Every finding on record at St. John's Hospital Camarillo D/P SNF

Based on observation, record review and interviews, the facility failed to adhere to established standards of practice regarding the documentation of skin condition for one of 21 sampled residents (Resident 17).This failure resulted in Resident 1's inaccurate assessment and subsequently placed Resident 1 at risk for additional skin breakdown due to the absence of reliable nursing documentation.Findings:A review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 243 in the section titled, Data Documentation indicates, Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse.During Resident 17's observation on 8/10, at 11:40 a.m. inside room [ROOM NUMBER]-02 the following skin condition was observed:a. Right side of the trach (a surgical hole made through the front of the neck for breathing) - a u-shaped flat dark reddish skin discoloration (approximately 2.5 centimeters (cm) x 2 cm) with medial side with fading purplish yellowish skin discoloration above the collar bone, approximately 4-5 cm away from the trach stoma site.b. Left side of the trach - flat dark reddish scattered skin discoloration (approximately 4 cm x 3 cm) on the left side of the trach above the collar bone, approximately 5-6 cm away from the trach stoma site.c. Mid chest area, below the trach - 4-5 small, flat scattered pale reddish skin discoloration (approximate measurement - ranging from 0.1 to 1 cm) on resident's mid chest area, below the collar bone.During a review of the document titled, Specifics Regarding Condition Change (SRCC), dated 8/1, the SRCC indicated that Resident 17 acquired a skin discoloration on the right side below the trach site. No additional information about Resident 17's skin condition was documented.During a review of the document titled, Nursing Progress Notes (NPN), dated 8/10, the NPN indicated Identified a new skin discoloration on the left side of the trach and sternum. The NPN did not provide additional documentation of Resident 17's skin condition.During a review of Resident 17's photograph taken on 8/1 and 8/10, the skin discoloration on the right side of the trach site has a black-colored thread-like discoloration located on the medial aspect of the observed skin discoloration and included in the photograph was a paper ruler next to the skin discoloration, no additional information was provided in the photograph. Additionally, the photograph taken on 8/10 indicated a skin discoloration on the left side and below the trach stoma site. No additional information indicated in the photograph.During a review of the document titled, Flowsheet Summary (FS), dated from 8/1 to 8/11, the FS indicated a documentation of Resident 17's location of the skin condition. No further information regarding the assessment or evaluation of Resident 17's skin was provided in the flowsheet.During an interview on 8/10, at 11:48 a.m. with Licensed Vocational Nurse (LN 1), LN 1 verbalized that the right-side skin discoloration was observed on 8/1, and the left side and mid chest area skin discoloration was observed today during trach dressing change after resident's shower.During an interview on 8/11, at 5:46 p.m. with Registered Nurse (RN 2), RN 2 acknowledged assessing Resident 17's skin and documented the assessment by taking a photograph of an elongated skin discoloration located on the right side below the trach site, measuring 4 cm in length, and small amount of dry blood, confirming a break in Resident 17's skin. RN 2 further acknowledged that, apart from the length noted in the photograph taken on 8/1, there was no additional documentation regarding Resident 17's skin condition. RN 2 admitted that more comprehensive details about Resident 17's skin status could have been documented but was not.During a concurrent interview and record review on 8/12, at 3:20 p.m. with RN 3, Resident 17's photograph taken dated 8/1 and 8/10, SRCC dated 8/1, NPN dated 8/10 and SF dated 8/1 to 8/11. RN 3 acknowledged the lack of comprehensive assessment and accurate details of information on Resident 17's skin condition.During an interview on 8/13, at 2:21 p.m. with the Director of Nursing (DON), the DON acknowledged that standards of practice and importance of proper documentation regarding Resident 17's skin condition must be comprehensive, descriptive, and detailed. Furthermore, the documentation should accurately reflect Resident 17's skin condition at each assessment, ensuring that all relevant findings are recorded and clearly presented in the resident's clinical record.

Based on observation, interview and record review, the facility failed to ensure comprehensive person-centered care plans (plan of care) were implemented for four of four sampled residents (Resident 17, 20, 31 & 50) when care plans for Resident 17's skin condition and Resident 20's pain did not include resident-specific, measurable interventions, objectives, and timeframes that were regularly updated. Resident 31 and 50 did not have active mobility-related care plans and Resident 50 did not have an active infection-related care plan. These failures placed Resident 17 at an increased risk for additional skin breakdown, Resident 20 at risk for unmanaged pain, Resident 31 and 50 at risk for worsening mobility conditions and left Resident 50 without a tailored plan of care to address prevention of sepsis re-hospitalization, potentially compromising Resident 17, 20, 31 and 50's well-being and recovery.During Resident 17's observation on 8/10, at 11:40 a.m. inside room [ROOM NUMBER]-02, the following skin condition was observed: a. Right side of the trach (a surgical hole made through the front of the neck for breathing) – a u-shaped flat dark reddish skin discoloration (approximately 2.5 centimeters (cm) x 2 cm) with medial side with fading purplish yellowish skin discoloration above the collar bone, approximately 4-5 cm away from the trach stoma site. b. Left side of the trach – flat dark reddish scattered skin discoloration (approximately 4 cm x 3 cm) on the left side of the trach above the collar bone, approximately 5-6 cm away from the trach stoma site. c. Mid chest area, below the trach - 4-5 small, flat scattered pale reddish skin discoloration (approximate measurement - ranging from 0.1 to 1 cm) on resident's mid chest area, below the collar bone. During a review of Resident 17's Physician's order (PO), dated 8/1, the PO indicated to apply abdominal pad to skin discoloration on the right side below the trach site and to monitor and notify the doctor (MD) if worsen. Further review of the PO dated 8/4, the PO indicated to apply foam pad dressing to collar bone every three days and PRN (as needed) for protection. During a review of Resident care plan (plan of care), dated 8/1 and 8/10, the care plan interventions, dated 8/1, indicated to apply an abdominal pad to affected site (skin discoloration). No further updates or additional planned interventions were found within the care plan for either date. During a concurrent record review and interview on 8/13, at 2:21 p.m. with the Director of Nursing (DON), Resident 17's skin condition care plan for 8/1 and 8/10 were reviewed. The DON confirmed the presence of skin discoloration on both the right and left sides of the trach as well as below the trach site on the mid sternum area. The DON further confirmed that the initial plan of care involved applying an abdominal pad to the right side of the trach, but this approach was subsequently changed to the application of a foam pad. Resident 17 was referred to wound care nurse and the MD to further assessment Resident 17's skin condition, ongoing monitoring for changes and reporting to the MD as needed. Additionally, the respiratory support was adjusted from a trach mask to a T piece. The DON acknowledged that the care plan was not person-centered, was not updated and did not accurately reflect the intended interventions Resident' 17's skin condition. During review of clinical records for both Resident 31 and 50 on 8/12/26 at 11:48 AM, care plans specific to positioning or mobility (a patient's ability to move or change positions independently or with help) to address resident contractures (a permanent tightening of muscles and tendons that stops or limits joints from moving normally) were not found. Care Plan for Resident 31 titled, ADL Function Rehab addressing some poisitioning and movement therapy found initiated on 4/23/23. Last update on 1/22/26 done to add Bilateral Palm protector as ordered. Interventions listed were not patient specific and did not include goals with timeframes. During review of care plans on 8/12/26 at 11:48 AM for Resident 50, an updated care plan related to infection prevention to address Resident 50's most recent hospitalization for sepsis (the body's extreme and life-threatening reaction to an infection), was not found. During concurrent interview and Record review 8/12/26 at 2:55PM, with the Minimum Data Set Coordinator (MDS), the Pain care plan for Resident 20 was reviewed. MDS coordinator acknowledged that the initiation date of 9/27/23 and last update date of 12/16/25 for the care plan were correct. MDS acknowledged there were no patient-specific interventions, goals and outcomes with timeframes within Resident 20's Pain care plan. The MDS stated that care plans are initiated by the MDS coordinator and registered nurses during different admission processes. Modifications and/or updates to care plans are completed primarily by the MDS only when there are new physician orders, a significant change in resident status and as needed following interdisciplinary meetings. MDS stated that goals and timeframes are not entered when care plans are initiated or modified and regular review of care plans for all residents is not practiced. During a review of the facilities policy and procedure (P&P) titled., Comprehensive Person Centered Care Plan: Sub Acute Unit, revised 2/00, the P&P indicated, PROCEDURE:.3. Establish both long term and short term goals for residents. They must be specific, measurable and realistic. Include objectives as appropriate to the goals and indicate a time frame for them to be met. 4. Establish and document the interventions that will be used to accomplish the goals for the resident. All disciplines providing care, treatment or services are involved in the creation and maintenance of the resident plan of care. During an interview with the Director of Nursing (DON) on 8/13/26 at 2:54 PM, DON acknowledged that care plans initated per individual resident are not consistently person-centered, there are no goals set with timeframes. and care plans are not regularly maintained.

Based on observation, interview, and record review, the facility failed to ensure a safe, functional, and comfortable environment for 1 out of 23 sampled residents (Resident 36). When an extension cord with six sockets was mounted on the right upper side rail, approximately 12 inches from Resident 36's head while lying in bed. This failure creates an unsafe environment for the resident. Findings: During an observation on 4/7/26 at 10:09 a.m., in room W222-01, Resident was seen lying in bed with a blue extension cord with six sockets mounted on the right upper side rail, approximately 12 inches from Resident 36's head. Four bulky adapter devices were plugged into the extension cord, and the cord's power indicator light was lit, indicating that it was active. During a concurrent observation and interview on 4/7/25 at 11:00 a.m. with Maintenance (MT) in Residents 36's room, MT stated that the blue extension cord is used for medical equipment and not intended for the resident's personal use. MT further stated that no extension cord should be mounted on the side rail, as it poses electrical and fire hazards. During an interview on 4/7/25 at 11:05 a.m. with Registered Nurse (RN) 1, RN 1 stated that the blue extension cord should not be mounted on the upper side rails due to safety concerns and said she would inform Resident 36's nurse to remove the extension cord. During a review of the facility's policy and procedure (P&P) titled, Extension Cords, dated 11/21/95, the P&P indicated, .extension cords shall not be used: as a substitute for fixed wiring .where attached to building surfaces.

The facility failed to ensure medication is correctly labelled according to the physician's order and was sent to the pharmacy when medication discrepancy is found for 1 of 3 unsampled residents (Resident 64). This failure had the potential to result in a medication administration error. Findings: During a review of Resident 64's Physician Progress Notes (PPN), dated 4/7/25, the PPN indicated, Resident 64 had a diagnosis of Diabetes (a condition where the body cannot regulate blood sugar properly). Complicated by Retinoplathy (any disease of the retina, the light-sensitive tissue at the back of the eye). During a review of Resident 64's Active Order Profile (AOP), dated 4/4/25, the AOP indicated, Resident 64 is to receive 25 Units (unit of measurement) subcutaneously injection BID. During the medication observation on 4/4/25, at 8:00 a.m. with the Licensed Vocational Nurse (LN 1), LN 1 picked up the bottle of Insulin (a medication that helps to process sugar from food to energy) inside the medication cart, and then read the eMAR (electronic Medication Administration Record). The insulin bottle packaging instruction indicated, 28 units subcutaneous injection ( fatty tissue underneath the skin) at bedtime. On the other hand, the eMAR indicated, 25 units subcutaneous BID (twice a day). Another Licensed Nurse (LN 2) was called to verify the physician's order and the insulin bottle packaging instructions for Resident 64 with LN 1. And both confirmed and agreed that Resident 64 had an incorrect insulin packaging instruction and instructed LN 1 to inform the pharmacy. During an interview on 4/8/25, at 9:30 a.m. with the Registered Nurse (RN 2), the RN 2 verbalized, that the assigned nurse were responsible with informing the pharmacy when inaccurate or a discrepancy in the eMAR with medication on hand was detected. Once the pharmacy is informed, the medication is sent to the pharmacy for repackaging or the medication can be re-ordered with the correct label. During a concurrent record review and interview on 4/9/25 at 11:56 a.m. with RN 2, Resident' 64's electronic Active Order Profile was reviewed, indicated Resident 64's order for 28 units of Lantus/Glargine insulin (type of insulin) started on 3/17/25, was changed to 30 units on 3/26/25, 35 units on 3/29/25, and 25 units on 4/4/25. RN 2 acknowledged that the insulin order had been changed several times and the pharmacy must be informed. RN 2 further acknowledged the medication discrepancy and was unable to provide proof of documentation that pharmacy had been informed of the discrepancy between the eMAR and the packaging instruction on the bottle of insulin medication. During an interview on 4/9/25, at 2:10 p.m. with the Case Manager (CM 2), CM 2 acknowledged acknowledged and verbalized that the medication must be sent to the pharmacy for repackaging to reflect current physician's insulin order. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 9/2000, the P&P indicated in part, 7. If there is a discrepancy between the eMAR and the label or medication packaging, check the physician's order before administering the medication. a. If the label is wrong or missing a bar code, send the medication to the pharmacy for re-labelling or repackaging. b. If there is a change of direction and medication can still be used, send the medication to the pharmacy for re-labelling or repackaging.

Based on interview and record review, the facility staff failed to ensure the Physician was notified of a Weight variance of five pounds or more for 1 of 23 sampled residents (Resident 25's) when the weight record was examined and noted that the resident experienced a significant 14 percent weight loss in less than two months. This failure resulted in a delay in the need to alter treatment significantly to Resident 25. Findings: During a review of Resident 25's Admission Record (AR), dated 4/7/25, the AR indicated, Resident 25 was admitted on [DATE] with diagnoses that includes Amyotrophic Lateral Sclerosis (progressive disease that causes muscle weakness and paralysis), Quadriplegia ( paralysis that affects all a person's limbs and body from the neck down), and Ileus (intestine can't push food and waste out of your body). During a review of Resident 25's Weight Record, the weight record indicated, on 2/24/25, Resident 25's weight was recorded as 69 kilograms. The resident refused to be weighed in March, and on 4/2/25, Resident 25's weight was recorded as 59.9 kilograms. During a concurrent interview and record review on 4/9/25 at 2:20 p.m. with Registered Dietitian (RD1), the weight record was examined. RD1 calculated the difference between Resident 25's recorded weights on 2/24/25 and 4/2/25 and noted that the resident experienced a significant 14 percent weight loss in less than two months. RD1 further stated that the weight loss had not been previously identified. During a concurrent interview and record review on 4/9/25 at 3:05 p.m. with Nurse Informatics (NI), the nursing daily progress note for Resident 25 was reviewed. NI confirmed that there was no documentation indicating that the doctor had been notified regarding the resident's weight loss. During an interview on 4/9/25 at 4:20 p.m. with Registered Nurse (RN 2), the RN 2 stated that it is their practice to notify the doctor about significant weight loss in residents. During an interview on 4/10/25 at 10:00 a.m. with the Case Manager (CM) 2, the CM 2 acknowledged that the doctor should have been notified immediately regarding Resident 25's weight loss. During a review of the facility's policy and procedure (P&P) titled, Resident Height and Weight Monitoring, Sub-Acute Care Unit, dated 10/2023, the P&P indicated, Weight variance of five pounds or more will be communicated to the physician and registered dietician for further review and subsequent evaluation will be documented as warranted.

Based on observation, interview, and record review the facility failed to ensure care plan interventions were implemented for one of 23 sampled residents (Resident 25). This failure had the potential to result in Resident 25 needs not being met. Findings: During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person Centered Care Plan, dated 3/2025, the P&P indicated, Discipline providing care, treatment or services to the residents are required to review and contribute to the resident's care plan . the comprehensive person centered care plan will address: the services that are to be furnished to attain or maintain the residents highest practicable physical, mental and psychosocial well-being. During a review of Resident 25's Admission Record (AR), dated 4/7/25, the AR indicated, Resident 25 was admitted in Long Term Care (LTC) on 2/24/25 with diagnoses including but not limited to, Amyotrophic Lateral Sclerosis (progressive disease that causes muscle weakness and paralysis), quadriplegia ( paralysis that affects all a person's limbs and body from the neck down), and ileus (intestine unable to move food and waste effectively). During a review of Resident 25's Facility Order Summary Report, dated 4/7/25, the Order Summary indicated, an order dated 2/24/25 for Resident 25 to be weight monthly. During a review of Resident 25's Weight Record, the weight record indicated, on 2/24/25, Resident 25's weight was recorded as 69 kilograms. The resident refused to be weighed in March, and on 4/2/25, Resident 25's weight was recorded as 59.9 kilograms. During a review of Resident 25's Care Plan (CP), titled Enteral Feeding (delivering nutrition directly into the stomach or small intestine through a tube) included an outcome to monitor for weight change more than 5% in 1 month and listed an intervention to consult a dietitian for caloric intake needs, as needed. During a concurrent interview and record review on 4/9/25 at 2:20 p.m. with Registered Dietitian (RD1), Resident 25's weight record was reviewed. RD1 calculated the difference between Resident 25's weight on 2/24/25 and 4/2/25 and stated that the resident experienced a significant 14 percent weight loss in less than two months. RD1 further stated that no action had been taken regarding the resident's current weight, as they were not aware of it.

Based on observation, interview, and record review, the facility failed to maintain patient care equipment in safe operating condition when a residue build up was found inside of the ice machine panels. This failure had the potential for residents to Waterborne diseases (illnesses caused by consuming contaminated water). Findings: During a concurrent observation on 04/08/25 at 11:20 a.m. with the kitchen manager (KM), inspection of the ice machine was done and a pink residue and dark streaks of residue was observed in the panels of the ice machine using the white paper towel. The KM acknowledged and stated that there should be no residue found on panels. During a concurrent observation and interview on 04/08/25 at 02:25 p.m. with the Facility Maintenance Director ([NAME]), [NAME] acknowledged residue and stated that the filter needed to be changed. During a review of the facility's policy and procedure titled, Ice Machine Preventative Maintenance Procedure, undated, the policy and procedure indicated the facility has established procedures for Ice machine cleaning and sanitizing, check and clean (sanitize) ice an water dispenser for proper operation and check filter date and replace every 6 months at a minimum or sooner depending on usage.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident 1) was not exposed to pathogens carried by flies resulting to formation of maggots (the larvae of flies that are typically found in decaying organic matter). Maggots were found in the tracheostomy (an opening in the neck and into the windpipe to help a person breathe) site of the resident . This failure placed Resident 1 at risk for parasitic infection (Myiasis). Findings: During a review of Resident 1 ' s history and Physical (H/P) dated 09/22/21 indicated, an admitted [DATE], with diagnosis that included past medical history (PMH) of coronary artery disease (CAD), Type 2 diabetes mellitus (DMII) and Depression (symptoms that affect how a person feels, thinks, and handles daily activities) who was initially admitted to Surgical Assessment Unit (SAU) Status Post S/P left (Middle Cerebral Artery) (MCA) infarct with resultant expressive Aphasia (Loss of ability to understand or express speech) and Right Hemiplegia (paralysis of the right side of the body after injury to the brain or spinal cord) S/P trach (inserted through the hole and secured in place with a strap around your neck) and PEG placement (is a feeding tube surgically placed through your abdomen into your stomach.) During a review of a Physician Note (PN) dated 8/23/24 for Resident 1, the PN indicated, During a tracheostomy change on 8/22/24, noted to have 5 large (sic larvae- a wormlike form that hatches from the egg of insects) removed during wound care; local wound care measures now include hydrogen peroxide for 7 days and has also been started on ivermectin (a medication used to treat parasitic worms). During an interview and concurrent observation with the Director of Nursing (DON) 8/26/24 at 1:00 pm., the DON indicated, that as soon as the infestation was noted on Resident 1, this was immediately communicated to nurses with consultation with the attending physician , with orders for the treament of Myiasis).No fly infestations were observed in the facility . During a review of Policies and Procedures (P&P) titled Infection Prevention and Control Plan dated 2024, the P&P indicated, C. Address prioritized risk, limit unprotected exposure to pathogens, limit transmission of infections associated with procedures and the use of medical equipment, devices, and supplies. During an interview on 8/26/24 at 2:15 pm., with Respiratory Therapist (RT1), RT1 verbalized that tracheostomy care (TC) and change of equipment are performed every shift and there is no issues with supplies used to do the TC. During an interview on 8/26/24 at 2:40 pm., with Charge Nurse (LN1) LN1 indicated that dressing changes were also done by the nurses when needed, after the routine TC. LN1 indicated the maggots on Resident 1's tracheostomy site is just recent.

Based on interview and record review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for one of three residents (Resident 1). This failure had the potential for further abuse to occur to residents. Findings: During a review of Resident 1's History and Physical (H&P), dated June 29, 2024, the H&P indicated the following diagnoses: atrial fibrillation (irregular and fast heart rhythm), cancer at base of tongue, metastatic (spreads to other areas) squamous cell carcinoma (cancer that starts on skin surface) to head and neck, palliative care (specialized medical care for people with incurable illness), percutaneous endoscopic gastrostomy tube (a tube to allow a person to get nutrition through the stomach), trismus (mouth remains tightly closed). During a review of Resident 1's Nursing Progress Note (NPN), dated 7/12/24 at 11:00 p.m., the NPN indicated, in part, Patient reported to nurse during rounds that (Resident 1) feels everyone here hates (Resident 1), and (Resident 1) feels (Resident 1) does not deserve to be treated that way, but (Resident 1) did not want to mention any names. I did let patient know that I would be reporting this to my charge nurse . During a review of Resident 1's Nursing Progress Note (NPN), dated 7/12/24 at 11:30 p.m., the NPN indicated, in part, Patient verbalized, ' I'm going to die soon probably in less than 3 months and I don't want to die feeling like everyone hates me .' The NPN further indicated law enforcement, the ombudsman, California Department of Public Health (CDPH), Adult Protective Services (APS), Director of Sub-Acute (DSU) and Licensed Nurse (LN 9) were all notified. During a telephone interview on 8/1/24 at 1:10 p.m. with the Director of Sub-Acute (DSU), the DSU was asked if the 5 day report was completed. The DSU stated, Who does that? During review of an email correspondence with the DSU on 8/1/24 at 3:42 p.m., the email from DSU indicated, There was never a 5 day investigative report sent from quality, legal and reporting because it was not considered an abuse case. During a review of the facility's policy and procedure (P&P) titled, Prevention of abuse, Neglect and Exploitation of Residents Sub-Acute Facility, revised date 3/28/24, the P&P indicated, in part, Report the results of all investigations in writing to the administrator or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency within 5 working days of the incident . and The Quality and Risk Management Department will submit the 5 day report to the State Department (CDPH) .

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions within the food service operation when: 1. A nutrition assistant (NA 1) removed dirty gloves after handling dirty dishes, and put on a new pair of gloves, without washing her hands. 2. The high temperature dish machine manufacturer's guidelines were not followed. 3. Posted manufacturer's guidelines for contact time of food service equipment immersed in the sanitizer solution at the three (3) compartment sink was not followed. Failure to ensure proper hand washing and implementing manufacturer's guidelines for cleaning and sanitizing of the dishes had the potential to place five of 70 residents (Residents 52, 58, 61, 1, and 3) who received food from the kitchen at an increased risk of a foodborne illness. Findings: 1. During a concurrent observation and interview on 03/05/24 at 2:31 p.m. with Nutrition Assistant (NA) 2 in the kitchen, in the presence of the Certified Dietary Manager (CDM), NA 2 was wearing gloves while scraping dirty dishes and to move a large garbage bin closer to the high temperature dish machine area. Next, NA 2 was observed to remove her gloves and proceeded to put on a new (clean) pair of gloves that were in a box on the clean side of the high temperature dish machine, without washing her hands. NA 2 stated she did not was her hands after removing her dirty gloves and should have washed her hands prior to putting on a new pair of gloves. CDM verified NA 2 had not washed her hands after removing her dirty gloves, and CDM stated she should have washed her hands prior to putting on a new, clean pair of gloves. During a review of the facility's policy and procedure (P&P) titled, IC [Infection Control]129:FNS [Food & Nutrition Services] Hand Washing, dated 2019, the P&P indicated, 1. Alcohol-based sanitizer can be used when no visible soiling. This is appropriate when staff returns to the department or before or after using gloves. FNS staff must use soap and water when in FNS department .4. Wash hands after smoking, drinking, eating, using bathroom, handling money, soiled glad or dinnerware, garbage, mops, sneezing. 2. During a concurrent observation and interview on 03/05/24 at 2:35 p.m. with NA 1 in the kitchen, in the presence of the Certified Dietary Manager (CDM), NA 1 was observed loading the high temperature (temp) dish machine with dirty dishes from the lunch meal for residents. NA 1 observed the wash water temperature that digitally displayed on the monitor affixed to the outside of the high temp dish machine, and NA 1 stated it was 156 degrees F (Fahrenheit). NA 1 continued to monitor the digital thermometer reading display for the final rinse cycle, and NA 1 stated, the final rinse cycle was over 180 degrees F. NA 1 ran a thermocromatic (property of substances to change color due to a change in temperature) color-change band through the high temp dish machine which was observed to turn orange which was a method to ensure the dishes final rinse cycle reached 180 degrees F for sanitizing the dishes. During a review of the manufacturer's data plate affixed to the high temp dish machine, the data plate indicated, Hot Water Sanitizing; Wash Temp 160 degrees F Min [minimum], Final Rinse Temp 180 degrees F Min, 194 degrees Max [maximum]. During a concurrent interview and record review on 3/5/24 at 2:44 p.m. with CDM, the CDM showed a binder that was on a shelf in the dish machine room that contained directions to dietary staff and a monitoring log for the high temp dish machine that was reviewed. The directions indicated, The 'Dish Machine Temperature Log' is used to record the water temperatures of the wash, rinse, and final rinse cycles of the dish machine. You will find the temperatures measured by the machine on the display at the front of the dish machine. All three temperatures (wash, rinse, and final rinse) must be recorded and within range before use. Temperatures must be checked three times a day: before breakfast items are washed, before lunch items are washed, before dinner items are washed. Steps: To record the temperatures from the display, start machine and run for a few minutes before looking at the display. Record the wash, rinse, and final rinse temps noted on the display onto the 'Dish Machine Temperature Log.' Check to see if temps are within the appropriate range as follows: WASH temp must be between 110 degrees F - 140 degrees F, RINSE temp must be between 150 degrees F - 165 degrees F, FINAL RINSE temp must be between 180 degrees F - 200 degrees F .CORRECTIVE ACTION: If temps on the display are out of range, start booster heater and allow machine to run a few minutes. Re-check the display .If temps remain below goal, notify manager and take the equipment out of service. Submit a work order for repair. Wash and sanitize all items in the three-compartment sink until the machine is repaired. CDM reviewed the Dish Machine Temperature Log, dated 3/5/24 for lunch that indicated, wash 129 [degrees F], rinse 157 [degrees F] and final 185 [degrees F] initialed by NA 1. CDM stated the directions to staff located in the binder and the directions located on the dish machine temperature log contained incorrect directions. CDM stated the high temperature dish machine manufacturer's guidelines should have been followed and were not. During a concurrent interview and record review on 3/6/24 at 10:24 a.m. with CDM, Patient Services Manager (PSM) and Director of Nutrition Services (DNS), the high temp dish machine logs from December 2023 to current (3/5/24) were reviewed. CDM stated, the high temp dish machine logs were not correct daily for the logs reviewed. DNS stated it was her role as a Registered Dietitian (RD) to provide frequently scheduled consultation to the CDM to include oversight over system operations within the food service department. DNS stated the facility does conduct monthly QI (quality improvement) inspections within food service operations that included food safety and sanitation. DNS stated the incorrect directions and out of range temperatures recorded daily on the high temp dish machine log, during the review period of December 2023 to current, was missed. During a review of the facility's policy and procedure (P&P) titled, IC [infection control]137: FNS [Food & Nutrition Services] Dish Machine Documentation of Temperatures, dated 2019, the P&P indicated, Steps; 1. Dish machine wash and rinse temps must be maintained based on manufacturer's guidelines. Dish machines depending on model and manufacturer could have different temperature ranges. 2. Start dish machine, run for full cycle. Take temp using thermometer or test strip while running wash cycle. Temperature testing should be done at the start of each meal service wash cycle. 3. Document temperature. Reconcile temperatures out of range. Ensure staff is in-serviced on how to address out-of-range temperatures. 4. Rerun test strip or thermometer through cycle, if temp out of range report to supervisor. 5. Stop using dish machine if out of range. Call for service. Wash dishes in pot sink or use paper products until machine in service . During a review of the FDA (Food & Drug Administration) Food Code Annex (FDAFC), dated 2022, the FDAFC indicated, The data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The warewashing machine has been tested , and the information on the data plate represents the parameters that ensure effective operation and sanitization and that need to be monitored. (FDA Food Code Annex 3, 4-204.113 Warewashing Machine, Data Plate Operating Specifications.) During a review of the FDAFC, dated 2022, the FDAFC indicated, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. (FDA Food Code Annex 3, 4-501.15 Warewashing Machines) During a review of the facility's job description for Director of Nutrition Services (JDDNS), (undated), the JDDNS indicated, Job Summary: Plans, administers and directs all location activities related to food service including financial accountability, compliance with standards established by the [name of corporation] and regulatory agencies. Leads food and nutrition services departments Has authority and delegated responsibility including, the daily management of the food services, implementing training programs for dietary staff and assuring that established polices and procedures are maintained. 3. During an observation on 3/0/24 at 2:45 p.m. in the kitchen, NA 3 was observed utilizing the three (3) compartment sink to wash cooking equipment used inside the kitchen. NA 3 was observed placing containers from the rinse water into the sanitizer solution in the third compartment of the 3-compartment sink for twenty-five seconds as counted by the second hand located on a large clock on the wall at the 3-compartment sink area. After 25 seconds, NA 3 removed the cooking equipment (containers) from the sanitizer solution and placed them on a rack to air dry to be available for use. During an interview on 3/5/24 at 2:49 p.m. with NA 3, in the presence of the Certified Dietary Manager (CDM), NA 3 stated he was trained to keep the dishes/containers in the sanitizer solution for one minute. NA 3 was asked if he had kept the food containers that he had just removed from the sanitizer compartment in the sanitizer for one minute, and NA 3 stated, No, I was in a hurry. CDM stated the expectation was immersion of dishes/containers in the sanitizer solution of the third compartment of the 3-compartment sink for one minute to effectively sanitize. During a review of a poster labeled with the manufacturer's name of the sanitizer in use, the poster titled, Three Compartment Sink Set-Up, indicated, Sanitize one minute. During a review of the facility's directions to staff located in a binder near the 3-compartment sink, the directions indicated, To manually wash and sanitize equipment and dishes, we use a three-compartment sink method. The first sink is used for washing, the second for rinsing, and the third for sanitizing . During a review of the facility's policy and procedure (P&P) titled, IC [Infection Control] 136: FNS [Food & Nutrition Services] Sanitation Food Contact Surfaces, dated 2019, the P&P indicated, Steps; 1. Sanitizing solutions are used to clean all work areas based on manufacturer recommendation.

Based on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 62), had their head of bed (HOB) elevated to 30 degrees or greater per physician order, due to being on a ventilator by a tracheostomy. This failure had the potential to result in respiratory distress. Findings: During a review of Resident 62's MDS (The Minimum Data Set is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) which indicated, Resident 62 had diagnoses including, limited range of motion, tracheostomy (surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing) and connected to a ventilator (breathing machine that helps keep your lungs working). During a concurrent observation and interview on 3/4/24 at 4:14 PM with Licensed Nurse 1 (LN 1), in Resident 62's room, Resident 62 was observed with HOB at approximately 10 degrees. LN 1 stated HOB was less than 30 degrees and should be at 30 degrees. During a concurrent interview and record review on 3/6/24 at 2:55 PM with Registered Nurse (RN 2), Resident 62's Physician Order, dated 10/9/23, and Care Plan, dated 10/10/23, were reviewed. The order indicated, Elevate Head of Bed, greater than 30 degrees. The Care Plan indicated, Elevate Head of Bed as Ordered. RN 2 confirmed the HOB should be elevated 30 degrees at all times and at times it wasn't.

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 72) had an accurate Minimum Data Set ((MDS) a standardized assessment tool designed to identify potential problems). This failure resulted in Resident 72 not having a care plan ((CP) a tool that outlines the interventions (actions) to be taken to meet the resident's needs) developed for their discharge goal of returning home. Findings: During a review of Resident 72's admission MDS, Section Q, dated 11/14/23, the MDS indicated, neither Resident 72 nor his spouse participated in the assessment and Resident 72's goal was to remain in the facility. During a review of Resident 72's Resident Care Team Meeting, Social Work Review (CTM), dated 11/16/23 at 11:30 a.m., the CTM indicated, Patient is a [AGE] year old, English speaking married male. Patient was transferred from [hospital name] on 11/08/2023 for deconditioning [decreased strength and/or balance] due to sepsis [the body's extreme response to an infection], osteomyelitis [inflammation of bone] left hip . The patient is looking forward to returning home . Prior to being admitted he was independent with ADL's [activities of daily living such as dressing, bathing, ambulating] and was driving, he did not use any DME's [durable medical equipment such as walker, wheel chair, cane] . Social Worker will provide counseling as appropriate to patient and family, encourage participation in IDT to help family reflect on progress and needs, and provide community resources and referrals as needed. During a concurrent interview and record review on 3/7/24 at 10:05 a.m. with a licensed nurse (MDS-C), Resident 72's MDS dated [DATE] and CTM dated 11/16/23 were reviewed. MDS-C stated the MDS and CTM Don't match. MDS-C further stated there was no discharge care plan for Resident 72 and there should have been one. MDS-C additionally agreed if the MDS accurately reflected Resident 72's discharge goal of wanting to return home then it would have triggered the care plan to be developed. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Resident/Patient-Subacute Care, dated 8/20, the P&P indicated, PURPOSE: To identify resident/patient care needs and develop a care plan that indicates the care to be given, the goals desired and the approach to achieve these goals within an acceptable time frame. According to Fundamentals of Nursing ([NAME] et al.; Elsevier: 2017, p. 66), The long-term care setting includes skilled nursing facilities . Individual state regulations, TJC [The Joint Commission], and The CMS [Centers for Medicare and Medicaid Services] govern documentation requirements in these facilities. The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA), is the data set that is federally mandated for use in long-term care facilities by CMS. Compliance with state and federal requirements and reimbursement for care provided in a long-term care facility depend on accurate completion of the required documentation to justify the care provided .

Based on interview and record review, the facility failed to report to the California Department of Public Health (CDPH) a bruise on the forearm of unknown origin and allegation of abuse for one of one resident (Resident 22).within 2 hours of discovery. This failure had the potential to delay investigation and affect physical and psychosocial well-being of the resident. Findings: On 2/27/24 at 5:30 p.m., CDPH received a facsimile (FAX) letter from Quality Assurance (QA). The letter was to inform CDPH of bruising identified on Resident 22's forearm noted on 2/26/24 at 11:20 p.m. Initial interviews were completed, unable to identify contributing cause to bruising. During a review of Resident 22's Nursing Progress Note, dated 2/26/24, the Nursing Progress Note indicated, . discoloration on her left forearm just below left AC (Antecubital, the space inside the crook of the elbow), . asked her if somebody hit her and she nod yes. During an interview on 3/6/24 at 3:48 p.m. with QA, QA confirmed the mandated report of injury/allegation of abuse was not reported to CDPH within 2 hours of knowing of alleged incident. During a review of facility's policy and procedure (P&P) titled, Abuse-Reporting, dated 8/2014, the P&P indicated, The case is reported to the CDPH and to local law enforcement services as an alleged abuse within 24 hours . unless there has been serious bodily injury or if the case involves sexual abuse. If either of these two elements are present, the case must be reported to CDPH and local law enforcement within two hours.

The facility failed to maintain the infection control program when staff left an unflushed suction catheter (a tube used to clear the airway by removing secretions from the oropharynx with the aid of a rigid suction tip) resulting in secretions dripped on top of the nightstand for one of six residents (Resident 50) with a tracheostomy tube. This failure placed Resident 50 at risk for the spread of healthcare-associated infection. Findings: During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Plan, dated 4/06, the P&P indicated, VI. Prevention Strategies A. The Infection Prevention and Control Program includes prevention strategies, including but not limited to: . 2. Cleaning, disinfection (process to remove microorganisms by liquid chemicals) and sterilization (a process to destroy microorganism with the use of heat, radiation or chemical agent) . 6. Compliance to Infection Prevention and Control Program. During a review of the P&P titled, Use of Closed System Suction Apparatus, dated 6/14, the P&P indicated, Equipment Suction source, 1. wall or portable. 2. Sterile saline for irrigation - 3 cc vials .in part . Procedure 8. Use normal saline vial to flush catheter by initiating suction and then introducing solution slowly . Rationale/Precautions: Normal Saline will clear secretions from catheter. During a review of Resident 50's Physician Progress Notes (PPN), dated 3/24, the PPN indicated, Resident 50 had a diagnosis of Chronic Respiratory Failure and was dependent on tracheostomy (an opening to the trachea to help with breathing). During an observation on 3/4/24 at 11:44 a.m. in the second level nursing floor, there was a drip of clear liquid on top of Resident 50's nightstand just directly above the end of the used suction catheter that was filled with white frothy sputum (mucus). During an interview on 3/4/24 at 11:50 a.m. with Registered Nurse 1 (RN 1), RN 1 verbalized that suction catheters must be flushed with normal saline solution after each use to clear the catheter from secretions. RN 1 further verbalized the table must also be cleansed and disinfected. RN 1 acknowledged the suction catheter was not flushed, and Resident 50's nightstand was not cleaned and disinfected.

Based on observation, interview and record review the facility failed to develop individualized care plans for 2 of 18 sampled residents (Residents 34 and 63): 1. For Resident 34, the facility failed to develop an individualized care plan that reflected specific target weight range with measurable goals and timeframe's, and failed to update and revise the care plan when there were changes to the tube feeding (providing nutrition through a tube to the stomach) order. 2. For Resident 63, the facility failed to develop an individualized care plan for a resident with a urinary catheter. This failure resulted in lack of individualized care plans that reflected specific care and measurable goals which impedes the IDT (interdisciplinary team) from effectively monitoring, evaluating and revising the care plan, as appropriate, to ensure care needs would not go unrecognized and unmet. Findings: 1. During an observation on 3/4/23 at 12:50 p.m. in Resident 34's room, Resident 34's tube feeding pump was observed to be providing Glucerna (formula to provide nutrition and help manage blood sugar) 1.2 calories per milliliter (a metric unit to measure capacity) at 60 milliliter per hour for 22 hours a day. During a concurrent interview and record review on 3/5/24 at 10:11 a.m. with Patient Services Manager(PSM)/ Registered Dietitian (RD), Resident 34's Nutrition Services Assessment (NSA), dated 1/10/2024, was reviewed. The NSA indicated, Ideal Body Weight: 79.52 kg (kilograms which is = to 175 pounds [lbs]), IBW (ideal body weight) range, 160 - 196 lbs. The NSA documented Resident 34's weight history as: Weights (lb): 3/9/21 - 162, 3/9/22 - 180, 1/11/23 - 197, 2/9/23 - 192, 3/8/23 - 188, 4/18/23 - 194, 5/11/23 - 180, 6/7/23 - 180, 7/5/23 - 172, 8/9/23 - 167, 9/14/23 - 163, 10/4/23 - 160, 11/1/23 - 161, 12/6/23 - 168, 1/3/24 - 157 lbs .Usual Weight: 73.64 kg (162 lbs). PSM stated Resident 34 previously had an unplanned weight gain, then recently had a planned weight loss to get him back to his usual body weight of 162 lbs. During a concurrent interview and record review on 3/4/23 at 10:35 a.m. with PSM, Resident 34's interdisciplinary (IDT) nutritional status care plan (IDTNCP), last updated on 4/23/23, was reviewed. PSM stated the IDTNCP indicated, Will maintain target weight range. PSM stated the target weight range for Resident 34 was anywhere between 160 - 178 lbs. PSM acknowledged the IDTNCP had not listed Resident 34's individual, specific target weight range on the IDTNCP for clear communication amongst the IDT. PSM stated she would need to find out whose role it was to document on the IDT nutrition care plan. During an interview on 3/5/24 at 11:08 a.m. with Nurse Manager (NM), NM stated it was the MDS [minimum data set] Coordinator role to initiate IDT care plans, and after that nursing can update and revise the care plans as needed. NM reviewed Resident 34's IDTNCP and NM stated he did not know what Resident 34's target weight range was by reviewing the IDTNCP since it was not specific. During a concurrent interview and record review on 3/5/24 at 11:17 a.m. with MDS [minimum data set] coordinator (MDSC), MDSC stated MDSC was responsible for developing the initial admission baseline care plan. MDSC stated the IDTNCP should be individualized, resident specific and should be updated and revised when there was a change to a tube feeding order. MDSC reviewed Resident 34's IDTNCP, last updated on 4/23/23, and stated she did not know what Resident 34's Will maintain target weight range was as listed on the IDTNCP care plan. MDSC stated she would need to review the RDs notes to find out. Further, MDSC verified Resident IDTNCP was not updated and revised when there were changes to Resident 34's tube feeding order, and should have been. During a review of Resident 34's IDTNCP, last updated on 4/23/23, the IDTNCP indicated, Tube feeding, Ensure rate infusion meets estimated needs, Monitor I/O [input/output], Monitor weight as ordered . During a review of Resident 34's Nutrition Services Brief Note (NSBN), dated 10/11/23, the NSBN indicated, .Pt [patient] continues on Glucerna 1.2 at 50 mL/hr x 22 hrs .kcal [calories] provision below estimated needs, however was appropriate to ameliorate [to make better] previous weight gain. Now clinically significant weight loss is noted at 6 months; - 34 lbs at 6 months (17.5%). Will increase EN by 5 mL and monitor weight trends. Discussed w/family and IDT, who are in agreement with nutrition POC. RDN will continue to monitor. During a review of Resident 34's tube feeding order, dated 10/11/23, the order indicated, Glucerna 1.2, G Tube, 55, x 22 hrs . During a review of Resident 34's tube feeding order, dated 1/10/24, the order indicated, Glucerna 1.2, G Tube, 60, x 22 hrs . During a concurrent interview and record review on 03/06/24 at 11:25 a.m. with NM, NM stated Resident 34's IDTNCP was not updated and revised when there were changes in the tube feeding order, and verified Resident 34's IDTNCP was not individualized to reflect resident was on a planned weight loss after have had an unplanned significant weight gain, and lacked specific target weight range with measurable goals and timeframe's for communication of clear goals amongst the IDT in order to provide effective monitoring of the nutrition plan of care. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Resident/Patient-Subacute Care, dated 2/00, the P&P indicated, Purpose: To identify resident/patient care needs and develop a care plan that indicates the care to be given, the goals desired and the approach to achieve these goals within an acceptable time frame. Policy: . Resident's/patient's care plan will include resident/patient problems, projected patient goals, specific approaches for each discipline to accomplish projected goals, review dates and timely updates with change in resident's patient's status ., Procedure: C. Establish goals for resident/patient. Long-term goals must be re-evaluated quarterly. Short-term goals as specified when goal is established. Goals must be specific and measurable. Indicate a definite date for a goal to be met ., D. Establish the approach that will be used to accomplish the goals for the resident/patient. Involve all disciplines. Be specific ., F. Update resident/patient care plan where there is a change in the resident's/patient's condition, or when a goal has been reached, or when a review date has been met, or when an approach is ineffective and needs to be changed. Update the care plan when a goal has to be revised. Date and initial updates and reviews . 2. During a review of the facility's P&P titled, Implementation of the Comprehensive Person-Centered Care Sub-Acute, dated 1/2024, the P&P indicated, (Name of facility) will implement a comprehensive person-centered care plan for each resident that is consistent with resident rights. The comprehensive person-centered care plan will include: The services that are to be furnished to attain or maintain the resident's highest physical, mental, and psychosocial well-being as required. All disciplines will review the care plan and will implement those interventions identified to reach the goals that have been identified by the interdisciplinary team and resident/family. During an observation on 3/5/24, at 10 a.m., Resident 63 had a foley catheter connected by a tubing to a cannister attached to the wall. During a concurrent record review and interview on 3/7/24 at 11:29 a.m. with the Registered Nurse (RN 1), Resident 63's care plan for a urinary incontinence was reviewed. The care plan indicated, urinary incontinence intervention and does not specify the type of intervention for Resident 63's urinary incontinence. RN 1 acknowledged that care plan must be person centered and Resident 63's care plan does not reflect the foley catheter as the intervention for urinary incontinence. 44589

Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 72), had a care plan ((CP) a tool that outlines the interventions (actions) to be taken to meet the resident's needs) developed for their discharge goal of returning home. Findings: During a review of Resident 72's admission MDS, Section Q, dated 11/14/23, the MDS indicated, neither Resident 72 nor his spouse participated in the assessment and Resident 72's goal was to remain in the facility. During a review of Resident 72's Resident Care Team Meeting, Social Work Review (CTM), dated 11/16/23 at 11:30 a.m., the CTM indicated, Patient is a [AGE] year old, English speaking married male. Patient was transferred from [hospital name] on 11/08/2023 for deconditioning [decreased strength and/or balance] due to sepsis [the body's extreme response to an infection], osteomyelitis [inflammation of bone] left hip . The patient is looking forward to returning home . Prior to being admitted he was independent with ADL's [activities of daily living such as dressing, bathing, ambulating] and was driving, he did not use any DME's [durable medical equipment such as walker, wheel chair, cane] . Social Worker will provide counseling as appropriate to patient and family, encourage participation in IDT to help family reflect on progress and needs, and provide community resources and referrals as needed. During a concurrent interview and record review on 3/7/24 at 10:05 a.m. with a licensed nurse (MDS-C), Resident 72's MDS dated [DATE] and CTM dated 11/16/23 were reviewed. MDS-C stated the MDS and CTM Don't match. MDS-C further stated there was no discharge care plan for Resident 72 and there should have been one. MDS-C additionally agreed if the MDS accurately reflected Resident 72's discharge goal of wanting to return home then it would have triggered the care plan to be developed. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Resident/Patient-Subacute Care, dated 8/20, the P&P indicated, PURPOSE: To identify resident/patient care needs and develop a care plan that indicates the care to be given, the goals desired and the approach to achieve these goals within an acceptable time frame.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 3 sampled residents (Resident 1), who had a treatment consisting of ear irrigation for ear wax removal and the facility did not document the resident's response to treatment. This failure had the potential to result in complications in the resident's care as it was unknown if the outcome was desired or further intervention was required. Findings: During a review of the facility's policy and procedure (P&P) titled, Documentation: Nursing dated 8/20, the P&P indicated, All resident/patient care data collection, treatment and interventions performed, resident/patient responses to treatment, and any other information relating to the resident's/patient's condition are recorded in the EMR. During a review of Resident 1's Physician's Orders dated 8/5/23, the Physician Orders indicated Debrox 6.5% otic (ear drops used to treat earwax buildup. It helps to soften, loosen, and remove the earwax) to be given five drops in both ears, two times a day for five days. Then irrigate (apply a continuous flow of water) with NS (normal saline, a solution of salt and water) on the fifth day. During an interview on 9/21/23 at 12:48 p.m. with Licensed Nurse (LN) 3, LN 3 confirmed he provided the last treatment dose on day 5 but did not remember if he performed the irrigation and confirmed the treatment should have been documented as to how Resident 1 tolerated the procedure and if it was effective, but stated he did not do this.

Based on observation, interview, and record review the facility failed to implement their policy and procedure for posting the level of assistance required by one of two sampled residents (Resident 1) in such a way to communicate safe handling by the staff during position changes. This failure had the potential for physical injury to residents and staff. Findings: During a review of the facility's policy and procedure titled, Safe Patient Handling and Mobility, dated December 13, 2017, indicated in part . The level of assist and type of equipment will be posted in such a way to communicate to the patient care team what is required to safely handle the patient. During a review of the Minimum Data Set (MDS - a tool for implementing standardized assessment and for facilitating care management in nursing homes), for Resident 1, dated 3/21/2023, indicated in part . Section G Functional Status Bed mobility . Total dependence . Two person physical assist . During an interview on 9/13/23 at 11:40 AM with the Administrator (ADM), and Nurse Manager (NM), both ADM and NM agreed that the board posted in Resident 1's room with care instructions should include the requirement of a two person assist for Resident 1's positioning needs and it was blank.

Based on observation, interview, and record review, the facility failed to accurately assess and document 13 out of 18 sampled residents' (8, 71, 53, 59, 41, 4, 25, 65, 35, 63, 43, 34, and 48) Minimum Data Set (MDS- assessment tool to assess all residents' functional capabilities and facilitate care management in nursing homes) assessments for Section P (Physical Restraints) when quarter siderails were used and were coded as zero (not used). This facility failure resulted in inaccurate comprehensive assessments for 16 residents with restraints and had the potential for physical harm. Findings: During a review of the facility's policy and procedure (P&P) titled, Assessment Instrument, Resident/Patient, last reviewed 8/20, the P&P indicated, in part . Purpose: to produce a comprehensive, accurate, standardized, reproducible assessment of each resident's/patient's functional capacity .the assessment is done on each resident/patient initially and periodically .The assessment is based on a uniform data set used to describe the resident's/patient's capabilities to perform daily life functions and significant impairments in functional capacity . During an observation on 3/21/23, at 10:44 a.m., in Resident 4's room, Resident 4 was observed sitting up in bed with all four bed side rails up. During an observation on 3/21/23, at 11:20 a.m., in Resident 25's room, Resident 25 was observed sitting up tilted on left side, in bed, with all four bed side rails up. During an observation on 3/21/23, at 2:50 p.m., in Resident 48's room, Resident 48 was observed sitting up in bed with all four bed side rails up. During a concurrent interview and record review on 3/24/23, at 3:24p.m., with the Administrator (Admin 1), Residents 4, 25, and 48's MDS Section P, dated 1/16/23, 8/18/23, and 12/21/23 respectively, were reviewed. Residents 4, 25, and 48's MDS indicated, in part . Section P -Physical Restraints for bed rails were coded zero (not used). Admin 1 confirmed the sections were coded zero. When asked about all four bed side rails being up, when the residents are in bed, Admin 1 verbalized, having all of four bed side rails up is considered a restraint. 40678 During an observation on 3/21/23, at 10:51 a.m., 3/24/23, at 11:31 a.m., and 11:45 a.m., in Resident 8's room, Resident 8 was observed in bed with all four bed side rails up. During an observation on 3/21/23, at 10:15 a.m., 3/22/23 at 10:17 a.m., and 3/24/23, at 11:45 a.m., in Resident 53's room, Resident 53 was observed in bed with all four bed side rails up. During a concurrent interview and record review, on 3/24/23, at 3:24 p.m., with Admin 1, Residents 8 and 53's health records were reviewed. When asked about all four bed side rails being up, when the residents are in bed, Admin 1 verbalized, having all of four bed side rails up is considered a restraint. During a review of Residents 8 and 48's Minimum Data Set (MDS)-Version 3.0 Resident Assessment and Care Screening, dated 1/26/23, and 2/6/23, respectively, the MDSs indicated, Section P -Physical Restraints for bed rails was coded zero. 47112 During an observation on 03/21/23, at 03:22 p.m., in Resident 71's room, Resident 71 was observed sitting in bed with three of four bed siderails up. During a review of Resident 71's active order profile, the profile indicated, no orders for side rails to be up. During a review of the Resident 71's admission MDS, dated [DATE], the MDS indicated, section P- Physical Restraints for bed rails, was coded zero. 39912 During an observation on 3/21/23 at 10:18 a.m. in Resident 35's room, Resident 35 was observed in bed with all four side rails up. During a review of Resident 35's MDS dated [DATE], the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23 at 10:25 a.m. in Resident 41's room, Resident 41 was observed in bed with all four side rails up. During a review of Resident 41's MDS dated , 2/24/23, the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23 at 10:40 a.m. in Resident 59's room, Resident 59 was observed in bed with all four side rails up. During a review of Resident 59's MDS, dated [DATE], the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. 45741 During an observation on 3/21/23, at 12:25 p.m., in Resident 63's room, Resident 63 was observed sitting up on their left side, and all four bed rails were up. During a review of Resident 63's Physician Order, dated 1/12/23, at 9:10 a.m., the Physician Order indicated, Safety device/upper side rails up, side rails up while patient in bed, for possible involuntary movement. During a review of Resident's 63's MDS, dated [DATE], the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23, at 10:31 a.m., in Resident 43's room, Resident 43 was observed sitting up on their left side, and all four side rails were up. During a review of Resident 43's MDS, dated [DATE], the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. 40861 During an observation on 3/21/23, at 10:41 a.m., in Resident 65's room, Resident 65 was observer laying in bed with all four side rails up. During a review of of Resident 65's MDS,dated 1/16/23, the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero. During an observation on 3/21/23, at 10:46 a.m., in Resident 34's room, Resident 34 was observed laying in bed with all four side rails up. During a review of of Resident 34's MDS, dated [DATE], the MDS indicated, in Section P- Physical Restraints for bed rails was coded zero.

Based on observation, interview and record review, the facility failed to initiate and implement care plans for six out of 18 residents when: 1. Resident 35's care plan for position and mobility was not implemented. 2. Resident 35' has no careplan for the use of the medication Doxycline (an antibiotic/medication used to treat infections). 3. Resident 48's care plan for position and mobility was not implemented. 4. a.) Resident 4's care plan for pressure ulcer was not implemented. b.) Resident 25's care plan for pressure ulcer was not implemented. 5. Resident 48's care plan for refusal of SCDs (sequential compression device- wraps placed around the patient's lower legs in order to decrease the chance of blood clot formation) was not initiated. 6. Resident 8's and Resident 53's care plan for position and mobility was not implemented. These facility failures had the potential for health complications due to developing pressure sores for not documenting resident's position, pressure sore worsening when care plan interventions are not implemented, potential blood clot formation for refusing SCDs, and risk for resident not receiving correct respiratory care. Findings: During a review of the facility's policy and procedure (P&P) titled, Care Plans, Resident/Patient-Subacute Care, reviewed 8/20, the P&P indicated, in part . Purpose: To identify resident/patient care needs and develop a care plan that indicates the care to be given, the goals desired, and the approach to achieve these goals within an acceptable timeframe .Procedure: A. Gather information about the resident/patient .1. Resident assessment .2. Resident/patient history from chart and/or from resident/patient, family and past care givers .3. Physician orders .4. MDS Resident Assessment Forms .B. Identify resident/patient problems based on the above information .identify needs, weaknesses and strengths .C. Establish goals for resident/patient .long-term goals must be re-evaluated quarterly .short-term goals as specified when goal is established .goals must be specific and measurable .indicate a definite date for a goal to be met .goals must be realistic for the resident/patient . 1. During a concurrent interview and record review on 3/23/23, at 3:45 p.m., with the Registered Nurse (RN 4), Resident 35's health record was reviewed. The records indicated, Resident 35 had a care plan for impaired skin integrity, with an intervention to turn and reposition at least every 2 hours. The record further indicated, staff documented positioning of Resident 35, as the head of bed up, without indicating if Resident 35 was on their left, or right side, or flat on the back, multiple times. RN 4 acknowledged, staff should indicate where the resident is facing when repositioning. 2. During a concurrent interview and record review, on 3/23/23, at 3:47 p.m., with RN 4, Resident 35's health record was reviewed. The record indicated, Resident 35 was prescribed Doxycline 100 miligrams tablet, twice a day. No care plan for the antibiotic was located in Resident 35's health record. RN 4 acknowledged, there was no care plan for Doxycycline at the time the order was implemented. 39520 3. During a concurrent interview and record review, on 3/24/23, at 09:39 a.m., with the Informatics Registered Nurse (IRN), Resident 48's Care Plan for ADL Function and Rehab and ADL Flowsheet, dated 3/19/23 through 3/23/23, were reviewed. The care plan indicated, in part .resident requires total assist with ADL's .outcome: resident provided total ADL care .interventions: provide assistance to support level of need .explain all procedures and purpose as needed . turn and reposition at least every two hours. The ADL flowsheet under category of positioning, was missing documentation of turning the resident. The documentation indicated head of bed (HOB) was elevated, but, was missing position changes on 3/13/23 through 3/23/23, for day shift and night shifts. IRN acknowledged Resident 48's ADL care plan indicated to turn and reposition resident every two hours. IRN acknowledged, the documentation was missing on these days and was inconsistent. IRN verbalized if there is no documentation then there is no evidence the turning was done. IRN further acknowledged, Resident 48's care plan was not followed. 4. a.) During an interview on 3/21/23, 10:45 a.m., with Resident 4, Resident 4 verbalized, having wounds on their left hip bone and back. Resident 4 verbalized, for the most part wound care, dressing changes, and position changes are done if the facility is not short staffed. During a concurrent interview and record review, on 3/24/23, at 10:19 a.m., with the IRN, Resident 4's Care Plan for Skin Integrity, updated 6/4/22 and ADL Flowsheet, dated 3/19/23 through 3/23/23, were reviewed. The care plan indicated, in part .resident has chronic left hip abscess . outcome: skin integrity maintained .pressure ulcer will show signs of healing .skin integrity intact .interventions: dressing change per orders .reduce friction and shear . turn and reposition at least every two hours. The ADL flowsheet under category of positioning, was missing documentation of turning the resident. The documentation indicated head of bed (HOB) was elevated, but was missing position changes on 3/13/23 through 3/23/23, for day shift and night shifts. IRN acknowledged, Resident 4's Care Plan for skin Integrity indicated to turn and reposition resident every two hours. IRN acknowledged, the documentation was missing on these days and was inconsistent. IRN verbalized, if there is no documentation then there is no evidence the turning was done. IRN further acknowledged, Resident 4's care plan was not followed. 4. b.) During a concurrent interview and record review on 3/23/23, at 3:31 p.m., with the Registered Nurse (RN 1), Resident 25's Care Plan for Skin Integrity, updated 11/22/22 and ADL Flowsheet, dated 3/19/23 through 3/23/23 were reviewed. The care plan indicated, in part .resident at risk for further skin breakdown due to immobility, admitted with pressure injury . outcome: skin integrity maintained .skin integrity intact .interventions: reduce friction and shear . turn and reposition at least every two hours. The ADL flowsheet indicated, under category of positioning, was missing documentation of turning the resident. The documentation indicated, head of bed (HOB) was elevated, but was missing position changes on 3/13/23 through 3/23/23, for day shift and night shifts. RN 1 acknowledged, Resident 25's care plan indicated to turn and reposition resident every two hours. RN 1 acknowledged, the documentation was missing on these days and was inconsistent. RN 1 verbalized, if there is no documentation then there is no evidence the turning was done. RN 1 further acknowledged, Resident 25's care plan was not followed. During an interview on 3/24/23, at 3:24 p.m., with the Administrator (Admin 1) and the Nursing Supervisor (NSUP), Admin 1 and NSUP both verbalized, turning and positioning the resident should be documented in the medical record every two hours and further verbalized, if not documented then not done. 5. During a review of the facility's P&P titled, Care Plans, Resident/Patient-Subacute Care, reviewed 8/20, the P&P indicated, in part . Purpose: To identify resident/patient care needs and develop a care plan that indicates the care to be given, the goals desired, and the approach to achieve these goals within an acceptable timeframe .Procedure: A. Gather information about the resident/patient .1. Resident assessment .2. Resident/patient history from chart and/or from resident/patient, family and past care givers .3. Physician orders .4. MDS Resident Assessment Forms .F. Update resident/patient care plan where there is a change in the resident's/patient's condition, or when a goal has been reached, or when a review date has been met, or when an approach is ineffective and needs to be changed .update the care plan when a goal has to be revised .date/initial updates and reviews . During an observation on 3/21/23, at 2:49 p.m., in Resident 48's room, Resident 48 was observed sitting up in bed, without any SCDs on the lower legs. During a concurrent observation and interview, on 3/22/23, at 11:00 a.m., with Licensed Vocational Nurse (LVN 2), in Resident 48's room, Resident 48 was observed lying in bed without any SCD's on the lower legs. LVN 2 acknowledged, Resident 48 was not wearing any SCDs and further verbalized, Resident 48 refuses to wear them. During a concurrent interview and record review, on 3/22/23, at 11:05 a.m., with Registered Nurse (RN 3) and RN 4, Resident 48's Physician Orders,dated 1/6/22, Devices Flowsheet, dated 3/13/23 through 3/23/23, and Care Plans were reviewed. The Physician Orders, indicated, Resident 48 was to wear SCDs to both extremities, while in bed for circulation, and to check skin integrity. The Devices Flowsheet indicated, documentation that Resident 48 refused to wear the SCDs. The care plan indicated, no plan for Resident 48's refusal to wear SCDs. RN 3 and RN 4 acknowledged, the physician orders indicated Resident 48 was to wear SCDs to both extremities, while in bed for circulation. RN 3 and RN 4 acknowledged, the Devices Flowsheet had documentation that Resident 48 refused to wear his SCDs. When asked about what you as nurses do when Resident 48 refuses to wear SCD's, RN 3 verbalized, we could call the physician for any new orders or care interventions and initiate a refusal care plan for not wearing the SCDs. RN 3 and RN 4 reviewed Resident 48's Care Plans, and could not find any care plans for SCD refusal. RN3 further verbalized, a refusal care plan for SCDs should have been initiated and implemented. 40678 6. During a review of the facility's P&P titled, Care Plans, Resident/Patient-Subacute Care, last reviewed 8/20, the P&P indicated in part . Purpose: To identify resident/patient care needs and develop a care plan that indicates the care to be given, the goals desired and the approach to achieve these goals within an acceptable time frame. Policy: All residents/patients will have a completed care plan within seven days of admission . Procedure: Identify needs, weaknesses and strengths. Establish the approach that will be used to accomplish the goals for the resident/patient. During a concurrent interview and record review, on 3/24/23, at 10:01 a.m., with IRN, Resident 53's care plan, dated 2/5/23, and Resident 8's care plan, dated 1/24/23, and flow sheets were reviewed. The care plans indicated, turn and reposition at lease every 2 hours. Resident 53's and Resident 8's flow sheet indicted, position is not changed every 2 hours. IRN stated, the reposition every 2 hours should be documented and is not. During a concurrent interview and record review, on 3/24/23, at 3:24 p.m., with Admin 1 and NSUP, Admin 1 and NSUP verbalized, turning and positioning should be documented in the medical record every 2 hours, if not documented, then not done.