Every finding on record at Stonebrook Post Acute

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when:The dishwashing machine failed to reach the required sanitization temperature.Two dietary staff did not wear required beard restraints while in food preparation areas.This failure had the potential to result in food contamination and foodborne illnesses for a medically vulnerable population with a census of 114 residents.Findings:During a concurrent observation and interview on 6/22/26 at 1:53 p.m. in the Main Kitchen with Dietary Aide (DA) 1, DA 1 was operating the facility's dishwashing machine with a stationary rack and dual operating temperatures. The temperature gauges on the machine, labeled Rinse 180oF (Fahrenheit, unit of measurement for temperature) (MIN [minimum]), indicated a temperature of 170oF during the rinse cycle. DA 1 confirmed the temperatures were not rising to the minimum required temperature of 180oF for the rinse cycles.During an interview on 6/22/26 at 2:21 p.m. with the Dietary Supervisor (DS), the DS stated dietary staff were responsible for checking that the dishwasher machine reached the correct temperatures for every rinse cycle to ensure dishes were properly sanitized to prevent food borne illnesses. The DS further confirmed that all food served to residents was prepared in the Main Kitchen.During an interview on 6/24/26 at 2:18 p.m. with the Manufacturer Representative (REP), the REP stated the purpose of the final rinse temperature was to properly sanitize the dishes and must be at a minimum of 180 F.During a review of the facility provided Manufacturer's Guide titled, [Brand Name] Dishmachine, dated 2022, the guide indicated the facility's dishwasher was a high-temperature machine with a minimum operating temperature of 180 F for the rinse cycle.During a review of the facility's policy and procedure (P&P) titled, Dishwashing Machine Use, dated March 2010, the P&P indicated, Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 F, or less than.180 F.During a review of the Food and Drug Administration's Food Code, dated 1/18/22, the Food Code indicated, .the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than. (194 F), or less than. (180 F). 2.During a concurrent observation and interview on 6/22/26 at 1:29 p.m. with Dietary Aide (DA) 2 and DA 3 in the Main Kitchen, DA 2 and DA 3 were not wearing any nets or restraints over their full beards while near the food preparation area. DA 2 confirmed he was not wearing a beard covering and did not know where he could get one. DA 3 stated he should wear a beard covering but his reusable beard net was not in the kitchen.During an interview on 6/22/26 at 1:31 p.m. with the Dietary Supervisor (DS), the DS stated kitchen staff should wear a hair and beard net while in the kitchen. The DS further stated there were no available beard nets in the kitchen.During an interview on 6/24/26 at 9:10 a.m. with the Registered Dietician (RD), the RD stated dietary staff should cover their beards with a beard net at all times in the kitchen because hair can be dirty and residents would not want that on their food.During a review of the facility's policy and procedure (P&P) titled, Dress Code and Personal Hygiene, May 2019, the P&P indicated, Dietary staff must wear a hairnet and if applicable a beardnet.During a review of the Food and Drug Administration's Food Code, dated 1/18/22, the Food Code indicated, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on observation, interview, and record review, the facility failed ensure infection prevention and control practices was consistently implemented for three (Resident 88, 72 and 38) of 23 sampled residents when: Airborne Precautions (infection control measures used to prevent the spread of illnesses transmitted by tiny pathogens suspended in the air) for Resident 88 was not followed when the door to resident's room was open.Registered Nurse (RN) 1 did not wear a gown to administer antibiotics intravenously (IV, route directly into the bloodstream) to Resident 72 on Enhanced Barrier Precautions (EBP, infection control intervention used to reduce the transmission of multi-drug-resistant organisms (MDROs) by wearing gown and gloves during high contact resident care activities). The Oxygen (O2) concentrator (a medical device that draws in ambient air and delivers concentrated oxygen) for Resident 38 had a dusty filter.These failures had the potential to increase the risk of transmission of infectious organisms and adversely affect the health and safety of residents, staff and visitors. 1.During a review of Resident 88's admission Record (demographics), record indicated that Resident 88 was admitted to the facility on [DATE] with a diagnosis that included zoster without complications (localized Shingles outbreak where Varicella-Zoster virus reactivates – can be contagious to those who have not had chicken pox or the chicken pox vaccine). During a concurrent observation and interview on 6/22/26 at 3:58 p.m. with Licensed Vocational Nurse (LVN) 3 in front of Resident 88's room [ROOM NUMBER], the door to the room was wide open and an Airborne Precautions signage was posted that read, Door to room must remain closed. LVN 3 stated that door to Resident 88's room should have been closed because she was on airborne precautions for Shingles virus. During an interview on 6/24/26 at 2:30 p.m. with Infection Preventionist (IP), IP confirmed the door to Resident 88's room should have been closed. IP stated the importance of the door being closed was to prevent the possible spread of an airborne illness to other residents in the facility. During a review of the facility's policy and procedure (P&P) titled, Isolation – Categories of Transmission-Based Precautions, [undated], the P&P indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection. and is at risk of transmitting the infection to other residents. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door. so that personnel and visitors are aware of the need for and type of precaution. 2. During a review of Resident 72's Admissions Record (demographics), dated 6/22/26, the record indicated Resident 72 was admitted on [DATE] with a diagnosis of extradural and subdural abscess (infection characterized by pockets of pus around the brain), bacteremia (bacterial infection in the blood), staphylococcus aureus infection (type of bacterial infection commonly treated with antibiotics). During an observation on 6/22/26 at 3:19 p.m. in Resident 72's room, there was signage posted by the door that indicated EBP applied to Resident 72 in Bed B. The sign instructed providers and staff to wear gloves and a gown for the following high-contact resident care activities such as device care or use including central line. Resident 72 was observed in bed with a peripherally inserted central catheter (PICC, type of central line inserted into a vein in the upper arm) in his right upper arm. During a concurrent observation and interview on 6/22/26 at 3:36 p.m. with RN 1, RN 1 was not wearing a gown while administering IV medication to Resident 72. RN 1 stated, I just administered IV nafcillin (medication classified as antibiotic to treat bacterial infection). RN 1 further stated staff were not required to wear a gown when administering IV medications through a PICC line. During an interview on 6/24/26 at 2:41 p.m. with the Infection Preventionist (IP), the IP confirmed Resident 72 was on EBP because of his PICC line. The IP further stated RN 1 should have worn a gown when giving IV medications through the PICC line to Resident 72 to decrease the risk of spreading MDRO infections. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions – Infection Prevention, dated December 2024, the P&P indicated EBP applies when a resident has an indwelling medical device, including central lines, and that gown and glove use is required during high contact resident care activities including device care or use. 3. During observations on 6/23/26 at 9:10 a.m. and 6/24/26 at 2:41 p.m. in Resident 38's room, Resident 38 was on oxygen via nasal cannula and the oxygen concentrator had a filter clogged with dust. During a review of Resident 38's Order Summary (OS), dated 2/2/24, the OS indicated Resident 38 had an order for oxygen set to one to two liters of oxygen via nasal cannula. During an interview on 6/24/26 at 2:44 p.m. with LVN 2, LVN 2 stated the oxygen concentrators should be cleaned every so often, but didn't know timeframes. LVN 2 stated The filter should be cleaned to prevent potential respiratory infection to residents. During an interview on 6/24/26 at 3:14 p.m. with the Respiratory Therapist (RT), the RT stated the oxygen concentrators should have been cleaned at least monthly. The RT stated he did not know when the last time they were cleaned or serviced. The RT stated the cabinet filter should have been cleaned to prevent any respiratory infection to the residents and to work efficiently. During a review of the policy and procedure (P&P) titled Oxygen Administration, dated October 2010, the P&P indicated, .Oxygen equipment shall be maintained by the vendor in accordance with applicable standards; facility staff are responsible for notifying the vendor of any equipment concerns or malfunctions requiring attention. During a review of the manufacturer's guidelines titled Oxygen Concentrator User Manual, dated March 2025, indicated, . Cabinet filter should be inspected periodically and cleaned as needed by the user or caregiver.Recommended cleaning interval.Cabinet filter.7 days.

Based on interview and record review the facility failed to ensure the rights of one of 23 sampled residents (Resident 3), when Resident 3 did not give informed consent for an antidepressant (medications used to treat major depressive disorder-severe mental health condition causing persistent sadness, hopelessness, and a loss of interest in activities) medication.This failure resulted in Resident 3 not being informed of potential side effects or complications and the ability to refuse treatment.During a review of Resident 3's Order Summary (OS), dated 4/28/26, the OS indicated Resident 3 had Venlafaxine (antidepressant) ordered for major depressive disorder.During a review of Resident 3's Psychotherapeutic Drug Informed Consent Forms (IC), there was no IC before 6/22/26 for Venlafaxine.During an interview on 6/25/26 8:37 a.m. with Supervisor Registered Nurse (SRN) 1, SRN 1 stated the purpose of informed consent for antidepressants was to ensure the resident and resident's representative understood the indications for use, symptoms, and side effects before making a decision about receiving the medication. SRN 1 stated the IC for Venlafaxine should have been completed before the medication was ordered. SRN 1 stated there was no informed consent for Resident 3's antidepressant before 6/22/26.During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated October 2025, the P&P indicated, .be informed of, and participate in, their care planning and treatment.During a review of the facility P&P titled Medication Management, dated September 2010, the P&P indicated, .A resident and/or representative had the right to be informed about the resident's condition; treatment options, relative risks and benefits of treatment, required monitoring, expected outcomes of the treatment; and has the right to refuse care and treatment.

Based on observation, interview and record review, the facility failed to ensure safe smoking practices were implemented and monitored for one of 23 sampled residents (Resident 52) who used the designated smoking area. This failure placed Resident 52 and other residents who accessed the smoking area at risk for an uncontrolled fire and potential burns.Findings:During an observation on 6/24/26 at 7:45 a.m. the designated smoking area was observed to have no safety equipment, including the absence of a fire extinguisher or fire blanket. Multiple used cigarette butts were noted discarded in a flower planter rather than in proper receptacles. During an observation on 6/24/26 at 9 a.m. Resident 52 was noted to be smoking in the designated smoking area. During an interview on 6/24/26 at 2:35 p.m. with Administrator (ADM), ADM stated, there was no safety equipment placed in the smoking area. The ADM further stated he did not know who was responsible for monitoring the smoking area.During a review of the facility's policy and procedure (P&P) titled, Smoking Policy-Residents dated July 2017, the P&P indicated, . 5. The resident will be evaluated . d. ability to smoke safely . The facility was not able to provide documentation regarding safety equipment in smoking area.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled Residents' (Resident 1) was free from accidents during incontinence care (the management and support for individuals with involuntary urine or stool leakage, aiming to maintain hygiene, skin health, dignity, and quality of life).This failure resulted in Resident 1 falling out of bed and sustaining a bruise (discolored skin on the body, caused by a blow or impact rupturing underlying blood vessels) to the forehead, perinasal hematoma (accumulation of blood within the nasal septum, which is the wall of cartilage and bone that divides the two nostrils), right elbow abrasion (a superficial, minor injury where the top layer of skin is scraped or rubbed away), and right femoral fracture (a serious, high-impact break in the longest, strongest bone in the leg, usually caused by severe trauma like car accidents or falls). During a review of Resident 1's admission Record, printed on 2/5/26, the admission Record indicated Resident 1 was admitted in December 2025.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/17/25, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score was 3 out of 15, indicating Resident 1's cognition was severely impaired. MDS Section GG Functional Abilities indicated Resident 1 was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) in toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement).During a review of Resident 1's Baseline Care Plan, dated 12/12/25, the care plan indicated Resident 1's personal hygiene: support provided, two persons physical assist.bed mobility: support provided, two persons assist.During a review of Resident 1's Potential for Falls Care Plan Report, initiated 12/12/25, the care plan indicated Floor mats on both side of bed.Keep bed in low position. Monitor resident frequently when in bed or chair. The 'Goals' within the care plan indicated, No fall daily in 90 days.During a review of Resident 1's Skilled Charting, dated 12/31/2025, Skilled Charting indicated, Functional Status: does not bear weight, unsteady gait requiring supervision, impaired balance, weakness, paralysis.Late loss ADL's (activity of daily living; which are essential self-care tasks such as eating, bathing, dressing, toileting): requires assistance with transfers, requires assistance with toilet use.Bladder function: incontinent of urine.Skin/Wound: no new changes to skin integrity noted.During a review of Resident 1's Change of Condition, dated 1/2/26, at 4:21 p.m., the Change in Condition indicated Resident 1 had a fall out of bed and identified Fall risk factors.impaired balance.During a review of Resident 1's Post Fall Evaluation, dated 1/2/26, at 4:38 p.m., the Post Fall Evaluation indicated the date, time and location of the fall was on 1/2/26 at 12:00 p.m. in Resident 1's room. Factors involved in the fall indicated poor balance. The incident summary indicated, Patient 77 y/o (year old) female with hemiplegia and hemiparesis (weakness or partial paralysis [loss of voluntary movement] affecting one entire side of the body) following cerebral infarction affecting left dominant side. Patient is confused, but able to move herself towards her left side and fell on the floor from her bed. Patient sustained a skin tear on her forehead and right face right below periorbital area, also complaining of left arm pain 6/10 (on a scale of 0 to 10, with 6 representing moderate to severe pain). Patient transported to Hospital in Concord for medical evaluation.During a review of Resident 1's Rehab Post Fall Review, dated 1/8/26, at 3:02 p.m., the review indicated date, time and location of event was 1/2/26 at 12 p.m. in Resident 1's bedroom from bed. Circumstances of Event indicated Certified Nursing Assistant (CNA) was beginning to change resident, CNA left room to get supplies and assistance. Bed was at working height, not lowered when CNA left the room, air mattress adjusted and slid the pt (patient) out of bed. Pt was found on the floor when CNA returned. Listed interventions included Post Fall IDT interventions: floor mats.During an interview with Certified Nurse Assistant (CNA) 1 on 3/23/26, at 11:23 a.m., CNA 1 stated was informed by Resident 1's family that Resident 1 needed incontinence care. CNA 1 stated went into Resident 1's room alone to ensure Resident was incontinent and gain consent for a shower. CNA 1 stated the family stepped out for privacy and CNA 1 elevated the bed, and turned resident to assess brief and confirmed resident was soiled in stool. CNA 1 stated lowered the bed a little and went outside of Resident 1's room to gather gloves and request assistance from another staff member. CNA 1 stated moments later Resident 1 fell out of bed and was seen on the floor. CNA 1 stated was unsure if floor mats were in place at the time of fall. CNA 1 stated was aware that Resident 1 needed a two person assist for incontinence care, but wanted to confirm resident was soiled and consented to a shower first. CNA 1 stated it was important to use two person assist for dependent residents so they are not alone and to ensure safety.During a concurrent interview and record review on 3/11/26, at 3:11 p.m., with Assistant Director of Nursing (ADON) and Director of Nursing (DON), Resident 1's Potential for Falls care plan and Rehab Post Fall Review were reviewed. Resident 1's Potential for Falls care plan, initiated 12/12/2025, indicated Floor mats on both side of bed, keep bed in low position, monitor Resident frequently when in bed or chair. DON stated based on documentation within Rehab Post Fall Review, dated 1/8/26, which indicated Post fall IDT intervention: floor mats, it could be assumed there were no floor mats in place at time of fall. DON stated CNA 1 should not have left Resident 1 with side rails down and bed elevated before exited room. DON stated CNA 1 should have gathered necessary supplies and requested assistance from another staff member before entering Resident 1's room for incontinence care. DON stated due to Resident 1's limited cognition and one-sided, partial mobility, Resident 1 was able to shift self-off of bed onto floor. DON stated dependent, total care residents always warranted a two person assist for incontinence care, and residents should not be left alone in the middle of incontinence care. DON stated CNA 1 should have stayed at Resident 1's bedside and used call light system to alert staff for additional help and supplies. DON stated it was important to implement fall precautions and utilize two staff members during incontinence care of dependent residents to prevent accidents and ensure resident safety.During a review of the hospital Emergency Department (ED) Provider Notes, dated 1/2/26 at 3:40 p.m., the 'Chief Complaint and Triage Note' indicated, Brought in by ambulance from SNF. Pt had unwitnessed fall from bed. Pt seen 15 minutes prior to being discovered on floor. Pt has lac (laceration) between eyes, beneath L (left) eye, abrasion to R (right) elbow, shortening to R leg. The History and Present Illness note indicated, Patient is a 77 y.o. female brought in from skilled nursing facility. Patient had unwitnessed fall from bed. Patient was seen 15 minutes prior to her fall and discovered on the floor. Patient states that she heard a pop in her right lower extremity. Patient has abrasion to face abrasion to right elbow as well. Patient has some shortening to the right leg.During a review of the Hospitalist History and Physical (H&P) note dated 1/2/2026 at 6:06 p.m., the H&P indicated, Patient is a [AGE] year-old female with left sided hemiparesis presenting after an unwitnessed fall at her SNF. The patient was found on the floor by nursing staff after they briefly left the room to obtain supplies. The exact circumstances of the fall are unknown. She was noted to have significant pain and bruising on her forehead concerning for trauma. She underwent a full trauma workup in the ER. Head CT (computed tomography scan; a noninvasive, rapid diagnostic imaging test that uses a rotating X-ray machine and computers to create detailed, cross-sectional slices of the brain, skull, sinuses, and blood vessels) was unremarkable. Pelvis x-ray (a noninvasive medical imaging test that uses a small amount of electromagnetic radiation to produce images of the body's internal structures) was unremarkable, but femur x-ray revealed a distal femur fracture. Physical exam within record indicated, Skin: obvious bruising on forehead with dried blood extending to bridge of nose and left eye.During a review of Resident 1's CT head, dated 1/2/26 at 2:03 p.m., indicated frontal/perinasal hematoma (accumulation of blood within the nasal septum, which is the wall of cartilage and bone that divides the two nostrils),.During a review of Resident 1's x-ray of right femur dated 1/2/26 at 2:35 p.m., indicated, comminuted distal femoral fracture (a severe, high-energy injury where the lower end of the thigh bone (femur) breaks into three or more pieces just above the knee joint).During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol and Prevention, dated March 2018, the P&P indicated, The staff and practitioner will review each resident's risk factors for falling and document in the medical record. Examples of risk factors for falling include musculoskeletal abnormalities (disorders affecting muscles, bones, joints and ligaments, causing pain, inflammation and reduced mobility), peripheral neuropathy (nerve damage causing numbness, tingling, burning pain, or weakness), gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. During a review of the facility's P&P titled, Compliance Risks - Resident Quality of Care and Quality of Life, dated January 2025, indicated, Residents are provided with a safe, clean, and comfortable environment that is free of accident hazards, and adequately supervised.

Based on interview and record review, the facility failed to ensure for one of two sampled residents, (Resident 2) the Physician's Orders for Life Sustaining Treatment (POLST) was completed and the Do not Resuscitate physician order was followed during a medical emergency. This failure resulted in medical interventions for CPR (Cardiopulmonary Resuscitation - an emergency technique combining chest compressions and rescue breaths to maintain blood flow and oxygen to the brain and vital organs when someone's heart has stopped (cardiac arrest) and defibrillation (uses an electrical shock inside or outside the body to stop an abnormal heart rhythm in the heart's ventricles to allow the heart to start a normal rhythm again) on Resident 2 which were not requested. During a review of Resident 2's admission record (AR), the AR indicated Resident 2 was originally admitted [DATE], initially admitted on [DATE], and readmitted on [DATE] and discharged to the hospital on [DATE]. AR indicated Resident 2 was self-responsible.During a review of Resident 2's Statement of Resident Capacity (SRC) dated [DATE], the SRC indicated Resident 2 had capacity and had been informed of their condition.During a concurrent interview and record review on [DATE] at 1:48 p.m. with Registered Nurse Supervisor (RNS) 2. Resident 2's progress notes (PNs) dated [DATE] and the physician orders were reviewed, the PN dated [DATE] at 5:38 indicated, Patient up on his wheelchair, unresponsive to verbal and tactile stimuli, pale in color, no neurological response, unable to obtain any vital signs including oxygen saturation, on a slouched position and drooling at the same time, assisted to lay down, CPR initiated. PN indicated, on [DATE] at 5:43 a.m. 911 emergency was called. The PNs indicated, at 5:53 a.m. two police officers came with a defibrillator and used it on Resident 2 and were able to get a pulse, then CPR was suspended. The PNs indicated Fire department and ambulance arrived at the facility at 5:55 a.m. and they were made aware that Resident 2 was DNR but no POLST on file, facility were asked to call the family to clarify the code status. Then Resident 2 was transported to the hospital at 6:05 a.m. The active physician orders for [DATE] indicated DNR (Do Not Resuscitate) with order date [DATE].During a concurrent interview and record review on [DATE] at 3:46 p.m. with Director of Nursing (DON), DON confirmed that Resident 2 had a DNR order but CPR was performed on him by Registered Nurse (RN) 3 when he was unresponsive. During a concurrent interview and record review on [DATE] at 5:23 p.m. with DON, DON stated there was no copy of Resident 2's POLST (medical form for individuals with chronic or self-limiting illnesses to specify their wishes for end-of-life care, and it is a set of medical orders that guides emergency responders and health care providers, often involving decisions on CPR, intubation, and artificial nutrition). DON stated that when the patient came from the hospital, he did not have a POLST that was sent with him and the facility did not have one completed.During an interview on [DATE] at 5:26 p.m. with DON, DON stated they were supposed to follow the DNR order (a specific physician's order to withhold CPR if the heart or breathing stops) since there was no POLST.During a concurrent interview and record review on [DATE] at 5:30 p.m. with Medical Record Assistant (MRA), the physician progress notes titled, POLST Verbal Discussion dated [DATE], indicated, if patient has no pulse and is not breathing. with a check mark in the box in front of Do not attempt resuscitation/DNR (Allow Natural Death) and with a check mark in the box in front of selective treatment-. It also indicated the physician's signature and verbal consent obtained from Resident 2 dated [DATE]. When asked for an updated one, MRA stated they did not have an updated one and there was no POLST on file for Resident 2.During a review of Resident 2's physician admission note (PAN) dated [DATE], PAN indicated Code status: with an X in front of POLST reviewed/signed. PAN also indicated Patient: with an X in the front of has capacity to understand and make medical decisions.During a review of the facility's policy and procedure (P&P) titled, Do Not Resuscitate Order revised [DATE], the P&P indicated, Our facility will not use cardiopulmonary and related emergency measures to maintain life functions on a resident when there is a DO Not Resuscitate Order in effect.In addition to the. and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. Stated- specific forms include: POLST.Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order.During a review of the blank POLST form, under the Directions for Health Care Provider, indicated, if found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a patient who has chosen Do Not Attempt Resuscitation.

Based on interview and record review, the facility failed to ensure the results of the investigations of an abuse allegation were reported timely to the State Agency (SA, which is the California Department of Public Health, CDPH), for one sampled resident (Resident 1) when Resident 1 alleged that staff was rough with him.This failure had the potential to compromise the safety of all residents in the facility from unreported investigations and results of the investigations. Review of Resident 1's admission record, undated, indicated that he was admitted on [DATE] with diagnoses that included diabetes, urine retention, and hyperlipidemia.Review of Resident 1's Minimum Data Set (MDS- an assessment and care screening tool used to guide care) dated 8/23/25 indicated Resident 1's Brief Interview for Mental Status (BIMS- a short scanner to help detect cognitive impairment) score was 14, indicating no cognitive impairment.During a review of the social services note (SSN) note dated 8/7/25, the SSN note indicated, Resident 1 stated that a CNA (certified Nursing Assistant) has been rough with him and hurt him when she was putting his brief on by pulling it up aggressively 2 times, Resident claims his testicles were sore and he could not urinate for 2 days. CDPH, Ombudsman, Concord PD & MD notified by phone. Social Services notified. SOC341 faxed to CDPH & Ombudsman.During an interview on 12/18/25 at 9:10 a.m. with Director of Nursing (DON), When asked for the investigation summary for this allegation, DON stated they don't have it as the facility transitioned to a new company. DON stated they have all the documentation in the Point Click Care (PCC- Electronic Health Record). DON stated the CNA was suspended for three days and when she came back, was assigned to a different station.During an interview on 12/18/25 at 11:10 a.m. Administrator (ADM) stated they are still unable to find the investigation documents done by former Administrator (ADM) and staff have been trying to reach her to ask about it.During a telephone interview on 12/18/25 at 1:39 pm, with the former ADM, former ADM stated she did the investigation for that incident. She stated she could not remember all the specific details. She stated former AADM would be able to remember the details. Former ADM stated she had left all her investigation documents/notes in the ADM's office.During a telephone interview on 12/18/25 at 2:30 p.m. with former Assistant Administrator (AADM), AADM stated she left a day before transition to the new company on 10/31/25, reported it to the new company and they left all the investigation documents. Former AADM stated she was the one that reported the abuse allegation to the appropriate agencies.During an interview on 12/18/25 at 4 p.m. with DON, DON stated the incident was reported to them on 8/7/25 and it happened on the night of 8/6/25 going to 8/7/25. DON stated he and the former AADM went in to interview Resident 1.During an interview on 12/22/25 at 5:55 p.m. with ADM, ADM stated he had searched for the former ADM's investigation notes and summary and cannot locate them.During a telephone interview on 12/26/25 at 10:18 a.m. with DON, DON stated it was very important to keep the investigation reports, to know what happened as everything is in that report; they can see what happened, what the allegation was, and what they could do about it and then they would let everybody know this and make sure this does not happen again. DON stated they do not have the policy and procedure for reporting of investigation notes/summary in the P&P provided but did not know why. DON stated that was the P&P they were following at the time of the incident. DON stated the new company for the facility took over on 11/1/25. During an interview on 12/29/25 at around 12:05 p.m. with ADM, ADM stated his expectation, after sending the SOC 341, is to conduct the investigation within 5 days, reach a conclusion and send it to the State agency. When asked, ADM stated he did not know if the 5 day investigation report about Resident 1's allegation was sent to the state agency. He also confirmed there was no fax confirmation that it was sent.During an interview on 12/29/25 at 12:14 p.m. with ADM, ADM stated the new company would hold onto the investigation records for seven years. ADM stated he expected the old company to follow the regulations to keep them. He stated further, .if they don't have documentation it didn't happen. ADM stated it was important for them to keep the investigation records to protect the patient, staff, and the building.During a review of the facility's P&P, titled, Abuse Prevention, undated, the P&P indicated, When an incident or suspected incident of resident abuse is reported, .shall utilize abuse/.investigation process as required by federal and stated law.

Based on observation, interview, and record review, the facility failed to maintain a homelike environment when three out of four sampled rooms (Room A, B, and C) were observed to have privacy curtains that were worn and frayed along the bottom and side edges, detracting from the homelike appearance of the resident rooms. This failure had the potential to negatively affect the residents' quality of life and homelike environment.During a concurrent observation and interview with Housekeeping Supervisor (HS) on 12/18/25 at 9:29 a.m., the bottom hems of the privacy curtains in room A and B were frayed with loose threads that were hanging down, and the fabric linings/nettings were exposed and detached near the lower edge. The side hem of the privacy curtain in room C appeared worn and frayed. The HS stated the curtains were torn and in need of replacement. HS stated there was no schedule for the facility staff to routinely check and inspect the curtains; instead, inspections were conducted on an as-needed basis. HS stated checking the condition of the privacy curtains was on his to-do list and he believed the facility had ordered new privacy curtains.During a record review of the facility's purchase order dated 11/6/25 with the Administrator (ADM) on 12/18/25 at 2:50 p.m., there were no privacy curtains ordered.During an interview on 12/22/25 at 12:35 p.m., HS stated that 28 out of 69 resident rooms required replacement of privacy curtains.A review of facility policy and procedures (P&P) titled Homelike Environment, revision dated 2/2021, indicated, residents are provided with a safe, clean, comfortable, and homelike environment.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 3 (Residents #24, #54, and #87) of 18 sampled residents. Findings included: A facility policy titled, Health Information Record Manual, revised [DATE], specified, The assessment portion (Minimum Data Set - MDS) will describe the resident's ability to perform daily life functions and significant impairment in functional capacity. 1. An Admission Record revealed the facility admitted Resident #24 on [DATE]. According to the Admission Record, the resident had a medical history that included diagnoses of spinal stenosis, chronic obstructive pulmonary disease, dementia, and major depressive disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident's code status was attempt resuscitation / cardiopulmonary resuscitation (CPR). Resident #24's Order Summary Report, with active orders as of [DATE], revealed an order dated [DATE], that indicated the resident's code status as do not resuscitate (DNR). On [DATE] at 12:45 PM, 1:44 PM, and 2:45 PM, the surveyor attempted to interview MDS Nurse #8. A message was left and no return telephone call was received. During an interview on [DATE] at 1:07 PM, the Director of Nursing stated he was not familiar with the process for MDS assessments but expected them to be accurate. During an interview on [DATE] at 1:17 PM, the Administrator stated she did not know the process to complete an MDS; however, she expected the MDS assessment to be accurate. 52219 2. An Admission Record revealed the facility admitted Resident #54 on [DATE]. According to the Admission Record, the resident had a medical history to include a diagnosis of hypertensive chronic kidney disease. Resident #54's Dental Evaluation Form, dated [DATE], revealed the resident had ill-fitting upper and lower dentures. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #54 had a Brief Interview for Mental Status Score (BIMS) of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not have broken or loosely fitting full or partial dentures. Resident #54's Social Services Quarterly Assessment, dated [DATE], revealed it had been recommended by the dentist to have the resident's dentures realigned. A quarterly MDS, with an ARD of [DATE], revealed Resident #54 had a BIMS of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident did not have broken or loosely fitting full or partial dentures. During an interview on [DATE] at 8:05 AM, Resident #54 stated they could not wear their lower partial dentures because they did not fit. Resident #54 stated initially there was a problem with their top set of dentures, but that was fixed then they started to have a problem with their bottom set of dentures. Resident #54 stated their dentures were not aligned. During an interview on [DATE] at 11:12 AM, MDS Nurse #7 stated Resident #54 wore dentures and it was overlooked on the resident's MDS assessments. During an interview on [DATE] at 2:05 PM, the Director of Nursing stated he expected the MDS to be accurate. 52454 3. An Admission Record indicated the facility admitted Resident #87 to the facility on [DATE]. According to the Admission Record, the resident discharged to a private home/apartment with home health services on [DATE]. Resident #87's Notice of Proposed Transfer/Discharge, dated [DATE], revealed the resident would discharge home. Resident #87's Discharge Summary, revealed the resident discharged home on [DATE]. A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #87 discharged to a short-term general hospital on [DATE]. During an interview on [DATE] at 11:29 AM, MDS Nurse #7 stated she was responsible for ensuring the accuracy of the MDS. MDS Nurse #7 stated Resident #87 discharged home and the MDS indicated the resident discharged to the hospital, which was wrong. MDS Nurse #7 stated she made an error. During an interview on [DATE] at 1:38 PM, the Director of Nursing (DON) stated the MDS should be as accurate as possible and should indicate where the resident discharged to. The DON stated if a resident discharged home, the MDS should reflect the resident discharged home and not the hospital. During an interview on [DATE] at 1:59 PM, the Administrator stated the discharge MDS should be accurate and indicate where the resident discharged to.

Based on interview, record review, and facility policy review, the facility failed to refer the resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) evaluation once a resident was identified to have a new mental illness diagnosis for 1 (Resident #22) of 1 sampled resident reviewed for PASARR. Findings included: A facility policy titled, Preadmission Screening & Resident Review, revised 11/30/2023, revealed, 1. Facility will: a. Coordinate assessments with the pre-admission screening and resident review program under Medicaid to the maximum extent practicable to avoid duplicative testing to include: F644 483.20(c) i. Incorporating the recommendations from the [PASARR] level II determination and the [PASARR] evaluation report into a resident's assessment, care planning, and transitions of care. ii. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. An Admission Record revealed the facility admitted Resident #22 on 08/28/2015. According to the Admission Record, the resident had a medical history to include a diagnosis of bipolar disorder. Per the Admission Record, the resident received a diagnosis of major depressive disorder with psychotic symptoms on 01/20/2023. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/2025, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had an active diagnosis to include depression. Resident #22's Care Plan Report included a focus area initiated 12/03/2024, that indicated the resident had depression manifested by complaints of depression with mood disorder and episodes of tearfulness and sleeplessness. Interventions directed the staff to administer antidepressant medication as ordered by the physician. Resident #22's Order Summary Report, revealed an order dated 08/21/2024, for duloxetine hydrochloride capsule delayed related particles 20 milligrams, give one capsule by mouth every 12 hours related to major depressive disorder. Resident #22's medical record revealed no evidence to indicate the facility referred the resident to the appropriate state-designated authority for a Level II PASARR evaluation once the resident was identified to have a diagnosis of major depressive disorder on 01/20/2023. During an interview on 03/06/2025 at 11:32 AM, the Receptionist stated she was responsible for the process of PASARR in the facility. The Receptionist stated she was unaware another screening needed to be done when a resident received a new mental illness diagnosis. During an interview on 03/06/2025 at 1:54 PM, the Administrator stated if a resident had a new mental illness diagnosis, a new PASARR should be completed.

Based on observation, interview, record review, and facility policy review, the facility failed to assess a resident for the use of a bed rail for 2 (Resident #20 and Resident #34) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Proper Use of Bed Rail Policy, dated 01/30/2025, indicated, 1. An assessment will be made to determine the resident's symptoms or reason for using bed rails. This assessment may be completed at the following intervals: upon admission, readmission, quarterly and change of condition status. 1. An Admission Record indicated the facility readmitted Resident #20 on 10/30/2021. According to the Admission Record, the resident had a medical history that included diagnoses of polymyalgia rheumatica (an inflammatory disorder that caused muscle pain and stiffness) and a history of falling. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2025, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance to roll left and right, sit to lying, and lying to sitting on the side of the bed and was dependent on staff for chair/bed-to-chair transfer. Resident #20's Care Plan Report, included a focus area, initiated 02/12/2025, that indicated the resident was totally dependent on staff for activities of daily living to include bed mobility, dressing and locomotion. Interventions directed staff to transfer the resident in and out of bed as needed (initiated 02/04/2023). During an observation on 03/03/2025 at 10:20 AM, Resident #20 was noted lying in bed with quarter rails in the up position on both sides of the upper portion of the resident's bed. During an interview on 03/05/2025 at 12:22 PM, the Administrator stated the facility did not have an assessment for the use of bed rails for Resident #20. During an interview on 03/06/2025 at 8:20 AM, the Administrator stated therapy was supposed to assess a resident for the use of a bed rail but had failed to assess the resident. Per the Administrator, there had been a break in their system in all their departments to include maintenance, therapy and nursing. The Administrator stated those residents that had not been assessed for a bed rail, should not have a bed rail in use. During an interview on 03/06/2025 at 9:31 AM, the Director of Rehabilitation (DOR) stated if a resident wanted a bed rail, there should be a full evaluation to assess the resident for the use of a bed rail. The DOR stated she did not think Resident #20 had been assessed for the use of a bed rail. During an interview on 03/06/2025 at 11:39 AM, the Director of Nursing (DON) stated the nurses should make sure that the use of the bed rail was appropriate when requested by the resident, and then therapy should assess the resident, and if appropriate then they would submit a work order to maintenance for the bed rails. According to the DON, he was not aware that so many residents had bed rails in use without an assessment. 2. An Admission Record indicated the facility admitted Resident #34 on 12/22/2023. According to the Admission Record, the resident had a medical history that included diagnoses of hemiplegia (partial paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following nontraumatic intracerebral hemorrhage which affected the right dominant side and epilepsy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required substantial/maximal assistance to roll left and right, sit to lying, and lying to sitting on the side of the bed and was dependent on staff for chair/bed-to-chair transfers. Resident #34's Care Plan Report included a focus area initiated 01/01/2024, that indicated the resident had a decreased in functional performance related to a recent illness and muscle weakness. Interventions revealed the resident required total assistance from two staff for bed mobility and transfers. During an observation on 03/03/2025 at 10:23 AM, Resident #34 was noted in bed with a bed cane (rail) on each side of the upper portion of their bed. During an observation on 03/04/2025 at 3:02 PM, Resident #34 was noted in bed with a bed cane (rail) on each side of the upper portion of their bed. Resident #34 was not able to state whether they used the bed cane (rail) or not. During an interview on 03/05/2025 at 12:19 PM, Licensed Vocational Nurse (LVN) #3 stated Resident #34 used the bed canes (rails) to hold themself over when the staff provided care. LVN #3 stated therapy was responsible for assessing the resident for the use of bed rails. During an interview on 03/05/2025 at 12:22 PM, the Administrator stated the facility did not have an assessment for the use of bed rails for Resident #34. During an interview on 03/06/2025 at 8:20 AM, the Administrator stated therapy was supposed to assess a resident for the use of a bed rail but had failed to assess the resident. Per the Administrator, there had been a break in their system in all their departments to include maintenance, therapy and nursing. The Administrator stated those residents that had not been assessed for a bed rail, should not have a bed rail in use. During an interview on 03/06/2025 at 9:31 AM, the Director of Rehabilitation (DOR) stated if a resident wanted a bed rail, there should be a full evaluation to assess the resident for the use of a bed rail. The DOR stated she did not think Resident #34 had been assessed for the use of a bed rail. During an interview on 03/06/2025 at 9:41 AM, Certified Nursing Assistant (CNA) #1 stated a resident should not have beds rails on their bed if they had not been assessed for them. CNA #1 stated Resident #34 used their bed rails for positioning in bed while care was being provided. During an interview on 03/06/2025 at 11:39 AM, the Director of Nursing (DON) stated the nurses should make sure that the use of the bed rail was appropriate when requested by the resident, and then therapy should assess the resident, and if appropriate then they would submit a work order to maintenance for the bed rails. According to the DON, he was not aware that so many residents had bed rails in use without an assessment.

Based on interview, record review, and document review, the facility failed to provide timely follow up of medically related social services to obtain dental services related to the replacement of dentures for 1 (Resident #54) of 1 sampled resident reviewed for dental services. Findings included: The undated Social Service Designee/Discharge Planner job description, revealed, The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The job description specified the duties and responsibilities included, Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident. An Admission Record revealed the facility admitted Resident #54 on 08/15/2022. According to the Admission Record, the resident had a medical history to include a diagnosis of hypertensive chronic kidney disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/22/2025, revealed Resident #54 had a Brief Interview for Mental Status Score (BIMS) of 8, which indicated the resident had moderate cognitive impairment. Resident #54's Dental Evaluation Form, dated 09/14/2024, revealed the resident had ill-fitting upper and lower dentures. Resident #54's physician Progress Notes dated 11/14/2024, revealed the resident's concern was that their denture situation was still not resolved. Per the Progress Notes, Resident #54 specified the dental people told them recently that their denture care was not covered by Medicaid. The Progress Notes indicated Resident #54 specified they had not heard back from the Director of Social Services (DSS) regarding this. According to the Progress Notes, the resident needed dentures especially in their bilateral lower teeth and the physician called and spoke with the DSS about this. Per the Progress Notes, the DSS indicated she needed to follow up with the dentist, to which the physician indicated that if the dentist did not treat the resident, that the DSS should assist the resident in finding another dentist that would treat the resident under Medicaid. Resident #54's Social Services Quarterly Assessment, dated 11/22/2024, revealed it had been recommended by the dentist to have the resident's dentures realigned. Resident #54's physician's Progress Notes dated 01/30/2025, revealed the resident was seen with the DSS present. Per the Progress Notes, the DSS notified the resident that their dentist indicated their denture work was not covered under their current medical plan. The Progress Notes indicated the DSS would follow up with the state's Medicaid plan about denture coverage for the resident and would look for a different dentist for the resident as the resident wanted to switch dentists During an interview on 03/06/2025 at 8:05 AM, Resident #54 stated they could not wear their lower partial dentures because they did not fit. Resident #54 stated initially there was a problem with their top set of dentures, but that was fixed then they started to have a problem with their bottom set of dentures. Resident #54 stated their dentures were not aligned. Resident #54 stated the DSS kept telling them that she was taking care of their dentures but never did. During an interview on 03/06/2025 at 10:31 AM, the DSS confirmed she was aware that Resident #54 had ill-fitting dentures, but stated she was not aware the resident's dental plan denied the claim for a new set of dentures for the resident. The DSS stated she followed up with the resident, but acknowledged she did not document such follow-up interaction. The DSS stated the facility did not have a dental care policy or procedure. During an interview on 03/06/2025 at 1:14 PM, the Dental Hygienist (DH) stated Resident #54 informed her on 09/14/2024 that their lower partial denture was ill fitting. The DH stated she reported the resident's concern to the dentist and even tried to put the resident's dentures in, but the dentures would not go into the resident's mouth. During an interview on 03/06/2025 at 1:28 PM, the dental Office Manager (OM) stated the dentist examined Resident #54 on 09/14/2024 and determined the resident needed a new set of dentures. The OM stated a denial for new dentures from the state insurance company was received 09/30/2024 and this information was conveyed to the DSS on 10/01/2024. During an interview on 03/06/2025 at 1:47 PM, the Administrator stated that was the first time she heard about Resident #54 not having lower dentures that fit. The Administrator stated her expectation was if something was denied there was follow-up with the resident and possibly offer a personal dentist or ask what the resident would like. Per the Administrator, the DSS should have followed up with Resident #54. During an interview on 03/06/2025 at 2:05 PM, the Director of Nursing stated usually social services coordinated dental.

Based on observation, interview, record review, and facility policy review, the facility failed to: implement enhanced barrier precautions for 1 (Resident #34) of 1 sampled resident reviewed for tube feeding; perform hand hygiene when gloves were removed during the provision of care for 1 (Resident #29) of 1 sampled resident reviewed for pressure ulcer/injury and 1 (Resident #34) of 1 sampled resident reviewed for tube feeding; and store respiratory equipment for 1 (Resident #24) of 4 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, Enhanced Standard (Barrier) Precautions, last reviewed 01/30/2025, indicated, Policy: The facility will implement Enhanced Standard Precautions (ESP), also known as Enhanced Barrier Precautions (EBP), when performing any direct patient care where close body contact presents the potential of transmitting known or unknown organisms. Definitions: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The policy specified, 1. Enhanced Standard (Barrier) Precautions (ESP) are to be used in conjunction with standard precautions. 2. ESP expands the use of PPE (gown and gloves) during high-contact resident care activities that include: a. Dressing b. Bathing/showering c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. A facility policy titled, Hand Washing, reviewed 01/30/2025, indicated, 1. All personnel shall follow our established hand washing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. 2. Appropriate 20 to 30 second handwashing must be performed under the following conditions: j. After removing gloves. The policy specified, 5. The use of gloves does not replace hand washing. 1. An Admission Record indicated the facility admitted Resident #34 on 12/22/2023. According to the Admission Record, the resident had a medical history that included diagnoses of dysphagia following a cerebrovascular disease and gastrostomy status. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #34's Care Plan Report, included a focus area initiated 12/27/2023, that indicated the resident had a need for enteral feeding. Resident #34's Order Summary Report with active orders as of 03/06/2025, revealed an order dated 01/27/2025, for gastrostomy tube dressing that instructed staff to cleanse the area, pat dry, apply 2 x 2 split antimicrobial dressing and secure with retention ring, then a split gauze secured with paper tape every dayshift. During a concurrent observation and interview on 03/03/2025 at 1:37 PM, Certified Nursing Assistant (CNA) #1 entered Resident #34's room and stated she was about to change the resident's incontinence brief. CNA #1 did not wear a gown when she provided care to the resident. During a concurrent observation and interview on 03/05/2025 at 10:05 AM, Licensed Vocational Nurse (LVN) #3 and LVN #4 entered Resident #34's room to change the resident's gastrostomy tube. LVN #3 and LVN #4 did not wear a gown. Once LVN #4 removed the dressing from around Resident #34's gastrostomy site, she discarded her gloves and put on a pair of clean gloves, without first performing hand hygiene. During an interview on 03/05/2025 at 10:10 AM, both LVN #3 and LVN #4 stated they should have worn a gown when they provided care for the resident. During an interview on 03/05/2025 at 2:24 PM, LVN #4 stated hand hygiene should be performed whenever she changed her gloves. LVN #4 confirmed that she did not perform hand hygiene when she changed her gloves during wound care for Resident #34 but should have. During an interview on 03/06/2025 at 11:25 AM, the Infection Preventionist (IP) stated EBP should be used for any resident with a catheter, wound, central lines and a feeding tube. The IP stated staff should wear a mask and gown if they were to provide a resident on EBP with a wound dressing change, a bath, a shower, incontinence care, and hygiene. According to the IP, staff should have worn a gown and gloves when they provided care to Resident #34. During an interview on 03/06/2025 at 11:39 AM, the Director of Nursing (DON) stated EBP should be used on any residents with an invasive line, a feeding tube, or a wound that required care. The DON stated staff should wear gloves, and a gown and hand hygiene should occur before staff put on gloves and whenever gloves were removed prior to new gloves being put on. During an interview on 03/06/2025 at 11:51 AM, the Administrator stated any resident that had a wound or line in their body, like a catheter or feeding tube, the staff should wear a gown and gloves every time they went in the room to provide care. Per the Administrator, hand hygiene should occur before and after and in between glove changes. 2. An Admission Record indicated the facility readmitted Resident #29 on 08/08/2022. According to the Admission Record, the resident had a medical history that included a diagnosis of displaced spiral fracture of the shaft of the right tibia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2025, revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had one unstageable pressure injury that presented as a deep tissue injury. Resident #29's Care Plan Report, included a focus area initiated 12/05/2024, that indicated the resident had a skin integrity issue related to the right heel deep tissue injury. Interventions directed staff to complete the treatment as ordered on scheduled days; keep the dressing clean, dry, and intact; and monitor of signs of infection. Resident #29's Order Summary Report with active orders as of 03/05/2025, revealed an order dated 01/09/2025, that directed the staff to clean the resident's right heel deep tissue pressure injury with sterile water, pat dry, apply providone iodine Betadine soak gauze on areas with eschar, cover with abdominal pad, wrap with kerlix then an elastic bandage wrap every day and as needed for soiling. During an observation on 03/05/2025 at 2:30 PM, Licensed Vocational Nurse (LVN) #2 removed her gloves and put on a pair of clean gloves, without performing hand hygiene during the provision of wound care for Resident #29. During an interview on 03/05/2025 at 2:37 PM, LVN #2 stated hand hygiene should occur before and after gloves are changed. LVN #2 confirmed he did not perform hand hygiene when he removed his gloves but should have. During an interview on 03/06/2025 at 11:39 AM, the Director of Nursing stated hand hygiene should occur before staff put on gloves and whenever gloves were removed prior to new gloves being put on. During an interview on 03/06/2025 at 11:51 AM, the Administrator stated hand hygiene should occur before and after and in between glove changes. 46258 3. An Admission Record revealed the facility admitted Resident #24 on 06/11/2016. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and dementia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2024, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #24 utilized a non-invasive mechanical ventilator. Resident #24's care plan included a focus area initiated 12/18/2024, that indicated the resident's breathing patterns were impaired due to COPD. Interventions directed staff to administer medication as ordered (initiated 06/27/2023). Resident #24's Order Summary Report, with active orders as of 03/06/2025, revealed an order dated 07/30/2024, for continuous positive airway pressure (CPAP) every evening and night shift. There was also an order dated 08/09/2024, for budesonide suspension 0.5 milligram/2 milliliters, inhale one vial orally by way of a nebulizer two times a day for COPD. During an observation on 03/03/2025 at 10:31 AM, the surveyor noted a CPAP mask lying on its side on top of the machine in Resident #24's room and a nebulizer mask on the resident's bedside table in the upward position. The CPAP and nebulizer mask were not in use and not stored in a bag. During an observation on 03/04/2025 at 3:39 PM, the surveyor noted a CPAP mask lying on top of the machine in Resident #24's room and a nebulizer mask lying on the bedside table. The CPAP and nebulizer mask were not in use and not stored in a bag. During an observation on 03/05/2025 at 9:09 AM, the surveyor noted a CPAP mask lying on top of the CPAP machine in Resident #24's room. The CPAP mask was not in use and not stored in a bag. During a concurrent observation and interview on 03/05/2025 at 9:13 AM, Licensed Vocational Nurse (LVN) #2 stated both a nebulizer mask and a CPAP mask must be stored in a bag when not in use. LVN #2 entered Resident #24's room and acknowledged the resident's CPAP mask was not in use and not stored in a bag. During an interview on 03/05/2025 at 2:25 PM, LVN #6 stated a CPAP mask should be stored in a bag after each use. During an interview on 03/05/2025 at 4:24 PM, the Administrator stated the facility did not have a policy that referenced how respiratory equipment should be stored. During an interview on 03/06/2025 at 9:07 AM, the Infection Preventionist stated masks should be stored in a black infection prevention bag after each use as it helped to prevent infections. During an interview on 03/06/2025 at 1:03 PM, the Director of Nursing stated masks should be stored in a bag when not in use to prevent infections. During an interview on 03/06/2025 at 1:17 PM, the Administrator stated she did not know the procedure, but if the expectation was the masks should be cleaned and stored in a bag after each use, then that was what should happen.

Based on interview, record review, and facility policy review, the facility failed to address and make prompt efforts to resolve complaint allegation for one (Resident 1) of three sampled residents when facility did not thoroughly investigate and provide timely response to Resident 1 ' s allegation that Certified Nursing Assistant (CNA1) dragged and bumped his right foot into a wall while pushing him in wheelchair. This failure had the potential to cause Resident 1 emotional distress. Findings: During a review of Resident 1's Admission-Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 10/3/24, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. MDS indicated Resident 1 was able to recall the correct year, month and day of the week. Resident 1 had clear speech, able to express ideas and wants, and understood others. MDS indicated Resident 1 does not use a wheelchair and/or scooter. Resident 1 had limitation in range of motion to lower extremity. Resident 1 diagnoses included heart failure (when heart cannot pump of fill adequately) and muscle wasting and atrophy. During an interview on 1/16/25 at 11:09 a.m. with Rehabilitation Director/Occupational Therapy Assistant (OTA1), OTA 1 stated the Occupational Therapist (OT) informed OTA1 that while CNA1 pushed Resident 1 out of weight room Resident 1 ' s right foot on leg rest bumped into the door frame. OTA1 stated incident was discussed with Director of Nursing (DON) and mentioned during facility ' s daily stand up meeting. During an interview on 1/16/25 at 11:34 a.m. with CNA1, CNA1 stated DON informed CNA1 that Resident 1 alleged that CNA1 bumped Resident 1 ' s right foot into the doorway while pushing Resident 1 out of weight room. CNA1 stated she knew that Resident 1 ' s right foot did not hit the wall or door frame because Resident 1 ' s wheelchair had foot rest attached. During an interview on 1/16/25 at 12:04 p.m. with Occupational Therapy (OT), OT stated OT observed CNA1 push Resident 1 out of weight room while OT held the door opened. OT stated she observed Resident 1 ' s wheelchair right foot rest bumped and hit the corner of the wall by door frame. OT stated she did not observed the actual right foot hit or bumped the wall or door frame. OT stated Resident 1 complained that right foot hit the wall. OT stated she immediately notified OTA1. During a concurrent interview and record review on 1/16/25 at 12:10 p.m. with DON , DON stated Resident 1 ' s daughter/responsible party (RP) complained to DON that Resident 1 alleged CNA1 dragged and bumped Resident 1 ' s right leg on door frame. DON stated CNA1 was interviewed and CNA1 denied Resident 1 right foot was bumped on door frame. DON stated he did not interview the witness or complete investigation because he believed CNA1. Resident 1 ' s progress notes, care plans, incident report log, facility ' s policy and procedure (P&P) titled, Grievance were reviewed. DON stated he was unable to find documentation if facility followed up with Resident 1 or RP complaint allegation. DON stated he did not document complaint allegation in Resident ' s 1 medical records. DON stated he was busy and forget about Resident 1 ' s complaint. DON stated he did not follow up with Resident 1 ' s RP regarding complaint allegation. During a review of the facility ' s policy and procedure (P&P) titled, Grievance Policy and Procedure, dated 11/2016, the P&P indicated, [NAME] Healthcare Center believes that it is your right to an accessible procedure, which protects your ability to speak up your concerns. You can expect your complaints to be addressed promptly and fairly. You have the right: To voice either orally in writing, concerns and complaints relating to the treatment or care we provided or the behavior of other residents; To receive a timely response by us in which we agree to consider the issues you raise and to act upon; and To be free from any pressure intended to discourage you from voicing your concerns or complaints. Based on interview, record review, and facility policy review, the facility failed to address and make prompt efforts to resolve complaint allegation for one (Resident 1) of three sampled residents when facility did not thoroughly investigate and provide timely response to Resident 1's allegation that Certified Nursing Assistant (CNA1) dragged and bumped his right foot into a wall while pushing him in wheelchair. This failure had the potential to cause Resident 1 emotional distress. Findings: During a review of Resident 1's Admission-Minimum Data Set (MDS - a federally mandated resident assessment and care guide tool), dated 10/3/24, the MDS indicated Resident 1's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 15 and indicated intact mental status. MDS indicated Resident 1 was able to recall the correct year, month and day of the week. Resident 1 had clear speech, able to express ideas and wants, and understood others. MDS indicated Resident 1 does not use a wheelchair and/or scooter. Resident 1 had limitation in range of motion to lower extremity. Resident 1 diagnoses included heart failure (when heart cannot pump of fill adequately) and muscle wasting and atrophy. During an interview on 1/16/25 at 11:09 a.m. with Rehabilitation Director/Occupational Therapy Assistant (OTA1), OTA 1 stated the Occupational Therapist (OT) informed OTA1 that while CNA1 pushed Resident 1 out of weight room Resident 1's right foot on leg rest bumped into the door frame. OTA1 stated incident was discussed with Director of Nursing (DON) and mentioned during facility's daily stand up meeting. During an interview on 1/16/25 at 11:34 a.m. with CNA1, CNA1 stated DON informed CNA1 that Resident 1 alleged that CNA1 bumped Resident 1's right foot into the doorway while pushing Resident 1 out of weight room. CNA1 stated she knew that Resident 1's right foot did not hit the wall or door frame because Resident 1's wheelchair had foot rest attached. During an interview on 1/16/25 at 12:04 p.m. with Occupational Therapy (OT), OT stated OT observed CNA1 push Resident 1 out of weight room while OT held the door opened. OT stated she observed Resident 1's wheelchair right foot rest bumped and hit the corner of the wall by door frame. OT stated she did not observed the actual right foot hit or bumped the wall or door frame. OT stated Resident 1 complained that right foot hit the wall. OT stated she immediately notified OTA1. During a concurrent interview and record review on 1/16/25 at 12:10 p.m. with DON , DON stated Resident 1's daughter/responsible party (RP) complained to DON that Resident 1 alleged CNA1 dragged and bumped Resident 1's right leg on door frame. DON stated CNA1 was interviewed and CNA1 denied Resident 1 right foot was bumped on door frame. DON stated he did not interview the witness or complete investigation because he believed CNA1. Resident 1's progress notes, care plans, incident report log, facility's policy and procedure (P&P) titled, Grievance were reviewed. DON stated he was unable to find documentation if facility followed up with Resident 1 or RP complaint allegation. DON stated he did not document complaint allegation in Resident's 1 medical records. DON stated he was busy and forget about Resident 1's complaint. DON stated he did not follow up with Resident 1's RP regarding complaint allegation. During a review of the facility's policy and procedure (P&P) titled, Grievance Policy and Procedure, dated 11/2016, the P&P indicated, [NAME] Healthcare Center believes that it is your right to an accessible procedure, which protects your ability to speak up your concerns. You can expect your complaints to be addressed promptly and fairly. You have the right: To voice either orally in writing, concerns and complaints relating to the treatment or care we provided or the behavior of other residents; To receive a timely response by us in which we agree to consider the issues you raise and to act upon; and To be free from any pressure intended to discourage you from voicing your concerns or complaints.

Based on interview and record review, the facility failed to ensure a licensed vocational nurse (LVN 1) administered medication accurately and safely to one of two sampled residents (Resident 1) according to the physician orders when Bengay cream (used to treat minor aches and pains of the muscles/joints) was administered instead of a skin barrier cream on Resident 1 ' s moisture associated skin damage (a form of incontinence-associated dermatitis, which is inflammation of the skin from extended exposure to urine or stool). This failure resulted in pain and discomfort for Resident 1. Findings: A review of the Admission Record for Resident 1 indicated Resident 1 was initially admitted in March 2018 with diagnoses that included dementia, diabetes, asthma, and osteoarthritis. A review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 8/14/24, indicated a score of 3 on her Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information.) indicating severe cognitive impairment. The MDS for Resident 1 ' s skin conditions indicated Moisture Associated Skin Damage (MASD) (e.g. incontinence-associated dermatitis (IAD), perspiration, drainage). During an interview on 8/27/24 at 1:35 p.m. with Director of Nursing (DON), DON stated LVN 1 had a medication error by administering Bengay cream on Resident 1. DON stated Coloplast Critic-Aid cream, a barrier cream, was supposed to be applied on Resident 1. During a telephone interview on 8/27/24 at 5:18 p.m. with LVN 1, LVN 1 confirmed that he made an error of wrong medication to Resident 1. LVN 1 stated he handed Bengay cream instead of the barrier cream to CNA 1 to apply on Resident 1 ' s skin on her buttocks, while CNA 1 and another CNA were changing Resident 1. LVN 1 stated he was present there during the time. LVN 1 stated Resident 1 experienced pain and burning sensation in the buttock area. LVN 1 stated he knew afterwards that it was Bengay cream that was applied on Resident 1 instead of the barrier cream (Coloplast critic-aid). During a telephone interview on 8/28/24 at 9:20 a.m. with CNA 1, CNA 1 stated while she was changing Resident 1 with the help of another CNA on 8/8/24 after dinner, LVN 1 gave her the cream in a medicine cup to apply on Resident 1 ' s skin. CNA 1 stated she put the cream on Resident ' s groin area, then she smelt something like menthol, then Resident 1 complained of burning in that area. CNA 1 stated she asked LVN 1 what the cream was. LVN 1 stated they found out it was Bengay cream, but it was supposed to be the barrier cream. During a review of Resident 1 ' s Order Summary Report, dated active orders as of 8/27/24, the Order Summary Report indicated Moisture Associated Skin Dermatitis on sacrococcygeal region (tailbone area), gluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum), opposing medial buttock region: Apply Coloplast Critic-Aid barrier cream every shift and as needed for episodes of incontinence (May apply Clotrimazole 1% antifungal cream on natal/gluteal cleft for skin erythema) . order date 6/4/24. The Order Summary Report indicated Bengay (ultra strength external cream 4-10-30% (Camphor-menthol-methyl salicylate). Apply to both knees and shoulders topically every 6 hours as needed for pain related to primary osteoarthritis, left shoulder, right ankle, and foot, left ankle and foot. During a review of the Medication Error Report. dated 8/8/24, the Medication Error Report indicated Bengay external topical cream was given to Resident 1 instead of Coloplast Critic-Aid barrier cream as ordered, and this caused Resident 1 pain/burning sensation in the affected area. During a review of the facility ' s policy and procedure (P&P), titled, Administration of Medication, undated, the P&P indicated, The policy .is that medications will be administered by licensed nurses as ordered by the resident ' s physician .Residents shall receive their medications . and in accordance with our established policies .The same person preparing the doses for administration must administer medications.

Based on interview and record review the facility failed to initiate and implement person-centered care plans for one resident (Resident 1) of three sampled residents when the facility: 1. Did not initiate a care plan when Resident 1 obtained Moisture-Associated Skin Damage (MASD); 2. Did not implement interventions to prevent Resident 1 from obtaining a pressure injury (damage to skin because of continuous pressure); and, 3. Did not initiate a care plan when Resident 1 obtained a facility acquired Stage 3 pressure injury on the sacrococcygeal (the area between the hip bone on a person ' s back and the tailbone) region. These failures resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin). Findings: 1. A review of an admission record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnosis which included rheumatic tricuspid insufficiency (a heart condition caused by infection in which the valve between two heart chambers does not close properly resulting in the heart working harder than it should), chronic combined systolic and diastolic heart failure (a condition in which the heart does not pump blood as well as it should) , and pulmonary hypertension (high blood pressure in the arteries and lungs). A review of Resident 1 ' s order summary report indicated the physician ' s order, [All] Care plan read and approved by MD [physician] .[ordered on] 6/27/23 . A review of Resident 1 ' s progress note dated 6/28/23 at 3:54 p.m. indicated, Admission Braden Scale [a tool used to predict pressure injury risk] of 11 [a score of 10-12 is high risk of developing a pressure injury]. A review of Resident 1 ' s care plan for, Bowel/bladder incontinence [unable to control bowel/bladder] related to cognitive [the thought process] loss, decreased awareness of urge was initiated on 6/28/23. Staff were to provide, .perineal [area between the anus and the vulva] care AM [in the morning], PM [in the afternoon/evening], and after each incontinence .[to assist Resident 1 to meet the goal of] .free of skin breakdown x 90 days [by] 10/1/23 . A review of Resident 1 ' s care plan for, Potential for skin breakdown related to history of skin breakdown, [history] of bruises or skin tears due to fragile skin, incontinence, others was initiated 6/28/23. Staff were to provide, .incontinence care as needed .monitor for discoloration, bruises, swelling, skin tears or redness and report promptly .pressure relieving mattress as needed .treatment as ordered .turn and reposition frequently as needed .[to assist Resident 1 to meet the goal of] Have less skin tears or bruises x90 days .will be healed .no bruises or skin tears x90 days by [10/1/23] . A review of Resident 1 ' s order summary report indicated the following physician ' s orders: Skin protection for incontinence associated dermatitis [skin inflammation] on sacrococcygeal region, gluteal cleft [the groove between the buttocks], opposing medial buttock region: Apply [moisture barrier ointment] every shift [starting on 6/28/23] .[and] as needed [starting on 6/28/23] . Turn and reposition as needed off load from pressure areas. Observe decubitus [lying down] areas every shift and notify MD for skin discoloration .every shift [starting on] 6/28/23 . A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 7/3/23 indicated, Resident has pressure .injury, a scar over bony prominence, or a non-removable dressing/device .[facility chose] No .Does this resident have one or more unhealed pressure .injuries? .[facility chose] No . A review of progress notes dated 7/7/23 at 11:15 a.m., 7/13/23 at 11:15 a.m., 7/21/23 at 12:46 p.m., and 7/28/24 at 1:03 p.m. indicated a Braden Scale (a tool to predict pressure injury risk) score of 12 which indicated Resident 1 was at high risk for developing a pressure injury. A review of Resident 1 ' s progress note dated 8/6/23 at 1:07 a.m. indicated, .MASD on coccyx sacral [sacrococcygeal] area . A review of all of Resident 1 ' s care plans between 6/27/23 to 11/20/23 showed no documented evidence a care plan for MASD was initiated after the discovery of MASD. In an interview and concurrent record review on 3/5/24 at 4:15 p.m., the Wound Nurse (WN) confirmed Resident 1 developed MASD during her stay at the facility. The WN also confirmed he was unable to find a care plan initiated for Resident 1 ' s MASD. 2. A review of Resident 1 ' s order summary report indicated the following physician order, Eroded skin lesion/Open wound on sacrococcygeal region combined with [MASD] Treatment Order: Apply .hydrophilic wound dressing paste [a paste used to keep a wound protected from moisture] .3x [three times] per day and as needed for episodes of incontinence. Paste should be applied after every stool and does not need to be scrub [sic] off completely. After stooling, remove soiled part of cream with wet cloth or wet gauze, avoid scrubbing. Notify MD for progression. (Only apply on areas with eroded/ open lesions) every shift .[starting on 9/11/23 .[and] as needed .starting on 9/11/23 . A review of Resident 1 ' s progress note dated 9/23/23 at 6:09 a.m. indicated, .eroded skin lesion to sacrococcygeal region combined with MASD . A review of Resident 1 ' s progress notes dated 7/23/23 to 10/12/23 indicated 178 incidences Resident 1 was documented as, Stayed in bed .[or] In bed . There was no documented evidence in these progress notes Resident 1 had been turned and repositioned every two hours as indicated in the care plan for her potential for skin breakdown. In an interview and record review of Resident 1 ' s medical chart on 3/5/24 at 4:15 p.m., the WN confirmed Resident 1 did not have a pressure injury upon admission to the facility. The WN also confirmed Resident 1 did not have a low air-loss (LAL) mattress (a type of pressure relieving mattress). The WN stated Resident 1 ' s MASD was, profuse eroded skin on the sacral area. There was no measurable depth .the wound was a Stage 2 [a partial-thickness skin loss involving the outer most layer of the skin and/ or the dermis layer which contains nerve endings, sweat glands and oil glands, hair follicles, and blood vessels]. In an interview and record review on 3/5/24 at 4:30 p.m., the Director of Nursing (DON) confirmed Resident 1 was on a regular mattress, not on a LAL mattress. The DON also confirmed Resident 1 ' s care plan indicated, pressure relieving mattress as an intervention. The DON stated an order for a pressure relieving mattress should have been obtained from the physician and applied for the resident. The DON verified the only order placed for Resident 1 ' s LAL mattress was upon discharge. The DON also stated he expected nursing staff to turn and reposition residents every two hours and to provide incontinence care as soon as possible to prevent the development of pressure injuries. 3. A review of Resident 1 ' s progress note dated 10/1/23 at 4:13 p.m. indicated, Sacral with open area, with scant red drainage, pink in color . A review of Resident 1 ' s progress note dated 10/30/23 at 11:19 a.m. indicated, .Open Wound on sacrococcygeal region, measurement 1.5x2x0.1cm [centimeter, a unit of measure] combined with [MASD] .Continue same treatment as ordered . A review of Resident 1 ' s order summary report indicated, Stage 3 coccyx [injury] Treatment Order: Cleanse with NSS [normal saline, a cleaning solution] Pat dry, Apply [Brand Name] barrier film on peri-wound [the area surrounding the wound] areas, calcium alginate [a substance used to assist in wound healing] impregnated with [leptospermum honey which helps with wound healing] on wound bed then secure with [foam dressing] every day .in the morning .and [as needed] soiling .[starting on] 11/16/23 . A review of Resident 1 ' s progress note dated 11/18/23 at 11:30 a.m. indicated, Coccygeal [tailbone area] eroded skin reclassified by [physician] to Stage 3 pressure injury 2x3 cm in size/ progressing . A review of Resident 1 ' s discharge summary dated 11/17/23 at 3:25 p.m. indicated, .Resident was admitted to [facility] for skilled services. During her stay there .developed an open area on her coccyx while in house. A review of Resident 1 ' s MDS dated [DATE] indicated, Resident has a pressure .injury, a scar over bony prominence, or a non-removable dressing/device .[facility chose] Yes .Does this resident have one or more unhealed pressure .injuries? .[facility chose] Yes .Number of Stage 3 pressure [injuries] .1 . In an interview on 3/5/24 at 4:15 p.m., the WN confirmed there was no documented evidence of a care plan for Resident 1 ' s Stage 3 sacrococcygeal wound in her medical chart. In a telephone interview and concurrent record review on 4/30/24 at 3:30 p.m., the DON confirmed there was no care plan for Resident 1 ' s Stage 3 sacrococcygeal wound in her medical chart. The DON stated a care plan should have been initiated for each skin concern. A review of the facility ' s undated policy and procedure titled Prevention of Pressure [Injuries] indicated, Protect against adverse effects of external mechanical forces: friction, shear and pressure .Systematically reposition and turn frequently while in bed .Pressure reduction devices (i.e. mattresses) should be considered for bed-bound/ chair-bound residents. Apply pressure-reducing mattress or air mattress to bed upon admission . A review of the facility ' s undated policy and procedure titled Treatment of Pressure [Injuries] indicated, Residents with pressure [injuries] can expect to maintain and/or improve skin integrity .Care planning must be provided by licensed nursing personnel .Implementation may include other caregivers under the direction of the Nursing Supervisor and MDS Coordinator .At the time any stage II, III, IV [injury] is first identified .Initiate a plan of care including reassessment interval .Monitor response to treatment [with every] dressing change or according to plan of care and document changes in wound status .At least every 7 days, evaluate [injuries] in plan of care as indicated .Implement measures for minimize of pressure [injuries] .Position resident off pressure [injuries] .

Based on interview and record review the facility failed to ensure care provided met professional standards of care for one resident (Resident 1) of three sampled residents when: 1. Nursing staff did not weigh Resident 1 per physician ' s orders; 2. Nursing staff did not get Resident 1 out of bed as ordered by the physician; 3. Nursing staff did not implement or initiate care plans as Resident 1 ' s wound continued to worsen; and, 4. There was no oversight of Resident 1 ' s worsening wound on the sacrococcygeal region (the backside area between a person ' s hips and down to the tailbone). This failure resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin). Findings: 1. A review of an admission record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnosis which included rheumatic tricuspid insufficiency (a heart condition caused by infection in which the valve between two heart chambers does not close properly resulting in the heart working harder than it should), chronic combined systolic and diastolic heart failure (a condition in which the heart does not pump blood as well as it should) , and pulmonary hypertension (high blood pressure in the arteries and lungs). A review of Resident 1 ' s order summary report indicated the following physician ' s orders: -Weekly weights every day shift every Wednesday [starting on] 6/28/23 . -Weigh weekly one time a day every Fri [starting on] 7/7/23 . -Weigh weekly in the morning every Tue [starting on] 8/8/23 . -Weekly weights x4. Please weight [sic] on 9/14/23 every day shift every Thu for 1 month [starting on] 9/14/23 . A review of Resident 1 ' s weights and vitals summary indicated Resident 1 was not weighed on the following dates: -Wednesday, 6/28/23 -Wednesday, 7/5/23 -Friday, 7/8/23 -Tuesday, 8/8/23 -Tuesday, 8/15/23 -Tuesday, 8/29/23 -Tuesday, 9/5/23 -Tuesday, 9/12/23 -Thursday, 9/14/23 -and Thursday 10/5/23. In a telephone interview and concurrent record review of Resident 1 ' s physician ' s orders and documented weights on 4/30/24 at 3:30 p.m., the Director of Nursing (DON) confirmed Resident 1 ' s physician ' s orders and verified Resident 1 was not weighed as ordered by the physician. 2. A review of Resident 1 ' s order summary report indicated Resident 1 had the following physician ' s orders, .resident lacks decision making capacity- surrogate decision maker is .daughter .[ordered on] 6/27/23 .Care plan read and approved by MD [physician] .[ordered on] 6/27/23 .[and] Activity program has been approved and is not in conflict with treatment plan .[ordered on] 6/27/23 . A review of Resident 1 ' s care plan initiated on 3/28/23 for, Cognitive loss related to confusion .[and] decreased mental status indicated staff was to, Encourage [Resident 1] to attend activities as offered. A review of social service progress notes dated 7/3/23, 7/10/23, and 8/7/23 indicated Resident 1 was cooperative, communicative, and motivated. A review of Resident 1 ' s order summary report indicated the physician ' s order, Resident has capacity to understand rights and nature and consequences of proposed treatment .[facility chose] No .[ordered on] 8/5/23 . A review of Resident 1 ' s order summary report indicated the physician ' s order, Out of bed to chair for meals every shift .[starting on] 9/21/23 . A review of Resident 1 ' s progress notes dated 7/23/23 to 10/12/23 indicated 178 incidences Resident 1 was documented as, Stayed in bed .[or] In bed . There was no documented evidence in these progress notes Resident 1 had been taken out of bed for every meal. A review of Resident 1 ' s care plan regarding Activities of Daily Living (ADL, activities related to personal care such as getting out of bed), initiated on 10/13/23 indicated staff were to, .Encourage independence with assistance in order for Resident 1 to meet her goal of, .will be out of bed daily as tolerated x90 days . A review of Resident 1 ' s order summary report indicated the physician ' s order, Up in wheelchair for at least 4 hours a day reposition in bed/wheelchair [every] 2 hours .every 2 hours .[starting on 10/26/23] . In a telephone interview and concurrent record review on 4/30/24 at 3:30 p.m., the DON confirmed Resident 1 ' s nursing progress notes dated 7/23/23 to 10/12/23 did not indicate Resident 1 was mobilized out of bed during the morning and afternoon/evening shifts. The DON stated he expected nursing staff to mobilize residents out of bed. In an interview on 5/2/24 at 2 p.m., the DON stated he would obtain nursing progress notes dated 10/18/23 to 11/15/23 to provide the surveyor. The DON did not provide the nursing progress notes. 3. A review of Resident 1 ' s care plan for, Potential for skin breakdown related to history of skin breakdown, [history] of bruises or skin tears due to fragile skin, incontinence, others was initiated 6/28/23. Staff were to provide, .incontinence care as needed .monitor for discoloration, bruises, swelling, skin tears or redness and report promptly .pressure relieving mattress as needed .treatment as ordered .turn and reposition frequently as needed .[to assist Resident 1 to meet the goal of] Have less skin tears or bruises x90 days .will be healed .no bruises or skin tears x90 days by [10/1/23] . A review of Resident 1 ' s order summary report indicated the following physician ' s orders: Skin protection for incontinence associated dermatitis on sacrococcygeal region, gluteal cleft, opposing medial buttock region: Apply [moisture barrier ointment] every shift [starting on 6/28/23] .[and] as needed [starting on 6/28/23] . Turn and reposition as needed off load from pressure areas. Observe decubitus [lying down] areas every shift and notify MD for skin discoloration .every shift [starting on] 6/28/23 . A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 7/3/23 indicated, Resident has pressure .injury, a scar over bony prominence, or a non-removable dressing/device .[facility chose] No .Does this resident have one or more unhealed pressure .injuries? .[facility chose] No . A review of a progress note dated 8/6/23 at 1:07 a.m. indicated, .MASD [Moisture-Associated Skin Damage] on coccyx sacral area . A review of all of Resident 1 ' s care plans between 6/27/23 to 11/20/23 showed no documented evidence a care plan for MASD was initiated after the discovery of MASD. A review of Resident 1 ' s order summary report indicated the following physician order, Eroded skin lesion/Open wound on sacrococcygeal region combined with [MASD] Treatment Order: Apply .hydrophilic wound dressing paste [a paste used to keep a wound protected from moisture] .3x [three times] per day and as needed for episodes of incontinence. Paste should be applied after every stool and does not need to be scrub [sic] off completely. After stooling, remove soiled part of cream with wet cloth or wet gauze, avoid scrubbing. Notify MD for progression. (Only apply on areas with eroded/ open lesions) every shift .[starting on 9/11/23 .[and] as needed .starting on 9/11/23 . A review of Resident 1 ' s progress note dated 9/23/23 at 6:09 a.m. indicated, .eroded skin lesion to sacrococcygeal region combined with MASD . A review of Resident 1 ' s progress note dated 10/1/23 at 4:13 p.m. indicated, Sacral with open area, with scant red drainage, pink in color . A review of Resident 1 ' s progress note dated 10/30/23 at 11:19 a.m. indicated, .Open Wound on sacrococcygeal region, measurement 1.5x2x0.1cm combined with [MASD] .Continue same treatment as ordered . A review of Resident 1 ' s order summary report indicated, Stage 3 coccyx [injury] Treatment Order: Cleanse with NSS [normal saline, a cleaning solution] Pat dry, Apply [Brand Name] barrier film on peri-wound areas, calcium alginate impregnated with [leptospermum honey which helps with wound healing] on wound bed then secure with [foam dressing] every day .in the morning .and [as needed] soiling .[starting on] 11/16/23 . A review of Resident 1 ' s progress note dated 11/18/23 at 11:30 a.m. indicated, Coccygeal eroded skin reclassified by [physician] to Stage 3 pressure injury 2x3 cm in size/ progressing . A review of Resident 1 ' s discharge summary dated 11/17/23 at 3:25 p.m. indicated, .Resident was admitted to [facility] for skilled services. During her stay there .developed an open area on her coccyx while in house. A review of Resident 1 ' s MDS dated [DATE] indicated, Resident has a pressure .injury, a scar over bony prominence, or a non-removable dressing/device .[facility chose] Yes .Does this resident have one or more unhealed pressure .injuries? .[facility chose] Yes .Number of Stage 3 pressure [injuries] .1 . In an interview and concurrent record review on 3/5/24 at 4:15 p.m., the Wound Nurse (WN) confirmed Resident 1 did not have a pressure injury upon admission to the facility. The WN also confirmed Resident 1 did not have a low air-loss (LAL) mattress and Resident 1 developed MASD during her stay at the facility. The WN also confirmed he was unable to find a care plan initiated for Resident 1 ' s MASD. The WN stated Resident 1 ' s MASD was, profuse eroded skin on the sacral area. There was no measurable depth .the wound was a Stage 2 [a partial-thickness skin loss involving the outer most layer of the skin and/ or the dermis layer which contains nerve endings, sweat glands and oil glands, hair follicles, and blood vessels]. The WN also verified there was no documented evidence of a care plan for Resident 1 ' s Stage 3 sacrococcygeal wound in her medical chart. In an interview and record review on 3/5/24 at 4:30 p.m., the Director of Nursing (DON) confirmed Resident 1 was on a regular mattress, not on a LAL mattress. The DON also confirmed Resident 1 ' s care plan indicated, pressure relieving mattress as an intervention. The DON verified Resident 1 did not have a care plan regarding MASD. In a telephone interview and concurrent record review on 4/30/24 at 3:30 p.m., the DON confirmed there was no care plan for Resident 1 ' s Stage 3 sacrococcygeal wound in her medical chart. The DON stated a care plan should have been initiated for each skin concern. 4. A review of Resident 1 ' s progress note dated 6/28/23 at 3:54 p.m., Admission Braden Scale [a tool used to predict pressure injury risk] of 11 [a score of 10-12 is high risk]. A review of progress notes dated 7/7/23 at 11:15 a.m., 7/13/23 at 11:15 a.m., 7/21/23 at 12:46 p.m., and 7/28/24 at 1:03 p.m. indicated a Braden Scale (a tool to predict pressure injury risk) score of 12 which indicated Resident 1 was at high risk for developing a pressure injury. There were no additional Braden scale assessments documented after 7/28/23. In an interview on 4/30/24 at 3:30 p.m., the DON stated the WN was responsible for assessing and documenting skin assessments. The DON confirmed no other nursing staff conducted wound treatment and stated the WN was responsible for ensuring residents who required a pressure relieving device or low air-loss mattress had one in place. The DON verified there was no nurse overseeing the WN ' s work. The DON also explained the facility did not have a specialized wound consultant. The DON stated the facility physician wrote orders for wound treatment and the WN carried them out. The DON stated an order for a pressure relieving mattress should have been obtained from the physician and applied for the resident. The DON verified the only order placed for Resident 1 ' s LAL mattress was upon discharge. In a telephone interview and concurrent record review on 5/3/24 at 12:15 p.m., the DON confirmed there was no additional Braden Scale assessments documented after 7/28/24. The DON verified the facility ' s policy indicated a Braden Scale assessment should have been conducted quarterly. A review of the facility ' s undated policy and procedure titled Prevention of Pressure [Injuries] indicated, Protect against adverse effects of external mechanical forces: friction, shear and pressure .Systematically reposition and turn frequently while in bed .Pressure reduction devices (i.e. mattresses) should be considered for bed-bound/ chair-bound residents. Apply pressure-reducing mattress or air mattress to bed upon admission . A review of the facility ' s undated policy and procedure titled Treatment of Pressure [Injuries] indicated, Residents with pressure [injuries] can expect to maintain and/or improve skin integrity through safe and timely assessment, treatment and education from qualified health care providers .Care planning must be provided by licensed nursing personnel, physical, occupational .therapist .and activity director as needed. Implementation may include other caregivers under the direction of the Nursing Supervisor and MDS Coordinator .At the time any stage II, III, IV [injury] is first identified .Notify physician and nutritional services and initiate the Skin Wound Record .Initiate a plan of care including reassessment interval .Monitor response to treatment [with every] dressing change or according to plan of care and document changes in wound status .At least every 7 days, evaluate ulcer as in plan of care as indicated .Implement measures for minimize of pressure [injuries] .Position resident off pressure ulcers .Standard Practice .Reassessment using the Braden Scale will be done quarterly. The nursing staff will implement strategies to minimize skin breakdown.

Based on interview and record review the facility failed to ensure one resident (Resident 1) of three sampled residents received care to prevent the development of a pressure injury (damage to skin because of continuous pressure) when Resident 1 developed a Stage 3 pressure injury on the sacrococcygeal (the area between the hip bone on person ' s back and the tailbone) region. This failure resulted in Resident 1 obtaining a facility acquired Stage 3 pressure injury (the loss of skin which extends to the tissue beneath the skin). Findings: A review of an admission record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses which included rheumatic tricuspid insufficiency (a heart condition in which the valve between two heart chambers does not close properly resulting in the heart working harder than it should), chronic combined systolic and diastolic heart failure (a condition in which the heart does not pump blood as well as it should) , and pulmonary hypertension (high blood pressure in the arteries and lungs). A review of Resident 1 ' s order summary report indicated the physician ' s order, [All] Care plan read and approved by MD [physician] .[ordered on] 6/27/23 . A review of Resident 1 ' s progress note dated 6/28/23 at 3:54 p.m. indicated, Admission Braden Scale [a tool used to predict pressure injury risk] of 11 [a score of 10-12 is high risk of developing a pressure injury]. A review of Resident 1 ' s care plan for, Bowel/bladder incontinence [unable to control bowel/bladder] related to cognitive loss [the thought process], decreased awareness of urge was initiated on 6/28/23. Staff were to provide, .perineal care [area between the anus and the vulva] care AM [in the morning], PM [in the afternoon/evening], and after each incontinence .[to assist Resident 1 to meet the goal of] .free of skin breakdown x 90 days [by] 10/1/23 . A review of Resident 1 ' s care plan for, Potential for skin breakdown related to history of skin breakdown, [history] of bruises or skin tears due to fragile skin, incontinence, others was initiated 6/28/23. Staff were to provide, .incontinence care as needed .monitor for discoloration, bruises, swelling, skin tears or redness and report promptly .pressure relieving mattress as needed .treatment as ordered .turn and reposition frequently as needed .[to assist Resident 1 to meet the goal of] Have less skin tears or bruises x90 days .will be healed .no bruises or skin tears x90 days by [10/1/23] . A review of Resident 1 ' s order summary report indicated the following physician ' s orders: Skin protection for incontinence associated dermatitis [skin inflammation] on sacrococcygeal region, gluteal cleft [the groove between the buttocks], opposing medial buttock region: Apply [moisture barrier ointment] every shift [starting on 6/28/23] .[and] as needed [starting on 6/28/23] . Turn and reposition as needed off load from pressure areas. Observe decubitus [lying down] areas every shift and notify MD for skin discoloration .every shift [starting on] 6/28/23 . A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 7/3/23 indicated, Resident has pressure .injury, a scar over bony prominence, or a non-removable dressing/device .[facility chose] No .Does this resident have one or more unhealed pressure .injuries? .[facility chose] No . A review of social service progress notes dated 7/3/23, 7/10/23, and 8/7/23 indicated Resident 1 was cooperative, communicative, and motivated. A review of progress notes dated 7/7/23 at 11:15 a.m., 7/13/23 at 11:15 a.m., 7/21/23 at 12:46 p.m., and 7/28/23 at 1:03 p.m. indicated a Braden Scale (a tool to predict pressure injury risk) score of 12 which indicated Resident 1 was at high risk for developing a pressure injury. There were no additional Braden scale assessments documented after 7/28/23. A review of Resident 1 ' s progress notes dated 7/23/23 to 10/12/23 indicated 178 incidences Resident 1 was documented as, Stayed in bed .[or] In bed . There was no documented evidence in these progress notes Resident 1 had been turned and repositioned every two hours as indicated in the care plan for her potential for skin breakdown. A review of Resident 1 ' s progress note dated 8/6/23 at 1:07 a.m. indicated, .MASD on coccyx sacral [sacrococcygeal] area . A review of Resident 1 ' s order summary report indicated the following physician order, Eroded skin lesion/Open wound on sacrococcygeal region combined with [MASD] Treatment Order: Apply .hydrophilic wound dressing paste [a paste used to keep a wound protected from moisture] .3x [three times] per day and as needed for episodes of incontinence. Paste should be applied after every stool and does not need to be scrub [sic] off completely. After stooling, remove soiled part of cream with wet cloth or wet gauze, avoid scrubbing. Notify MD for progression. (Only apply on areas with eroded/ open lesions) every shift .[starting on 9/11/23 .[and] as needed .starting on 9/11/23 . A review of Resident 1 ' s progress note dated 9/23/23 at 6:09 a.m. indicated, .eroded skin lesion to sacrococcygeal region combined with MASD . A review of Resident 1 ' s progress note dated 10/1/23 at 4:13 p.m. indicated, Sacral with open area, with scant red drainage, pink in color . A review of a progress note initiated on 10/13/23 indicated Resident 1 needed extensive assistance from staff for bed mobility, toilet use, and transfers from surface to surface. A review of Resident 1 ' s progress note dated 10/30/23 at 11:19 a.m. indicated, .Open Wound on sacrococcygeal region, measurement 1.5x2x0.1cm [centimeter, a unit of measure] combined with [MASD] .Continue same treatment as ordered . A review of Resident 1 ' s order summary report indicated, Stage 3 coccyx [injury] Treatment Order: Cleanse with NSS [normal saline, a cleaning solution] Pat dry, Apply [Brand Name] barrier film on peri-wound [the area surrounding the wound] areas, calcium alginate [a substance used to assist in wound healing] impregnated with [leptospermum honey which helps with wound healing] on wound bed then secure with [foam dressing] every day .in the morning .and [as needed] soiling .[starting on] 11/16/23 . A review of Resident 1 ' s discharge summary dated 11/17/23 at 3:25 p.m. indicated, .Resident was admitted to [facility] for skilled services. During her stay there .developed an open area on her coccyx while in house. A review of Resident 1 ' s progress note dated 11/18/23 at 11:30 a.m. indicated, Coccygeal eroded skin reclassified by [physician] to Stage 3 pressure injury 2x3 cm in size/ progressing . A review of Resident 1 ' s MDS dated [DATE] indicated, Resident has a pressure .injury, a scar over bony prominence, or a non-removable dressing/device .[facility chose] Yes .Does this resident have one or more unhealed pressure .injuries? .[facility chose] Yes .Number of Stage 3 pressure [injuries] .1 . In an interview and record review of Resident 1 ' s medical chart on 3/5/24 at 4:15 p.m., the WN confirmed Resident 1 did not have a pressure injury upon admission to the facility. The WN also confirmed Resident 1 did not have a low air-loss (LAL) mattress (a type of pressure relieving mattress). The WN stated Resident 1 ' s MASD was, profuse eroded skin on the sacral area. There was no measurable depth .the wound was a Stage 2 [a partial-thickness skin loss involving the outer most layer of the skin and/ or the dermis layer which contains nerve endings, sweat glands and oil glands, hair follicles, and blood vessels]. The WN further stated the physician assessed Resident 1 ' s wound and determined it had progressed to a Stage 3. In an interview and record review on 3/5/24 at 4:30 p.m., the Director of Nursing (DON) confirmed Resident 1 was on a regular mattress, not on a LAL mattress. The DON also confirmed Resident 1 ' s care plan indicated, pressure relieving mattress as an intervention. The DON stated an order for a pressure relieving mattress should have been obtained from the physician and applied for the resident. The DON verified the only order placed for Resident 1 ' s LAL mattress was upon discharge. The DON also stated he expected nursing staff to turn and reposition residents every two hours and to provide incontinence care as soon as possible to prevent the development of pressure injuries. In a telephone interview and concurrent record review on 4/30/24 at 3:30 p.m., the DON confirmed there was no care plan for Resident 1 ' s Stage 3 sacrococcygeal wound in her medical chart. The DON stated a care plan should have been initiated for each skin concern. In a telephone interview and concurrent record review on 5/3/24 at 12:15 p.m., the DON confirmed there was no additional Braden Scale assessments documented after 7/28/24. The DON verified the facility ' s policy indicated a Braden Scale assessment should have been conducted quarterly. A review of the facility ' s undated policy and procedure titled Prevention of Pressure [Injuries] indicated, Protect against adverse effects of external mechanical forces: friction, shear and pressure .Systematically reposition and turn frequently while in bed .Pressure reduction devices (i.e. mattresses) should be considered for bed-bound/ chair-bound residents. Apply pressure-reducing mattress or air mattress to bed upon admission . A review of the facility ' s undated policy and procedure titled Treatment of Pressure [Injuries] indicated, Residents with pressure [injuries] can expect to maintain and/or improve skin integrity .Care planning must be provided by licensed nursing personnel .Implementation may include other caregivers under the direction of the Nursing Supervisor and MDS Coordinator .At the time any stage II, III, IV [injury] is first identified .Initiate a plan of care including reassessment interval . Monitor response to treatment [with every] dressing change or according to plan of care and document changes in wound status .At least every 7 days, evaluate ulcer as in plan of care as indicated .Implement measures for minimize of pressure [injuries] .Position resident off pressure ulcers .It is the policy of the [facility] to complete a .reassessment using the Braden Scale will be done quarterly.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to notify and consult with the physician when Resident 1 had a change in condition. This failure had potentially resulted in delayed management of a change in health status. Findings: During a review of Resident 1's Order Summary Report dated 3/1/22, the Order Summary Report indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of the right thigh, elevated white blood cell count (WBC, blood component that fights infection), and diabetes mellitus. During a telephone interview on 8/30/23 at 8:13 a.m. with Family Member (FM) 1, FM 1 stated there was a big change in Resident 1's health condition during a visit at the facility on 3/18/22 that licensed nurses failed to see. FM 1 stated Resident 1 had refused to eat and was lethargic (sluggish). During an interview and concurrent record review on 8/30/23 at 12:06 p.m. with Director of Nursing (DON), Resident 1's Progress Notes dated 3/16/22 were reviewed. The Progress Notes indicated, on 3/16/22, at 1:56 p.m., Resident 1 refused the 1 p.m. scheduled medication. The progress notes also indicated Resident 1 reported not feeling well and that Resident 1 had stated feeling nauseous. Another progress note, also dated 3/16/22, at 2:10 p.m., indicated Resident 1 had refused weight assessment because [Resident 1] feels sick and not willing to get OOB (out of bed). DON stated Resident 1's feeling nauseated and not being able to get out of bed for the entire shift was a change of condition that warranted physician notification. DON stated Resident 1's clinical record did not indicate a physician notification. Further review of the progress notes indicated, on 3/17/22, Resident 1 continued to refuse to get out of bed. On 3/18/22, the progress notes indicated Resident 1's representative was at bedside and requested for Resident 1 to be transferred to the hospital via 911 after Resident 1 refused to eat dinner and was observed with confusion. During further review of Resident 1's Progress Notes from 3/16/22 to 3/18/22, the progress notes did not indicate Resident 1 or Resident 1's representatives were notified of the change in condition. During a review of Resident 1's Hospital Discharge Summary Notes dated 8/31/23, the Discharge Summary Notes indicated diagnoses that included severe sepsis with acute organ dysfunction, acute UTI (urinary tract infection), acute renal failure, metabolic acidosis (when too much acid builds up in the body, causes include build up of toxins and kidney failure, symptoms include nausea, vomiting, fast breathing and lethargy) and delirium (confused thinking and lack of awareness to surroundings) due to metabolic encephalopathy (disorder affecting brain function, caused by other severe health concerns like infection or organ failure). During a concurrent interview and record review on 8/30/23 at 1:23 p.m., with Director of Rehabilitation (DOR), Resident 1's Physical Therapy Encounter Note dated 3/16/22 was reviewed. DOR stated Resident 1 consistently participated with therapy until 3/16/22. The Physical Therapy Encounter Note indicated Resident 1 initially refused therapy due to nausea and abdominal discomfort. Resident 1 reported a vomiting episode earlier that morning. During a telephone interview on 8/30/23 at 12:50 p.m. with Registered Nurse (RN) 1, RN 1 stated if a resident who was admitted to the facility for rehabilitation/therapy was not seen walking around the facility because the resident was not feeling well, was nauseous and unable to eat, it should be identified as a change of condition that warrant physician notification. During a telephone interview on 9/8/23 at 1:07 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1's clinical record did not indicate the attending physician was notified of Resident 1's change in condition. LVN 1 stated, if the attending physician was notified, further assessment would have been requested by the physician to identify appropriate intervention. LVN 1 stated, being the liaison for the attending physician, the facility's communication process was to notify LVN 1 of any change in condition, and LVN 1 notifies the attending physician and obtains further instructions that will then be given back to whoever is the resident's charge nurse. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status last revised 1/19/23, the P&P indicated, to notify the resident and/or resident representative and resident's attending physician of the resident's change in condition and/or status. The policy also indicated, regardless of resident's mental or physical condition, nursing services will inform resident of any change in his/her medical care or nursing treatments and the nurse will document in the clinical record any changes in the resident's medical condition or status, in addition to a change of status report.

Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 was administered doxycycline (a prescription antibiotic, treats infection) with adequate monitoring of adverse effects from the medication. This failure had the potential to result in delayed management of adverse effects and unnecessary use of medication. Findings: During a review of Resident 1's Order Summary Report dated 3/1/22, the Order Summary Report indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of the right thigh and elevated white blood cell count (WBC, blood component that fights infection). The report also indicated Resident 1 received doxycycline monohydrate (antibiotic, treats infection) 100 milligram tablet one tablet every 12 hours. During a review of Resident 1's Medication Administration Record (MAR) for March 2022, the MAR indicated Resident 1 received doxycycline twice daily from 3/1/22 to 3/18/22. The MAR did not indicate licensed staff monitored Resident 1 for adverse effects. During a telephone interview on 8/30/23 at 8:13 a.m. with Family Member (FM) 1, FM 1 stated there was a big change in Resident 1's health condition during a visit at the facility on 3/18/22 that licensed nurses failed to see. FM 1 stated Resident 1 had refused to eat and was lethargic (sluggish). During a review of the Emergency Department Note dated 3/18/22, the Emergency Department Note indicated Resident 1 presented to the ED with nausea, vomiting and loose stools. During a review of Resident 1's Hospital Discharge Summary Notes dated 4/6/23, the Discharge Summary Notes indicated diagnoses that included severe sepsis with acute organ dysfunction, acute UTI (urinary tract infection), acute renal failure, metabolic acidosis (when too much acid builds up in the body, causes include build up of toxins and kidney failure, symptoms include nausea, vomiting, fast breathing and lethargy) and delirium (confused thinking and lack of awareness to surroundings) due to metabolic encephalopathy (disorder affecting brain function, caused by other severe health concerns like infection or organ failure). During an interview and concurrent record review on 8/30/23 at 12:06 p.m. with Director of Nursing (DON), Resident 1's Progress Notes dated 3/16/22 was reviewed. The Progress Note indicated, on 3/16/22, at 1:56 p.m., Resident 1 refused the 1 p.m. scheduled medication. The progress notes also indicated Resident 1 reported not feeling well and that Resident 1 had stated feeling nauseous. Another progress note, also dated 3/16/22, at 2:10 p.m., indicated Resident 1 had refused weight assessment because [Resident 1] feels sick and not willing to get OOB (out of bed). DON stated Resident 1's feeling nauseated and not being able to get out of bed for the entire shift was a change of condition that warranted physician notification. DON stated Resident 1's clinical record did not indicate a physician notification. Further review of the progress notes indicated, on 3/17/22, Resident 1 continued to refuse to get out of bed. On 3/18/22, the progress notes indicated Resident 1's representative was at bedside and requested for Resident 1 to be transferred to the hospital via 911 after Resident 1 refused to eat dinner and was observed with confusion. During a concurrent interview and record review on 8/30/23 at 1:40 p.m. with DON, Resident 1's care plans were reviewed. DON stated Resident 1's care plans did not address antibiotic use and its adverse effects. DON stated, when a resident is on antibiotics, especially doxycycline which is known to cause abdominal discomfort, the care plan should identify which adverse reactions the licensed staff should be watching out for and when to notify the physician. During a telephone interview on 9/8/23 at 3:16 p.m. with DON, DON stated there was no facility policy and procedure to address antibiotic use, but the procedure was for the charge nurse to document in the clinical record any signs and symptoms of adverse reactions from the antibiotic. DON stated documentation should cover the whole course of the antibiotic therapy. During a review of Daily Med (a nationally recognized publication of the National Institute of Health in the U.S. National Library of Medicine and includes references to drug information submitted to the Food and Drug Administration), when giving doxycycline to residents, adequate amounts of fluid along with capsule and tablet forms of drugs is recommended to wash down the drugs and reduce the risk of esophageal irritation and ulceration. Adverse reactions to doxycycline include anorexia (an eating disorder that could cause significant health risks), nausea, vomiting, diarrhea, dysphagia (difficulty swallowing) and rare instances of esophagitis (inflammation of the muscular tube that delivers food from the mouth to the stomach [esophagus]) and esophageal ulcerations.

Based on observation, interview, and record review, the facility failed to implement a fall prevention precaution for one of three residents (Resident 1) when there was no fall mattress (a padded floor mat) placed adjacent to Resident 1's bed to decrease the chance of injury from falls as indicated in the care plan. This failure resulted in Resident 1 receiving emergency room treatment after he sustained a laceration (a skin cut) above his left eyebrow, bruising of his left cheek, and a broken hip prosthesis (an artificial, surgical implant replacing the original body part) after he fell from his bed onto the floor. Findings: A review of Resident 1's undated Admission Record indicated Resident 1 was admitted to the facility in 2019 with a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities) and repeated falls. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/2/21, indicated Resident 1 required extensive physical assistance from at least one person for bed mobility, transfer between surfaces, and toilet use. The MDS indicated Resident 1 used a wheelchair for locomotion and was unsteady without assistance during transfer between surfaces, with impairment of both lower extremities. A review of Resident 1's facility document Quarterly Fall Risk Assessment, dated 4/2/21, indicated, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. The Quarterly Fall Risk Assessment indicated Resident 1 had a score of 12, an indication of high risk of falls. A review of Resident 1's care plan with the focus of, Potential for fall related to recent history of falls, Unsteady Gait, start date of 9/25/19, indicated an intervention, . mattress on the floor to keep resident safe as needed. A review of Resident 1's Nurses' Notes dated 6/19/21 at 9:31 a.m., indicated Resident 1 was found on the floor at 6 a.m., with, skin laceration top of his left eyebrow approx.[approximately] 2.5 cm. [centimeters, 2.5 cm equals 0.98 inches] long with slight bleeding and redness to left cheek. The Nurses' Notes indicated Resident 1 was lifted back into his bed with the assistance of three staff members, 9-1-1 was called, and Resident 1 went to the acute care hospital for further evaluation. During an interview on 7/26/21 at 12:45 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she was permanently assigned to care for Resident 1 on the night shift (the shift beginning at 11 p.m. and ending the next morning at 7:30 a.m.). CNA 1 stated during her last round of the shift on 6/19/21 she was changing Resident 1's adult brief when she realized she needed a new brief to replace the soiled brief. CNA 1 stated Resident 1 was in the middle of the bed, when she left the bedside and went to the sink cabinet to get another brief. CNA 1 stated when she turned around, Resident 1 was directly on the floor as there was no fall mattress on the floor. CNA 1 stated she called the charge nurse for assistance. During an interview on 7/19/21 at 1 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was called to Resident 1's room by CNA 1 on 6/19/21 at 6 a.m. LVN 2 stated when she entered the room Resident 1 was lying on his left side on the floor, as there was no fall mattress in place. LVN 2 stated she assessed Resident 1's condition, and noticed he was bleeding from a skin tear above his left eyebrow. LVN 2 stated Resident 1 then went to the acute care hospital for further evaluation. A review of Resident 1's acute care hospital, ED [Emergency Department] Provider Notes dated 6/19/21, indicated Resident 1 had a two-centimeter laceration above his eyebrow with a hematoma (a collection of blood under the skin, outside the blood vessels), which was treated with surgical skin glue to close the wound edges. The ED Provider Notes indicated, Patient had a pelvic x-ray with concern for acute fracture. A review of Resident 1's acute care hospital document, X-ray Pelvis AP, dated 6/19/21, indicated Resident 1 had a fractured left hip prosthesis. The ED Provider Notes indicated Resident 1 returned to the facility on [DATE]. A review of Resident 1's care plan with the focus of, Potential for fall related to recent history of falls, Unsteady Gait, start date of 9/25/19, indicated the last care plan review was completed 7/5/21, with the continued intervention .mattress on the floor to keep resident safe as needed, with no changes to the care plan. During a concurrent observation and interview on 7/7/21 at 10:10 a.m., with Licensed Vocation Nurse 1 (LVN 1), in Resident 1's room, there was no fall mattress on the floor at Resident 1's bedside. LVN 1 stated Resident 1's care plan indicated Resident 1 should have a fall mattress as part of his fall prevention interventions.

Based on observation, interviews, and record review, the facility failed to ensure that one (Resident 1) of three sampled residents received adequate supervision to prevent falls and failed to plan care to prevent future falls. Resident 1, who was unable to sustain an upright position in a wheelchair due to left sided contractures and weakness, was left unsupervised, sitting upright in a wheelchair by a therapist and fell face first onto the floor. According to ER report dated 11/19/14 Resident 1 sustained a fractured skull (CT scan showed left frontal skull fracture extending into the left frontal sinus and orbital roof) and a fractured elbow. Findings: According to the medical record, Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]." The complete resident assessment, dated 11/17/14, showed that Resident 1 required the extensive assistance of one staff for bed mobility, dressing and hygiene, assistance of two staff for transfer from bed to chair, for toilet use, and for bathing. It showed, "Moving from seated to standing- Only able to stabilize with staff assistance. Uses a wheelchair." Review of Resident 1's Fall Risk Assessments showed that on 10/27/14, the score was 10 and on 11/2/14, the score was 14. A score of 10 or more meant there was a high risk for falls. Review of a care plan, dated 10/27/14, showed "Impaired Cognition (thought process) related to stroke; Goal- Will understand simple statements and commands. Interventions- Encourage to attend activities, Minimize distractions, reality orient." A care plan, dated 10/28/14, showed, "Focus: Mobility deficit related to stroke and fall risk due to weakness and unsteady gait." A care plan, dated 10/31/14, showed "Preventing Falls." The interventions were "Keep call light nearby and monitor frequently." Review of nurses' notes, dated 10/27/14, showed, "Alert and forgetful. Sit upright for dinner. Fed by staff." A nursing note, dated 11/19/14, signed by RN 1, showed, "Notified to come to patient's room at 10:50 a.m. Noted patient lying prone (face down) on the floor with abrasion to the left forehead with minimal bleeding noted. Also noted abrasion on the left hand. Patient able to move right arm and leg. ...Patient complained of pain but unable to tell exactly where he is hurting. Called 911 and sent to hospital." Review of the hospital emergency department social worker's notes, dated 11/19/14, showed, "When his therapist went to get something..., patient fell forward from the wheelchair and hit his head. Per relative,..., who is at bedside, patient generally stoic about pain but reporting pain at level 8 (out of 10) in left wrist. Patient has a reclining wheelchair and has never fallen out of it. Relative described that it would not be possible to fall out of it when at a recline due to positioning and patient's [DIAGNOSES REDACTED]. Nonetheless, when speech therapy was working with patient and left patient alone, patient fell out of chair." Review of the hospital emergency department showed a skull fracture seen on a CT (computerized tomography) scan, extending into the left frontal sinus and orbital roof (eye area) and a left elbow fracture. During an interview and concurrent record review on 12/10/14 at 10:00 a.m., the Assistant Director of Nurses (ADON) stated, "I assessed him after the unwitnessed fall. He was sitting on the floor next to his reclining wheelchair. He was alert and giving one word answers. He tends to lean forward which makes him unsteady. A couple of days before the fall, family brought in the reclining wheelchair. He was sitting upright in our (facility) wheelchair before that and he didn't fall." ADON confirmed that no new interventions or information was added to the fall prevention care plan after the 11/19/14 fall. During interview on 12/10/14 at 10:30 a.m., the Director of Nurses (DON) stated, "We did not do an investigation because we knew why he fell . She left him at a ninety degree angle and he always falls when he is sitting upright. We found this out after he fell ." During interview on 12/10/14 at 11:30 a.m., RN 1 stated, "The nursing assistant called me and I was at the desk. I saw him face down on the floor next to the wheelchair. The seat back was reclined, tilted back, greater than 90 degrees. I assessed him and saw bleeding, so I called 911. I didn't write anything on the care plan regarding preventing future falls. We know he is at high risk for falls." During observation and interview on 12/10/14 at 2:20 p.m., Resident 1 was sitting in an upright position in his bed. He stared straight ahead and stated, "I hurt. My arm." A splint was on his left forearm which was elevated on a pillow. During a phone interview on 12/26/14 at 10:35 a.m., the Speech Therapist (ST) stated, "He had been in physical therapy before he came to me. We went to his room for oral care before I started to test swallowing deficits. He had an NG tube (naso-gastic tube inserted through the nostril into the stomach for liquid food, fluids and medication) but the family wanted him to be able to eat for pleasure. I ran out of the room to grab a towel when he started drooling. He was leaning back a little when I left him. I went back into the room with a CNA who heard him fall. I wasn't aware of any precautions or that he shouldn't be left alone. I didn't check with anyone about whether he could be left alone."