should be made on a case-by-case basis, depending on the clinical and functional status of the resident, i.e., when the resident's secretions or drainage can be contained, and how dependent the resident is on staff for activities of daily living. Repeated bacterial culturing to demonstrate CRE clearance is not necessary to discontinue contact precautions.

Based on interview and record review the facility failed to ensure criminal background checks were completed prior to direct resident care employment for one of three direct care staff (Certified Nurse Assistant 1 [CNA 1]) when CNA 1's criminal background check was completed nine months after he was hired. This failure had the potential to result in resident abuse, neglect and/or mistreatment by hiring staff with possible criminal records.A review of the facility's document titled, General Orientation List, dated 1/17/23, indicated CNA 1's date of hire was 1/17/23. A review of an undated facility document titled, Background Report, indicated a background report was conducted on 10/16/23 for CNA 1 by the facility.During an interview on 7/30/25 at 3:32 p.m., the Director of Staff Development (DSD) verified CNA 1's date of hire was 1/17/23. The DSD confirmed CNA 1's background check was ordered after the employee was hired and began to work directly with residents in the facility. The DSD further stated, I don't have a good answer for you. Usually, I don't let anyone get an offer letter or start orientation until it [background check] is complete.A review of the facility's policy and procedure titled, Background Screening Investigations, dated 2019, indicated, Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents.Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment.

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were met for one of five sampled residents (Resident 1) when supervisory staff did not provide oversight and follow-up after Resident 1 did not receive any showers or baths for seventeen days.This failure had the potential to increase Resident 1's susceptibility to infections, skin problems, and negatively impact his mental health and activities of daily living (ADL, activities such as bathing, dressing and toileting a person performs daily).A review of Resident 1's admission record indicated he was admitted to the facility in May 2025 with medical diagnosis which included vertebrogenic low back pain (chronic low back pain originating from the vertebral endplates, the surfaces of the vertebrae that meet the intervertebral discs in the spine), absence of left leg above the knee, schizophrenia (a mental illness that is characterized by disturbances in thought), depression (depression (a mental health condition characterized by symptoms like sadness, loss of interest and low energy) and PTSD (Post traumatic stress disorder- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 5/23/25 indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 12, which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). In addition, this document indicated Resident 1 had impairment on one side of his lower extremity (hip, knee, ankle & foot) and required substantial/maximal assistance (helper does more than half the effort) with showers and baths. Resident 1's MDS also indicated Resident 1 was wheelchair dependent for ambulation.A review of Resident 1's care plan report, initiated date 5/16/25, indicated, Skin: [Resident 1] is at risk for skin breakdown related to impaired mobility.[staff were expected to] Keep skin clean and dry to the extent possible.A review of Resident 1's care plan report, initiated date 5/17/25, indicated, Mood: [Resident 1] At risk for decreased psychosocial well-being and adjustment issues, emotional distress.[staff were expected to] Encourage participation in ADL's.A review of Resident 1's progress notes, type SBAR [Situation, Background, Assessment, and Recommendation] Summary for Providers, dated 7/03/25 at 10:12 p.m., indicated, Patient [Resident 1] c/o [complain of] pain to R [right] forearm, area assessed and observed to have redden protruding pimple with white head. Slight swelling with firm induration (hardening of tissue) peri pimple and tender to touch observed.A review of Resident 1's progress notes, type Skin/Wound Note, dated 7/7/25 at 2:13 p.m., indicated, This pimple area ruptured now presenting as a abscess. The area is open very bright red with yellow thin pus draining on dressing.with increased swelling forearm to down to hand.now order to start po (by mouth) ATB (antibiotics- a medication used to treat infections).A review of the facility's document titled Shower Schedule, dated 7/16/25, indicated Resident 1 was scheduled to shower on Wednesdays and Saturdays.A review of a facility document titled, Documentation Survey Report v2, for Resident 1 dated 6/1/25-6/30/25, indicated a shower or bath was given on 6/1/25, 6/3/25, 6/12/25, 6/23/25, and 6/26/25. This document indicated Resident 1 refused a shower/bath on 6/30/25. The remaining dates were documented as no (not scheduled for this shift).A review of a facility document titled, Documentation Survey Report v2, for Resident 1 dated 7/1/25-7/31/25, indicated a shower/bath was given on 7/13/25. This document indicated Resident 1 refused a shower/bath on 7/10/25 and was unavailable on 7/3/25, and 7/11/25. The remaining dates were documented as no (not scheduled for this shift).During an interview on 7/31/25 at 1:30 p.m., Certified Nurse Assistant 2 (CNA 2) stated when she offered showers to Resident 1 he would tell her Later. CNA 2 further stated, I will follow up with the resident, but he will continue to say Later and then it's another shift and I did not get to it. During an interview on 7/31/25 at 2:30 p.m., Resident 1 stated, It's been a few weeks since I've taken one [a shower], yesterday was the first time in two weeks. Resident 1 further stated, Since the incident [a reported allegation of abuse that occurred in the shower room between himself and a direct care staff member], I'm just not comfortable with it.During an interview and concurrent record review on 8/1/25 at 10:55 p.m., the Director of Nursing (DON) stated the Director of Staff Development (DSD) was responsible for overseeing and auditing (examine) shower check offs. The DON further stated, If showers have not been given, the DSD should interview the nurse and the resident about it. The DON reviewed Resident 1's Documentation Survey Report v2, dated 6/1/25-6/30/25, and verified, based on the documentation, Resident 1 did not receive a shower or bath between the dates of 6/4-6/11 [indicating eight days without bathing], and 6/13-6/22 [indicating ten days without bathing]. The DON reviewed Resident 1's Documentation Survey Report v2, dated 7/1/25-7/31/25, and verified, based on the documentation, Resident 1 only received one shower or bath for the entire month of July. The DON confirmed all other dates were documented as no (not scheduled for this shift). The DON stated, According to the documentation it appears the resident has not been receiving his showers and it's not documented as refused. The DON further stated, If they [the resident] refuse, the CNA is expected to tell the nurse and they [CNA] need to document it as refused.During an interview and concurrent record review on 8/1/25 at 11:31 a.m., the DSD stated she was responsible for auditing the shower check offs, and further stated, Auditing has been a hit and miss. The DSD stated residents were supposed to receive showers twice a week. The DSD stated, We don't want them to go more than a week without a shower, because of skin issues, amongst other things that can happen. The DSD reviewed Resident 1's Documentation Survey Report v2, dated 6/1/25-6/30/25, and stated, Oh my goodness.yeah, 11 days or more.he's gone too long without a shower. That doesn't look good. The DSD reviewed Resident 1's Documentation Survey Report v2, dated 7/1/25-7/31/25, and confirmed a shower was documented as given on 7/13/25 and documented as no (not scheduled for this shift) for the remaining month through 7/30/25. The DSD verified Resident 1 did not receive a shower or bath for seventeen consecutive days. The DSD confirmed Resident 1's lack of bathing could be an underlying psychosocial (a combined influence of psychological [the mental and emotional state of a person] factors and the surrounding social environment on physical, emotional, and/or mental wellness) concern. A review of the facility's policies and procedure (P&P) titled Activities of Daily Living (ADL), Supporting dated 2001 indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Residents will be provided with care, treatment and services to ensure their ADLs do not diminish.Appropriate care and services.including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).Interventions to improve or minimize a resident's functional abilities will be in accordance with.recognized standards of practice.The resident's response to interventions will be monitored, evaluated, and revised as appropriate.A review of the facility's P&P titled Bath, Shower/Tub dated 2001 indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.Reporting.Notify the supervisor if the resident refuses to shower/tub bath.Report other information in accordance with facility policy and professional standards of practice.A review of the facility's document titled Job Description: Certified Nursing Assistant dated 2024 indicated, The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessments and care plan.

Based on observation, interview, and record review, the facility failed to ensure resident care met professional standards for one resident (Resident 1) of eight sampled residents when following Resident 1's unwitnessed fall nursing and neurological (neuro, relating to the nervous system, includes: brain, spinal cord, and nerves) assessments were not conducted, monitored, or documented in Resident 1's medical record. These failures had the potential to misrepresent Resident 1's actual condition status post (after) fall, which could lead to a delay in treatment and other negative outcomes. Findings:A review of Resident 1's admission record indicated admission to the facility in September 2024 with diagnosis of malignant neoplasm (a cancerous tumor) of unspecified part of the left lung. A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/20/24, indicated Resident 1: Had moderate cognitive (relating to or involving the processes of thinking and reasoning) impairment; Required substantial/maximal assistance (helper does more than half the effort) sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 10-50 feet; and, Was wheelchair dependent.A review of Resident 1's care plan initiated on 9/17/24 indicated, Falls: Resident is at risk for falls with or without injury related to weakness. A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, a communication technique used in healthcare to facilitate clear and concise information) progress note dated 9/19/24 at 11:33 p.m., indicated Resident 1 had an unwitnessed fall on 9/19/24 at 10:45 p.m. A review of Resident 1's SBAR Communication form dated 9/19/24 indicated, Resident/Patient Evaluation.Functional Status Evaluation [check marked] Falls.Skin Evaluation [check marked] Not clinically applicable to the change in condition being reported.Pain Evaluation [check marked] Not clinically applicable to the change in condition being reported.Neurological Evaluation [check marked] Not clinically applicable to the change in condition being reported. The form further indicated, APPERANCE- Summarize your observations and evaluation: Per report given this morning, [Resident 1] had an unwitnessed fall on 9/19/24 at 10:45 p.m. [Resident 1] was found on the floor in her room, next to her bed and the wall. A review of Resident 1's care plan report initiated on 9/19/24 indicated, Resident had unwitnessed fall found lying on her back.Interventions/Tasks [for nursing staff to implement included] Neuro assessment, nursing assessment. During an interview on 7/21/25 at 3 p.m., the Director of Nursing (DON) stated if a resident had an unwitnessed fall, post fall protocol indicated neuro checks would be initiated automatically. The DON stated the expectation was for neuro checks to be completed every 15 minutes (min) for the first hour (hr), every 30 min. for one hr., every hr. for four hrs., and then every four hrs. for 24 hrs. and documented on a neurological flow sheet. The DON stated, The reason neuro checks are conducted after an unwitnessed fall is because we [facility staff] are not sure if the resident hit their head or not. We [facility staff] want to make sure they [the resident] are monitored and to make sure there is no initial or lasting effects indicating any kind of brain injury. The DON stated it was her expectation for 72 hr monitoring to be conducted at least once a day and documented in the resident's progress notes after a fall was reported. During an interview and concurrent record review on 7/22/25 at 1:05 p.m., the Licensed Nurse 1 (LN 1) stated it was expected for licensed nurses to initiate monitoring with vital signs, neuro assessments, and a nursing assessment following a resident fall every 15 minutes (Q 15 min). LN 1 stated the nursing assessment included an assessment for injury, pain, and any changes to skin (ex: bruising and swelling) and the assessment should be documented when completing the resident's Change of Condition (COC) or SBAR report. LN 1 further stated neuro assessments were expected to be conducted for 72 hrs. post fall and COC progress notes would be completed up to 3 days and documented under the resident's progress notes. LN 1 reviewed Resident 1's progress notes dated 9/19/24 to 9/21/24 and confirmed there were no COC 72 hr. progress notes for Resident 1 status post fall. During an interview and concurrent record review on 7/22/24 at 2 p.m., the DON reviewed Resident 1's SBAR report dated 9/19/25 and confirmed pain, skin, neuro, and appearance should have been thoroughly assessed. The DON further confirmed the nursing assessment was not adequate. After a review of Resident 1's medical record, the DON stated, There is no proof of neuro checks being complete following the fall based on the lack of documentation. A review of the facility's policies and procedure (P&P) titled Change in a Resident's Condition or Status dated 2001 indicated, .the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication form.A review of the facility's P&P titled Assessing Falls and Their Causes dated 2001 indicated, If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities.Observe for delayed complications of a fall for approximately forty-eight hours.and document findings in the medical record.Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in the level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings.

Based on interview and record review, the facility failed to provide services that met professional standards of quality for one resident (Resident 1) of three sampled residents when prescriber order to hold a blood pressure (BP - the force of your blood pushing against blood vessels) medication when BP measurement was below a certain parameter was not followed.This failure had the potential for Resident 1 to become hypotensive (low blood pressure) and experience dizziness, lightheadedness, fatigue, visual disturbances, and/or fainting, especially when standing up quickly.Findings:A review of Resident 1's admission record indicated admission to the facility on 6/6/25 with diagnoses including lung cancer, chronic lung disease, heart failure, and hypertension (HTP- high blood pressure).A record review of Resident 1's Medication Administration Record (MAR) dated June and July 2025 indicated an order for doxazosin mesylate (a medication used to control high blood pressure) oral tablet 2 milligrams (mg - a unit of measure), give 1 tablet by mouth at bedtime for HTN, hold if Systolic Blood Pressure (SBP - the higher number on a blood pressure reading) was less than 100 or pulse (P - heart rate) was less than 60. These MARs also indicated doxazosin mesylate was administered to Resident 1 on the following days: 6/23/25 with an SBP of 99; on 6/25/25 with an SBP of 93; and, on 7/2/25 with an SBP of 96. During a concurrent interview and record review on 7/18/25 at 1:28 p.m., Licensed Nurse A (LN A) stated parameters for BP medication were provided to prevent a resident's BP from becoming too low. LN A stated symptoms of low BP included lethargy and/or dizziness. When shown a copy of Resident 1's MAR dated June 2025 and July 2025, LN A stated she would have held the doxazosin mesylate on 6/23/25, 6/25/25, and 7/2/25 because the resident's SBP was below the ordered parameter for administration. LN A further stated it was important to follow the physician's orders, especially for critical medications. LN A stated BP medications were considered critical medications. During a concurrent interview and record review on 7/18/25 at 1:50 p.m., the Director of Nursing (DON) stated LNs were expected to check the resident's BP before administering BP medications for accuracy. The DON stated the physician wrote parameters because some BP medications can drop the BP and/or the heart rate. The DON stated signs of hypotension were dizziness, lethargy, and/or fainting. When shown Resident 1's MAR dated June 2025 and July 2025, the DON stated she expected the doxazosin to have been held on 6/23/25, 6/25/25, and 7/2/25. The DON further stated the LN did not follow the physician's orders if the doxazosin mesylate had been administered despite SPB being outside of the ordered parameters.A record review of the facility's policy titled, Administering Medications revised in April 2019, indicated, The director of nursing services supervises and directs all personnel who administer medications and.medications are administered in accordance with prescriber orders.

Based on interviews and record reviews the facility failed to provide services that meet professional standards for one of three sampled residents (Resident 1), when Resident 1 was administered glucose gel (medical product used to treat low blood sugar levels) in his mouth while unresponsive and unable to follow directions. The failure had the potential to cause Resident 1 to choke on or aspirate (accidental entry of food, liquid or other material into the lungs) the glucose gel. Findings: During a review of Resident 1 ' s admission record indicated, Resident 1 was admitted to the facility in February 2025, with a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1 ' s care plan titled, Diabetes ., initiated on 2/20/25, indicated, .Resident has a diagnosis of diabetes and is at risk for complications . with goals including, .will minimize the risk for complication of diabetes to the extent possible . During an interview on 5/15/25 at 1:22 p.m., Paramedic 1 (PMD 1) stated he responded to a 911 call a for a hypoglycemic emergency on 4/26/25. PMD 1 stated upon arriving at the facility he observed Resident 1 unconscious with clear gel around his mouth and in his mouth, and with a blood glucose level measuring in the low 30s mg/dL (milligrams per deciliter, a unit of measure used for sugar in blood). The paramedic added, the nurse who was in the room with Resident 1, stated she gave Resident 1 glucose gel into his mouth, despite him being unconscious. The paramedic explained, giving glucose gel in the mouth while the resident was unconscious, created a choking or aspiration (accidental entry of food, liquid or other material into the lungs) risk. The paramedic stated, to be aligned with professional standards, he expected a glucagon injection (an emergency medicine used through syringe/need a to treat hypoglycemia for situations where someone cannot take glucose/sugar by mouth) should have been administered to Resident 1 while unconscious. An interview on 5/15/25 at 2:31 p.m., Resident 1 stated on 4/26/25 he had very low blood sugar, measured in the low 30s mg/dL, doesn ' t remember much about the emergency, but remembered waking up in the ambulance on the way to the hospital. An interview on 5/15/25 at 3:01 p.m., the Director of Nursing (DON) confirmed on 4/26/25 Resident 1 experienced a hypoglycemic emergency which rendered Resident 1 unconscious. The DON stated the Lead Nurse (LN 1) called 911 and Resident 1 was ultimately taken to the hospital for care related to his low blood sugar. An interview on 5/15/25 at 3:13 p.m., Licensed Nurse 1 (LN 1) stated she was the Lead Nurse on 4/26/25 when at approximately 10:30 a.m. she was alerted that Resident 1 was found unconscious. LN 1 confirmed Resident 1 was unresponsive . he could not follow commands . he did not respond to voice, and she gave Resident 1 glucose gel in the mouth to try to bring up his blood sugar. An interview on 5/15/25 at 3:47 p.m., LN 4 stated he has been trained when a resident is found unconscious or unresponsive in a hypoglycemic emergency, he would, give a glucagon needle shot . there is a glucagon needle shot in every medication cart . it ' s in the [facility ' s] policy. LN 4 added giving glucose gel in an unresponsive or unconscious resident ' s mouth would be a risk for aspiration or choking. A review of the facility ' s policy and procedure titled, Management of Hypoglycemia, revised March 2025, indicated, .To provide guidelines for managing hypoglycemia . in the diabetic resident .signs and symptoms of hypoglycemia .may include .(more severe) .unconsciousness . Level 3 hypoglycemia: altered mental and/or physical status requiring assistance for treatment . if a resident has Level 3 hypoglycemia and is unresponsive .administer 1 mg of glucagon subcutaneously [into the layer of tissue just beneath the skin] .

Based on interview and record review, the facility failed to meet the requirements for a safe discharge for one of three sampled residents (Resident 1) when Resident 1 was discharged due to being unable to get a ride back to the facility at the agreed upon return time during an approved leave. This failure resulted in emotional distress for Resident 1 as she did not have access to equipment for safe ambulation (walking) or her essential medications (medications ordered by a physician for treating/and or preventing symptoms of a significant health condition). Findings: A review of Resident 1's admission record indicated she was admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition characterized by difficulty in blood sugar control and poor wound healing), acute and chronic respiratory failure (a serious condition that makes it difficult to breathe on your own. It develops when the lungs can't get enough oxygen into the blood), acute kidney failure (a sudden and significant decline in kidney function that leads to an accumulation of waste products in the blood), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety disorder (a mental health disorder where a person experiences frequent, intense, excessive, and persistent worry and fear about everyday situations), muscle weakness, need for assistance with personal care, hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), and hypertension (HTN-high blood pressure). A review of a document titled Order Summary Report for Resident 1 indicated the following medication orders: Albuterol Sulfate Aerosol Solution (a medication breathed through the mouth to open the air passages in the lungs), 1 puff every 4 hours as needed for shortness of breath /wheezing (a high-pitched whistling sound that occurs when air flows through narrowed airways in the lungs); Aspirin Oral Tablet (a medication used to prevent a heart attack or stroke) Chewable 81 mg (milligram, a unit of measure), give 1 tablet by mouth one time a day; Atorvastatin Calcium (a medication used to lower cholesterol [a fat like substance found in all the cells of the body] and prevent heart attacks and strokes) Oral Tablet 40 mg, give 1 tablet by mouth at bedtime; Bupropion HCL Tablet Extended Release (a medication used to treat depression) 12-hour 100 mg, give 1 tablet by mouth two times a day; Fluoxetine Capsule (a medication used to treat depression) 10 mg by mouth one time a day; Insulin Glargine (an injectable medication used to treat high blood sugar in individuals with diabetes)100 unit/ml (milliliter, a unit of measure) solution pen injector, inject 17 units subcutaneously (under the skin) at bedtime; Lorazepam (a medication used to treat anxiety) Oral Tablet 0.5 mg, give 1 tablet by mouth every 8 hours as needed; Lyrica (a medication used to treat neuropathic pain [pain that occurs when there is damage to your nerves due to disease or injury]) Oral Capsule 75 mg, give 1 capsule by mouth 2 times a day; Methocarbamol (a medication used to treat muscle pain and stiffness) Oral Tablet 500 mg, give 3 tablets by mouth two times a day; and, Metoprolol Tartrate (a medication used to treat high blood pressure) Tablet 25 mg, give 1 tablet by mouth two times a day. During an interview on 3/19/25 at 2:15 p.m., Resident 1 stated she had been on an approved leave from the facility when her ride/driver received an emergency call and was unable to drive her back to the facility. Resident 1 stated she called the facility and explained the situation. Resident 1 received a call from the facility the following afternoon and was informed she had been discharged from the facility. Resident 1 stated she begged them to let her come back to the facility. Resident 1 further stated she had a cane but needed a walker. Resident 1 also stated she did not have her medications, and the facility refused to provide them. Resident 1 stated she had suffered two strokes in an acute care facility prior to transferring to the current facility. Resident 1 stated she had no access to care, she was experiencing withdrawal symptoms from her medications, and she was very scared. Resident 1 was crying during the interview. A record review of Resident 1's Care Plan Report, initiated 2/20/25, indicated under focus area of Discharge/Transfer, the following interventions: Assess residents needs for discharge; coordinate durable medical equipment (DME - reusable medical devices and equipment prescribed by a healthcare provider to assist with treatment, monitoring, or management of a medical condition or disability), pharmacy, home health, and/or in home support services; nursing to provide discharge instructions and education for all physician orders including but not limited to level of activity, medications, and follow up appointments; provide community resources for discharge needs; provide post-discharge plan of care in a language that caregivers and resident can understand. During an interview on 3/19/25 at 4:18 p.m., the Social Services Director (SSD) stated Resident 1 had a planned discharge on [DATE]. The SSD stated Resident 1 was on an approved leave on 3/11/25 and wanted to come back to the facility and not be discharged . The SSD further stated Resident 1 told him her ride was unavailable due to an emergency with her ride's family member. During an interview on 3/19/25 at 5:10 p.m., the Director of Rehabilitation (DOR) stated Resident 1 had been discharged from Physical Therapy Services (PT - a healthcare profession focused on promoting, maintaining, or restoring health through movement, exercise, and patient education) but had not been discharged from Occupational Services (OT - a healthcare profession focused on developing and improving skills that are needed to live life as independently as possible). The DOR further stated the rehabilitation department had planned to order Resident 1 an ankle foot orthosis (AFO - a medical device, often a brace, designed to support and improve the function of the foot and ankle) for left foot drop (a condition where the muscles that lift the front of the foot are weakened or paralyzed). During an interview on 3/19/25 at 5:10 p.m., the director of Nursing (DON) stated the facility received a phone call from a friend of Resident 1 and the friend explained he had an emergency with a family member and was unable to drive Resident 1 back to the facility. When asked if Resident 1 left the facility against medical advice (AMA) the DON stated AMA was when a resident left the facility even though they were advised not to for medical reasons. The DON stated this did not apply to Resident 1 as she wanted to stay in the facility. During an interview on 3/19/25 at 6 p.m., the DON stated when residents were discharged from the facility the nursing department ensured adequate medications were on hand and provided to the resident on the day of discharge. During an interview on 3/20/25 at 10:10 a.m., Licensed Nurse B (LN B) stated the facility had a consistent process for discharging residents. When the nursing department was notified of an upcoming discharge, they called the pharmacy and ordered enough medications for the resident to transition to home or another facility. The goal was for the discharged resident to have time to get their medications from their primary care provider (PCP) at their usual pharmacy. The discharging nurse provided education to the resident regarding dosage, timing, and any special considerations such as blood pressure parameters (refers to keeping blood pressure within a safe range). Certain medications prescribed to Resident 1 were considered essential and therefore vital to maintaining Resident 1's well-being. LN B stated Resident 1 had been taking a medication for blood clot prevention and medications for depression. LN B further stated it had not been safe for Resident 1 to suddenly stop taking antidepressant medication as this could have caused a deeper depression, suicidal ideation (thoughts or ideas centered around death or suicide), and interference with mental stability and daily life. During an interview on 3/20/25 at 10:55 a.m., Licensed Nurse C (LN C), LN C stated the facility procedure had been to order medications from the pharmacy four to five days before a discharge. LN C stated Resident 1 should have continued her medications after she was discharged from the facility. LN C further stated Resident 1 had an order for insulin, which was considered an essential medication to treat diabetes. LN C stated Resident 1 could have suffered from hyperglycemia (high blood sugar) if she did not have insulin available. LN C also stated it was standard practice for a physician to taper (gradually decrease) the dose of an antidepressant instead of stopping it suddenly. LN C stated stopping an antidepressant suddenly could have affected Resident 1's mental health and Resident 1 could have experienced withdrawal effects such as insomnia (inability to sleep), mood swings, agitation, and sweating. During an interview on 3/20/25 at 11:30 a. m. Licensed Nurse D (LN D) stated Resident 1 had been prescribed essential medications. LN D stated aspirin, atorvastatin, and metoprolol were important to prevent high blood pressure and decrease Resident 1's risk for another stroke. LN D stated insulin was an essential medication for Resident 1 to prevent hyperglycemia. LN D also stated Resident 1's medications for depression should have been tapered to prevent increased feelings of depression. During an interview on 3/20/25 at 12:55 p.m. the DOR stated he had seen Resident 1 in front of the facility with a single cane. The DOR stated the facility only issued quad canes (a mobility aid featuring a four-point base for enhanced stability, offering more support than a standard cane, and designed for individuals with limited mobility or balance issues) when a resident was discharged . He further stated quad canes were a lot safer than single canes for ambulation. The DOR stated the Interdisciplinary Team (IDT - a team of healthcare providers that collaborate on health care planning) decided what was necessary for a home discharge and arranged for equipment to be supplied. The DOR confirmed Resident 1 did not receive any DME when discharged from the facility. A record review of the facility policy titled, Transfer or Discharge, Facility-Initiated, revised October 2022, indicated, Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility c. the safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident d. the health of individuals in the facility would otherwise be endangered e. the resident has failed, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at this facility f. the facility ceases to operate.

Based on observation, interview and record review, the facility failed to ensure that the Policy and Procedure for using a bed alarm, (A device to alert staff when resident was moving or getting out of bed) was implemented for one resident, Resident 1 when: 1) On 9/26/22, the bed alarm pad with sensor was not placed directly under Resident 1, in between sheets. Certified Nursing Assistant (CNA) placed the bed alarm pad with sensor in between two mattresses of Resident 1 ' s bed. 2) The staff reported that they did not hear the bed alarm sound off when Resident 1 moved or got out the bed on 3/15/2022, 5/17/2022 and 9/25/2022. Resident 1 was found on the floor during rounds (an act of visiting) on dates 3/15/2022, 5/17/2022 and 9/25/2922. On 9/10/22, Staff responded to Resident 1 yelling for help. 3) Between dates 3/15/2022 thru 9/26/2022 the Medical Doctor (MD) for Resident 1 did not write an order to put a bed alarm for fall interventions. These failures resulted in a broken wrist on 3/15/22, a broken hip on 5/17/22, a broken knee on 9/10/22, and another fall from bed on 9/25/22 (no injury documented). Findings: A record review for Resident 1 revealed, Resident 1 was originally admitted on [DATE] for physical therapy due to weakness. Resident 1 had multiple readmissions due to fall with fractures. Resident 1's most recent readmission was on 9/20/2022, from the hospital, for fall with fracture of left knee. Resident 1 had a Brief Interview Mental Services (BIMS) dated 9/12/22, with a score of 9 which indicated she was not cognitively intact. A record review for Resident 1's fall incidents revealed: 1) March 15, 2022, fall from bed resulted in fracture (broken bone) of left wrist. 2) May17, 2022, Unwitnessed fall from bed resulted in left hip fracture. 3) September 10, 2022, Unwitnessed fall from bed resulted in left knee fracture. 4) September 25, 2022, unwitnessed fall from bed without injury. (1) During a concurrent observation and interview on 9/26/2022 at 4:45 p.m., Unlicensed Staff B (CNA) stated, when a resident was a high risk for fall, the bed must be in a low position, needs a floor mat (a soft mat placed next to the bed), and a bed alarm pad with sensor. when asked to show the bed alarm pad, Unlicensed Staff B located the bed alarm pad for Resident 1 placed in between two mattresses. Unlicensed Staff B stated that the bed alarm pad with sensor was placed incorrectly. Unlicensed Staff B stated that the bed alarm pad must be placed on top of the mattress under a sheet and should be directly under Resident 1. Unlicensed Staff B stated that the alarm pad with sensor must be under the sheet, so when Resident 1 attempted to get out of bed, the alarm would go off and that would alert staff that Resident 1 was getting out of bed. Unlicensed Staff B stated only Resident 1 had the bed alarm pad with sensor in the facility. Unlicensed Staff B stated the staff on the morning shift (typically between 7 am and 3 pm) of 9/26/22 placed the bed alarm pad with sensor in between the mattresses. During a concurrent observation and interview on 9/26/2022 at 4:50 p.m., this Surveyor informed Director of Nursing (DON) that the bed alarm pad with sensor was placed in between two mattresses. DON entered Resident 1 ' s room and Unlicensed Staff B pointed at the placement of the bed alarm pad with sensor which was in between the two mattresses. DON confirmed and verified that the bed alarm pad sensor was placed under the mattress. DON stated the bed alarm pad sensor must be placed on top of the mattress, under Resident 1. DON also stated no one should be using a bed alarm in the facility. DON stated that he was not aware that Resident 1 had a bed alarm pad with sensor. (2) During an interview on 9/26/2022 at 4:40 p.m., Licensed Staff A stated that any resident who was a fall risk, the management would discuss preventions during the meeting in the morning and would discussed plan(s) with residents' family. Licensed Staff A stated in order to prevent falls, in a resident ' s room, the bed would be in a low bed position, a floor mat placed, a bed alarm placed, a chair alarm placed (if the resident had a wheelchair) and a rehabilitation evaluation would be ordered. During an interview on 9/26/2022 at 4:55 p.m., Licensed Nurse C stated, on 9/10/2022 at approximately 3 p.m., she heard Resident 1 called out, help, help, help. Licensed Nurse C stated she ran to resident 1's room and found Resident 1 on the floor sitting up leaning against the bed. Licensed Nurse C stated Resident 1 did not use the call light. Licensed Nurse C stated she called MD for an order for an X-ray (picture of the bone) of left knee due to swelling. Licensed Nurse C stated that she did not hear a bed alarm, and only heard Resident 1's call for help. Licensed Nurse C stated Resident 1 did not have a bed alarm and there was no floor mat but the bed was in a low position. During an interview on 9/26/2022 at 5:05 p.m., Director of Staff Development (DSD) stated she provided trainings on Fall Prevention every two years. DSD stated that residents at high risk for falls must have the bed in a low position, the call light within reached, the room free of clutter, a floor mat was sometimes optional, a bed alarm, and a Licensed Nurse was to get an order from the doctor before installing a bed alarm. DSD stated that she provided a verbal training to staff on how to place the bed alarm properly. When asked when she provided the verbal training to staff regarding correct placement of a bed alarm pad, DSD stated she could not remember. DSD stated that she did not have any signed documentation or returned demonstrations by staff who received training for proper placement of a bed alarm pad with sensor. DSD stated that she would start having signed training sheets now. DSD stated that the bed alarm pad with sensor was placed on the day that Resident 1 returned from the hospital on 9/20/22. A review of the Care plan dated 11/19/2019 for Resident 1 revealed: Resident 1 was admitted for short-term nursing and rehabilitation services due to recent physical decline related to admission to hospital. History of hip fracture prior to facility admission 11/19/2019. She wishes to return to prior to living arrangements when she is medically cleared and has reached functional goals regarding therapy. A record review for Resident 1 titled Nursing-Fall Risk Observation/assessment dated [DATE] revealed, History of falls 1-2 falls within 90 days with a score was 26 which indicated Resident 1 was a high risk for falls. A record review for Resident 1 titled Nursing-Fall Risk Observation/Assessment, under Reason for Assessment Request indicated, recent falls. Under History of Falls Within Last 6 Months indicated, 5 Multiple falls. Under Default Score was 13 which indicated Resident 1 was at moderate risk for falls. A record review for Resident 1 titled Rehabilitation-Status Post-Fall Screen dated 9/12/2022, revealed, Date of Event of Fall 9/10/2022. Documented in resident 1's medical record as Unwitnessed fall. A review of the Care Plan for Resident 1 revealed: Under Focus [Resident 1] was admitted for short term nursing and rehab services due to recent physical decline. Fall with Left, hip fracture. (Undated) fracture of left hip, Date of Initiation-None noted. Under Goal, [Resident 1] will be fully prepared at the time of discharge. Revision date was undated. Under Interventions, revealed, encourage participation in treatment and rehabilitation, provide ongoing support, discuss plans with [Resident 1] and Responsible Party. A review of the Care Plan for Resident 1 revealed: Under Focus Falls: [Resident 1] at high risk for fall and injuries r/t to Unsteady gait and weakness dated 3/15/2022. Under Goal reoccurrence of falls and injuries will be minimized through review date. Date initiated 3/15/2022, Revision on 9/26/2022. Under Interventions/Tasks bed alarm and floor mat date initiated 9/26/2022, bed in low possible position, date initiated 3/15/2022. Frequent checks date initiated 9/26/2022. A review of the Care Plan for Resident 1 revealed: Three more falls, actual fall, and unwitnessed falls with injuries to left knee and left hip. Date initiated: Undated, Revision: Undated. Interventions: floor mattress and bed alarm, low bed position. A review of Resident 1 ' s Care Plan, under Intervention for fall stated Bed alarm. [Resident 1] had unwitnessed falls with injury dated 3/15/2022, 5/17/2022, 9/10/2022 and 9/25/2022. A review of the Care Plan for Resident 1 revealed: fracture of left wrist fracture, initiated on 5/17/2022, revision date 9/26/2022. A review of the Care Plan for Resident 1 revealed: Un-witness fall, fracture of left knee dated 9/10/2022. A review of the Care Plan for Resident 1 revealed: Resident 1 had an unwitnessed fall, dated 9/26/2022. Under Interventions: low bed position, floor mattress and bed alarm initiated 9/26/22. (3) During an observation on 9/26/2022 at 4:35 p.m., Resident 1 ' s room was in the middle of the hallway, away from the nurse ' s station. Resident 1 was sleeping on her bed near the window, the bed was in a low position, had a floor mat, a bed alarm, and a chair alarm on a wheelchair. A record review for Resident 1's Progress Notes, by the skin/wound care nurse dated 3/15/2022, revealed, found [Resident 1] sitting at the foot of the bed, charge nurse was informed and will place floor mat. A record review for Resident 1 titled Progress Notes dated 3/16/2022, from a Care Conference Meeting indicated that the fall on 3/15/2022, with a wrist fracture, was not discussed. A record review titled Care Plan date initiated 3/15/22, for Resident 1, revealed under Intervention/Task: to prevent future fall, bed alarm and floor mat were initiated on 9/26/22, bed in low position. A review of the Doctor ' s Summary report for Resident 1 dated 3/31/2022, indicated that a bed alarm with pad sensor was not ordered. A review of Resident 1 ' s Request for Ordering Practitioner's Signature dated 9/10/2022 revealed the MD ordered an X-ray of left knee due to pain of left knee. Resident 1 ' s MD did not order bed alarm pad with sensor, chair alarm, bed in low position or floor mat for fall intervention. A review of the Doctor ' s Summary Report for Resident 1 dated 9/20/22 to 10/12/2022 revealed, bed alarm, chair alarm, bed in low position and floor mat were ordered by the MD on 9/26/2022. A record review for Resident 1 titled Progress Notes dated 5/17/2022 at 1:28 a.m., by Licensed Staff D, revealed, [Unlicensed Nurse] reported to [LN D] at 12 midnight that [Resident 1] was on the ground next to bed, left wrist deformation (change in shape), swelling and unable to move wrist. Lump on left forehead noted. Called MD to send out [Resident 1] to the hospital . MD and family were contacted, call light within reach, will continue to monitor. A record review for Resident 1 titled Progress Notes by DON dated 5/17/2022, revealed, Upon further investigation, [Resident 1] was last seen in bed before the fall. [Resident 1] was put on (sic) the bathroom at 9:21 p.m., [Resident 1] was sleeping during the first round made by the night shift staff. Staff found [Resident 1] on the floor at midnight. [Resident 1 ' s] bed was in low position; non-skid socks are on. A record review for Resident 1 titled Progress notes by IDT (Interdepartmental Team) dated 5/17/2022 at 2:18 p.m., Attendants, Management Team, revealed: Un-witness (sic) Fall 5/17/2022 at midnight. [Resident 1] was found on the ground next to her bed. [Resident 1] is transferring herself unassisted. [Resident 1] was examined and noted swelling and deformation and inability to move left wrist. Prior Intervention(s) low bed, therapy, urine test, frequent checks. A record review for Resident 1 titled Progress Notes dated 9/10/2022 at 3:51 p.m., by Licensed Nurse C, revealed change of condition due to fall . [Resident 1] was found beside her bed sitting up. Noted left knee swelling. A record review for Resident 1 titled Progress Notes by Licensed Staff E dated 9/25/2022 at 11:40 p.m. revealed, Unlicensed Nurse reported that she found Resident 1 laying on the floor on 9/25/2022. [Resident 1] had a previous fall 9/10/22. [Resident 1] with left wrist brace (a strip of material worn around the wrist) and knee immobilizer (A soft, lightweight support for knee and leg injuries) to left knee were intact. No new injury found. A record review titled Medical Progress Notes by MD dated 3/15/2022, revealed, Under Assessment and Plan Monitor blood test and left leg weakness -Fall Precautions. A record review titled Medical Progress Notes by Medical Doctor (MD) dated 5/23/2022 revealed, Under Assessment and Plan, left wrist fracture after fall on 5/17/2022 - Fall Precautions, discussed with nursing and [Resident 1]. A record review titled Medical Progress Notes by MD dated 9/02/2022, revealed, left leg weakness -Fall Precautions. A record review titled Medical Progress Notes by MD dated 9/23/2022 revealed, Left knee fracture -Fall Precautions. During a phone interview on 10/11/2022 at 3:21 p.m., MD stated he expected the facility to follow their Policy and Procedures on Fall Risk and Fall Precautions. MD stated that any bed alarm or chair alarm placement must have a doctor ' s order prior to implementing. MD stated that the facility usually called him to get a bed alarm order. Review of the Policy & Procedures titled, Fall and Fall Risk, Managing revised 3/2018 revealed, The staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Under Definition: A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level. A fall without injury is still a fall. When a resident is found on the floor, a fall is considered to have occurred. Fall Risk factors: 2) Resident conditions that may contribute to the risk of falls include: c) delirium (Delirium is a mental state in which you are confused, disoriented, and not able to think or remember clearly) and other cognitive impairment. Review of Policy and Procedures titled Fall Preventions-Potential Interventions revised 4/2012 revealed, under Interventions for bed: bed brakes locked, mattress placed on floor, bed alarm. Under Staff Education, Orientation for staff and volunteers about fall prevention efforts and strategies.

Based on observation, interview, and record review, the facility did not ensure safe oxygen therapy when: 1. Facility staff did not assess and monitor the volume of oxygen remaining in portable oxygen tanks for two of nine sampled residents (Resident 10 and Resident 48) with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Portable oxygen tanks are steel cylinders filled with concentrated oxygen; they can be put on the back of wheel chairs, allowing residents to move about and prevent residents from being confined to their rooms or bed) This failure prevented Resident 10 and Resident 48 from receiving their oxygen as ordered by their physicians and caused potential for Resident 10 and Resident 48 to experience shortness of breath, harm, and possible death from [CONDITION(S)] (an absence of adequate oxygen in the body); and 2. The facility did not have back up supplies of portable oxygen available for eight of eight sampled residents receiving physician-ordered oxygen (Residents 10, 48, 38, 272, 23, 120, 47, and 3). The facility had one full tank of portable oxygen in their supply room. This failure caused potential for residents requiring a portable oxygen tank to experience shortness of breath, [CONDITION(S)], and harm in the event they were not provided access to needed oxygen. (Oxygen is the main gas in air; it is essential to life. The human body needs a certain amount of oxygen to function properly. Oxygen therapy is prescribed for people who cannot get enough oxygen on their own, for example, residents experiencing lung disease.) An IMMEDIATE JEOPARDY (IJ - A situation in which the facility's noncompliance with one or more regulations has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified on 3/24/22 at 12:58 p.m., under §483.23(i) Respiratory Services. The Administrator, Regional Consultant I, and Regional Consultant J were notified in the Administrator's office, of the IJ, from the failure to monitor and ensure enough oxygen was available, prevented Resident 10 and Resident 48 from receiving their oxygen, as ordered by their physicians, and had the potential for suffering and harm from shortness of breath, and possible death from lack of adequate oxygen, for eight of eight Residents (10, 48, 38, 272, 23, 120, 47, and 3) who would require portable oxygen urgently or if they needed to be evacuated during an emergency. The IMMEDIATE JEOPARDY was removed on 3/25/22 at 2:35 p.m., while onsite, when 32 oxygen tanks were verified in the oxygen storage room, a formula to calculate residents on oxygen, and how many oxygen tanks were required by residents for daily, weekend and emergency use was provided by the Director of Nursing, responsible staff were identified to ensure daily, weekend, and emergent oxygen supply was ordered and available, staff education in-services were provided to facility staff on how to monitor residents' portable oxygen tank supply and communication to nurses and administration of urgent needs. Findings: 1. During an interview and observation on 3/23/22 at 11:25 p.m., Resident 48 was observed in his wheelchair, at his bedside, with a nasal cannula (small plastic tubing that carries oxygen from an oxygen source to a resident's nostrils, through a small, two-pronged plastic device), connected to his oxygen tank, and the portable oxygen tank was turned on. Observation of the oxygen tank volume gauge indicated the oxygen volume level was on the empty/red zone line that indicated the oxygen tank volume was empty. Resident 48 stated, I asked [Unlicensed Staff R] to replace the oxygen tank because I have a doctor's appointment soon and I don't want it to run out. Resident 48 stated, I get short of breath when that happens. At 11:45 p.m., Resident 48 was observed in his bedroom sitting at his bedside in a wheelchair, and his portable oxygen tank gauge was observed to be in the empty/red zone. During an observation on 3/23/22 at 1:30 p.m., Resident 48 was observed in a wheelchair at the nurse's station and his portable oxygen tank volume gauge was observed to read empty/in the red zone, and the oxygen flow was turned on. During an interview on 3/23/22 at 1:55 p.m., Unlicensed Staff T stated, [Resident 48] asked me for a full portable oxygen tank, to replace his empty portable oxygen tank before he was picked up and transported to a doctor's appointment on 3/23/22, between 1:30 p.m. and 1:55 p.m. Unlicensed Staff T stated, I replaced it with a new one and turned it onto 2 or 3 liters per minute. She stated if Resident 48 ran out of oxygen he might have experienced shortness of breath. She stated, Shortness of breath is not a good feeling, it's like you just can't get enough air. During an observation and interview on 3/23/22, at 5 p.m., Resident 10 was observed to be seated in his wheelchair, with a nasal cannula connected to a portable oxygen tank located on the back of his wheelchair, to both nostrils on his face, leaning against the nursing station counter. An observation of his portable oxygen tank, located on the back of his wheelchair indicated it was turned on. The observation indicated the portable oxygen tank volume gauge was on the empty volume/red zone line. During an observation on 3/23/22, at 5:05p.m., Resident 48 had returned from his doctor's appointment and was observed to be seated next to his bed, in his wheelchair, wearing a nasal cannula that was connected to a portable oxygen tank located on the back of his wheelchair. The portable oxygen tank flow was observed to be turned on and the portable oxygen tank volume gauge was observed to be in the low volume area of the oxygen volume gauge just above the red/empty volume zone. During an observation, on 3/24/22, at 9:05 a.m., in the Therapy Room, Resident 48 was observed seated in his wheelchair, without wearing an oxygen nasal cannula, but had a portable oxygen tank on the back of his wheelchair. No other residents were observed in the room. Occupational Therapist U and Unlicensed Staff V were observed seated in the room, not engaged in any resident therapy or documentation activity. They were observed talking and engaged with Resident 48 in a social atmosphere. During an interview and observation on 3/24/22, at 9:06 a.m., Occupational Therapist U stated Resident 48 only needed oxygen when he was short of breath. She checked Resident 48's electronic medical record and stated he had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Unlicensed Staff V was observed to get a new portable oxygen tank and Occupational Therapist U got a new nasal cannula and placed it on Resident 48 and turned the oxygen on. During an interview on 3/24/22, at 9:55 Director of Staff Development A stated she had competencies for licensed and unlicensed staff for oxygen administration. She was unable to provide documentation of a new employee orientation program that addressed Oxygen Therapy Safety with a validation check off list for Licensed and unlicensed staff. She stated she reviews materials related to Oxygen administration, but it provided to staff as an informal discussion, and nothing was documented. She stated all staff should know to look at the portable Oxygen tanks to determine if the Oxygen supply was full or empty. She stated if it was empty or close to empty her expectation of unlicensed staff was to inform the licensed staff, replace the portable Oxygen tank and have the licensed staff conduct an assessment and administer Oxygen flow according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview, on 3/24/22, at 10 a.m., Resident 17 was observed seated at the nurse's station, leaning against the counter. His oxygen tank gauge was observed to be in the red/empty zone. Resident 17 stated I run out of the portable tanks a lot. He stated he was the one who monitored the Oxygen tank supply and reported it to staff when empty. He stated he would get dizzy or short of breath when the tank would get empty. Resident 17 stated staff do not monitor it and he is responsible for telling them when to change it. He stated staff are busy and would not change it for a long time and have told him it is not a high priority for them. He stated he offered to have his oxygen concentrator (a medical device that gives you extra oxygen. An oxygen concentrator isn't the same thing as an oxygen tank, which delivers gas oxygen, instead, the concentrator is a machine that pulls in the air around you and filters out the nitrogen. A thin tube (cannula) runs from the device to your face, giving you purified oxygen through two open prongs below your nostrils), moved into the facility lobby during the day, so he would not waste the oxygen tanks by sitting in the lobby all day. He stated it made him feel unimportant and worthless when staff did not check his oxygen tanks and make sure he had enough portable oxygen. During an observation and interview, on 3/24/22, at 10:05 a.m., Director of Nursing checked the portable oxygen tank volume level gauge for Resident 17 and stated, it is not empty it is almost empty. 2. During an observation and interview with Director of Nursing, on 3/24/22, at 10:15 a.m., in the portable oxygen tank storage room, only one full oxygen tank was observed with the oxygen volume gauge observed to be completely in the full/green zone on the volume gauge. 24 empty portable oxygen tanks were observed with all of their volume gauges observed to be in the red/empty zone. Director of Nursing stated he had ordered nine portable oxygen tanks yesterday (3/23/22), but they had not arrived yet. He was unable to state how Resident 10, Resident 48, Resident 38, Resident 272, Resident 23, Resident 120, Resident 47, and Resident 3 would get physician-ordered oxygen if an emergency occurred, and they had to be evacuated and transferred out of the facility urgently. He stated if there was an emergency and residents were evacuated there would not be enough portable oxygen tanks for the eleven residents on physician ordered oxygen therapy. He stated the oxygen delivery was once a week. Director of Nursing stated Central Supply Manager was responsible for checking and ordering the portable oxygen tank inventory. He could not state how the required number of tanks were calculated to meet the needs of the facility. Review of Resident 272's electronic medical record document titled Order Summary Report, dated 3/8/22, indicated Resident 272 was admitted [DATE], with a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .), dated 3/8/22. Diagnosis .Acute Respiratory Failure with [CONDITION(S)] (It means that a person is not exchanging oxygen properly in their lungs; A person with acute respiratory failure has very low oxygen levels.). Review of Resident 47's electronic medical record document titled Order Summary Report, dated 3/1/22, indicated he was admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) . Chronic Obstructive Pulmonary Disease ([CONDITION(S)])( A group of lung diseases that block airflow and make it difficult to breathe. Damage to the lungs from [CONDITION(S)] can't be reversed. Symptoms include shortness of breath, wheezing, or a chronic cough.), .Muscle Weakness, and included a physician order, dated 2/9/22, that, indicated O2 @ (at) 5 LPM VIA NASAL CANNULA CONTINUOUS PER CONCENTRATOR /TANK every shift for [CONDITION(S)], started 2/9/22. Review of Resident 38's electronic medical record document titled Order Summary Report, dated 3/1/22, indicated he was admitted [DATE], and the document indicated Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 3/1/22, indicated Oxygen - @ 1-2 Liters/Min Via Nasal Cannula (Routine/Continuous/PRN) (Medical Dx(diagnoses): SOB (Shortness of breath) wheezing) Goal to Maintain O2 Sats Greater Than 90% every shift. Review of Resident 23's electronic medical record document titled ADMISSION RECORD, indicated he was admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Blood often backs up and causes fluid to build up in the lungs (congest) and in the legs. The fluid buildup can cause shortness of breath and swelling of the legs and feet), Hypertension, Chronic Obstructive Pulmonary Disease, and Acute Respiratory Distress (When fluid builds up in the tiny, elastic air sacs in your lungs. The fluid keeps your lungs from filling with enough air, which means less oxygen reaches your bloodstream. This deprives your organs of the oxygen they need to function.) Review of a document titled Order Summary Report, dated 3/28/22, indicated a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 10's electronic medical record document titled ADMISSION RECORD, indicated he was admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Because of that, the heart can't relax the way it should. When it pumps, it can't fill up with blood as it's supposed to. Because there's less blood in the ventricle, less blood is pumped out to your body.), Acute and Chronic Respiratory Failure with [CONDITION(S)], Chronic Obstructive Pulmonary Disease Hypertension, Obstructive Sleep Apnea (Stop and start breathing while you sleep). A document titled Order Summary Report, dated 3/24/22, indicated a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 48's electronic medical record document titled ADMISSION RECORD, indicated he was admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a document titled Order Summary Report, dated 3/24/22, indicated a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2 lpm via nasal cannula continuous per concentrator/tank every shift for [CONDITION(S)]. Review of Resident 3's electronic medical record document titled ADMISSION RECORD, indicated he was admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a document titled Order Summary Report, dated 3/24/22, indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 120's electronic medical record document titled Order Summary Report, indicated he was admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), Muscle Weakness, and Aortic Aneurysm without Rupture (A balloon-like bulge in the heart and the vessels that carry blood from the heart through the chest and torso.). A physician order, dated 3/9/22, indicated O2 @ 2 LPM VIA NASAL CANNULA CONTINUOUS PER CONCENTRATOR/TANK every shift. During an observation and interview with Central Supply Manager W, on 3/24/22, at 11 a.m., she verified there was only one full portable oxygen tank in the oxygen supply closet. She stated the facility had oxygen delivered once a week, and they delivered nine tanks on 3/23/22. She stated she does not calculate the number of tanks needed or monitor the oxygen supply closet. She stated the delivery company delivers nine tanks every week unless the facility runs out and then they order more. She stated if an emergency happened, and the facility had to evacuate residents there would not be enough portable oxygen supply. She stated resident might become short of breath and have trouble breathing if there were no oxygen tanks available. An IMMEDIATE JEOPARDY (IJ) was identified on 3/24/22 at 12:58 p.m., under §483.23(i) Respiratory Services. The Administrator, Regional Consultant I, and Regional Consultant J were notified of the IJ in the Administrator's office. The Administrator, Regional Consultant I, and Regional Consultant J were notified the failure to monitor and ensure enough oxygen was available, prevented Resident 10 and Resident 48 from receiving their oxygen, as ordered by their physicians, and had the potential for suffering and harm from shortness of breath, and possible death from lack of adequate oxygen, for eight of eight Residents (Residents 10, 48, 38, 272, 23, 120, 47, and 3), who would require portable oxygen if they needed to be evacuated urgently during an emergency. The facility submitted a Plan of Action #1 (IJ Removal Plan) to the Survey team on 3/24/22 at 3:56 p.m The Plan of Action #1 was determined to be unacceptable to remove the IJ. During an interview at the nurse's station, on 3/24/22, at 4:30 p.m., Nurse Practitioner K stated oxygen administration safety included making sure the portable oxygen tank did not run out of oxygen. She stated staff must check the tank consistently because if a resident did not receive the prescribed oxygen there was a risk of shortness of breath and [CONDITION(S)]. The facility submitted a revised Plan of Action #2 to the Survey team on 3/24/22 at 4:53 p.m The Plan of Action #2 was determined to be unacceptable to remove the IJ on 3/24/22 at 5:10 p.m The facility submitted Plan of Action #3 to the Survey team on 3/25/22 at 9:09 a.m The Plan of Action #3 was determined to be acceptable on 3/25/22 at 9:19 a.m The Plan of Action #3 indicated: Immediate Correction Actions included having 32 portable tanks of Oxygen available in the facility. The facility developed a protocol to ensure adequate Oxygen Inventory System for daily and weekly Oxygen supplies. The facility developed a formula to calculate the number of residents who had Oxygen ordered by their physicians, and how many tanks of portable Oxygen were required for daily use, per resident and for potential emergency use. The facility determined the Director of Nursing would be responsible for calculating the amount of portable Oxygen tanks needed daily, anticipate the weekend use, and communicate the amount to the Central Supply Manager and/or Administrator daily. Inservice education for all licensed, unlicensed staff, activity staff and therapy staff on Oxygen administration safety and monitoring of resident portable Oxygen tank levels. In addition, all staff were provided education on how to, and when to contact the Administrator and/or Central Supply Manager if the facility Oxygen tank storage room inventory was running low, to allow for immediate Oxygen tank delivery from the contracted vendor. The IMMEDIATE JEOPARDY was removed, onsite, on 3/25/22 at 2:35 p.m. The Plan of Action #3 was verified by interview, observation, and record review when: Observation of 32 tanks of portable oxygen tanks were available in the oxygen tank storage room; Observation of the Director of Nursing calculated the number of residents who had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing, Administrator and Central Supply Manager indicated they understood the Director of Nursing would be responsible for calculating the amount of portable oxygen tanks needed daily, anticipate the weekend use, and communicate the amount to the Central Supply Manager and/or Administrator daily, and check the portable oxygen tank inventory daily. Interview and record review with the Director of Staff Development A confirmed and validated Inservice education for all licensed staff, unlicensed staff, activity staff and physical therapy staff on oxygen administration safety and monitoring of residents on portable Oxygen tank levels had occurred, and the facility had a plan to ensure any staff who were not at work or out of leave would receive Oxygen Safety Inservices before they started their next shift. In addition, all staff were provided education on how to, and when to contact the Administrator and/or Central Supply Manager, if the facility oxygen tank storage room inventory was running low, to allow for immediate oxygen tank delivery from the contracted vendor. Review of a facility Policy and Procedure (P&P) titled Oxygen Administration, revised October 2010, indicated Purpose The purpose of this procedure is to provide for safe oxygen administration.Report other information in accordance with facility policy and professional standards of practice. There was no indication in the P&P for monitoring Oxygen levels on portable Oxygen tanks to ensure Oxygen was available, or a process to have back up oxygen supply available for transfer or emergencies. Review of a document titled FACILITY ASSESSMENT TOOL, (A Facility Assessment is a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operation and emergencies.), dated March 2022, indicated Common diseases, conditions physical and cognitive disabilities, or combinations of conditions that (Facility) can treat / provide care for : .Respiratory System - Chronic Obstructive Pulmonary Disease ([CONDITION(S)]) (A group of lung diseases that block airflow and make it difficult to breathe. [CONDITION(S)] and chronic [CONDITION(S)] are the most common conditions that make up [CONDITION(S)]. Symptoms include shortness of breath, wheezing, or a chronic cough.), Pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid. With pneumonia, the air sacs may fill with fluid or pus. The infection can be life-threatening to anyone, but particularly to infants, children, and people over 65. Symptoms include cough with phlegm or pus, fever, chills, and difficulty breathing.), Asthma (A condition in which a person's airways become inflamed, narrow, and swell, and produce extra [MEDICATION(S)], which makes it difficult to breathe. Asthma can be minor, or it can interfere with daily activities. In some cases, it may lead to a life-threatening attack. Asthma may cause difficulty breathing, chest pain, cough, and wheezing.), Respiratory Failure (Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon [MEDICATION(S)]. Sometimes you can have both problems.).Special Treatments and Conditions, Respiratory Treatments, Oxygen therapy, Number / Average or Range of Residents 21, .Staff are testing annually on the following competencies .Specialized care .oxygen administration. Physical environment and building / plant needs .Physical equipment Resources .oxygen tanks and tubing.

Based on interview and record review the facility failed to ensure Healthcare Personnel (HCP) provided the necessary foot care per the physician's orders, and nursing assessments, for one of two sampled residents (Resident 1), who had been admitted to the facility for physical therapy post surgery of a fractured left ankle and was at risk for poor circulation (blood flow) because of comorbidities (two or more diseases), diabetes (high blood sugar) and on [CONDITION(S)] (a procedure to divert blood to a machine to remove waste products and excess fluid from the blood when the kidneys stop working properly). The HCP's failure to routinely assess and follow Resident 1's physician's left foot care orders led to Resident 1's eventual left second toe infection and requiring amputation of the toe. Findings: A review of Resident 1's acute hospital discharged Summary, dated 3/27/21, indicated Resident 1 had fallen at home and fractured her left distal tibia (larger bone on the inside of the lower leg) and fibula (smaller bone on the outside of the leg)) and left ankle. Resident 1 underwent an ORIF (Open Reduction and Internal Fixation: a type of surgery used to stabilize and heal a broken bone) of the left ankle. A review of Resident 1's Admission Record, dated 4/6/21, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Nursing - Admission/Readmission Assessment, dated 3/27/21, indicated Resident 1 was admitted to the facility for Physical Therapy (PT) and Occupational Therapy (OT: treat patients who have injuries, illnesses, or disabilities through the therapeutic use of everyday activities) post ORIF of left ankle on 3/24/21. There was swelling present at Resident 1's left lower extremity, limited physical mobility, non-weight bearing (NWB) to left lower extremity, and needed assistance with bathing, dressing and toileting upon admission. A review of Resident 1's Baseline Care Plan Person-Centered Care Planning, dated 3/28/21, indicated Resident 1 was Developmentally Delayed, was to be NWB to LLE (left lower extremity: leg) for 8 weeks, starting 3/24/21, was to go out for [CONDITION(S)] Monday, Wednesday and Friday, and her left foot/ankle dressing would be changed by physician one week after admission. A review of Resident 1's Progress Notes, dated 4/12/21, and Doctors' Order Sheet, dated 4/12/21, indicated Resident 1 saw her orthopedic surgeon on 4/12/21 and had new care orders for Resident 1's LLE, which included: NWB for four more weeks, ok to wash foot and ankle, ok to put lotion on foot and ankle, boot on except for bathing, and follow-up appointment in four weeks. Progress Notes indicated Resident 1 had nine Steri-Strips intact to left outer ankle and three Steri-Strips intact to left inner ankle. Skin warm and dry. A review of Resident 1's Medication Administration Record (MAR), dated 4/2021 and 5/2021, indicated Ok to wash foot and ankle every shift (Day shift, P.M. shift and Night shift) and Ok to put lotion on foot and ankle every shift. A review of Resident 1's Nursing - Daily Skilled Charting Form - V 3.0, dated 4/27/21, 4/28/21, 4/29/21, 4/30/21, 5/4/21, 5/5/21, 5/6/21, 5/8/21, 5/9/21, and 5/10/21, indicated: Integumentary (external layer of skin) Status was warm, dry and skin color normal (white to pink). Resident 1's Nursing - Daily Skilled Charting Form - V 3.0, dated 5/1/21, 5/2/21, and 5/7/21, indicated: Integumentary was warm and skin color normal. Resident 1's Nursing - Daily Skilled Charting Form - V 3.0, dated 5/3/21, indicated: Integumentary was warm and dry, skin color normal and wounds, but Wound Sites and Treatments (specify wound and site) indicated, None. Resident 1's Nursing - Daily Skilled Charting Form - V 3.0, dated 5/3/21 and 5/9/21, under Musculoskeletal per check box, were the only two assessments to indicate the nurse did a Skin/Circulation/Surgical Site Assessment of the LLE, but no details describing the incision and Steri-strips were documented. A review of Resident 1's Weekly Summary Notes, effective 4/17/21, 4/24/21, and 5/6/21 indicated there were, No new skin issues this week. There was no mention of the LLE. Resident 1's Weekly Summary Notes, effective date 5/1/21, indicated, Surgical site to LLE and no new skin issues this week. A review of Resident 1's Bathing Record, dated 4/2021, indicated she had five out of her eight scheduled showers or bed baths in the month of April: on 4/7/21, 4/14/21, 4/17/21, 4/21/21, and 4/28/21. Resident 1 refused her shower on 4/3/31 and on 4/10/21, 4/11/21, 4/24/21 and 4/25/21 indicated NA (Not Applicable). Resident 1's Bathing Record, dated 5/2021, indicated Resident 1 had two out of three of her scheduled showers or bed baths from 5/1/21 through 5/10/21: 5/1/21 a bed bath and 5/7/21 a shower. On 5/4/21 the Bathing Record indicated NA. During an interview on 7/15/21 at 12:10 p.m., Licensed Staff A stated Resident 1 did have an attitude, A brat. Resident 1 would have temper tantrums. Refused showers and did not want her foot touched. During an interview on 7/15/21 at 1:40 p.m., the DSD (Director of Staff Development) stated a resident should receive a shower or bed bath twice per week. The DSD stated if a resident refused a shower/bed bath, the Certified Nursing Assistant (CNA) should record a refusal of a shower or bed bath as RR (Resident Refused), not NA. The DSD stated the CNA should let the nurse know if the resident refused a shower or bed bath. The DSD stated the CNA should have given the nurse a Shower sheet and the nurse signs the sheet indicated she reviewed the Shower sheet. On 1/20/22 at 4:06 p.m., the Administrator was asked to provide Resident 1's Shower sheets filled out by her CNAs. None could be provided. A review of Resident 1's Alteration in skin integrity related to surgical wound to left ankle status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's Diabetic Mellitus care plan, initiated 3/29/21, indicated: Check all of body for breaks in skin and treat promptly as ordered by doctor. If infection is present, consult doctor regarding any changes in diabetic medications. Inspect feet daily for open areas, sores pressure areas, blisters, [CONDITION(S)] or redness. Monitor for dry skin and apply lotion as needed. Resident 1's [CONDITION(S)] care plan, initiated 3/29/21, indicated: Monitor for peripheral [CONDITION(S)] (leg swelling caused by the retention of fluid in leg tissues). Resident 1's At Risk for Pain/Discomfort Related to Left Ankle Fracture care plan, initiated 3/29/21, indicated: Assess level of pain, frequently, site and factors that trigger the pain. Consider pre-medicating for pain prn (as needed) to optimize participation. Document and notify physician of increasing and/or unrelieved pain. A review of Resident 1's Nurse's Notes, created date 5/11/21, indicated Resident 1 went to her orthopedic surgeon appointment on 5/10/21 and the physician called the facility to indicate Resident 1 had a wound on her foot, which looked infected when her cast was removed. Resident 1 was going to be sent to the ER (emergency room ). Resident 1 had Steri-Strips and a boot, not a cast to her LLE per her orthopedic surgeon appointment on 4/12/21. During an interview on 8/3/21 at 3 p.m., Physician B stated Resident 1 saw him on 4/12/21, whereby he removed the stitches to her left ankle and applied Steri-Strips. On 5/10/21, Resident 1 went to Physician B's office for a follow-up appointment regarding Resident 1's left ankle. Physician B stated when he removed Resident 1's boot and dirty sock, he could tell no one had cleaned her left foot and ankle for at least two weeks. Physician B stated Resident 1's Steri-Strips were still intact after a month, there was caked-on dead skin at Resident 1's left foot and her second toe (next to her big toe) looked ulcerated (sore on the skin). Physician B stated no one could have assessed and washed Resident 1's left foot and ankle for at least two weeks because there were layers of dead skin. Physician B stated if a nurse had assessed Resident 1's left foot, the nurse would have seen there was a change of condition: Resident 1's left second toe was infected. Physician B stated Resident 1's infected left second toe did not happen overnight; it took at least two weeks to become that infected. Physician B stated he sent Resident 1 to the ER, whereby Resident 1 had to have her second toe amputated. Physician B stated the facility had instructions for wound care: to wash Resident 1's left foot and ankle, and apply lotion to Resident 1's foot and ankle daily. Physician B stated if Resident 1's left foot and ankle had been cleaned daily, Resident 1's Steri-Strips should have fallen off and there would not have been caked on dead skin. Physician B said, The dead skin was that bad. Physician B stated the skin around Resident 1's left foot and ankle looked like what Physician B would have seen after removing a cast after six weeks. The sock was dirty, and the dead skin was caked on. Physician B stated again, no one at the facility assessed and cleaned Resident 1's left foot and ankle for at least two weeks or they would have noticed her infected toe. Physician B stated Resident 1 was vulnerable because of her intellectual capacity and developmentally delayed along with psychological issues. Physician B stated Resident 1 did not have the intellectual capacity to take it upon herself to take off her boot and sock, assess her left foot and ankle, and let someone know her toe did not look good. Physician B stated Resident 1 was really at the mercy of the facility to take care of her. Physician B stated Resident 1 was neglected. During a concurrent interview and record review on 8/19/21 at 11:55 p.m., Resident 1's Comprehensive Skilled Review Note-V 3.0, dated 4/9/21 and 4/23/21, indicated: I. Barrier to Nursing Progress: Resident 1's Barriers: NWB eight weeks LLE, MD to remove dressing in one week . Nursing left lateral ankle wound . and Resident 1's Comprehensive Skilled Review Note-V 3.0, dated 5/8/21, indicated: I. Barrier to Nursing Progress: Resident 1's Barriers: NWB eight weeks LLE, MD to remove dressing in one week . Note: Resident 1's dressing was removed by Physician B on 4/12/21 and Steri-Strips were applied, NWB order end date was 5/19/21 and Resident 1 was to wear a boot at all times unless Resident 1's foot and ankle was being washed and lotion applied, start date, 4/12/21, which was never mentioned. The MDS Coordinator stated he did not talk to Resident 1 nor assess her left foot and ankle to complete Resident 1's Comprehensive Skilled Review Note-V 3.0 form. The MDS (Minimal Data Set) Coordinator stated he reviewed and relied on the nurses' latest documentation of Resident 1's left surgical ankle wound and he cut and pasted the nurses' notes into the Comprehensive Skilled Review Note-V 3.0: I. Barrier to Nursing Progress document. The MDS Coordinator stated the Comprehensive Skilled Review Note was just a review to see if Resident 1 should stay on Skilled Services (patient's need for care or treatment that can only be performed by licensed nurses). The MDS Coordinator stated it was not his fault if the nurse(s) did not document Resident 1's left foot and ankle details accurately. During an interview on 10/21/21 at 5:15 p.m., Licensed Staff C stated he did not recall any abnormalities to Resident 1's left foot and ankle. Licensed Staff C was asked when he was assigned to care for Resident 1 on 5/4/21 and 5/5/21, P.M. shift and 5/5/21, Night shift, per Resident 1's 5/2021 MAR, if he took off her boot, washed her foot and ankle, and applied lotion? Licensed Staff C stated he could not recall. Licensed Staff C stated the order: Ok to wash foot and ankle every shift and Ok to apply lotion to foot and ankle every shift to him meant, he could have removed Resident 1's boot, washed her foot and ankle and applied lotion, not that he necessarily had to follow through with the order. Resident C stated there probably should have been a clarification of the order. Resident C stated any order placed on a resident's MAR and TAR (Treatment Administration Record) was the responsibility of the nurse to complete. Licensed Staff C stated he did recall Resident 1 was not being cooperative with taking her medication/insulin (controls the blood sugar levels), but Licensed Staff C could not recall in specific treatment to Resident 1's left foot and ankle. Licensed Staff C was asked if Resident 1's Steri-Strips, which were applied on 4/12/21, should have fallen off by the time Resident 1 went to her follow-up appointment, on 5/10/21? Licensed Staff C stated Resident 1's Steri-Strips should have fallen off by 5/10/21, and her incision to her ankle should have been healed. During a concurrent interview on 10/22/21 at 12:09 p.m., Resident 1's MAR, dated 4/2021 and 5/2021, indicated Licensed Staff D was assigned to care for Resident 1 on 4/12/21-4/15/21, 4/19/21-4/21/21, 4/25/21, 4/27/21, and 5/8/21, Night shift. When Licensed Staff D was asked about Resident 1's order indicated on Resident 1's 4/2021 and 5/2021 MAR with a start date, 4/12/21, OK to put lotion on foot and ankle every shift . OK to wash foot and ankle every shift, Licensed Staff D stated, to her, the order meant FYI (For Your Information), it did not mean Resident 1's foot and ankle needed to be washed every shift and lotion applied every shift. Licensed Staff D stated she really could not recall Resident 1. Licensed Staff D stated if Resident 1 was asleep, she would not have woken her up to assess her left foot and ankle unless the previous shift had reported to her there was a Change in Condition regarding Resident 1's left foot and ankle. Licensed Staff D stated if Resident 1 was awake she would have checked Resident 1's left foot for circulation. Licensed Staff D stated she would not wake a resident up out of respect unless something had been reported to her from the nurse on the previous shift. She stated she recalled Resident 1 wore a boot and had a splint. Licensed Staff D was asked why the order for, Keep Splint on until follow-up visit with physician, start 3/27/21, was not discontinued on Resident 1's MAR when she returned from seeing her physician on 4/12/21. Licensed Staff D stated someone forgot to take the order out of the electronic MAR system. During a concurrent interview and record review on 10/22/21 at 12:41 p.m., Resident 1's MAR, dated 4/2021 and 5/2021, indicated Licensed Staff A was assigned to care for Resident 1 on 4/13/21, 4/18/21, 4/27/21 and 5/3/21, P.M. shift and 5/7/21, A.M shift. When Licensed Staff A was asked about Resident 1's order, indicated on Resident 1's 4/2021 and 5/2021 MAR with a start date of 4/12/21, OK to put lotion on foot and ankle every shift . OK to wash foot and ankle every shift, Licensed Staff A stated if Resident 1's MAR indicated to wash and apply lotion to Resident 1's left foot and ankle every shift and was not a prn (as needed) order, the nurse should have washed, and applied lotion as indicated on the MAR. When Licensed Staff A was asked if Resident 1's left foot and ankle was washed and lotion applied every shift from 5/1/21-5/10/21, should Resident 1's left foot and ankle have been dirty and dry? Licensed Staff A stated Resident 1's left foot and ankle should have been clean and moist. Licensed Staff A stated when an order was placed on the MAR, it was up to the nurse to carry through with the order, not the CNA. Licensed Staff A stated she recalled Resident 1 would not let Licensed Staff A remove Resident 1's boot and touch Resident 1's left foot and ankle because Resident 1 was complaining of her left foot hurting. Licensed Staff A stated if Resident 1 was refusing to let nurses remove Resident 1's boot, wash her left foot and ankle, and assess her foot, the nurse should have documented refusal on Resident 1's MAR and on Resident 1's Nurse's Progress Notes. Licensed Staff A stated Resident 1's physician should have been notified about Resident 1 not being cooperative with letting Resident 1's nurse remove her boot, wash and apply lotion to Resident 1's left foot and ankle, and assess her foot and ankle. Licensed Staff A was asked if Resident 1's Steri-Strips, which were applied on 4/12/21, should have still been on Resident 1's left ankle incision during Resident 1's follow-up appointment on 5/10/21? Licensed Staff A said, I would think the Steri-Strips would have been loose, almost fallen off Resident 1's incision. Licensed Staff A was asked if Resident 1's Steri-Strips should have been plastered on Resident 1's incision if Resident 1's left foot and ankle had been washed and lotion applied per Resident 1's order? Licensed Staff A said, No, her foot and ankle should have been clean and moist. A review of Resident 1's hospital ED (emergengy department) Summary, dated 5/10/21, indicated Resident 1 had developed a diabetic left second toe ulcer and was admitted to the hospital. Resident 1's Podiatry Progress Note, dated 5/14/21, indicated Resident 1 had an amputation of the left second toe on 5/12/21. Resident 1's Operative Report, dated 5/12/21, indicated Resident 1's left second toe had a full-thickness ulcer over the dorsal aspect of the proximal interphalangeal joint (between the phalanx bones of the toes in the feet) with bone exposed. The second toe was also moderately edematous (swollen) and erythematous (abnormal redness of the skin). Resident 1's second toe was disarticulated (amputated). The facility job description titled, LPN (Licensed Practical Nurse)/LVN (Licensed Vocational Nurse), dated 11/2018, indicated: Charting and Documentation: Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care . Report all discrepancies noted concerning physician's orders . Nursing Care Functions: Review the resident's chart for specific treatments . Make periodic checks to ensure the prescribed treatments are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status . Notify the resident's attending physician and next-of-kin when there is a change in a resident's condition . Monitor seriously ill residents as necessary . Ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes . Care Plan and Assessment Functions: . Ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care or treatment . The facility job description titled, Registered Nurse (RN), dated 9/2018, indicated: Personnel Functions: Make daily rounds of nursing services department to ensure that all nursing services personnel are performing their work assignments in accordance with acceptable nursing standards. Report findings to the Director . Nursing Care Functions: Visit residents on a daily basis in order to observe and evaluate each resident's physical and emotional status . Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that each care is provided in accordance with the resident's wishes . The facility Policy/Procedure (P/P) titled, Bath, Shower/Tub, revised 2/2018, indicated: Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Documentation: 3. All assessments data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath . 5. If the resident refused the shower/tub bath, the reason(s )why and the intervention taken . Reporting: 1. Notifying the supervisor if resident refuses the shower/tub bath. 2. Notify the physician of any skin areas that may need to be treated . The facility P/P titled, Medication Orders, revision 11/2014, Recording Orders: 6. Treatment Orders: When recording treatment orders, specify the treatment, frequency and duration of the treatment . The facility P/P titled, Medication and Treatment Orders, revised 7/2016, Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing. The facility P/P titled, Diabetes - Clinical Protocol, revised 11/2020, Monitoring and Follow-up: 5. The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration .

Based on observation, interview, and record review, the facility failed to provide one of two sampled residents (Resident 1) with adequate supervision or assistance to prevent Resident 1 from falling from his wheelchair when he was left unattended in his bedroom and not put to bed in a timely manner. Resident 1 fell on to the floor and sustained two lacerations (a wound that is produced by the tearing of skin) and bruising to his face. Resident 1 required transport to the acute care hospital emergency department. One laceration required sutures (stitches) and the other was treated with steri-strips (small pieces of medical tape used to close a wound). Failure to provide supervision and bedtime care in a timely manner contributed to Resident 1 falling from his wheelchair and sustaining injuries to his face. Findings: The facility's Admission Record indicated Resident 1 was a [AGE] year old male admitted to the facility in (MONTH) (YEAR). Resident 1 had multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS - a resident assessment tool) dated 1/5/19, indicated Resident 1 required a wheelchair for mobility (he no longer could walk), and had severely impaired cognition (attention, comprehension, thinking ability), and disorganized thinking. Resident 1 was dependent on staff for activities of daily living and required extensive assistance of two persons for dressing, toileting, hygiene, bathing, and transfers to and from his bed to the wheelchair. The MDS indicated Resident had a fall with injury (skin tear, abrasion or bruise) since his prior assessment date of 10/5/18. During a telephone interview on 3/28/19 at 9:45 a.m., FM stated she visited Resident 1 on the evening of Saturday, 3/23/19. At approximately 7:10 p.m., FM stated she could not find LN-A and told a male certified nursing assistant (CNA-C) that she was leaving the facility and to please put (Resident 1) in bed by 7:30 p.m. or 8 p.m. at the latest. FM stated she received a phone call later that evening at 9:10 p.m. from the facility. The facility informed her Resident 1 fell out of his wheelchair, and they could not stop the bleeding to his forehead and he was being sent to the emergency department. FM stated when she met up with Resident 1 at the hospital's emergency department, he still had his clothes on, and was not in his pajamas for bed. The next day, FM stated she asked a nurse at the facility why Resident 1 was not put to bed, as she had requested the evening before, and was told, the CNA was busy and we're short staffed. FM stated, they're always saying 'we're short staffed or two people called off ' . especially on weekends. When asked how that impacted Resident 1, FM stated, well, he didn't get put to bed (on 3/23/19) when I asked, then he fell . Review of a Nurse's Note dated 3/23/19 and documented at 10:38 p.m., indicated the following: At 8:45pm CNA came and told me that resident is on the floor in his room, found on the floor on his right side. Profuse bleeding was noted on his head. First aid rendered by staffs (sic). Called 911 for transfer at 8:47 pm. Resident sent to the ER (emergency room ) at 9pm . sent to . Hospital. An Interdisciplinary Team (IDT) note dated 3/25/19 at 9:50 a.m., which reviewed the fall, indicated on the evening of 3/23/19, after dinner, FM had wheeled Resident 1 (in his wheelchair) back into his room. Resident 1's roommate witnessed the fall and told the Director of Nursing (DON), he leaned forward and fell out of the wheelchair. During an observation on 4/4/19 at 10:37 p.m., Resident 1 was seated in his wheelchair across from the nurses's station. There were four staff members working at the nurse's station with Resident 1 within line of sight. Resident 1's eyes were closed and he did not respond to a greeting. There was a scar at the center of his forehead about one inch long, and sutures remained over his left eyebrow which was about one and one half inches long. There was faint, remnant bruising to his face. During an interview on 4/4/19 at 10:40 a.m., CNA-B confirmed Resident 1 required two people to transfer him from his wheelchair to his bed and sometimes he could be very resistant. CNA-B stated she was called into another resident's room on the evening of 3/23/19 to help with a transfer. CNA-B stated while she was in the midst of helping with the other resident's transfer, someone informed her Resident 1 had fallen. CNA-B stated, I shouldn't have left him in his room, normally he's within sight. CNA-B was tearful as she described being told Resident 1 fell to the floor, and stated, I was so upset. During an interview on 4/4/19 at 11:40 a.m., the Director of Staff Development (DSD) was asked what fall prevention interventions were being implemented for Resident 1. The DSD stated the facility utilized a wheelchair alarm (an alarm that sounds if a resident attempts to get out of a wheelchair unassisted), bilateral floor pads (padded mats) on each side of the bed one of which had an alarm within it, and a low bed. Resident 1's Plan of Care, initiated on 4/2/18 and revised on 10/19/18, addressed his high risk for falls related to his limited physical mobility, loss of strength, and dementia. The Care Plan indicated Resident 1 had poor safety awareness and repeated falls. Although the alarm systems, floor pads, and low bed position were documented as interventions there was no mention of having Resident 1 within line of sight. During an interview on 4/4/19 at 12:45 p.m., Resident 1's Roommate stated he saw him fall (on the evening of 3/23/19). The Roommate stated, it looked like he was trying to get up from the wheelchair but fell and hit his head. The Roommate stated he had called out to facility staff for help after Resident fell . The Roommate stated Resident 1 falls easily. During a telephone interview on 4/5/19 at 12:17 p.m., LN-A stated she took care of Resident 1 on the evening of 3/23/19. LN-A stated a CNA notified her that Resident 1 fell and she found him on the floor (in his room) bleeding. When asked how Resident 1 fell , LN-A did not know and stated, he was found on his side (lying) next to his bed. During a telephone interview and concurrent record review on 7/24/19 at 10:50 a.m., Resident 1's Fall Risk Assessments dated 12/29/18 and 3/24/19 were reviewed with the DON. The DON verified Resident 1's Fall Risk Score for each assessment was 26/high risk for falls. High risk scores were between 16-42; moderate risk scores were between 9-15; and low risk scores were between 0-8. The most recent Fall Risk assessment dated [DATE], indicated Resident 1 remained at a high risk for falls with a score of 26. The facility's policy and procedure titled, Falls and Fall Risk, Managing, revised 3/2018, indicated under the section Resident-Centered Approaches to Managing Falls and Fall Risk: #5, If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. #6, If underlying causes cannot be readily . corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. #7, In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding .) to try to minimize serious consequences of falling.