Every finding on record at Vacaville Ranch Post Acute

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:1. Several metal sheet pans in clean and ready-to-use storage areas:a. Were stacked wet while stored awayb. Had food debris and brown substance on outside surface; 2. There were opened bags of food items in dry storage, refrigerator, and freezer with issues:a. 12 opened bottles of spices did not have a use by dateb. One opened bin of chicken soup base did not have a use by date c .One opened loaf of bread did not have a use by dated. Four pallets of bread did not have a receive date e. One package of thawed country fried steak did not have a pull datef. One opened box of frozen beef patties did not have an open or use by dateg .One opened package of frozen cookie dough had an illegible open and use by date 3. The ice machine was not clean; and, 4. The concentration of the sanitizer solution for the sanitation (red) bucket was not in range. These failures had potential to cause food-borne illness in a highly susceptible population of 47 out of 47 residents who received food from the kitchen.Findings:1. During an initial tour concurrent observation and interview with the Dietary Manger (DM) and the Registered Dietician (RD) on 8/5/25 at 8:57 a.m. at the kitchen, several metal sheet pans stored at the clean and ready-to-use storage areas were observed stacked wet, had food debris, and brown substance. The metal pans included:-2 full sheet pans (wet)-2 full sheet pans (food debris and brown substance outside)The RD confirmed the metal sheet pans were wet, had food debris, and brown substance. The RD stated the pans should have been completely air-dried and clean before being stored away. During an interview on 8/7/25 at 1:41 p.m. with RD, RD stated the expectation was for pans to be clean, dry and free from debris. RD acknowledged there was a risk for bacteria and food contamination when pans were stored wet and dirty. During a review of the facility's policy and procedure (P&P) titled, Dish and Utensil Procedure, revised 3/3/2020, the P&P indicated, .dishes, trays, and utensils shall be routinely checked for stains or spots.shall be air dried before storage.any.tray.with debris should not be used. Send back to the dish room to be properly washed and sanitized.2. During a concurrent observation and interview with DM and RD on 8/5/25 at 9:00 a.m. at the kitchen's initial tour, 12 opened bottles of spices did not have a use by date ,one opened bin of chicken soup base did not have a use by date, one opened loaf of bread did not have a use by date, and four pallets of bread did not have a receive date. RD confirmed the food items were not labeled with a receive or use by date. RD acknowledged opened packages of food should have been labeled with a use by date and bread should have been labeled with a receive date. During an initial tour concurrent observation and interview with DM and RD on 8/5/25 at 9:11 a.m., at the kitchen, one package of thawed country fried steak did not have a pulled date (date food was removed from freezer for thawing). RD confirmed the food items were not labeled with a pull date. RD acknowledged food pulled from freezer for thawing should have been labeled with a pull date. During an initial tour concurrent observation and interview with DM and RD on 8/5/25 at 9:17 a.m., at the kitchen, one opened box of frozen beef patties did not have an open or use by date, and one opened package of frozen cookie dough had an illegible open and use by date. RD confirmed the food items were not labeled with open or used by date. RD acknowledged opened packages of food should have been labeled with open or use by date.During an interview on 8/7/25 at 1:41 p.m. with RD, RD stated the expectation was for food to be labeled with received, open, pull, and use by dates. RD further stated there was a risk for expired foods being served to residents when food was not labeled correctly. During a review of the facility's P&P titled, Food Storage revised 7/11/24, the P&P indicated, .All products should be.dated upon receipt, when open, and when prepared.Use Use-By dates on all foods stored.Frozen Meat/Poultry and Foods.label and date all food items.date when meat was taken out of freezer.Dry Storage.any opened products.should be labeled and dated.label and date all storage containers or bins. 3. During a concurrent inspection and interview on 8/5/25, at 11:30 a.m., with Maintenance Supervisor (MS) of the ice machine, MS stated he was responsible for the weekly cleaning and sanitizing of the ice machine. The MS removed the top access panel. There was a slimy grey substance on the upper right portion of the water curtain (a plastic cover rest on the ice making panel of the top machinery component, the function is to prevent ice shooting out and redirect the ice to the ice storage bin). MS confirmed there was a slimy grey substance (dirty, not clean) on the water curtain. During an interview on 8/7/25 at 1:41 p.m. with RD, RD stated the expectation was for the ice machine to be clean. RD further acknowledged there was a risk for residents to receive contaminated ice when the ice machine components were not clean. During a review of the facility's P&P titled, Ice Machine revised 10/18/2018, the P&P indicated, .Weekly.wash inside of the machine.make sure door liner, door gasket, and door frame are free of scale and/or mold.Ice Machine Cleaning Schedule.Clean inside of the ice machine.per manufacturer's instructions.According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae). 4. During a concurrent observation and interview on 8/6/25 at 8:36 a.m. with Dietary Aide (DA) 1 and DM, DA 1 checked the concentration levels of the red sanitizing bucket and it was at 0 ppm. DM stated the facility used Quat (Quaternary ammonium solution) as a disinfectant in the red sanitizing bucket. DM further stated the concentration range for red sanitizing bucket should have been 200-400 ppm. DM further stated there was a risk for cross contamination of bacteria when the Quat concentration was not within range. During an interview on 8/7/25 at 1:41 p.m. with RD, RD stated the expectation was for red sanitizing bucket to have appropriate disinfectant concentration. RD acknowledged there was a risk for food borne illness when the red sanitizing bucket was not within recommended FDA ranges. During a review of the facility's P&P titled, Sanitizer Use Concentrations for Food Service and Food Production Facilities revised 4/30/2020, the P&P indicated,.Use chemical sanitizers in accordance with the EPA-registered label.Sanitation buckets must be established with appropriate sanitizing solution.for quaternary solution, 150-400 ppm; or 200 ppm depending on the product.

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage for a census of 47, when garbage dumpsters were left uncovered. This failure had the potential to expose the facility to pests, disease, and odors.Findings:During a concurrent observation and interview on 8/6/25 at 8:43 a.m., with Dietary Manager (DM), two facility garbage dumpsters did not have a lid on and were open. DM confirmed the lids were open and should have been closed.During an interview on 8/7/25 at 1:41 p.m. with Registered Dietician (RD), RD stated the expectation was for the dumpster garbage lids to be closed. RD further stated there was a risk for contamination in the facility when the dumpster garbage lids were left open.During a review of the facility's policy and procedure (P&P) titled Garbage and Trashcans revised 05/20/2020, the P&P indicated, .All food waste must be placed in covered garbage and trashcans.the dumpster area must be free of debris.and the lid must be closed.

Based on observation, interview and record review the facility failed to follow guidelines for Enhanced Barrier Precaution (EBP, an infection prevention and control intervention and guidance on what and how to properly wear the PPE, [personal protective equipment]) to reduce transmission of multi-drug-resistant organisms) that utilize the use of gowns and gloves during direct care activities for three of 17 sampled residents (Resident 4, Resident 43 and Resident 29) when:1. Licensed Nurse (LN) 3 and Infection Preventionist (IP) did not wear gowns and gloves when they turned Resident 4 to her side;2. Physical Therapy (PT) staff did not wear a gown and gloves when he brought Resident 43 to the gym and back to her room; and,3. Certified Nursing Assistant (CNA) 2 and Physical Therapy staff did not wear gowns and gloves with Resident 29.These failures had the potential to spread multi-drug resistant organisms (MDRO's, bacteria that resist treatment with more than one antibiotic) among residents, staff and visitors. Findings: 1. During a review of Resident 4's admission Record (AR), the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnosis that included Pressure-Induced Deep Tissue Damage of Left Heel (severe types of pressure injury that appeared on the heel), and Diabetes (disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 4's “Order Summary” report dated 7/24/25, indicated, Resident 4 had a Catheter (urinary catheter - a tube designed to stay in the bladder and drain the urine). During a review of Resident 4's “Order Summary report,” dated 8/4/25, indicated, “…left heel pressure ulcer…” During an observation on 8/6/25 at 8:20 a.m., in Resident 4's room, there was an EBP signage posted by the door. The EBP signage indicated to wear gloves and a gown for “High-Contact Resident Care Activities.” LN 3 and IP were observed not wearing gowns and gloves as indicated on the signage, as they touched and assisted Resident 4 to turn on her side. During an interview with LN 3, on 8/6/25 at 10:40 a.m., LN 3 confirmed that Resident 4 had a Foley Catheter and a wound to left heel which was an indicator to practice EBP to promote infection prevention. LN 3 acknowledged she did wear a gown and gloves when she helped the IP turn Resident 4 to her side. LN 3 stated she should have worn a gown and gloves while rendering direct care to Resident 4. During an interview with the IP on 8/6/25 at 11:35 a.m., the IP stated her responsibility is to educate the facility staff about infection control prevention and conduct in-services such as EBP guidelines. The IP confirmed Resident 4 was on EBP. The IP acknowledged she did not wear a gown when they turned Resident 4 to her side, and the IP explained that she should have worn a gown to prevent the spread of infection. The IP stated that she was embarrassed of her actions as she is the IP of the facility. 2. During a review of Resident 43's AR , the AR indicated, Resident 43 was admitted to the facility on [DATE] with diagnosis that included Sepsis (a life-threatening condition, If not treated it may lead to organ failure, and death), and Osteomyelitis (infection of the bone caused by bacteria, treatment requires a medical consult and antibiotics and sometimes surgery). During a review of Resident 43's “Order Summary,” dated 7/18/25, indicated, “PICC (peripherally inserted central catheter, long, thin, flexible tube inserted into a vein. Used to administer medications) to right upper extremity,” During a review of Resident 43's “Order Summary,” dated 8/4/25, indicated, “Vancomycin (antibiotic) HCL (hydrogen chloride, a solution of hydrogen chloride in water) 650 mg (milligram, dosage) intravenously (through PICC) two times a day related to osteomyelitis. During a concurrent observation and interview with the PT, on 8/5/25 at 9:26 a.m., Resident 43 was seated in her wheelchair as the PT pushed the wheelchair back to her room and assisted Resident 43 transfer to her bed. The PT stated he picked up Resident 43 from her room and took her to the small gym via wheelchair to do leg, arms and strengthening exercises. The PT acknowledged Resident 43 was on EBP, and he did not wear a gown and gloves while assisting Resident 43. The PT further stated, he should have worn a gown and gloves to prevent contamination to keep the residents safe. During an interview with the Director of Nursing (DON), on 8/7/25 at 1:45 p.m., the DON stated, she expected the staff to always practice infection control to avoid the spread of infection. The DON continued, LN 3 and the IP should have worn gowns and gloves when rendering direct nursing care to residents with EBP for safety reasons. The DON expected the IP to be knowledgeable in promoting infection control to the facility staff. 3. During a review of Resident 29's admission Record, indicated, Resident 29 was admitted to the facility in May 2025 with multiple diagnoses that included neuromuscular dysfunction of bladder (nerves controlling the bladder are damaged or not working correctly) and dementia (a progressive state of decline in mental abilities). During an observation on 8/6/25 at 12:00 p.m. outside of Resident 29's room, a sign was posted by above resident name card by the door which indicated, Enhanced Barrier Precaution (EBP). During a concurrent observation and interview on 8/6/25 at 12:05 p.m. in Resident 29's room, CNA 2 and PT entered Resident 29's room without putting on gown and gloves. CNA 2 and PT were observed not wearing gowns or gloves while transferring Resident 29 from bed to wheelchair. PT observed to push Resident 29 to the hallway and CNA 2 started changing bed linens. CNA 2 confirmed that they did not wear gowns and gloves when assisting and transferring Resident 29 to bed. During a concurrent EBP document review and interview on 8/6/25 at 3:15 p.m. with Infection Control (IP), the IP confirmed that Resident 29 was on EBP precautions for foley catheter and open wounds. IP stated that provider and staff must wear gowns and gloves during high contact resident care activities such as transferring and changing linens. IP further stated staff need to wear gowns and gloves to prevent the spread of multi-drug-resistant bacteria on staff clothes to other residents. During a review of the facility's policy and procedures titled “Enhanced Barrier Precautions,” revised June 2024, indicated, “… Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents…EBPs employ targeted gown and glove use during high contact resident care activities… Staff are trained to care for residents on EBPs . Enhanced standard precautions (ESPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO's) to residents .high contact care activities requiring the use of gown and gloves for EBP's include…transferring .changing linens …EBPs are indicated .for residents with wounds and/or indwelling medical devices .

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed for the therapeutic diet for lunch on 8/6/25 when:1. 12 residents (Resident 5, Resident 6, Resident 9, Resident 15, Resident 18, Resident 21, Resident 29, Resident 31, Resident 35, Resident 39, Resident 41, and Resident 48) who were on a Mechanical Soft/Soft and Bite sized diet (a diet for people with mild to moderate chewing and/or swallowing difficulty) received whole green beans instead of soft and chopped green beans and hard bread instead of soft and buttered bread as indicated on the menu; and,2. Four residents (Resident 16, Resident 30, Resident 40, and Resident 57) who were on a Pureed diet (a diet for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) received 2.07 oz (ounces -unit of measure) serving of garlic bread instead of 2.78 oz serving of garlic bread as indicated on the menu.These failures had the potential to result in compromising the medical and nutrition status of the 16 residents.Findings: During an observation of lunch meal service on 8/6/25 beginning at 11:50 a.m., it was noted as follows:1. Resident 5, Resident 6, Resident 9, Resident 15, Resident 18, Resident 21, Resident 29, Resident 31, Resident 35, Resident 39, Resident 41, and Resident 48 who were on a Mechanical Soft/Soft and Bite sized diet did not receive soft and chopped green beans or soft and buttered bread respectively. A concurrent review of the facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, Daily Spreadsheet, Wednesday, indicated that Mechanical Soft/Soft and Bite sized diet should have received herbed whole green beans as soft and chopped and garlic bread as soft and buttered. 2. Resident 16, Resident 30, Resident 40, and Resident 57 who were on a pureed diet, received 2.07 oz serving of garlic bread. A concurrent review of the facility spreadsheet titled, Daily Spreadsheet, Wednesday indicated that pureed diet should have received 2.78 oz serving of garlic bread.During an interview on 8/7/25 at 1:41 p.m. with the Registered Dietician (RD), the RD acknowledged the issues that were found during meal service. The RD stated, residents should have received food items as they were reflected on the menu. The RD further stated there was a risk for residents' nutrition to be affected when the menu was not followed. During a review the facility's policy and procedure (P&P) titled, Cycle Menus revised 3/27/24, the P&P indicated, .Menus meet the daily requirements of the Food and Nutrition Board.Menus must be followed as written with exception for when ethnic, cultural, geographic, or religious preferences of the residents require a substitution.During a review of facility document and job description, titled Cook, revised 9/21/2018, the job description indicated, .Specific responsibilities.ensure appropriate portioned servings according to portion control standards and recipes.

Based on interview and record review, the facility failed to ensure 14 of 17 sampled residents (Resident 16, Resident 30, Resident 32, Resident 37, Resident 43, Resident 60, Resident 4, Resident 57, Resident 58, Resident 59, Resident 2, Resident 6, Resident 9, and Resident 29) were offered an advance directive (a legal document where a competent adult specifies their future medical care wishes in the event they cannot communicate them themselves, often due to illness or injury).This failure had the potential to result in the residents' medical wishes not being honored.Findings: During a record review of Resident 16's admission Record (AR), Resident 16 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (a condition where the blood flow to the parts of the brain is blocked, causing tissue damage to the brain), Unspecified dementia (a condition characterized by a progressive decline in cognitive functions, such as memory, thinking, language, judgment, and behavior). During a record review of Resident 30's AR, Resident 30 was admitted on [DATE] with diagnoses including Anoxic Brain Damage (brain damage occurs when the brain is deprived of oxygen), Aphasia (a neurological condition that affects a person's ability to communicate or speak). Review of Resident 16's and Resident 30's medical records, indicated there were no completed Advanced Directive (AD) documents found in Resident 16 and Resident 30's electronic medical records, nor in the physical medical records charts. During an interview with the Social Services Director (SSD) on 8/06/25 at 10:50 a.m., the SSD confirmed the ADs were asked for from the residents or family members upon admission. If there were no ADs completed, the resident or family member would be offered an AD and if they need assistance in completing one, the SSD stated she would help the resident or family. After reviewing the medical records of both Resident 16 and Resident 30, the SSD confirmed there were no Advanced Directive documents on file for Resident 16 and Resident 30. The SSD confirmed she had no documentation the residents or family were offered the services to complete the Advanced Directive documents. During an interview with the Licensed Nurse 4 (LN 4) on 8/8/25 at 7:41 a.m., LN 4 stated if there were no completed Advanced Directive, then the SSD would be notified and the SSD will get in touch with the resident or the resident's Responsible Party (RP, an individual or entity that has the authority and duty to manage and control a specific situation, asset, or area, and is accountable for the outcomes) to see if they would need assistance in completing an Advanced Directive. During an interview with the Director of Nursing (DON) on 8/8/25 at 8 a.m., the DON stated residents who were admitted without an Advanced Directive were referred to the SSD for follow up in obtaining and completing an Advanced Directive document. The SSD will assist in completing an Advanced Directive A review of Resident 32's admission Record (AR), the AR indicated Resident 32 was admitted to the facility on [DATE], with diagnosis that included dementia (decline in mental ability), and history of falling. A review of Resident 37's AR, the AR indicated Resident 37 was admitted to the facility on [DATE], with diagnosis that included depression and anxiety disorder. A review of Resident 43's AR, the AR indicated Resident 43 was admitted to the facility on [DATE] with diagnosis that included sepsis (a life-threatening condition, If not treated it may lead to organ failure, and death), and osteomyelitis (infection of the bone caused by bacteria, treatment requires a medical consult and antibiotics and sometimes surgery). A review of Resident 60's AR, the AR indicated Resident 60 was admitted to the facility on [DATE], with diagnosis that included Heart Failure (also known as congestive heart failure, a condition where the heart can't pump enough blood to meet the body's needs), and insomnia (a common sleep disorder characterized by persistent difficulty falling or staying asleep). During a concurrent interview and record review with the Social Services Director (SSD) on 8/6/25 at 10:55 a.m., the SSD reviewed the resident's electronic chart and physical charts and stated Resident 32, Resident 37, Resident 43 and Resident 60 did not have Advance Directives (AD) in their respective charts. During a review of Resident 4's admission record (AR), the AR indicated Resident 4 was admitted in July 2025 with several diagnosis including seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 57's AR, the AR indicated Resident 57 was admitted in June 2025 with several diagnosis including metabolic encephalopathy (a condition where brain dysfunction occurs due to a chemical imbalance in the body, often triggered by systemic illnesses or organ dysfunction). During a review of Resident 58's AR, the AR indicated Resident 58 was admitted in August 2025 with several diagnosis including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 59's AR, the AR indicated Resident 59 was admitted in August 2025 with several diagnosis including fracture of left rib. During a review of Resident 4's, Resident 57's, Resident 58's, and Resident 59 ‘s clinical records, the clinical records did not have an advance directive or documentation that indicated an advance directive was offered. During a concurrent interview and record review on 8/8/25 at 9:05 a.m. with Social Services Director (SSD), SSD confirmed Resident 4, Resident 57, Resident 58, and Resident 59 did not have an advance directive or documentation that indicated an advance directive was offered. SSD stated the expectation was for advance directives to be offered at admission. SSD further stated there should have been documentation that indicated an advance directive was offered if residents did not have an advance directive. SSD further stated there was a risk for residents' medical wishes to be unclear when an advance directive was not available. During a review of Resident 2's admission record (AR), the AR indicated Resident 2 was admitted in April 2020 with several diagnosis including chronic respiratory failure (a chronic lung disease causing difficulty in breathing) and muscle weakness. During a review of Resident 6's AR, the AR indicated Resident 6 was admitted to the facility on [DATE] with a diagnosis including Heart Failure (heart failure – the heart is unable to pump blood around the body properly). During a review of Resident 9's AR the AR indicated Resident 9 was admitted in April 2024 with a diagnosis of cerebral infarction (loss of blood flow to a part of the brain). During a review of Resident 29's AR, the AR indicated Resident 29 was admitted [DATE] with multiple diagnoses that included neuromuscular dysfunction of bladder ( nerves controlling the bladder are damaged or not working correctly) and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's, Resident 6's, Resident 9's, and Resident 29 ‘s clinical records, the clinical records did not have an advance directive or documented evidence that indicated an advance directive was offered. During a concurrent interview and record review on 8/8/25 at 1 p.m. with Social Services Director (SSD), SSD confirmed Resident 2, Resident 6, Resident 9, and Resident 29 did not have an advance directive or documentation that indicated an advance directive was offered. SSD stated the expectation was for advance directives to be offered at admission and follow up documentation. During a review of the facility's policy and procedure (P&P) titled, “Advance Directives” revised December 2016, the P&P indicated .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .Written information will include a description of the facility's policies to implement advance directives and applicable state law .Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advanced directives .Information about whether or not the resident has executed an Advanced Directive shall be displayed prominently in the medical record .If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .The resident will be given the option to accept to accept or decline the assistance, and care will not be contingent on either decision… Nursing staff will document in the medical record…the offer to assist and the resident's decision to accept or decline assistance… plan of care for reach resident will be consistent with…advance directive…”

Based on observation, interview and record review, the facility failed to ensure discharged /discontinued controlled medications (substances that have the potential for abuse and addiction and are therefore regulated by law) were jointly counted by the outgoing nurse and an oncoming nurse. This failure had the potential for diversion (obtain or use of prescription medicines such as controlled medications illegally), medication errors, and/or misuse of controlled medications in the facility.During a concurrent observation and interview on 8/5/25 at 10:45 a.m. with Licensed Nurse (LN) 2 of medication carts for A hall and part of B hall, LN 2 unlocked the narcotic box that contained active (active means, in-patient narcotic medications) and discharged /discontinued narcotic medications. LN 2 stated, the outgoing night shift nurse and herself counted the active narcotic medications but did not count the discharged /discontinued narcotic medications. Observed, bubble pack (unit dose packaging, to organize medications into individual doses, typically sealed in compartments with protective bubbles) for the discharged /discontinued narcotic medications that did not have the narcotic count sheet attached as required in the policy and procedures. LN 2 was unable to explain how they can prevent diversion, ensure patient safety and maintain an accurate accounting of the discharged /discontinued controlled substances if they did not perform medication reconciliation during shift change. During an interview on 8/6/25 at 3:45 p.m., with the Director of Nursing (DON), the DON stated nurses must count the active and discharged /discontinued narcotic medications, as there should be an accountability for everyone's' safety. The DON stated that the outgoing nurse and an oncoming nurse must count the physical medications together, documented and signed in the Narcotic Count Sheet to avoid possible drug diversion. A review of the facility's policy and procedure, titled Controlled Medication Storage, effective date March 2018, indicated, Medication included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. D. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on the controlled medication accountability record. All discontinued and expired drugs are counted until they can be transferred to the director of nursing.

Based on observation, interview and record review, the facility failed to ensure care received for two of 17 sampled residents (Resident 58 and Resident 29) met professional standards, when:1) Nursing staff did not notify the physician of Resident 58's fluid imbalance; and2) Nursing staff did not document Resident 29's left heel wound accurately and completely. These failures had the potential to result in Resident 58 having fluid overload, electrolyte imbalance, or urinary retention and Resident 29's left heel to worsen. Findings: 1) During a review of Resident 58's admission record (AR), the AR indicated Resident 58 was admitted to the facility in August 2025 with multiple diagnosis including atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls). During a review of Resident 58's physician orders, dated 8/5/25, the physician orders indicated Resident 58 had a foley catheter (a flexible, sterile tube inserted into the bladder to drain urine) due to urinary retention (the inability to completely empty the bladder). During a review of Resident 58's Input and Output record (I/O record - a log used in healthcare to track all fluids a patient consumes [intake] and eliminates from the body [output] over a specific time, such as 24 hours), the I/O record indicated the following: On 8/3/25, input was 890 ml (milliliter- a unit of measurement), output was 150 ml, On 8/4/25, input was 900 ml, output was 360 ml, On 8/5/25, input was 810 ml, output was 200 ml, and On 8/7/25, input was 1250 ml, output was 625 ml. During a review of Resident 58's clinical record, the clinical record indicated no documented evidence of any notes indicating a physician was notified of Resident 58's fluid imbalance. During a concurrent interview and record review on 8/7/25 at 1:10 p.m. with Director of Nursing (DON), the DON confirmed Resident 58's input and output record indicated a fluid imbalance. The DON confirmed a physician was not notified of Resident 58's fluid imbalance and follow up was not done. The DON stated the expectation was for staff to notify the physician of any changes to resident's condition including a fluid imbalance. The DON further stated there was a risk for urinary retention, decreased kidney function and urinary tract infection when the physician was not notified of Resident 58's fluid imbalance. During a review of the facility's policy and procedure (P&P) titled “Catheter Care, Urinary” revised September 2014, the P&P indicated, “…Input/Output…Observe the resident's urine level for noticeable increases or decreases…report it to the physician or supervisor…” During a review of the undated document titled, “Nursing Practice Act Rules and Regulations, “the document indicated, “Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following: (1) Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures.” (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing- Stated of California Department of Consumer Affairs). 2) During a review of Resident 29's admission Record indicated, Resident 29 was admitted to the facility in May 2025 with multiple diagnoses that included dementia (a progressive state of decline in mental abilities) and severe protein calorie malnutrition (calorie and protein intake are inadequate). During an observation on 8/6/25 at 11:53 a.m. in Resident 29's room, Resident 29 had eyes closed lying on his right side on a low air loss mattress (designed to distribute the body's weight over a broad surface and help prevent skin breakdown) with 6 pillows on the bed and positioned under his heels. During a record review of Resident 29's Order Summary Report (OSR), dated 8/8/25, Resident 29 had a wound treatment, indicated, “TX [treatment] LEFT HEEL: DTI [Deep tissue injury] clean with NS [normal saline], pat dry, apply betadine, cover with foam dressing, every day and evening shift for pressure injury [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence ] until resolved.” During a record review of Resident 29's Skin & Wound Evaluation, dated 6/14/25 and 7/19/25 respectively, Resident 29 had a left malleolus (ankle bone) stage 1- pressure injury (unbroken skin redness - intact skin with persistent, non-blanchable redness over a bony prominence, meaning the area of redness will not turn white when pressed, even when the pressure is removed.) During a record review of Resident 29's Skin and Wound Evaluation (assessment), dated 7/19/25, 7/28/25, 8/1/25, 8/4/25, and 8/8/25 respectively, indicated, the skin assessments were not completed and filled out by Licensed Nurse (LN) 5. During a concurrent interview and record review with LN 5 on 8/8/25 at 9:13 a.m., LN 5 confirmed Resident 29's original left malleolus wound location on 6/14/25 was documented wrong and was changed to the left heel on 7/19/25. LN 5 further confirmed documentation was inaccurate and incomplete on the Skin and Wound Evaluation assessments. LN 5 also confirmed the wound had worsened while Resident 29 was in the facility. During an interview with the Director of Nursing (DON) on 8/8/25 at 10:30 a.m., the DON stated the expectation for the licensed nurses is to document in all categories of the Skin and Wound Evaluation assessments. The DON confirmed LN 5 did not have a wound certification as part of continuing education. The DON further confirmed all the assessments were incomplete. During a review of the facility's policy and procedures (P&P) titled, Prevention of Pressure Ulcers/Injuries, revised July 2017, the P&P indicated, Conduct a comprehensive skin assessment…evaluate, report and document potential changes in the skin…” During a review of American Nurse's Association document titled “ANA's Principles for Nursing Documentation Guidance for Registered Nurses (https://www.nursingworld.org/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf), dated 2010, indicated “Principle 1. Documentation Characteristics…high quality documentation is: clear, concise and complete…reflective of the nursing process…Principle 5. Documentation Entries…the health record…must be: accurate, valid and complete…”

Based on interview and record review, the facility failed to ensure a written notice of bed-hold at the time of transfer was provided for two of 17 sampled residents (Resident 54 and Resident 6).This failure resulted in Resident 6 and Resident 54 not being fully informed about bed-hold options and rights.Findings: During a review of admission Record (AR) indicated, Resident 54 was admitted to the facility on [DATE] with a diagnosis including Heart Failure (heart failure – the heart is unable to pump blood around the body properly.) A concurrent record review and interview on 8/8/25 at 11:12 a.m. with Director of Nursing (DON), the DON confirmed that there was no documented evidence Resident 54 received a document related to the facility's bed hold policy prior to her transfer to the hospital. During an interview on 8/8/25 at 1:49 p.m. with Social Services Director (SSD), the SSD stated, “admission packet has the bed hold policy, but the facility does not provide bed hold policy upon transfer.” The SSD further stated and confirmed Resident 54 was transferred to the hospital on 6/2/25, and there was no documented evidence Resident 54, or the resident representative was notified in writing of the facility's bed-hold policy prior to transfer to the hospital. During a review of admission Record (AR) indicated, Resident 6 was admitted to the facility on [DATE] with a diagnosis including Congestive Heart Failure (the heart is unable to pump blood around the body properly). A concurrent record review and interview on 8/8/25 at 11:12 a.m. with Director of Nursing (DON), the DON confirmed that there is no documented evidence Resident 6 received a document related to the facility's bed hold policy prior to her transfer to the hospital. During an interview on 8/8/25 at 1:49 p.m. with Social Services Director (SSD), stated, “admission packet has the bed policy, but the facility does not provide bed hold upon transfer.” The SSD stated and confirmed that Resident 6 was transferred to the hospital on 2/11/25, 2/26/25, 6/12/25, and 6/27/25 respectively, and there was no documented evidence Resident 6, or the resident representative was notified in writing of the facility's bed-hold policy prior to transfer to the hospital. During an interview on 8/8/25 at 1:55 p.m. with Administrator (ADM), the ADM stated that no bed hold notification form was given upon transfer and stated per facility policy a bed hold notification must be given to the residents. During a review of the facility's policy and procedure (P&P) titled, Bed Hold, dated 11/16, the P&P indicated, ” It is the policy of this facility to provide resident the right to secure a bed hold during hospitalization or therapeutic leave from the facility…At the time of transfer to acute care hospitalization or as soon as feasible afterwards, the licensed nurse/designee shall obtain a copy of the original bed hold form and complete the bottom portion, second bed notice of bed hold. The facility indicates how the resident/representative was notified, and a copy of the form shall be sent to the representative and/or sent on transfer.”

Based on observations, interviews and record reviews, the facility failed to ensure: 1.Food items inside the refrigerator in the facility kitchen were labeled, open dated and had a use by date. These failures could lead to misidentification of food item and a potential for food borne illness (food poisoning) from consuming expired or spoiled items. 2.The utensils were stored in a sanitary condition when the drawers where utensils were stored were dirty with food crumbs and other residue from preparing food. This failure could result to cross contamination and the spread of bacteria. 3.A contaminated food item was not discarded properly. This failure could lead to consumption of unsafe food, diseases, and food borne illnesses. Findings: 1.During a concurrent observation and interview on [DATE] at 10:35 a.m., and 10:41 a.m., respectively, [NAME] 1 verified in refrigerator #1 the following items with no label and with no open and use-by-date (UBD): -sliced tomatoes -sliced meat in a clear plastic bag -cut up meat in a blue plastic bag - opened packaging containing hash browns that were taken off the original packaging Cook 1 stated items in the refrigerator should be labeled and should have open and UBD to ensure food items were identified properly, ensure freshness, ensure food served to the residents were not spoiled, and food items were safe for residents' consumption. During a concurrent observation and interview on [DATE] at 10:45 a.m., [NAME] 1 verified the carton of soy milk in refrigerator # 5 did not have an opened and used by date. [NAME] 1 stated the facility policy was to ensure items in the kitchen were clearly labeled, had opened and used by date. [NAME] 1 stated not labeling a food item and not placing an open or use by date on a food item, the facility policy was not followed. During an interview on [DATE] at 2:51 p.m., the Registered Dietician (RD) stated it was important to label with an open and use by date on food items to prevent food poisoning and food borne illness. The RD stated if the food item was not properly labeled and did not have an open or use by date, the facility policy was not followed. A review of the undated facility policy and procedure (P&P) Labeling and Dating of Foods, the P&P indicated, .all food items in the storeroom, refrigerator and freezer need to be labeled and dated .newly opened food items will need to be closed and labeled with an open date and use by date . 2.During a concurrent observation and interview on [DATE] at 10:52 a.m., [NAME] 1 verified drawer # 2, (drawer where utensils were stored) had a cooked macaroni noodle and was dirty. [NAME] 1 stated drawers should be clean and free of food debris because it could attract pests. [NAME] 1 stated pest droppings could make residents sick with infection, diarrhea (loose, watery stools that occur more frequently than usual) or stomach problems. During an interview on [DATE] at 2:51 p.m., the RD stated it was important to ensure kitchen and utensils were clean to ensure residents do not get sick from cross contamination. The facility did not have policy specific for cleaning the storage for utensils. 3.During a concurrent observation and interview on [DATE] at 10:53 a.m., [NAME] 1 was prepping to cook brown rice and poured the brown rice into the greased pan. [NAME] 1 was observed to pour the brown rice back into the brown rice container. [NAME] 1 stated she should have discarded the brown rice instead of pouring it back into the rice container. [NAME] 1 acknowledged it was a mistake pouring the brown rice back in the rice container. During an interview on [DATE] at 2:51 p.m., the RD stated it was not acceptable to put back the brown rice in the container after it was already poured into a pan greased with oil. The RD stated [NAME] 1's action was a risk for cross contamination. The RD stated it was also a concern for allergy. The facility did not have policy specific for discarding contaminated food items.

Based upon observation, interview and record review, the facility failed to remove two expired multi-dose vials of Tuberculin skin test solution (used to test for tuberculosis (TB), which is an airborne bacterial infection that primarily affects the lungs) with expired dates from use. Failure to remove the opened, expired vials of Tuberculin skin test solution decreased the facility's potential to safely administer medication and ensure residents benefitted from the full effects of the medications. Findings: During a concurrent observation and interview on [DATE], at 11:30 a.m., with Licensed Staff A, two multi-dose vials of Tuberculin skin test solution (Vial 1 one labeled with an opened date of [DATE], and an expired date of [DATE]; and Vial 2 labeled with an opened date of [DATE], and an expired date of [DATE]) were observed in the Medication Storage Room Refrigerator. Licensed Staff A stated, These vials were expired and should have been discarded. Review of the drug information on Tubersol (a prescription drug used to test for the presence of TB), via the National Library of Medicine which provides information about the United States Food & Drug Association (FDA) approved drug labels for humans, indicated, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Do not use after expiration date. Review of the facility policy and procedure titled, Storage of Medications, revised [DATE], indicated, .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed . Drugs shall be stored in an orderly manner in cabinets, draws, carts or automatic dispensing systems .

Based on interview and record review, the facility failed to ensure food was appetizing and palatable for three out of three sampled residents (Residents 42, 33, and 208). This failure put the residents at risk for decreased food intake and decline in their nutritional status. Findings: A review of Resident 42's face sheet (demographics) indicated she was admitted to the facility on [DATE] with a diagnoses of Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Chronic Pain Syndrome (CPS, persistent pain that last longer than 3 months) and Anemia (a condition where the body does not have enough healthy red blood cells). Resident 42's Brief Interview for Mental Status (BIMS, a short cognitive screening test used to assess a patient's mental status) score dated 11/1/24 was 14 over 15 indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 33's face sheet indicated an admitted to the facility of 5/5/24 with a diagnoses of Dysphagia (difficulty swallowing), Essential Hypertension (high blood pressure) and Hyperlipidemia (HLP, a condition in which there are high levels of fat particles (lipids) in the blood). A review of Resident 208's face sheet indicated an admitted to the facility of 12/10/24 with a diagnoses of Depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), Anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and Cellulitis (a skin infection that causes swelling and redness). A review of the facility menu for lunch dated 12/11/24 indicated the entree was oven crisp fish. During an interview on 12/11/24 1at 2:25 p.m., Resident 42 stated the fish served for lunch was dry and had no taste. During an interview on 12/11/24 at 1:12 p.m., after tasting the fish oven crisp on the sample meal tray, the Dietary Assistant (DA) agreed the fish oven crisp fish was dry and did not have a lot of taste. During an interview on 12/11/24 at 3:08 p.m., Resident 208 stated she took a bite of the fish and did not like it. Resident 208 stated the fish was dry and had no taste. During an interview on 12/11/24 at 3:17 p.m., Resident 33 stated he did not like the fish because it was too dry, was chewy and had no taste. During an interview on 12/12/24 at 2:51 p.m., the Registered Dietician (RD) stated she knew there was an issue with the fish that was served last Wednesday, 12/11/24, about being dry. The RD stated it was difficult to keep the fish moist due to it being thinly sliced. The RD stated if the fish was not moist, there was a risk resident might not eat it which could result to poor food intake. A review of the facility policy and procedure (P&P) titled Food Preparation, Healthcare Menus Direct 2023, the P&P indicated, .the food shall be prepared by methods that conserve nutritive value, flavor and appearance .prepared food will be sampled. The food and nutrition services employee who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency .

Based on interview and record review, the attending Physician failed to document that he or she reviewed the Pharmacist's findings and/or failed to document the action taken or not taken to address said recommendations for a period of five months (February 2024 to June 2024). This failure has the potential for all 49 vulnerable residents to experience adverse consequences from medication use, such as errors due to drug-drug interactions, omissions, duplication of therapy, or miscommunication between care providers. Findings: During a record review of the MRR Binder on 7/10/24 at 3:16 p.m., the Medication Regimen Review (MRR) reports by the Pharmacist included a form titled, Note to Attending Physician/Prescriber, which contained the Pharmacist's recommendations. At end of the notes included a section titled, Physician/Prescriber Response, with three boxes labeled, Agree, Disagree, and Other, and blank lines. Further review of the reports indicated: [DATE], had six recommendations, [DATE], had eight, [DATE], had four, MAY 2024, had three, and JUNE 2024, had five recommendations. All 26 notes revealed blank Physician/Prescriber Response sections. During an interview and concurrent review of the MRR on 7/10/24 at 4:35 p.m., Licensed Staff A confirmed the Physician/Prescriber Response sections for the 26 Pharmacist recommendations were empty. Licensed Staff A stated the current process was a verbal discussion of the recommendations between her and the Physician. Licensed Staff A stated, if the Physician agreed with the recommendation, the medication would be added, removed or changed. Licensed Staff A stated, if the Physician did not agree with the recommendation, she would write a Progress Note in the resident's chart about the discussion. Licensed Staff A stated there was no documentation of any rationale of the Physician's disagreement with the recommendation. Licensed Staff A described the process as, unclear, and stated it did not show that the Physician was responding to the Pharmacist's recommendations. During an interview on 7/12/24 at 9:26 a.m., Pharmacist Consultant J stated sometimes it took a while for the Physicians to respond to his recommendations. A review of the facility policy titled, Consultant Pharmacist Reports IIIA-1 Medication Regimen Review (Monthly Report), dated March 2018, indicated, .G. Recommendations are acted upon and documented by the facility staff or the prescriber. 1) Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing .

Based on observation, interview, and record review, the facility failed to provide prescribed medications, as ordered, for two of two sampled residents (Residents 153 and Resident 208), when: 1. Resident 153's Spiriva (an inhaled medication used to treat Chronic Obstructive Pulmonary Disease) was unavailable in the facility for four days; and, 2. Nine of nine scheduled medications (medications to be administered at a specific time) for Resident 208 were administered one hour and forty-five minutes past the scheduled administration time. These failures resulted in: 1. Resident 153 feeling anxious and increased the potential for an exacerbation of her chronic respiratory disease, which may have led to breathing difficulties, increased coughing, fatigue, and trouble sleeping or doing daily activities. 2. The potential to cause discomfort and/or jeopardize the health and safety of Resident 208. Findings: 1. During an interview on 7/8/24 at 3:48 p.m., Resident 153 stated she took inhaler medications at home. A review of Resident 153's, Face Sheet, indicated she was admitted to the facility on [DATE], with diagnoses that included chronic heart failure (a long-term condition that occurs when the heart cannot pump blood well enough to give the body a normal supply), Chronic Obstructive Pulmonary Disease (inflammatory lung disease that causes obstructed airflow from the lungs), muscle weakness and depression. During a concurrent observation and interview on 7/10/24 at 4:42 p.m., Resident 153 stated she had not been getting her Spiriva inhaler since admission. Resident 153 stated she notified the nurses about her use of the Spiriva medication at home but was told by the staff that the medication was, not available yet. Resident 153 appeared mildly distressed, occasionally grimacing throughout the interview, and frequently pausing as if to catch her breath. A review of Resident 153's, Orders History, indicated an order for, Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG/ACT 2 puff inhale orally in the morning, with a Start Date of 7/8/24. A concurrent review of Resident 153's, Medication Administration Record (MAR), dated, 7/1/24-7/31, indicated the following entries for Spiriva: 7/8/24 = 4, 7/9/24 = 9, 7/10/24 = 9, and 7/11/24 = 9. Further review of the MAR indicated, Chart Codes . 4 = Vitals Outside of Parameters for Administration . 9 = Other/See Progress Notes. During a concurrent observation and interview on 7/11/24 at 8:21 a.m., Resident 153 was lying in bed with an oxygen cannula on her nose. The oxygen tank displayed it was running at one lpm (liters per minute). Resident 153 stated she has had shortness of breath since the previous evening. During a concurrent interview and record review on 7/11/24 at 11:32 a.m., Licensed Staff C stated she did not give Resident 153 her Spiriva dose this morning because it was still awaiting delivery from the pharmacy. Upon review of Resident 153's MAR, Licensed Staff C stated Resident 153 did not receive four doses of Spiriva. Licensed Staff C stated she did not even realize Resident 153 had not been receiving her Spiriva since her admission. During a concurrent interview and record review of Resident 153's MAR on 4/12/24 at 9:12 a.m., Licensed Staff A stated Resident 153 missed four doses of the ordered Spiriva. Licensed Staff A stated nurses were expected to notify the Physician of missed medication doses, follow-up with the pharmacy, or if possible, check with the resident or their family if they could bring the medications from home until the ordered ones were delivered by the pharmacy. Licensed Staff A stated there was no documentation of these actions taken by the nurses after being unable to provide the Spiriva. Licensed Staff A stated the primary nurse should have reached out to the pharmacy regarding the delayed delivery. During an interview on 4/12/24 at 9:26 a.m., Pharmacist Consultant J stated it was his expectation that medications ordered for residents should be provided. When asked about the delayed delivery of Resident 153's Spiriva resulting in her to miss four doses, Pharmacist Consultant J stated the urgency needed to be there, and he expected better communication between the staff and the pharmacy. Pharmacist Consultant J stated while it was hard to say what caused Resident 153's recent shortness of breath; her being off the inhaler for several days could possibly have been a factor. A review of the facility policy titled, Medication Ordering and Receiving from Pharmacy, dated March 2018, indicated, Medications and related products are received from the dispensing pharmacy on a timely basis . Timely delivery of new orders is required so that medication administration is not delayed . 48660 2. During an observation on 7/10/24 at 10:43 AM, Licensed Staff E administered Enoxaparin 40 MG/0.4 ML Subcutaneous Injection to Resident 208. Record Review of a document titled, Medication Administration Audit Report, for Resident 208, dated 7/8/24-7/10/24, indicated the following scheduled times of administration and the actual times the medications were given: On 7/10/24, Polyethylene Glycol 3350 Powder, give 15 grams by mouth in the morning for Bowel Regulation, scheduled for 9 AM, and administered at 10:45 AM. On 7/10/24, Lasix Oral Tablet 20 MG, give one tablet by mouth two times a day related to HEART FAILURE, scheduled for 9 AM and administered at 10:45 AM. On 7/10/24, Carvedilol Oral Tablet 3.125 MG, give one tablet by mouth two times a day related to ESSENTIAL PRIMARY HYPERTENSION, scheduled for 9 AM and administered at 10:45 AM. On 7/10/24, Folic Acid Oral Tablet 1 MG, give one tablet by mouth in the morning for supplement, scheduled for 9 AM and administered at 10:45 AM. On 7/10/24, Ferrous Sulfate Oral Tablet 325 (65FE) MG, give one tablet by mouth in the morning related to ANEMIA, scheduled for 9 AM and administered at 10:45 AM. On 7/10/24, Ascorbic Acid Oral Tablet 500 MG, one tablet by mouth in the morning for supplement, scheduled for 9 AM and administered at 10:44 AM. On 7/10/24, Enoxaparin Sodium Injection Solution Pre-filled Syringe 40 MG/0.4 ML, inject 0.4 ML subcutaneously in the morning for DVT prophylaxis, scheduled for 9 AM and administered at 10:44 AM. On 7/10/24, Amiodarone HCl Oral Tablet 200 MG, give one tablet by mouth in the morning related to PAROXYSMAL ATRIAL FIBRILLATION, scheduled for 9 AM and administered at 10:44 AM. On 7/10/24, Finasteride Oral Tablet 5 MG, give one tablet by mouth in the morning related to BENIGN PROSTATIC HYPERPLASIA WITH LOWER URINARY TRACT SYMPTOMS, scheduled for 9 AM and administered at 10:45 AM. During an interview on 7/12/24 at 11:20 AM, Licensed Staff A stated medication administration time was one hour before and one hour after the scheduled time. During a concurrent interview and record review on 7/12/24 at 1:25 PM with Licensed Staff A, the Medication Administration Audit Report for Resident 208, dated 7/10/24, was reviewed. The Medication Administration Audit Report indicated all medications scheduled for 9 AM were administered at 10:44 AM or 10:45 AM. Licensed Staff A stated, all of the medications were administered late. During a review of the facility's policy and procedure titled, Medication Administration, dated March 2018, indicated, Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.

Based on observation, interview, and record review, the facility failed to follow guidelines for standard precautions (infection prevention practices that apply to all residents. Standard precautions are based on the principal that all blood, body fluids, secretions .may contain transmissible infectious agents. Standard precautions include hand hygiene .), when one licensed staff did not perform hand hygiene (refers to hand washing, antiseptic hand wash, and alcohol-based hand rub) during: 1. the administration of medications for two of five sampled residents (Residents 14 and 209); and, 2. prior to one of one sampled residents (Resident 9) eating her meal. These failures had the potential to expose residents to infectious agents causing illness and potentially death. Findings: 1. During medication administration observation on 07/10/24 at 8:26 AM, with Resident 14, Licensed Staff D did not perform hand hygiene before preparing medications, before entering the room, or after leaving the room. During medication administration observation on 07/10/24 at 12:16 PM, with Resident 209, Licensed Staff D did not perform hand hygiene before preparing medications, before entering the room, or after leaving the room. During medication administration observation on 07/10/24 at 12:20 PM, with Resident 14, Licensed Staff D did not perform hand hygiene before preparing medications, before entering the room, or after leaving the room. During an interview on 07/11/24 at 10 AM, Licensed Staff B stated staff washed hands anytime during medication administration if hands were visibly soiled. Licensed Staff B further stated an alcohol-based hand rub was used when entering a resident room and when leaving a resident room. During an interview on 07/12/24 at 11:20 AM, Licensed Staff A stated staff washed hands anytime during medication administration if hands were visibly soiled. Licensed Staff A further stated an alcohol-based hand rub was used before medication administration and between each resident. 2. During an observation on 7/8/24 at 12:05 p.m., Unlicensed Staff G was assisting in passing the lunch meal to residents who wished to eat in the dining room. This was the first lunch trays to be passed out to the residents. During a concurrent observation and interview on 7/28/24 at 12:28 pm., Resident 6 was laying in bed, and there was no lunch tray on her bedside table. When asked if she had eaten lunch, she indicated, No and indicated the staff would get her up to eat lunch in her wheelchair. During an observation on 7/8/24 at 12:44 p.m., Unlicensed Staff G took the meal cart over from the Dietary Staff for the residents on the hallway which included Resident 6's room. During an observation and interview on 7/8/24 at 12:46 p.m., two Unlicensed Staff members entered Resident 6's room with her lunch meal and repositioned Resident 6 so she could sit up in bed more comfortably to have lunch. Unlicensed Staff F assisted with Resident 6's meal tray, and there was no hand hygiene used by Unlicensed Staff F while setting up Resident 6's meal tray. Unlicensed Staff F was asked if there were hand hygiene wipes on the meal trays for residents to clean their hands. Unlicensed Staff F indicated the meal trays were not served with hand hygiene wipes; the staff had already provided hand hygiene to Resident 6 before the meals was delivered. Unlicensed Staff F could not provide a name of who had provided hand hygiene to Resident 6, but that it was usually done before the meal trays were provided to the residents. Unlicensed Staff F indicated the residents' hands were cleaned with wipes which were located in the dining room. Unlicensed Staff F indicated the dining room had multiple canisters where staff would take a canister and then proceed to wash the residents' hands prior to meals being served. During a review of a policy and procedure titled, Handwashing/Hand Hygiene, dated August 2015, the policy indicated in Step 7, Use an alcohol-based hand rub .or, alternatively, soap and water for the following situations: before and after direct contact with residents and before preparing or handling medications. During a review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated 8/2015, indicated .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .P. Before and after assisting a resident with meals. 48660

Based on observation and interview the facility did not ensure one of one sampled (Resident 6) residents had her preferences honored when she wanted to get out of bed to have meals and was not assisted. This failure had the result of not being able to enjoy meals while out of bed, reduced respiratory exercise from not getting out of bed and increased skin breakdown by staying in bed all day. Findings: During an interview on 7/8/24 at 11:05 a.m., Resident 6 indicated she liked to get out of bed and have meals in her wheelchair in her room or in the dining room, and the facility had not been helping her to get out of bed for her meals. During a concurrent observation and interview on 7/8/24 at 12:46 p.m., Resident 6 was being assisted to sit up in bed by two staff members so she would be able to eat lunch more comfortably in bed. Unlicensed Staff F indicated Resident 6 usually got up to have meals in the dining room but did not that day and could not explain why. During an observation on 7/9/24 at 1 p.m., Resident 6 was sitting in her bed with her lunch tray finished on the bedside table in front of her. Resident 6 indicated she did not get out of bed to have lunch and shrugged her shoulders as if she did not know why. During an observation on 7/10/24 at 11:30 a.m., Resident 6 was laying in her bed, and the lunch trays had not delivered yet. At 1:30 p.m., Resident 6 indicted she did not get out of bed to have lunch; she ate in her bed and pointed downward on the bed. During an interview on 7/11/24 at 9:41 a.m., Unlicensed Staff H indicated Resident 6 usually got up for lunch but did not get on 7/8/24, because Unlicensed Staff H was not working that day. During an observation on 7/11/24 at 12:55 p.m., Resident 6 was sitting in her wheelchair, next to her bed having lunch. During an interview with Licensed Staff A, Licensed Staff A indicated Resident 6 usually got up but could not explain why Resident 6 had not been out of bed on 7/8/24, 7/9/24 and 7/10/24.

Based on observation, interview, and record review, the facility failed to ensure expired medications were immediately removed from stock and disposed of, when six bottles of medication were in the medication storage room two months after their expiration date. This failure had the potential to expose residents to medications that were less effective or risky due to a decrease in strength or a change in chemical composition. Findings: During a concurrent observation and interview on 7/10/24 at 7:42 AM, with Licensed Staff A in the medication storage room, six 473 ML bottles of Docusate Sodium 50 MG/5 ML had expired 5/2024. Licensed staff A verified the six bottles of Docusate Sodium had expired 5/2024. During an interview on 7/10/24 at 1:40 PM, Licensed Staff A stated expiration dates of medication stored in the medication storage room had been checked at least once per month by the AM (morning shift) Unit Manager. Licensed Staff A further stated the six bottles were stored on a higher shelf and had been overlooked. During a review of the facility's policy and procedure titled, Medication Storage in the Facility, dated March 2018, indicated, Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal .

Based on interview and record review, the facility failed to implement its policies and procedures on antibiotic stewardship, when two of 18 residents, who acquired Urinary Tract Infections (UTIs), were prescribed antibiotics prior to the results of a culture sensitivity test (Residents 34 and 31). [A culture sensitivity test is a test to find germs, such as bacteria or a fungus, that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotics, will work best to treat the illness or infection]. This failure resulted in the inappropriate use of antibiotics and increased the risk for Residents 34 and 31 to develop multi-drug-resistant organisms and other antibiotic-related complications. Findings: During an interview on 7/11/24 at 9 a.m., Licensed Staff B stated the facility tracked the residents' antibiotic use and followed the McGreer Criteria for UTIs (a clinical criteria designed for the surveillance, diagnosis, and appropriate antibiotic use for UTIs in long-term care facilities). Licensed Staff B stated residents suspected of having a UTI should have at least one sign/symptom sub criteria and have urine culture sensitivity test results prior to starting antibiotics. During a concurrent review of the binder labeled, Surveillance Data Collection - Infection Control, Licensed Staff B stated Resident 34 had dysuria (painful urination) and was ordered Macrobid 100 mg (milligrams) for three days prior to receipt of the urine test results. Licensed Staff B stated Resident 34's test results later revealed no growth was detected on her urine culture, meaning there was no evidence of infection. When asked if Resident 34 met the criteria for antibiotic use, Licensed Staff B stated, No. Further review of the binder revealed Resident 31 received Keflex (a brand name of the antibiotic Cephalexin) 500 mg every six hours for seven days after he reported pain in the lower abdomen area and his catheter had purulent (containing pus) discharge. Licensed Staff B stated Resident 31's urine culture later had growth of Pseudomonas aeruginosa (a bacteria that is resistant to Cephalexin). When asked if Resident 31 met the criteria for antibiotic use, Licensed Staff B stated, No. Licensed Staff B stated the facility would not want to start residents on antibiotics if it would not work on the bacteria causing their infection, and added that the inappropriate use of antibiotics could result in multi-drug-resistant organisms. During an interview on 7/11/24 at 2:05 p.m., Medical Director I stated, waiting for the results of culture sensitivity testing was needed before Physicians could start residents on an antibiotic. Medical Director I stated, residents developing MDROs was a risk with the use of the wrong antibiotics. A review of the facility policy titled, Antibiotic Stewardship - Orders for Antibiotics, dated December 2016, indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing . Appropriate indications for use of antibiotics include: a. Criteria met for clinical definition of active infection or suspected sepsis; and b. Pathogen susceptibility, based on culture and sensitivity, to antimicrobial .

Based on interviews and records review, the facility failed to implement their policy on change of condition/ notification for one of two sampled residents (Resident 1) when Resident 1's Responsible Party was not notified of Resident 1's new sheared skin (one of the major causes of skin breakdown in sitting and occurs during transfers, reaching, weight shifts or repositioning) to his coccyx (small bone at the bottom of the spine). This failure did not ensure Resident 1's Responsible Party could exercise her right to be informed and to participate with Resident 1's care and treatment. Findings: During a telephone interview with Family Member A on 4/29/24 at 2:21 p.m., Family Member A stated Resident 1 was admitted to the facility with no skin issues. Family Member A stated on the day Resident 1 was discharged home, she noticed blood on Resident 1's underwear while assisting him to the toilet and found a wound on his buttocks. She stated the facility did not notify her of Resident 1's new wound. A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including but not limited to Cerebral Infarction (also known as stroke); Diabetes Mellitus (disease that result in too much sugar in the blood); and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of the document titled Order Summary Report dated 4/10/24 indicated a physician's order written on 3/27/24 stating Resident 1 does not have the capacity to make health care decisions. A review of the facility document titled SBAR (Situation, Background, Assessment and Recommendation - a tool used by health care professionals to communicate with each other about critical changes in patient's status) Communication Form and Progress Note dated 4/04/24 indicated Resident 1 had skin shearing to coccyx which started on 4/04/24. The document indicated Resident 1 was notified of the new skin issue. During an interview with Licensed Staff B on 4/30/24 at 11:48 a.m., when Licensed Staff B was asked about the facility's policy when a resident was found to have a new skin issue, Licensed Staff B stated she would notify the doctor, the Director of Nursing (DON), and the wound treatment nurse. When Licensed Staff B was asked should resident's responsible party be notified of the new skin issue, she stated if the resident had cognitive impairment, she would notify the responsible party and would document who was notified. During an interview with the DON on 4/30/24 at 12:01 p.m., when the DON was asked if Resident 1's responsible party was notified of Resident 1's new sheared skin to his coccyx, the DON stated Family Member A was not notified because Resident 1's admission record indicated he was responsible for himself. However, the DON stated Resident 1's physician wrote an order on 3/27/24 indicating Resident 1 did not have the capacity to make health care decisions and concurred that Family Member A should have been notified of the new skin issue. A review of the Facility policy and procedure titled Change Of Condition / Notification with effective date 11/2016 indicated, A facility must immediately inform the resident; consult with the resident's physician, and if known, notify the representative or an interested family member when there is an accident or incident, significant change, a need to alter treatments, or a transfer or change in roommate.

Based on interviews and records review, the facility failed to safeguard resident's property for one of two sampled residents (Resident 1). This failure resulted in Resident 1's missing clothes upon discharge from the facility. Findings: During a telephone interview with Family Member A on 4/29/24 at 2:21 p.m., Family Member A stated Resident 1 lost his gray pants, compression socks, underwear, and black shirt during his thirteen days stay at the facility. Family Member A stated she told the facility staff of the missing clothes; however, Family Member A was only told that they will look for it. Family Member A stated clothes from other residents were sent home with Resident 1. A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including but not limited to Cerebral Infarction (also known as stroke); and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 3/31/24 indicated Resident 1 had a BIMS score of 7 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive [relating to the mental process involved in knowing, learning, and understanding things] screening measure that evaluates memory and orientation. A score of 00 to 07 is severe impairment). A review of the Progress Note dated 4/10/24 indicated Resident 1 was discharged home. The Progress Note indicated, [Resident 1's] inventory sheet signed upon discharge. [Resident 1] verbalized all belongings are with resident upon discharge from facility. A review of the facility document titled Inventory of Personal Effects for Resident 1 indicated the following items were listed on 3/26/24: one black shirt, one hat, one gray jacket, one black slip on shoes, one gray sweatpants and one gray sweat top, upper and lower dentures and one ring. The document indicated, Upon discharge, use the checkmark columns to indicate that all personal belongings are accounted for. However, the checkmark columns were left blank upon discharge. The document indicated Resident 1's signature and an unknown CNA's (Certified Nursing Assistant) signature on 4/10/24. During an interview with Licensed Staff B on 4/30/24 at 11:48 a.m., when Licensed Staff B was asked about the facility's policy to ensure resident's belongings were returned to them upon discharge, Licensed Staff B stated nurses and CNAs were responsible of recording all items brought to the facility on admission. She stated either the CNA or the nurse will go over the list of items returned to the resident or responsible party upon discharge, then the resident or the responsible party would sign the inventory list to acknowledge what they received. When Licensed Staff B was asked if residents with cognitive impairment were allowed to sign the document, she stated no. During an interview with Licensed Staff C on 4/30/24 at 12:26 p.m., when asked about the facility's policy to ensure resident's belongings were returned upon discharge, Licensed Staff C stated all items listed on the inventory list will be returned to the resident. She stated for missing items, facility staff will start to search, and if unfound, the Social Service Director (SSD) will be notified of the lost items. When Licensed Staff C was asked if Family Member A reported that some of Resident 1's clothes were missing at the time of discharge, Licensed Staff C stated she could not remember. During an interview with the SSD on 4/30/24 at 12:38 p.m., when the SSD was asked about the facility's policy for resident's reported missing items, the SSD stated facility staff will search for the missing items, and if unable to locate, staff will fill out the form for lost items and submit to SSD for processing. When the SSD was asked if she was notified of Resident 1's missing clothes upon discharge, she stated no. A review of the Facility policy and procedure titled Theft and Loss revised on 5/2017 indicated, The facility shall maintain resident belongings in a safe manner to prevent theft and loss to the extent possible; On discharge of a resident, the resident/representative will sign the inventory sheet stating they have taken possession of the resident's personal property.

Based on observations, interviews and record reviews, the facility failed to ensure adequate pain relief for one out of one sampled resident (Resident 34), when: 1. the nurse administered acetaminophen (APAP, a non-opioid analgesic and antipyretic agent utilized for treating pain) 650 milligram (mg, a unit of weight) for an 8 out of 10 pain level (8/10 PL, severe pain, hard to do anything at all); 2. the facility honored the family's preference over Resident 34's comfort; and, 3. the facility did not follow the physician's order to relieve Resident 13's severe pain. These failures led to resident grimacing, moaning and continuously complaining of 8/10 PL. Findings: A review of Resident 34's face sheet (demographics) indicated he was initially admitted to the facility on [DATE]. His diagnoses included Hyperlipidemia (HLP, high cholesterol is an excess of lipids or fats in your blood), Essential Hypertension (high blood pressure) and Anxiety disorder (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness. His Minimum Data Sheet Assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 1/9/24, Brief Interview for Mental Status (BIMS, a mandatory tool used to screen and identify the cognitive condition of residents) score was 13, indicating intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 34's functional status indicated he was dependent on staff when performing his Activities of Daily Living (ADL, activities related to personal care which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet). Resident 34 was a recipient of hospice care (focuses on a person's quality of life as they near the end of life). During a concurrent observation and interview on 2/7/24 at 7:33 a.m., Resident 34 was moaning and shaking his right leg. When asked if he was experiencing, dolor (pain in Spanish), Resident 34 nodded his head. Unlicensed Staff A interpreted and stated Resident 34 was reporting an 8/10 PL on his right leg and his back. During a concurrent observation and interview on 2/7/24 at 8:09 a.m., Resident 34 was still moaning and was seen shaking his right leg. When asked if he was still experiencing, dolor, Resident 34 nodded his head. Unlicensed Staff A interpreted and stated Resident 34 was still reporting an 8/10 PL on his right leg and his back. During an interview, via the language interpreter line service, on 2/7/24 at 8:13 a.m., Resident 34 stated he was still experiencing an 8/10 PL. During an interview on 2/7/24 at 8:20 a.m., when asked if staff had notified her of Resident 34's complaint of 8/10 PL, Licensed Staff B stated, Yes, however had not gone to see him yet because she got busy passing medications to other residents. Licensed Staff B was notified Resident 34 was experiencing an 8/10 PL. Licensed Staff B stated Resident 34 received a 0.5 milligram (mg, a unit of measure) of morphine (a non-synthetic narcotic- a medication that reduce tension, pain and anxiety; a strong pain reliever) at 6:30 a.m., and was not due for another dose until 10:30 a.m. Licensed Staff B stated she would see Resident 34 later and ask him if he was still in pain. During an interview on 2/7/24 at 8:42 a.m., Licensed Staff B was again notified Resident 34 was still experiencing an 8/10 PL. Licensed Staff B stated she was still busy and had not seen Resident 34 yet. Licensed Staff B stated she would ask another nurse to see him now. During a concurrent observation and interview on 2/7/24 at 8:44 a.m., the Infection Control Preventionist (IP) did not use the language interpreter line service and relied on Unlicensed Staff A to translate for her. Resident 34 was noted to be grimacing and shaking his right leg. The IP was heard telling Resident 34 (through Unlicensed Staff A), the nurse could only give him APAP to address his pain since he was not due to receive a morphine dose at this time. Resident 34's wife asked when the last time Resident 34 received morphine to which the IP responded, 6:30 a.m. The IP stated the nurse would give him APAP for breakthrough pain and then would give him the morphine in two hours. The IP confirmed Resident 34 was still complaining of an 8/10 PL on his right leg. The IP stated she would tell the nurse in charge of his care to give him APAP for now. During an interview, using the language interpreter line service on 2/7/24 at 11:13 a.m., Resident 34 stated he was still experiencing an 8/10 PL, and the APAP given him earlier was not effective in managing his pain. Resident 34 stated the nurse did not come to see him after he was given APAP, to reassess his pain. Resident 34 stated he moved his right leg because it helped alleviate the pain a little. During an interview on 2/7/24 at 12:18 p.m., the IP confirmed Resident 34 received APAP 650 mg to address his complaint of 8/10 PL earlier. The IP stated the facility pain protocol was to give residents their pain medication as ordered, and if not effective to give another type of pain medication. When asked if it was appropriate for Resident 34 to receive APAP 650 mg for a complaint of 8/10 PL after he was given morphine, the IP stated, Why not? What we do is give the resident what was available, even if the medication available would only provide a little pain relief. The IP stated, since Resident 34 was not due for another dose of morphine earlier, Resident 34 could only receive APAP at that time and that was acceptable. During an interview on 2/7/24 at 12:32 p.m., the Director of Nursing (DON) stated Resident 34 did have an issue with pain management. When asked what the facility's pain management policy was, the DON stated, if a medication was ineffective, the nurses should call to notify the physician the pain medication was ineffective. The DON stated that in Resident 34's case, the nurses should have called the physician to ask whether they could give another dose of morphine. The DON stated it was not appropriate to give APAP 650 mg when Resident 34 was complaining of an 8/10 PL. The DON stated Resident 34's family was heavily involved in his care and would interfere with his pain management. When asked who made the decision for Resident 34, the DON stated Resident 34 was responsible for himself. The DON stated the facility had conversations with Resident 34's family regarding pain management but his family would say they would not want him to be sedated, so they would not like the nurse to give 1 mg of morphine for severe pain despite the physician's order. When asked why the facility nurses chose to honor Resident 34's family's wishes versus that of Resident 34's comfort, the DON stated the nurses probably felt intimidated not following Resident 34's family wishes. When asked if the nurses followed the facility policy for pain management, the DON stated, No, and she understood. The DON stated she would educate the nurses on the facility's policy and procedure (P & P) for pain management. During an interview on 2/7/24 at 3:04 p.m., the Medical Director (MD) stated Resident 34's pain started about two weeks ago. MD stated Resident 34 was able to make decisions for himself however his wife would sometimes intervene. When asked if it was acceptable for Resident 34 to receive APAP 650 mg for an 8/10 PL if the morphine was ineffective and was still not due for another dose, the MD stated, No. The MD stated the nurse should have called him after the initial dose of morphine was ineffective as he could easily give an order to give another dose of morphine to address Resident 34's complaint of an 8/10 PL. The MD stated he was sorry this happened. The MD stated this should not have happened. During an interview on 2/7/24 at 3:20 p.m., when asked if it was acceptable for Resident 34 to receive APAP 650 mg for an 8/10 PL, Licensed Staff C stated, Yes. Licensed Staff C stated, if Resident 34 was not due for a dose of morphine, even if the initial dose was ineffective, then the nurse should give him what was available, even if it was a lower form of analgesic (pain reliever). When asked if she thought APAP 650 mg would effectively relive Resident 34 of 8/10 PL, Licensed Staff C stated a little but not enough to make him comfortable. When asked what the risk was if Resident 34's pain was not relieved by APAP 650 mg, or if Resident 34 continued to have an 8/10 PL, Licensed Staff C stated Resident 34 would be uncomfortable, he would be in pain. Licensed Staff C stated Resident 34 would also be upset and frustrated and he would feel like his concerns were not heard. During an interview on 2/8/24 at 5 p.m., Resident 34's daughter stated three days ago, Resident 34 called her to tell her he was in pain. Resident 34's daughter stated the facility did not address Resident 34's pain adequately. During an interview on 2/8/24 at 5:15 p.m., Licensed Staff D stated pain was subjective. Licensed Staff D stated, if a resident was responsible for himself, staff should listen to what the resident's wishes were. When asked if it was appropriate to give APAP 650 mg to a resident complaining of an 8/10 PL, Licensed Staff D stated, No. Licensed Staff D stated an 8/10 PL meant the pain was severe and APAP 650 mg would not be effective in addressing a complaint of 8/10 PL. Licensed Staff D stated the goal of pain management was to keep residents comfortable. Licensed Staff D stated, giving APAP 650 mg for an 8/10 PL was ineffective and would result in the resident still being in a lot of pain. During an interview on 2/9/24 at 8:01 a.m., Licensed Staff F stated Resident 34 was under hospice care. Licensed Staff F stated the pain management goal was to keep Resident 34 comfortable and to have a dignified end of life. Licensed Staff F stated APAP 650 mg would not be appropriate to administer if Resident 34 was complaining of an 8/10 PL. Licensed Staff F stated APAP 650 mg would not significantly keep Resident 34 comfortable. Licensed Staff F stated, giving Resident 34 an APAP 650 mg when he was complaining of an 8/10 PL, could result in him being in considerable pain. Licensed Staff F stated Resident 34 would be uncomfortable and upset. A review of Resident 34's electronic medication administration record (EMAR, an electronic patient record system used to document information about medications) indicated, on 1/29/24, Resident 34's order for morphine was to give 0.5 mg by mouth every four hours as needed for mild to moderate pain and 1 mg by mouth every four hours as needed for severe pain. The EMAR also indicated Resident 34 received APAP 650 mg for a complaint of 8/10 PL on these dates: 1/27/24 and 1/30/24. A review of the facility's policy and procedure (P & P) titled, Pain Protocol, revised 3/2018, the P & P indicated: With input from resident to the extent possible, the physician and staff will establish goals of pain treatment, freedom from pain .pain medications should be selected based on pertinent treatment guidelines .staff will reassess the individual's pain and related consequences at regular intervals. 37797

Based on interview and record review, the facility failed to provide supervision and other fall prevention interventions to prevent falls for two of two residents at risk for falls (Residents 20 and 14). For Resident 20, the facility failed to supervise and monitor Resident 20 and failed to ensure Resident 20 had access to a call light to ask for help when she needed to ambulate. These failures resulted in Resident 20 falling and fracturing her hip. For Resident 14, the facility failed to supervise and monitor Resident 14 to prevent falls resulting in Resident 14 sustaining three falls within a period of two weeks and placing her at risk of injuries. Findings: RESIDENT 20 A review of Resident 20's Admission Record indicated a date of initial admission of 3/25/29. Resident 20's Admission record indicated she was [AGE] years-old and had diagnoses including generalized muscle weakness, abnormalities of gate and mobility, and senile degeneration of the brain (age-related cognitive impairment). A review of Resident 20's care plans indicated one fall care plan, dated 7/10/23, titled, Potential for falls r/t [related to] decreased mobility (The Fall Care Plan). The Fall Care Plan indicated the following fall prevention interventions: Ensure resident is wearing appropriate footwear, ensure call light is within reach and encourage resident to use it, and if fall occurs, investigate, find cause and monitor for signs and symptoms of injury. A review of Resident 20's Fall Care Plan indicated it was updated on 8/16/2,3 with the intervention to ensure Resident 20's wheelchair was locked as needed for transfers. A review of Resident 20's MDS Assessment, dated 10/4/23, indicated Resident 20 had a BIMs score of 11 (scores below 12 indicate impaired cognition), required staff assistance for transfer and ambulation, used a wheelchair for locomotion, and had a history of falls. A review of Resident 20's Morse Fall Scale, dated 10/4/23, indicated Resident 20 was at high risk for falls due to a history of falls, impaired gait (difficulty rising from chair, uses chair arms to get up, bounces to rise . cannot walk unassisted) and impaired mental status (overestimates or forgets limits). A review of SBAR Communication, dated 12/23/23, at 8:09 p.m., indicated Resident 20 had a fall that day. The noted indicated the fall was unwitnessed. The note indicated Licensed Nurse C heard Resident 20 yelling for help and then observed Resident 20 on the ground next to her wheelchair, on her right side, outside her room. The note indicated no visible injuries but Resident 20 reported being unable to move her right leg because of pain. A review of Fall IDT Note, dated 12/26/23, at 4:27 p.m., indicated the IDT team met to review Resident 20's fall on 12/23/23. The note indicated the fall occurred on 12/23/23 at 3:25 p.m., when she was observed laying on her right side on the floor at the end of the hallway outside her room where she sat with her tray table. The note indicated no visible injuries, and Resident 20 initially denied pain. The note indicated Resident 20 subsequently reported pain at her right leg at a level 9 (on a progressive zero to 10 scale). The note indicate Resident 20 fell when she stood out of the wheelchair to pick up something on the floor and then fell out of the wheelchair onto the floor. The note indicated an x-ray was performed the following day which indicated a right hip fracture. The note indicated Resident 20 was taken to the hospital for evaluation and treatment of her injuries. During an interview on 2/7/23, at 2:23 p.m., the DON stated she was familiar with Resident 20. During the same interview, the DON reviewed Resident 20's clinical record. The DON stated Resident 20 had dementia and was at high risk of falls. The DON stated Resident 20's most recent fall was on 12/23/23, during shift change when Resident 20 fell out of her wheelchair and landed on the floor, right side first. The DON stated Resident 20 was on her wheelchair and attempted to pick up something from the floor and fell . The DON stated Resident 20 suffered a hip fracture because of the fall and was taken to the hospital for evaluation and treatment. The DON stated the Fall Care Plan was the only fall care plan in place when Resident 20 fell on [DATE]. The DON was asked what fall prevention interventions were in place when Resident 20 fell . The DON stated to ensure the call light was within reach, that Resident 20 was wearing appropriate footwear and her wheelchair wheels were locked. During an interview on 2/7/24, at 3:09 p.m., Licensed Nurse C stated she was on duty on 12/23/23, when Resident 20 fell , and was assigned to care for Resident 20 that day. Licensed Nurse C stated Resident 20 fell in the afternoon of 12/23/2,3 during shift change. Licensed Nurse C stated she just had received report from the outgoing nurse and was checking resident records in front of the nurse's station when she heard someone yelling, Help, help. Licensed Nurse C stated she turned towards the yelling and saw Resident 20 on the floor in the hallway, next to her wheelchair, in front of the entrance to her room, calling for help. Licensed Nurse C stated she ran towards Resident 20 and assisted her back onto her wheelchair. Licensed Nurse C stated she asked Resident 20 what happened, and Resident 20 told he she was on her wheelchair and tried to pick an object from the floor and then fell out onto the floor. Licensed Nurse C stated, prior to the fall, Resident 20 was on her wheelchair in front of her room engaged with writing supplies placed on a table in front of her wheelchair. Licensed Nurse C stated it was customary for Resident 20 to be on her wheelchair in the hallway in front of her room playing with arts and crafts. Licensed Nurse C stated sometimes Resident 20 placed stuffed animals on side rails next to her wheelchair on the hallway. Licensed Nurse C stated, when Resident 20 fell , there was no staff in the hallway monitoring Resident 20. Licensed C restated she was at the nurse's station [roughly 100 feet from Resident 20's location] and was the first to report to the scene and assist Resident 20, followed by two Certified Nursing Assistants (CNAs), who came after her. Licensed Nurse C stated Resident 20 was, very good at using her call light to request assistance but there was no call light in the hallway where Resident 20 was, within her reach when she fell . RESIDENT 14 A review of Resident 14's Admission Record indicated a date of admission of 4/28/23. Resident 14's Admission record indicated she was [AGE] years-old and had diagnoses including generalized muscle weakness, difficulty walking, and dementia. A review of Resident 14's Care Plans (documents indicating the care to be provided to the resident) indicated the following care plans relating to fall prevention: 4/28/23: Resident at risk for falls due to cognitive deficits, non-compliance, weakness, decline in function (the Fall Care Plan). Interventions listed included: Be sure call light is within reach and encourage using it for assistance as needed, encourage activities that promote physical activity and improved mobility, and investigate and determine cause if falls occur; 5/8/23: Resident 14 had an ADL (Activities of Daily Living: Dressing, eating, hygiene, ambulation) self-care performance deficit related to weakness. Intervention included providing 1-2 staff assistance for bed mobility, transfers, toileting, bathing, feeding and ambulation; 5/8/23: Resident 14 had impaired cognitive function related to dementia. Interventions included to monitor Resident 14 for changes in cognitive function; 7/11/23: Resident 14's Fall Care Plan was updated to include a pressure alarm to chair; and, 7/14/23: Resident 14 was at risk of injury related to non-compliance . refusal to call staff for assistance. Interventions included adapting regimen to Resident 14's level of comprehension and Resident 14 had a right to refuse care/treatment. A review of Resident 14's MDS Assessment (MDS stands for Minimum Data Set and is a mandated comprehensive resident assessment), dated 8/4/23, indicated Resident 14 had a BIMS (Brief Interview form Mental Status - the part of the MDS assessment that measures the resident's cognition level) score of 3 (on a 0-15 scale; the lower the score the more cognitive impaired), indicating severe cognition deficits. The MDS further indicated Resident 14 needed staff assistance during transfers and ambulation. A review of Resident 14's Morse Fall Scale (a standardized assessment tool that indicates a resident's risk for falls), completed on 8/4/23, indicated Resident 14 was at, High Risk for Falling, due to the following fall risk factors including: History of falling, weak gait (manner of walking), use of ambulatory aids such as crutches, cane or walker, and Resident 14, overestimates or forgets limits. A review of Resident 14's Fall Care Plan indicated it was updated on 8/16/23, with two additional interventions to prevent falls: Confirm alarms are on during walking rounds and ensure appropriate footwear is on at all times. First fall A review of Resident 14's Progress Note, dated 10/20/23, at 7:20 p.m., titled, SBAR Communication Form, (SBAR stands for Situation, Background, Assessment and Recommendation; it is a standard form used to document incidents in health care facilities) indicated Resident 14 fell that day. The note indicated, Res[ident] was seen standing unassisted w/[ith] walker in front of nurses station, lost balance and fell on her bottom . no injuries noted. A review of Resident 14's Fall Care Plan indicated no new fall interventions after the first fall. A review of Resident 14's Progress Note, dated 10/23/23, at 12:02 p.m., titled, Fall IDT (IDT stands for Interdisciplinary Team, which is a committee of professionals from different disciplines who meet to review incidents reported in SBAR forms, identify the causes and implement interventions to prevent reoccurrence) indicated factors that contributed to Resident 14's fall on 10/20/23, included: Impulsive behaviors, dementia, and history of non-compliance with safety measures. The IDT note indicated recommendations to encourage use of wheelchair with pad alarm (a pad alarm is a pressure sensor placed on the wheelchair that emits a noise when the resident gets up from the wheelchair). A review of Resident 14's Fall Care Plan indicated it was updated on 10/25/23, with one additional intervention: Physical and Occupational Therapy to evaluate and treat. Second fall A review of Resident 14's Progress Note, dated 11/2/23, at 10:02 p.m., titled SBAR Communication Form, indicated Resident 14 fell on e more time. The note indicated the fall was detected around 9 p.m., when: Resident [14] was found on the floor next to her bed. The note indicated, no injuries noted. A review of Resident 14's Progress Note, dated 11/6/23, at 9:56 a.m., titled, Fall IDT, indicated the second fall happened when Resident 14 attempted to get up from the bed to use the bathroom and tripped on the blanket. The note indicated the pad alarm on the bed was disconnected. The note indicated contributing factors to the fall included dementia and disorientation. The IDT note indicated the recommendations for frequent visual checks and room change closer to the nurse's station for increased monitoring of residents. Third fall A review of Resident 14's Progress Note, dated 11/6/23, at 10:29 a.m., titled, Fall IDT, indicated Resident 14 fell a third time, less than 24 hours after the second fall, on 11/3/23 at around 10:40 a.m. The note indicated the fall occurred in the activities room when Resident 14 was observed by the Activity's Assistant getting up from the table using her walker, and the walker rolled out under her and she fell to the floor. The note indicated contributing factors to the fall included dementia and non-compliance with safety measure provided. The IDT note indicated the recommendations for removal of walker and use of wheelchair. A review of Resident 14's Fall Care Plan indicated it was updated with thee additional fall prevention interventions on 11/6/23: Encourage use of wheelchair instead of walker, room change to be closer to the nurse's station, and frequent visual checks. During an interview on 2/9/24, at 9:30 a.m., the Director of Nursing (DON) stated she was familiar with Resident 14. During the same interview, the DON reviewed Resident 14's clinical record. The DON stated Resident 14 was non-compliant with care. The DON stated Resident 14 had dementia and was at high risk of falls. The DON stated Resident 14 had three recent falls at the facility: On 10/20/23, 11/2/23 and 11/3/23. The DON stated all falls were documented in SBAR notes, and the facility's investigation of the falls was found in the IDT notes following the falls. The DON was asked what fall interventions the facility implemented to prevent falls for Resident 14. The DON stated the 4/28/23, Care Plan titled, Resident at risk for falls . was the facility's fall prevention care plan for Resident 14, and it contained the fall prevention interventions implemented by the facility to prevent falls for Resident 14. The DON stated only one new intervention was implemented after the first fall on 10/20/23 (PT/PT evaluation and treatment dated 10/25/23), none after the second fall on 11/2/23, and three new interventions after the third fall on 11/3/23 (encourage use of wheelchair instead of walker, room change to be closer to the nurse's station, and frequent visual checks on 11/6/23). A review of the facility's policy titled, Falls and Fall Risk, Managing, Revised March 2018, indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes and try to prevent the resident from falling and try to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions . Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. A review of facility policy and procedure titled, Dementia - Clinical Protocol, Revised November 2018, indicated: Direct care staff will support the resident in initiating and completing activities and tasks of daily living . Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day .

Based on observations, interviews, and record reviews, the facility failed to provide a safe and comfortable environment to 19 out of 49 residents, (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9 ,10, 11, 12, 13, 14, 15, 16, 17, 18, and 19) when the air temperatures in their rooms and Hall A, where Rooms # 1-9 were located, exceeded 81degrees F (Fahrenheit), ranging from 82 degrees F to 94.7 degrees F. This failure resulted in residents feeling too warm or too hot, and exposed to excessive heat that could potentially cause heat stroke, serious harm, or death. Due to the facility's failure to provide a safe and comfortable environment to 19 out of its 49 residents when the temperatures in the rooms of the affected residents or the temperature in Hall A, where the resident rooms were located, exceeded 81 degrees F, and up to 94.7 degrees F, the Administrator and the Infection Preventionist were verbally informed of an Immediate Jeopardy ( IJ -Immediate Jeopardy represents a situation in which a nursing home's noncompliance with CMS (Centers for Medicare and Medicaid) requirements of participation has caused or is likely to cause serious injury, serious harm, serious impairment, or death to a resident) situation, and were provided with a completed IJ template on 7/9/2021, at 4:55 p.m. On 7/9/2021, at 6:22 pm, the facility presented a corrective Plan of Action which included, but not limited to: providing residents with hydration every two hours, check the affected residents for safety and comfortability every two hours, monitor the temperatures in the rooms of the affected residents every two hours and log the results, and rent portable air-conditioning units. Removal of the Immediate Jeopardy occurred in the presence of the Administrator and Administrative Staff A on 7/14/2021, at 4:52 p.m. after observations, interviews, and records reviewed, including an assurance from the owner of the facility that the portable air-conditioning units will remain in the facility for at least three months until the roof and HVAC (Heating, Ventilation, and Air-Conditioning) work were finished. Findings: The intake information sheet, dated 7/2/2021, indicated, the California Department of Public Health, Licensing and Certification Unit, received a complaint against a Skilled Nursing Facility (an in-patient rehabilitation and medical treatment center staffed with trained medical professionals). The intake information sheet indicated an allegation that the facility was hot and without air-conditioning. During an on-site observation on 7/9/2021, at 1:25 p.m., it was visible from the facility's parking area that the roofing shingles of the facility building were stripped off. There were boxes of new roofing shingles stacked on the rooftop. It was observed that there were no workers currently working on the roofing project. Upon entering the facility, it was observed that industrial fans (Industrial fans are designed with heavier duty materials and components to operate longer, supply greater air flow and pressure, and meet more stringent (strict) environmental and ambient (immediate surrounding) requirements) were turned on in Halls A and B of the building. During a concurrent observation and interview with Administrative Staff A on 7/9/2021, at 1:50 p.m., Administrative Staff A started checking the temperatures inside the randomly selected rooms with a digital thermometer. Administrative Staff A would show then verify the digitally recorded temperature to this surveyor for documentation. The documented air temperature readings were as follows: Room Number Temperature Affected Resident/Residents in Room 2 88 degrees F Residents 5 and 6 6 89.8 degrees F Residents 10, 11, and 12 5 92.7 degrees F Residents 1 and 9 7 88.2 degrees F Resident 13 9 79.9 degrees F Temperature within range 15 85.1 degrees F Resident 18 14 82 degrees F Resident 17 17 83.7 degrees F Resident 19 21 76.1 degrees F Temperature within range 20 82.9 degrees F Unoccupied room 4 90 degrees F Residents 2 and 3 The thermostat (a device that automatically regulates temperature, or that activates a device when the temperature reaches a certain point) in Hall A where Rooms 1 to 9 were located, registered a temperature of 86 degrees F. When Administrative Staff A was asked how many HVAC units were working, he stated all 10 units were working. When Administrative Staff A was asked about the elevated temperatures in the building, he stated that some of the air-conditioning units might be malfunctioning and needed to be serviced or replaced. Administrative Staff A stated he already set the thermostat in Hall A at 60 degrees F, hoping to bring the temperature down, but the temperatures were not cooling down. The affected residents in Hall A were Resident 4 in Room #1, Resident 7 and 8 in Room # 3, and Resident 14 in Room #8. During a concurrent observation and interview on 7/9/2021, at 2:39 p.m., with Resident 1, in Room # 5, Resident 1 was observed lying in bed with his eyes closed. Administrative Staff A knocked on the door and asked for permission to enter the room to re-check the temperature, Resident 1 opened his eyes and stated, Ok. When this surveyor asked Resident 1, how he was doing, Resident 1 stated, Too hot. It was observed that there were two standing fans inside the room and one was directed towards Resident 1's bed. The temperature inside Room # 5 registered on the digital thermometer at 94.7 degrees F. It increased two degrees from 92.7 degrees F when it was last checked on 7/9/2021, at approximately 1:53 p.m. Resident 9 was observed asleep in his bed inside Room # 5. During an observation on 7/9/2021, at 2:59 p.m., with Administrative Staff A, Administrative Staff A began re-checking of the room air temperatures on the rest of the rooms that were previously checked. The room air temperatures in these rooms were documented as follows: Room Number Temperature Affected Resident/Residents in Room 2 90.2 degrees F Residents 5 and 6 6 88.5 degrees F Residents 10, 11, and 12 7 88.2 degrees F Resident 13 9 85 degrees F Residents 15 and 16 15 85 degrees F Resident 18 14 82.8 degrees F Resident 17 17 86.9 degrees F Resident 19 21 78.1 degrees F Temperature within range 20 83.1 degrees F Unoccupied Room 4 93.2 degrees F Residents 2 and 3 The thermostat in Hall A was observed at 86 degrees F. The affected residents in Hall A, where resident rooms 1, 3, and 8 were located, were Residents # 4, 7, 8, 14. During a concurrent observation and interview on 7/9/2021, at 3:15 p.m., with Licensed Staff B, at the nurses station, it was observed that the thermostat registered a temperature of 81 degrees F and the thermostat was set at 60 degrees F. Licensed Staff B stated that only Administrative Staff A could change the temperature setting of the thermostat. Licensed Staff B stated that Administrative Staff A was responsible to check and log the temperatures in resident rooms. When Licensed Staff B was asked when the workers stopped the roof repair, she stated, About three weeks ago. During a concurrent interview and document review on 7/9/2021, at 3:30 p.m., with Administrative Staff A, Administrative Staff A brought with him a binder which showed where he logged the room temperatures and temperatures of the different halls in the building in a facility document titled, Room Temperature Log. Administrative Staff A stated he checked the temperatures at 9:30 a.m. and at 1:30 p.m. Administrative Staff A stated he usually worked Monday to Friday and left the facility at around 6 p.m. Administrative Staff A stated he was the only one who did the checking of temperatures in the rooms and in the building. When Administrative Staff A was asked what was the facility's plan to bring down the temperatures in the building because the weather forecast indicated that it was going to be hotter over the weekend, Administrative Staff A stated the air-conditioning units needed to be repaired or replaced to be able to bring the temperatures down. During a concurrent observation and interview on 7/9/2021, at 4:48 p.m., with Resident 3, Resident 3 was observed having three electric fans directed toward his bed. When asked if these fans were helping to cool him down, he stated it was still too warm in the room. During a review of a document provided by the Administrator titled, OSHPD Building Permit, issued on 11/24/2020, with parent project number, SXXXXXX-XX-XX, the detailed description of the project indicated, Remove existing roof system, replace with new fiberglass shingle. Also replace (10) existing rooftop HVAC units on roof with new ones. During an interview on 7/10/2021, at 3:10 p.m., with the Administrator, the Administrator stated that Air-Conditioning (HVAC) units would not be put in place until the structural damage discovered on the roof trusses (a roof [NAME] is a structural framework of timbers that is designed to provide support for a roof) were repaired. During an interview on 7/13/2021, at 3:12 p.m., with the Compliance Officer from the Office of Statewide Health Planning and Development (OSHPD), who conducted a field visit at the facility earlier in the day. When the Compliance Officer was asked if he would be able to provide an estimation on when the roofing project and new HVAC installation would be completed, he stated that if the facility would be able to find a new contractor by next week, to finish the project, it would take at least three (3) months to finish. A review of the report provided by the Compliance Officer from OSHPD from his field visit of the facility conducted on 7/13/2021, stated, Walked the 10 rooftop units (HVAC units) on A, B, C, and D, wings and observed: A wing, neither unit 1 or 2 was running, B wing, unit 3 was off and unit 4 was running, C wing, unit 6 was running, unit 7 was off, D wing, neither unit 8 or 10 was running, unit 9 was running, Center wing unit 5, running. Of the 6 units observed not running, some were simply off and others had the disconnect in the off position, indicating that some are not functional and that some are thermostat controlled and do not provide airflows as required throughout the building. During a review of a facility policy and procedure (P&P) titled, Quality of Life-Homelike Environment, dated May 2017, the policy statement indicated, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The policy interpretation and implementation indicated, Comfortable and Safe temperatures (71 degrees F- 81 degrees F).

Based on interview and record review, the facility failed to ensure periodic routine visits at least every 60 days by the physician and/or Nurse Practitioner (NP) for one of two sampled residents (Resident 1). This failure for Resident 1 not being assessed by his physician and/or NP for three months (between 6/22/20 to 9/29/20), resulted in Resident 1's Activities of Daily Living (ADLs), fundamental skills which are required to independently care for oneself such as eating, bathing, and mobility, declining, and resulted in Resident 1 developing a facility-acquired pressure ulcer (PU): Sore on the skin) located at the coccyx (tailbone). Resident 1's PU continued to worsen, which led to Resident 1 becoming septic (an infection of the blood stream) and transferred to the acute care facility, where Resident 1 underwent surgical debridement (removal of dead or infected skin tissue) of the wounds, placed on hospice (end of life care), and passed away. Findings: A review of Resident 1's, Admission Record, dated 4/19/20, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This long-term condition results in too much sugar circulating in the bloodstream, which can lead to disorders of the circulatory, nervous and immune systems), retention of urine, anxiety, muscle weakness, Raynaud's Syndrome (smaller arteries that supply blood to your skin narrow, limiting blood circulation, causing numbness and coldness in response to cold temperatures or stress) . Resident 1's Admission Record did not indicate she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's, History and Physical, dated 4/20/20, indicated Resident 1 was at an acute care facility from 4/14/20 to 4/19/20, due to [CONDITION(S)] (bacterial skin infection) of her right hand, due to a cat bite. Resident 1 was transferred to the Skilled Nursing Facility, short-term, for physical therapy, and to monitor her right-hand [CONDITION(S)] and urine retention. Resident 1 was ambulatory (walked) with the use of assistive equipment, a walker or cane. There was no indication of a PU. A review of Resident 1's, Baseline Care Plan, dated 4/19/20, indicated Resident 1 needed one-person physical assist with personal hygiene, toilet use, dressing, and bed mobility. Resident 1 needed set-up help for eating. A review of Resident 1's, Braden Scale (predicts PU risk), upon admission, dated 4/19/20, indicated she was not at risk for pressure ulcers. A review of Resident 1's Braden Score, dated 4/26/20, indicated Resident 1 was at risk for pressure ulcers. There was no indication Resident 1 had a PU. A review of Resident 1's, Admission MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 4/26/20, indicated she had a BIMS (Brief Interview of Mental Status) score of 15 (score meant cognitively intact). A review of Resident 1's, NP J Progress Note, dated 5/6/20, indicated Resident 1 had been confused the night before, and her physical and mental decline was worsening. Resident 1's family requested Resident 1, who had been admitted to the facility short-term, be long-term (permanently) at the facility because of her multiple co-morbidities (multiple medical conditions). A review of Resident 1's, Physical Therapy Daily Treatment Note, dated 5/14/20, indicated Resident 1 could ambulate 110 feet with a front-wheeled walker. A review of Resident 1's, NP K Progress Note, dated 6/22/20, indicated Resident 1 continued to have delusions and stated to the NP she was concerned because she did not know what was real. Resident 1 ambulated with a front-wheeled walker, but she had not gotten up since 6/16/20. She was refusing RNA (Restorative Nursing Assistant - trained to help nurses in restoring mobility to patients). A review of Resident 1's, Bowel and Bladder Assessment V-2, dated 4/19/20, indicated Resident 1 was always continent of urine and stool. Resident 1's, Bowel and Bladder Assessment V-2, dated 7/27/20, indicated Resident 1 was not always continent of urine, but at least daily, and incontinent of stool 4-6 x/week. A review of Resident 1's, Skin Integrity Sheet (change of condition), dated 7/30/20, and, Nurses Change of Condition Progress Note, dated 7/30/20, indicated Resident 1 developed an open wound located at her coccyx, measuring 1 centimeter (cm) in length x 0.5 cm in width, described as an abrasion (scrap, superficial injury), and her epithelial tissue (skin layer that covers the outside of the body) was pink in color and moist. A review of Resident 1's, Wound - Weekly Observation Tool, dated 9/18/20, indicated Resident 1's facility-acquired PU, located at her coccyx, had worsened to a Stage 2 (an intact blister or a shallow open sore, which are often red or pink and surrounded by red and pink irritated skin. These sores can be moist if pus or fluid is present) and measured 1.5 cm in length x 0.5 cm in width. A review of Resident 1's, Wound - Weekly Observation Tool, dated 9/25/20, indicated Resident 1's facility-acquired PU located at her coccyx had worsened to a Stage 3 (the PU has developed into the soft tissue underneath the skin. This stage may show a deep wound), but no change in the length and width. A review of Resident 1's, Nurses Change of Condition Progress Note, dated 9/28/20, indicated Resident 1 was declining in ADL function and had difficulty in turning and repositioning. Resident 1 needed total assist from staff during ADL care including assistance with feeding. A review of Resident 1's, NP B Progress Note, dated 9/29/20, indicated Resident 1 had been ambulating 110 ft. with a front-wheeled walker while on short-term services, but since she was transferred to long-term services, Resident 1 had progressive deconditioning (physical change). Resident 1 was now bed-bound and had a Stage 1 decubitus ulcer (injury to the skin and its underlying tissue due to prolonged pressure on it). During an interview on 11/23/20 at 2 p.m., Resident Care Coordinator (RCC) E stated NP J, who saw Resident 1 on 5/6/20, went on vacation. NP K saw Resident 1 on 6/22/20, but retired soon after. RCC E stated she was not aware of Resident 1's coccyx and buttocks wounds until they were, really bad. RCC E stated NP B did not see Resident 1's wounds until they were, really bad, which was on 10/26/20, the day NP B ordered Resident 1 to be sent out to the acute care facility. During a concurrent interview and medical record review on 4/7/21 at 10:12 a.m., Resident 1's, NP Progress Notes, indicate no physician or NP had seen Resident 1 between 6/22/20 to 9/29/20. The Administrator stated Resident 1's physician or NP should have visited her at least one time between 6/22/20 to 9/29/20. The Administrator stated, once a resident was placed on long-term care, the resident's physician should visit and assess the resident every two months. During an interview on 2/23/21 at 1:36 p.m., the DON (Director of Nursing) was asked for additional physician and/or NP, Progress Notes, from 7/1/2020 to 9/28/20 pertaining to Resident 1. None were provided. During an interview on 4/6/21 at 3:31 p.m., NP B stated he started working for the acute care facility at the end of September and visited Resident 1 for the first time on 9/29/20. During an interview on 4/21/21 at 1:50 p.m., Physician A stated he oversaw the short-term residents, and the NP oversaw the long-term residents. Physician A stated there was a gap (between 7/1/20 to 9/28/20) in physicians/NPs seeing residents because they were short-staffed. Physician A stated, after a resident had been at the facility 90 days, the resident should be seen at least every two months, but sooner if the resident was declining. A review of Resident 1's, Nurse's Progress dated 10/1/20, and, Skin Integrity Sheet, effective date 10/1/20, indicated Resident 1 had a, Change of Condition. Resident 1's PU had worsened to a Stage 3, measuring 1.5 cm x 0.2 cm. Physician A was notified and changed the wound treatment: Clean with normal saline, pat dry, apply [MEDICATION(S)] (a natural anti-bacterial product to treat wounds), and dry dressing. A review of Resident 1's, Nurses Progress Notes, dated 10/24/20 (Saturday), indicated Resident 1 had an elevated temperature of 100.2 F (Fahrenheit). Licensed Staff H called the after-hour's advice nurse. Licensed Staff H explained to the advice nurse Resident 1 had a Stage 3 PU, but she had not assessed the wound personally, however, based on Resident 1's medical chart, there were no changes to the wound. Orders were to test for COVID (Coronavirus: Mild to severe respiratory illness), monitor and treat accordingly, and update Resident 1's physician on Monday, before the change of shift. A review of Resident 1's, Nurses Progress Notes, dated 10/25/20 (Sunday), indicated Resident 1's wounds on her right buttocks and coccyx, had worsened. Wound measurements were done: Length - 15 cm x width 8 cm x depth 0.8 cm, foul odor and some black spots on the wound. Physician A ordered a wound culture, a Foley catheter (thin, sterile tube inserted into the bladder to drain urine) inserted, [MEDICATION(S)] HCI 400 MG (milligrams: Antibiotic to treat a wound infection) daily, and change in wound care: Clean wounds with Normal Saline, pat dry, Santyl ointment (removes dead tissue from wounds so they can start to heal) and apply Opticell Antibacterial Silver (wound dressing). During a concurrent record review and interview on 4/6/21 at 3:31 p.m., Resident 1's, NP B Progress Note, dated 10/26/20, indicated NP B saw Resident 1 for a wound evaluation on 10/26/20. Resident 1 was lethargic, had a temperature of 101º F, and a wound he assessed a month ago at a Stage 1 PU on 9/29/20, was now unstageable (dead tissue). Resident 1 had another unstageable PU located at the buttock. NP B discussed with Physician A to send Resident 1 to the Emergency Department (ED) for further evaluation. NP B stated he was shocked when he saw Resident 1's coccyx. NP B stated he visited his long-term residents every other month. The nursing staff should have made sure he was called when Resident 1's PU increased greater than a Stage 2, to let him know the ordered treatment was not working. NP B stated he had no idea how bad Resident 1's PU had gotten because he was not called. A review of Resident 1's, ED Provider Notes, dated 10/26/20, indicated Resident 1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's surgeon's, History and Physical, dated 10/26/20, and, Post-op Diagnosis, dated 10/27/20, and, Inpatient Wound and Ostomy RN Note, dated 10/30/20, indicated Resident 1 had a Stage 4 PU located on the buttocks, which measured 10.5 cm in length x 16 cm in width x 2.5 cm in depth. Appearance was, Full Thickness [wound that extend beyond the two layers of skin (dermis and epidermis) and went into the subcutaneous tissue (muscle and fat) or even all the way to the bone or tendons]. Resident 1 had [CONDITION(S)] likely due to her UTI and PU. On 10/27/20, Resident 1 underwent sharp debridement of the PU of the buttocks. A review of Resident 1's acute care, Discharge Note, dated 11/3/20, indicated Resident 1 was discharged to a long-term care facility and was placed on Hospice. A review of Resident 1's, Certificate of Death, dated 11/23/20, indicated Resident 1 passed away on 11/19/20, from, Complications of [CONDITION(S)] Etiology (Cause) Unknown. The facility P/P titled, Physician Services, revised 4/2013, indicated: 1. The resident's Attending Physician participates in the resident's assessment and care planning, monitoring changes in the resident's medical status . oversees a relevant plan of care for the resident. 3. The Physician will perform pertinent, timely, medical assessments . provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. 4. Physician visits, frequency of visits . are provided with current OBRA regulations and facility policy . The facility P/P titled, Acute Condition Changes - Clinical Protocol, revised 4/2009, indicated, Monitoring and Follow-Up: . 3a. The Physician will make an interim visit, if needed, to assess the situation (especially if the individual is not stable or is not improving as anticipating [sic]).

Based on interview and record review, the facility failed to provide: 1. reliable wound assessments; 2. a Physician and/or NP (Nurse Practitioner) to assess a worsening pressure ulcer (PU: Sore on the skin) in a timely manner; and, 3. implementation of a pressure ulcer (PU: Sore on the skin) care plan at the onset of a PU for one of four sampled residents (Resident 1), to prevent a facility-acquired PU located at the coccyx (tailbone), from worsening, when: 1 The facility's, Wound - Weekly Wound Observation Tool, assessments and, Skin Integrity Sheet 'Change of Wound Condition,' assessments, per effective dates, were inconsistent with NP B's PU assessment, and inconsistent with the date nurses signed-off on assessments; 2. The facility failed to start a, PU care plan until Resident 1's PU was assessed at a Stage 3 (Sore extends into the tissue beneath the skin, forming a small crater. Fat may show, but not muscle, tendon, or bone), which prevented prevention interventions from being started sooner; and, 3. The facility failed to ensure Resident 1's NP, who assessed Resident 1's facility-acquired PU as a Stage 1 (intact skin with non-blanchable redness of a localized area), assessed Resident 1's worsening PU, until the PU was a Stage 4 (a large wound in which the skin is significantly damaged. Muscle, bone, and tendons may be visible through a hole in the skin). These failures resulted in Resident 1's facility-acquired PU worsening to a Stage 4 PU. This led to Resident 1 becoming septic (an infection of the blood stream) and being transferred to the acute care facility, where Resident 1 underwent surgical debridement (removal of dead or infected skin tissue) of the wounds, was placed on hospice (end of life care), and subsequently passed away. Findings: 1. A review of Resident 1's, Admission Record, dated 4/19/20, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This long-term condition results in too much sugar circulating in the bloodstream, which can lead to disorders of the circulatory, nervous and immune systems), retention of urine, anxiety, muscle weakness, and Raynaud's Syndrome (smaller arteries that supply blood to your skin narrow, limiting blood circulation, causing numbness and coldness in response to cold temperatures or stress) . Resident 1's Admission Record did not indicate she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's, History and Physical, dated 4/20/20, indicated Resident 1 was at an acute care facility from 4/14/20 to 4/19/20, due to [CONDITION(S)] (bacterial skin infection) of her right hand, due to a cat bite. Resident 1 was transferred to the Skilled Nursing Facility, short-term, for physical therapy, and to monitor her right-hand [CONDITION(S)] and urine retention. Resident 1 was ambulatory (walked) with the use of assistive equipment, a walker or cane. There was no indication of a PU. A review of Resident 1's, Baseline Care Plan, dated 4/19/20, indicated Resident 1 needed one-person physical assist with personal hygiene, toilet use, dressing, and bed mobility. Resident 1 needed set-up help for eating. A review of Resident 1's, Braden Scale (predicts PU risk), upon admission, dated 4/19/20, indicated she was not at risk for pressure ulcers. A review of Resident 1's Braden Score, dated 4/26/20, indicated Resident 1 was at risk for pressure ulcers. There was no indication Resident 1 had a PU. During a concurrent interview and record review on 2/23/21 at 2:05 p.m., and 4/22/21 at 12:09 p.m., the following information was obtained: a. Resident 1's electronic, Skin Integrity Sheets, effective date, 7/30/20, and, Wound -Weekly Observation Tool, effective dates, 8/7/20, 8/14/20, 8/21/20, 8/28/20, and 9/11/20, indicated Resident 1's PU wound to her coccyx was assessed as an abrasion, epithelial tissue was pink in color and moist, and the length ranging from 1.0 cm (centimeter) to 1.5 cm x width ranging from 0.03 cm to 0.05 cm. The wound assessment sheets dated 7/30/20, 8/7/20, 8/14/20, 8/21/20, and 8/28/20, were signed on 11/3/20, by Resident Care Coordinator (RCC) I. The wound assessment sheet dated 9/11/20, was signed on 11/3/20, by Licensed Staff D. Resident 1 was transferred to the acute care facility on 10/26/20, b. Resident 1's, Wound -Weekly Observation Tool, effective date 9/18/20, indicated Resident 1's wound was a Stage 2 PU (an intact blister or a shallow open sore, which are often red or pink and surrounded by red and pink irritated skin. These sores can be moist if pus or fluid is present). The wound assessment sheet was signed on 11/2/20, by Licensed Staff G. Resident 1 was transferred to the acute care facility on 10/26/20, c. The Wound -Weekly Observation Tool, effective dates 10/1/20 and 10/21/20, indicated Resident 1's PU was a Stage 3, length ranging from 1.5 cm to 3.5 cm x width ranging from 0.5 cm to 2 cm. The wound assessment sheet, dated 10/1/20, was signed on 10/27/20, by RCC E. The wound assessment sheet, dated 10/21/20, was signed on 10/27/20, by Licensed Staff C. Resident 1 was transferred to the acute care facility on 10/26/20, d. The, Skin Integrity Sheet, effective date 10/8/20, indicated Resident 1 had three new wounds on the right buttocks, total circumference of 6 cm x 6.6 cm because of, Moisture Associated Skin Damage [MASD (inflammation of the skin caused by prolonged exposure to urine, stool .)]. The wound assessment sheet was signed on 10/27/20, by RCC I. Resident 1 was transferred to the acute care facility on 10/26/20, and e. The, Skin Integrity Sheet, effective date 10/14/20, indicated Resident 1's right buttocks wounds were because of MASD; the length ranging from 0.5 cm to 4.4 cm x width ranging from 0.8 cm to 5 cm. The wound sheet was signed on 11/1/20, by Licensed Staff C. Resident 1 was transferred to the acute care facility on 10/26/20. The DON (Director of Nursing) stated the irregularities of the, Wound - Weekly Observation Tool and, Skin Integrity Sheets', effective dates and the date the documents were signed, could be due to late entries or because the documents were opened in the software system, but not locked (closed) until a later date. During an interview on 4/21/21 at 12:43 p.m., Licensed Staff G stated, if the nurse's signature date on a, Wound - Weekly Observation Tool, was not the same as the effective date, one of two things occurred; the nurse forgot to close out of the software after they finished their documentation or, the nurse never finished the assessment until the lock date (signature date/closed date). Licensed Staff G stated the date the, Wound - Weekly Observation Tool, was signed, was the date the wound assessment was completed. During an interview on 4/22/21 at 5:54 p.m., RCC I stated, when he did resident wound assessments, he used a facility in-house wound form. RCC I stated he must have inputted his data on the, Wound - Weekly Observation Tool and, Skin Integrity Sheet, software forms late, causing the irregularities of the effective dates and the date the documents were signed. RCC I stated he would then give the in-house wound forms to the Administrator, DON, and the Minimum Data Set (MDS--an assessment tool) Coordinator. During interviews on 2/22/21 at 12:05 p.m., 2/23/21 at 2:05 p.m., 4/7/21 at 10:12 p.m., and 4/22/21 at 12:09 p.m., when the Administrator and DON were asked about the wound assessment date irregularities, they did not mention there was an in-house wound form given to them by the treatment nurse. The facility did not provide any additional wound forms to verify Resident 1's PU assessments were completed on the effective date. A review of Resident 1's, NP B Progress Note, dated 9/29/20, indicated Resident 1 had been ambulating 110 ft. with a front-wheeled walker while on short-term services, but since she was transferred to long-term services, Resident 1 had progressive deconditioning (physical change). Resident 1 was now bed-bound and had a Stage 1 decubitus ulcer (injury to the skin and its underlying tissue due to prolonged pressure on it). During a concurrent interview and record review on 4/6/21 at 3:31 p.m., Resident 1's, Wound - Weekly Observation Tool, dated 9/18/20, indicated Resident 1's facility-acquired PU, located on her coccyx, had worsened to a Stage 2. Resident 1's, Wound - Weekly observation Tool, dated 9/25/20 and 10/1/20, indicated Resident 1's PU was assessed at a Stage 3. Resident 1's, Skin Integrity Sheet, dated 10/1/20, indicated Resident 1's PU was assessed at a Stage 3. NP B stated, on 9/29/20, he did a physical assessment on Resident 1 and assessed her facility-acquired PU at a Stage 1. If the nurses documented anything other than a Stage 1 on 9/18/20, 9/25/20, and 10/1/20, they were wrong in their assessments. NP B stated the nurses' assessments were inaccurate. During an interview and record review on 4/6/21 at 5:09 p.m., the DON stated the treatment nurse was not wound-certified. When the treatment nurse was off, other nurses would do the, Weekly Wound Assessments, and they were also not wound-certified. A review of Resident 1's, Skin Integrity Sheet, effective date 7/30/20, indicated Resident 1 had developed a Stage 1 PU, but per review of Resident 1's care plan, staff did not care plan for a PU until 10/1/20, when Resident 1's PU was assessed at a Stage 3. During an interview on 4/21/21 at 1:50 p.m., Physician A stated he oversaw NP B. Physician A stated, if NP B documented Resident 1's PU was a Stage 1, then it was a Stage 1. Physician A stated he believed NP B knew the difference between a Stage 1, Stage 2, and Stage 3. Physician A stated it would be very rare that a PU went from a Stage 1 to a Stage 3 in two days (9/29/20 to 10/1/20). The facility job description titled, Department Supervision, revision 8/2006, indicated: 4. The DON Services and/or the Nurse Supervisor/Charge Nurse, as a minimum, is responsible for: a. Making daily resident visits to observe and evaluate the resident's physical and emotional status . c. Reviewing individual resident care plans for appropriate goals, approaches, and revisions based on nursing needs; d. Assuring that the resident's plan of care is being followed . g. Charting and documenting medical records as necessary; h. Keeping nursing service personnel informed of status of the residents and other related matters through written reports . The facility job description titled, Director of Nursing Services, revised 8/2006. n. Assuring that nursing care personnel are administering care and services in accordance with the resident's assessment and care plan. 2. A review of Resident 1's, Nurse's Progress Note, dated 7/30/20, and Skin Integrity Sheet, effective date 7/30/20, indicated Resident 1 had a, Change of Condition, noted to have an open wound at the coccyx area measuring 1.5 cm x 0.5 cm. Physician A was notified and ordered the wound to be treated: Cleaned with normal saline [NSS - mixture of salt and water], pat dry, apply triple antibiotic (works to stop the growth of bacteria), and dry dressing. A review of Resident 1's, NP Progress Note, dated 9/29/2020, indicated Resident 1 had been ambulating 110 ft. with a front-wheeled walker while on short-term services, but since she was transferred to long-term services, Resident 1 had progressive deconditioning (physical change) and was now bed bound and had a Stage 1 PU. A review of Resident 1's, Nurse's Progress Note dated 10/1/20, and, Skin Integrity Sheet, effective date 10/1/20, indicated Resident 1 had a Change of Condition. Resident 1's PU had worsened to a Stage 3, measuring 1.5 cm x 0.2 cm. Physician A was notified and changed the wound treatment: Clean with normal saline, pat dry, apply [MEDICATION(S)] (a natural anti-bacterial product to treat wounds), and dry dressing. A review of Resident 1's, Nurse's Progress Notes, dated 10/8/20, and, Skin Integrity Sheet, effective date 10/8/20, with a signature date of 10/27/20 (after Resident 1 was transferred to the acute care facility), indicated Resident 1 had a, Change of Condition. Resident 1 had acquired three new wounds on the right buttocks, total circumference of 6 cm x 6.6 cm because of, MASD. The, Skin Integrity Sheet, indicated a physician was notified. During an interview on 11/23/20 at 12:50 p.m., Licensed Staff C stated she started working at the facility on 10/8/20. Resident 1's coccyx and right buttocks wounds were already being treated when she started treating the wounds. Licensed Staff C stated she did not think the [MEDICATION(S)] treatment was helping, so she left a note with her concerns in Resident 1's physician and/or NP's, Rounder, binder. Licensed Staff C did not specify the date she left the note in the physician/NP's Rounder Binder. A review of Resident 1's, Nurses Progress Notes, did not indicate Licensed Staff C left a note for Resident 1's physician and/or NP regarding wound concerns. A review of Resident 1's, Nurses Progress Notes, dated 10/24/20 (Saturday), indicated Resident 1 had an elevated temperature of 100.2 F (Fahrenheit). Licensed Staff H called the after-hour's advice nurse. Licensed Staff H explained to the advice nurse Resident 1 had a Stage 3 PU, but she had not assessed the wound personally, however, based on Resident 1's medical chart, there were no changes to the wound. Orders were to test for COVID (Coronavirus: Mild to severe respiratory illness), monitor and treat accordingly, and updated Resident 1's physician on Monday, before the change of shift. A review of Resident 1's, Nurses Progress Notes, dated 10/25/20 (Sunday), indicated Resident 1's wounds on her right buttocks and coccyx, had worsened. Wound measurements were done: Length - 15 cm x width 8 cm x depth 0.8 cm, foul odor, and some black spots on the wound. Physician A ordered a wound culture, a Foley catheter (thin, sterile tube inserted into the bladder to drain urine) inserted, [MEDICATION(S)] HCI 400 MG (milligrams: antibiotic to treat a wound infection) daily, and change in wound care: Clean wounds with Normal Saline, pat dry, Santyl ointment (removes dead tissue from wounds so they can start to heal) and apply Opticell Antibacterial Silver (wound dressing). During an interview on 11/23/20 at 2 p.m., Resident Care Coordinator (RCC) E stated NP J, who saw Resident 1 on 5/6/20, went on vacation; NP K saw Resident 1 on 6/22/20, but retired soon after. RCC E stated she was not aware of Resident 1's coccyx and buttocks wounds until they were, really bad. RCC E stated NP B did not see Resident 1's wounds until they were, really bad, which was on 10/26/20, the day NP B ordered Resident 1 to be sent out to the acute care facility. During a concurrent record review and interview on 2/23/21 at 2:05 p.m. and 4/22/21 at 12:09 p.m., the DON stated the, Rounder, Binder was a form of communication to the resident's physician and/or NP regarding a medical concern and/or, Change of Condition. The DON stated, if the concern was serious, the nurse should always call the resident's physician or NP. The DON was asked about Resident 1's, Progress Note, dated 10/11/20, which indicated Resident 1's wounds to her coccyx and right buttocks, still with worsening condition, and Licensed Staff D was concerned treatment was not working. Licensed Staff D left a written concern in the, Rounder, per, Nurse's Progress Note, and there was no indication of Resident 1's physician and/or NP were called. The DON stated Licensed Staff D should have called, especially if she was concerned the treatment was not helping, and the wound looked worse. The DON stated NP B took care of the long-term residents, but if the nurse could not get a hold of him, the nurse could contact Physician A, who visited the facility daily and oversaw the NP. The DON stated concerned nursing staff should have made sure Resident 1's NP and/or physician looked at Resident 1's worsening PU. During an interview on 3/9/21 at 4:49 p.m., Licensed Staff F stated, when a resident started to have a PU and when it became worse, the nurse would inform the RCC, who would inform the resident's physician or NP. The RCC would inform the after-hours advice nurse (who was always available) if the RCC could not get a hold of the physician or NP. Licensed Staff F stated Physician A and NP B were at the facility frequently. The nursing staff could have made Physician A and/or NP B aware of their concerns regarding Resident 1's wound not healing and the need for either one to assess the wounds. During a concurrent record review and interview on 4/6/21 at 3:31 p.m., Resident 1's, NP Progress Note, dated 10/26/20, indicated NP B saw Resident 1 for a wound evaluation. Resident 1 was lethargic, had a temperature of 101º F, and a wound he assessed a month ago at a Stage 1 PU on 9/29/20, was now unstageable (dead tissue). NP B discussed with Physician A to send Resident 1 to the Emergency Department for further evaluation. NP B stated he reviewed the wound orders written on 10/1/20: [MEDICATION(S)] . to the open wound, with the wound nurse. NP B stated he was never notified when Resident 1's PU worsened to a Stage 3. NP B stated he did not assess Resident 1's PU, which had been assessed at a Stage 2 by the wound nurse adding, the wound nurse should be able to handle treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . NP B stated he was not notified by nursing staff of Resident 1's coccyx Stage 2 PU worsening to a Stage 3. NP B stated he came into the facility on [DATE], to see a few other residents and was asked to assess Resident 1's PU. NP B stated he was aware Physician A had ordered a wound culture and antibiotics for Resident 1 over the weekend. NP B stated he was shocked when he saw Resident 1's coccyx. NP B stated he visited his long-term residents every other month. Nursing staff should have made sure he was called when Resident 1's PU increased greater than a Stage 2, and the ordered treatment was not working. NP B stated he had no idea how bad Resident 1's PU had gotten because he was not called. During an interview on 4/21/21 at 12:43 p.m., Licensed Staff G stated NP B took care of the long-term residents. Licensed Staff G stated Resident 1's PU started as a tiny 0.1 cm open wound at her coccyx. Resident 1's PU went to a Stage 3. Resident 1's PU advanced to a, Deep Tissue Injury, blackish in color. The nurse caring for Resident 1 and/or the wound nurse should have called NP B to notify him that treatment was not effective, and he needed to come in to assess Resident 1's PU when the wound worsened to a Stage 3. During an interview on 4/21/21 at 1:50 p.m., Physician A stated the NP took care of the long-term residents, and he took care of the short-term residents. Physician A stated, if a concern about Resident 1's wound or a, Change of Condition, was placed in the, Rounder, Binder for NP B on 10/11/20, NP B should have seen the note on 10/12/20. Physician A stated they were at the facility five days a week. On the weekends, the nursing staff would call the after-hours advice nurse, who would forward the concern to the on-call Physician. The on-call Physician would make recommendations based on the nurse's concerns. Physician A stated he has given the facility his personal cell phone, so the nursing staff could have called him, 24 hours/7 days a week. Physician A stated he would have let NP B know about Resident 1's wound. Physician A stated the nursing staff should have verbally communicated their concerns, regarding Resident 1's PU worsening from a Stage 2 to a Stage 3, to NP B. NP B needed to be made aware; NP B needed to assess Resident 1's worsening wound. During an interview on 4/21/ 21 at 6:34 p.m., Licensed Staff D stated she really did not know the proper communication with notifying Resident 1's physician and/or NP in October 2020. Licensed Staff D stated if she was concerned with a resident's wound, and Physician A was on duty, she would call Physician A. Licensed Staff D stated, over the weekend if she was concerned about a Resident 1's wound, she would place a note in Physician A/NP B's Rounder Binder, so they would see the note on Monday. Licensed Staff D stated Physician A/NP B's, Rounder Binder was like their, Bible; they both checked it several times per day. Licensed Staff D stated both Physician A and NP B were at the facility on a regular basis. Licensed Staff D stated, if Physician A was at the facility, she would have expressed her concerns about the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed Staff D stated, when she assessed Resident 1's Stage 3 PU on 10/11/20 (Sunday), she left a note in Physician A/NP B's Rounder Binder regarding her concerns that the [MEDICATION(S)] was not effective, thinking they would see the note on Monday. During a concurrent interview and record review on 4/22/21 at 12:40 p.m., the, Nursing Progress Note, dated 10/8/20, indicated Licensed Staff H documented Resident 1 had a, Change of Condition, three moisture-associated wounds on the right buttocks, measuring 4.9 cm x 5 cm, 1.1 cm x 1.2 cm, and 0.6 cm x .9 cm. Licensed Staff H noted recommendations were to apply [MEDICATION(S)] to wounds, reposition every two hours, daily dressing changes, monitor for worsening condition and notify the physician. There were no new recommendations since 10/1/20. RCC 1 indicated, on Resident 1's, Skin Integrity Sheet, effective date 10/8/20, Resident 1 had three new wounds on the right buttocks, total circumference of 6 cm x 6.6 cm because of, MASD, and a physician was notified on 10/8/20. The wound assessment sheet was not signed until 10/27/20, the day after Resident 1 was transferred to the acute care facility. Licensed Staff H stated she should have documented she placed a note in NP B's, Rounder, Binder informing NP B of Resident 1's, Change of Condition. Licensed Staff H stated, if it was not documented, it meant it was not done. During an interview on 4/22/21 at 1:47 p.m., NP B stated the, Rounder, Binder was a, hit or miss, with nurse's written medical concerns regarding residents; mostly resident's lab work was placed in the, Rounder, Binder. NP B stated the nursing staff could have asked him anytime to see Resident 1's PU. He was at the facility one week five days and the next week four days. NP B stated, The bottom line, if wound was getting worse; concerned, notify me to see and I would have. I am there often. The facility job description titled, Department Supervision, revised 8/2006, indicated: 4. The DON Services and/or the Nurse Supervisor/Charge Nurse, as a minimum, is responsible for . f. Informing attending physicians and resident families of changes in the resident's medical condition; Charting and documenting medical records as necessary; h. Keeping nursing service personnel informed of status of the residents and other related matters through written reports . The facility job description titled, DON Services, revised 8/2006, indicated, .n. Assuring that nursing care personnel are administering care and services in accordance with the resident's assessment and care plan. The Facility job description titled, Department Supervision, 8/2006, .4. The DON Services and/or the Nurse Supervisor/Charge Nurse, as a minimum is responsible for: a. Informing attending physicians and resident families of changes in the resident's medical condition . The facility P/P titled, Acute Condition Changes - Clinical Protocol, revised 4/2009, indicated: .6. The nursing staff will contact the Physician based on the urgency of the situation .3 a. The Physician will make an interim visit, if needed to access the situation (especially if the individual is not stable or is not improving as anticipated). The facility P/P, titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised 4/2017, Monitoring: 1. During resident visits, the physician will evaluate and document the progress of the wound healing-especially for those with complicated, extensive or non-healing wounds . 3. A review of Resident 1's care plans indicated there was no, PU care plan initiated, until 10/1/20, when Resident 1's coccyx PU had escalated to a Stage 3. There were no PU wound care treatment interventions indicated, until 10/1/21, which included daily wound care, per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's, Potential for Pressure Ulcer, care plan, initiated 4/23/20, included interventions Resident 1 needed monitoring/reminding/assistance to turn/position every two hours, to treat pain per order, and Resident 1 needed moisturizer applied to her skin. No goals were indicated. A review of Resident 1's, Potential for Impaired Skin Integrity, care plan, initiated on 4/19/20, included interventions: Encouraging fluids, evaluate skin weekly, monitor incontinence, observe skin integrity every shift, pressure-reducing cushion to wheelchair and pressure-reducing mattress to bed, and notify MD promptly of skin breakdown. A review of Resident 1's physician orders, dated 4/19-10/26/21, did not indicate Resident 1 had a, Pressure Reducing Cushion, ordered for her wheelchair. There was no order for a LLA Mattress until 10/1/20. Resident 1 had gone from short-term care to long-term care, so NP B was overseeing her care, and Physician A was overseeing NP B. NP B was not asked to assess Resident 1's worsening coccyx and buttocks wounds, until 10/26/20, the day NP B ordered her to be transferred to the acute care facility. The, Potential for Impaired Skin Integrity, care plan goal was for Resident 1's skin to remain intact, free from redness, blisters or discoloration, and no new PU from developing through the target date of 11/1/20. A review of Resident 1's, Skin Integrity Sheet (change of condition), dated 7/30/20, and, Nurses' Change of Condition Progress Note, dated 7/30/20, indicated Resident 1 had developed an open wound located at her coccyx, which was 1 cm in length x 0.5 cm in width, and described as an abrasion. There was no, PU care plan started. A review of Resident 1's, Wound - Weekly Observation Tool, dated 9/18/20, indicated Resident 1's facility-acquired PU, located at her coccyx, was now a Stage 2 and measured 1.5 cm in length x 0.5 cm in width. There was no, PU care plan started. A review of Resident 1's, Nurses Change of Condition Progress Note, dated 9/28/20, indicated Resident 1 was declining in ADL function and had difficulty in turning and repositioning. Resident 1 needed total assist from staff during ADL care, including assistance with feeding. There was no, PU care plan started. A review of Resident 1's, Treatment Administration Records, Physician Orders, and Nurses Progress Notes, dated 4/19/2020 through 10/26/2020, indicated Resident 1 was not placed on a LLA Mattress until 10/1/20. During an interview on 2/23/21 at 2:05 p.m. the DON stated, when Resident 1 had a, Change of Condition, on 7/30/20, indicating she had developed an open wound located at her coccyx, a, PU care plan should have been started and updated accordingly, to when the PU worsened. The DON stated the wound nurse, MDS Coordinator, nurse assigned to Resident 1 could have started the, PU care plan and/or updated the care plan accordingly. During an interview on 3/10/21 at 10 a.m., and 4/21/21 at 3:43 p.m., Licensed Staff F stated Resident 1's PU was getting worse because Resident 1 was non-compliant. She would want to go back to bed soon after getting up, she did not want to turn side-to-side, and the Certified Nursing Assistants (CNAs) needed to assist her with turning, and after 10 to 15 minutes on her side, she would go back to her back. Licensed Staff F stated Resident 1's nurses should have implemented a, PU care plan when Resident 1 had a, Change of Condition, dated 7/30/20, which indicated Resident 1 had developed an open wound located at her coccyx, and the care plan should have been updated when there was a change to her wound/physical condition. During an interview on 4/21/21 at 12:43 p.m., Licensed Staff G stated, when a, Change of Condition, was identified, a care plan should have been started, updated accordingly and treatments/interventions indicated. Licensed Staff G stated Resident 1's PU care plan was not started until her PU was assessed at a Stage 3. A review of Resident 1's, NP B Progress Note, dated 10/26/20, indicated NP B assessed Resident 1's PU on 10/26/20. Resident 1's PU had worsened. NP B indicated Resident 1 developed a Stage 1 PU one month ago, on 9/29/20, to her coccyx; the wound now was unstageable (ulcer covered by slough -- yellow/white and soft or leathery dead tissue) and/or eschar (dry, black, hard dead tissue). Resident 1 developed second wound located at her buttock, which was unstageable. A review of Resident 1's, Nursing Progress Notes, dated 10/26/20, indicated Resident 1 was transferred to the ED (Emergency Department) on 10/26/20, due to she had become lethargic, had a axillary (armpit) temperature of 101º F, had an offensive odor to her wound, with some black spots noted on the wound. NP B ordered Resident 1 to be transferred to the ED for further evaluation. A review of Resident 1's, ED Provider Notes, dated 10/26/20, indicated Resident 1's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's surgeon's, History and Physical, dated 10/26/20, and, Post-op Diagnosis, dated 10/27/20, and, Inpatient Wound and Ostomy RN Note, dated 10/30/20, indicated Resident 1 had a Stage 4 PU located on the buttocks, which measured 10.5 cm in length x 16 cm in width x 2.5 cm in depth. Appearance was, Full Thickness [wound that extend beyond the two layers of skin (dermis and epidermis) and went into the subcutaneous tissue (muscle and fat) or even all the way to the bone or tendons]. Resident 1 had [CONDITION(S)] likely due to her UTI and PU. On 10/27/20, Resident 1 underwent sharp debridement of the PU of the buttocks. A review of Resident 1's acute care, Discharge Note, dated 11/3/20, indicated Resident 1 was discharged to a long-term care facility and was placed on Hospice. A review of Resident 1's Certificate of Death, dated 11/23/20, indicated Resident 1 passed away on 11/19/20, from, Complications of [CONDITION(S)] Etiology (Cause) Unknown. A Facility job description titled, Department Supervision, revised 8/2006, indicated, 4. The DON Services and/or the Nurse Supervisor/Charge Nurse, as a minimum, is responsible for: . c. Reviewing individual resident care plans for appropriate goals, problems, approaches, and revisions based on nursing needs; d. Assuring that the resident's plan of care is being followed . Facility job description titled, Director of Nursing Services, 8/2006, indicated, 2. n. Assuring that nursing care personnel are administering care and services in accordance with the resident's assessment and care plan. The facility P/P titled, Care Plans - Comprehensive, 8/2006, indicated, . Care plans are revised as changes in the resident's condition dictate . The facility P/P, titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised 4/2017, i [TRUNCATED]

Based on observation interview and record review, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when: 1) PPE was not readily available in resident care areas; 2) Staff did not use PPE properly in resident care areas; 3) Staff did not perform hand hygiene before and after resident care; 4) The facility allowed a non-infected resident to share a room with two infected residents without precautions to prevent spread of COVID-19; 5) The facility transported two COVID-19 positive residents through the non-COVID unit without wearing masks or other PPE; 6) The facility's screening form for visitors did not include all the symptoms of COVID-19 listed by the Centers for Disease Control and Prevention (CDC); and, 7) The facility did not have an Infection Preventionist on site to ensure Infection Prevention and Control guidelines and standards were followed at the facility (cross-reference to tag F882). These failures placed residents and staff at risk of contracting infectious diseases such as COVID-19. At the start of the non-compliance period, on 1/5/21, there were 24 residents infected with COVID-19 (out of a census of 51 residents). By the day of the Exit Conference, on 1/15/21, 18 additional residents had tested been positive for COVID-19. Findings: During an interview on 1/5/21, at 9:30 a.m., the Receptionist was asked who was in charge of the facility. The Receptionist stated it was Licensed Vocational Nurse A (LVN A). During an interview on 1/5/21, 9:30 a.m., LVN A stated he was in charge. LVN A stated he was working as a floor nurse and had 31 residents. LVN A was asked to speak with the Administrator, Director of Nursing and Infection Preventionist (IP). LVN A stated all three were sick. LVN A stated there was no Administrative Staff at the facility. LVN A stated there were a total of 55 residents at the facility, 24 of which had COVID-19, and were isolated in the COVID Unit. The COVID Unit comprised rooms 16 to 28. LVN A stated the COVID Unit was divided in two sections: The first comprising Rooms 20-28 with 16 residents (COVID Unit I), and the second comprising Rooms 16-19 (COVID Unit II) with eight residents (together the COVID Unit). During an observation of COVID Unit I on 1/5/21, at 10:05 a.m., there was no Alcohol Based Hand Sanitizer (ABHS) or hand washing facilities outside the entrance of the unit. There was no Personal Protective Equipment (PPE - gowns, gloves, masks and face shields) available at the entrance of the Unit. There was a PPE cart hanging outside the door of the Unit, with compartments for gowns, gloves, masks and face shields. This cart was empty. Next to the cart there was a sign with the following message, in capital letters: PLEASE OBSERVE INFECTION CONTROL PRACTICES WHEN ENTERING/LEAVING OBSERVATION ROOM/UNIT BEFORE ENTERING ROOM/UNIT WASH HANDS/USE ALCOHOL GEL PUT ON GLOVES WEAR GOWN PUT ON N95 FACE MASK PUT ON FACE SHIELD WHEN LEAVING ROOM/UNIT TAKE OFF GOWN AND GLOVES AND THROW IN TRASH BIN USE ALCOHOL GEL TO DISINFECT HANDS WEAR ANOTHER SET OF GLOVES REMOVE FACE SHIELD AND DISINFECT WITH BLEACH SOLUTION ON BLUE TAP DISINFECTANT WIPE (FOR COVID-19) REMOVE N95 MASK AND THROW IN TRASH BIN WASH HANDS/DISINFECT HANDS WITH ALCOHOL GEL The CDC Guidelines for PPE and hand hygiene availability are as follows: Signs are posted immediately outside of resident rooms indicating appropriate IPC precautions and required personal protective equipment (PPE). Healthcare facilities should ensure that hand hygiene supplies are readily available to all personnel in every care location. Make necessary PPE available in areas where resident care is provided. Necessary PPE is available immediately outside of the resident room and in other areas where resident care is provided. https://www.cdc.gov/coronavirus/2019-ncov/downloads/novel-coronavirus-2019-Nursing-Homes-Preparedness-Checklist_3_13.pdf https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html During an observation of the COVID Unit I on 1/5/21, at 10:10 a.m., there was one hallway with nine resident rooms located on both sides and on one end of the hallway (the other end of the hallway was sealed with a plastic barrier). There were 16 residents in the Unit. Hand sanitizer dispensers were located outside, but not inside, the rooms. There was one PPE cart inside the Unit, which was filled with one mask and two boxes of gloves. One open pack of gowns was located on top of a crash cart, and three boxes of gloves, two of which empty, were on placed on top of handrails outside resident rooms. No other PPE was seen in the unit. A review of CDC Guidelines for hand sanitizer availability and use indicated: Put alcohol-based hand sanitizer with 60-95% alcohol in every resident room . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html The CDC Guidelines for PPE use are as follows: The PPE recommended when caring for a patient with suspected or confirmed COVID-19 includes the following: Respirator or Facemask (Cloth masks are NOT PPE and should not be worn for the care of patients with suspected or confirmed COVID-19 or other situations where use of a respirator or facemask is recommended). Eye Protection. Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply. Gloves. Put on clean, non-sterile gloves upon entry into the patient room or care area. Gowns. Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Reusable (i.e., washable or cloth) gowns should be laundered after each use. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html During an observation of COVID Unit I on 1/5/21, at 10:15 a.m., Licensed Nurse B was wearing the following PPE: A mask. Licensed Nurse B had no gown, no eye protection and no gloves. Licensed Nurse B went into room [ROOM NUMBER] and provided care to Resident 14. Then, without performing hand hygiene or donning gloves or other PPE, provided care to Resident 13, also in the same room. Without performing hand hygiene, and still only wearing a mask as PPE, Licensed Nurse B went to room [ROOM NUMBER] and provided care to Resident 25. The CDC Guidelines for Hand Hygiene are as follows: HCP (Health Care Providers) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. HCP should perform hand hygiene by using ABHS with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Remove and discard gloves before leaving the patient room or care area, and immediately perform hand hygiene. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html An observation of COVID Unit II on 1/5/21, at 10:30 a.m., revealed it was on the other side of the facility and was comprised of a cluster of four rooms in a row (Rooms 16 to 19). These rooms had two entrances. In the regular entrance were the room doors, which faced the hallway. These doors were sealed. On the other side, each room had a sliding door which faced the courtyard. These sliding doors were used as the exclusive entrance/exit to the rooms for staff and residents. There were no ABHS dispensers outside or inside Rooms 16 to 19. There were no handwashing facilities outside for use by staff before entering these rooms. Outside the sliding door entrance to room [ROOM NUMBER], in a corner against the outside wall of the dining room, there was one PPE cart containing one pack of gowns and two boxes of gloves. Next to the PPE cart there was the following sign: PLEASE OBSERVE INFECTION CONTROL PRACTICES WHEN ENTERING/LEAVING OBSERVATION ROOM/UNIT BEFORE ENTERING ROOM/UNIT WASH HANDS/USE ALCOHOL GEL PUT ON GLOVES WEAR GOWN PUT ON N95 FACE MASK PUT ON FACE SHIELD WHEN LEAVING ROOM/UNIT TAKE OFF GOWN AND GLOVES AND THROW IN TRASH BIN USE ALCOHOL GEL TO DISINFECT HANDS WEAR ANOTHER SET OF GLOVES REMOVE FACE SHIELD AND DISINFECT WITH BLEACH SOLUTION ON BLUE TAP DISINFECTANT WIPE (FOR COVID-19) REMOVE N95 MASK AND THROW IN TRASH BIN WASH HANDS/DISINFECT HANDS WITH ALCOHOL GEL On 1/5/21 at 2:45 p.m., the Department identified an Immediate Jeopardy situation with respect to Infection Control in the COVID Unit. On 1/5/21, at 3:27 p.m., the Department e-mailed the Owner the, IJ Template, indicating the following non-compliance re Infection Control: Insufficient PPE available in the COVID-19 area and failure to follow CDC infection control guidelines by staff in the COVID-19 area. During an interview on 1/5/21, at 3:35 p.m., the Regional Director of Operations (RDO) was asked if he was familiar with the IJ process and was offered assistance in creating an IJ Removal Plan. The RDO stated he was familiar with the process and declined assistance. On 1/5/21, at 3:50 p.m., the Department emailed the Owner, RDO and the DON a revised IJ Template in which the only change made was the date year was corrected from, 2020 to 2021. The recipients were requested to submit a written, IJ Removal Plan, with the immediate actions the facility will take to address noncompliance, indicated in the IJ Template. On 1/5/21, at 4:58 p.m., the RDO emailed the Department a, Plan of Correction, dated 1/5/21. This document listed no actions to address the IJ non-compliance of, Insufficient PPE available in the COVID-19 area and failure to follow CDC Infection Control guidelines by staff in the COVID-19 area. The words, Infection Control, CDC guidelines, and, PPE were not even mentioned in the Plan of Correction. There was only one indirect reference to Infection Control: Facility has developed a QAPI for COVID-19 precautions. There was no explanation of what was meant by, COVID-19 precautions. This was followed by the following sentence: The Director of Nursing and DSD are monitored for compliance by the Administrator, daily. The results will be presented to stand up meeting weekly and action will be taken for 100% compliance. The results will be presented to the Monthly QA for compliance. On 1/5/21, at 8:47 p.m., the Department emailed the RDO indicating the Plan of Correction was not accepted because it was not an IJ Removal Plan, and it did not indicate the, facility's immediate actions to address the non-compliance (Insufficient PPE available in the COVID-19 area and failure to follow CDC infection control guidelines by staff in the COVID-19 area). On 1/5/21, the at 9:31 p.m., the RDO submitted a revised document called, IJ Removal Plan, dated, 12/11/2020 (sic). The IJ Removal Plan indicated the following three actions to address the non-compliance identified in the IJ Template: (1) Staff are seen PPE inappropriately (sic), individual PPE is being requested for each door of the red-zone, and hand sanitizers to the installed inside the rooms. (2) Instruction materials have been ordered by 6:30PM for the items requested to be installed and in-services to be done for all staff beginning this night shift on 01.05.2021 at 7 p.m. by Acting Administrator and Nurse Consultant. (3) Assigned facility staff will review and audit/inspect daily that PPE is being used for each room individually. The assigned staff include the Director of Nursing, the InfecDon (sic) PrevenDon (sic) Consultant and Director of Staff Development. The above actions were not credible because there was no, Director of Nursing, the InfecDon (sic) PrevenDon (sic) Consultant and Director of Staff Development, or Nurse Consultant, at the facility on 1/5/21, to implement any of the actions. The only administrative staff at the facility was the Acting Administrator, who arrived on-site on 1/5/21, at 4:30 p.m., and was not knowledgeable about the facility, the resident population, and infection control and was not equipped to train nursing staff. The Acting Administrator did not even have access to paper and pen, which the Department supplied, at his request, so he could take notes. During an interview on 1/6/21, at 9:45 a.m., the Department met with the facility's Nurse Consultant (NC), who arrived on site. The NC was asked if he was the facility's Infection Preventionist (IP) or was overseeing the facility's Infection Prevention and Control program. The NC stated, No. The NC was asked if he was overseeing the facility's nursing care and stated, No. The NC was asked if he was providing administrative oversight to the facility and stated, No. The NC stated he was the, Nurse Consultant. During an interview on 1/6/21, at noon, the RDO submitted a revised IJ Removal. On 1/6/21 at 4 p.m., the facility's IJ Removal Plan was approved. A review of the facility's IJ Removal Plan, dated 1/5/21 at 4 p.m. indicated the following four actions to address the infection control non-compliance listed in the IJ Template: (1) The facility will stock covid unit with ppe, all ppe: gloves, n-95 masks, and gowns and face shields and make readily accessible to staff. (2) Hand sanitizer bottles will be placed inside rooms and nurses carts. (3) Proper Hand hygiene will be in serviced together with Use of ppe proper usage to all staff assigned to covid unit. (4) Facility will in-service all staff assigned to the Covid unit on the use of ppe and infection control practices per cdc guidelines. The Department did not see or talk with any Infection Preventionist staff on 1/6/21. No Infection Preventionist staff sought or introduced themselves to the Department or offered to speak with the Department, in that role, on 1/6/21. During an observation and on 1/7/21, at 10:05 a.m., Licensed Nurse C was outside room [ROOM NUMBER] preparing medications. Licensed Nurse C had full PPE: gown, gloves and mask and face shield. Licensed Nurse C stated he was preparing medications for Residents 8, 9 and 10 (occupants of room [ROOM NUMBER]). Licensed Nurse C stated the facility received new COVID-19 test results today, and Residents 8 and 9 tested positive for COVID-19. Licensed Nurse C stated Resident 10 was COVID-19 negative. Licensed Nurse C went inside the room and administered medications to Resident 8. The room had three beds, with the other two being used by Residents 9 and 10. The privacy curtains around all three beds in the room were open. There were no physical barriers between the beds. None of the three residents were wearing masks. After passing medications to Resident 8, Licensed Nurse C returned to his medication cart, removed his gloves, performed hand hygiene, put on new gloves and started preparing medications for Resident 9. Licensed Nurse C then administered medications to Resident 9. During an observation on 1/7/21, at 10:35 a.m., Licensed Nurse D and Maintenance Person E were moving Residents 8 and 9 out of room [ROOM NUMBER], in wheelchairs. They began pushing Residents 8 and 9 in their wheelchairs to the other side of the unit. During a concurrent interview, Licensed Nurse D and Maintenance Person E stated they were taking Residents 8 and 9 to room [ROOM NUMBER] in the COVID Unit (room [ROOM NUMBER] was now part of the COVID Unit). Residents 8 and 9 were transported without wearing masks or face covers. From room [ROOM NUMBER] to room [ROOM NUMBER], Resident 8 and 9 passed through at least six occupied resident rooms whose doors were open: Rooms 29, 30, 31, 35, 36 and 37. A review of the facility census for 1/7/21, indicated room [ROOM NUMBER] was occupied by Resident 38. No Infection Preventionist staff was observed monitoring the transfer of these residents. CDC guidelines requires that newly infected residents to be kept isolated and should wear a facemask when others are in the room and during transport. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (On 1/7/21, because new residents tested positive for COVID-19, COVID Unit II was rearranged to include Rooms 11 to 15.) During an interview on 1/7/21, at 11:25 a.m., the Nurse Consultant was asked to provide records of COVID-19 tests for residents and staff. The Nurse Consultant stated he did not have them, that it was not his job, and he was not responsible for it. The Nurse Consultant stated LVN A might be able to help. During an interview on 1/7/21, at 12:20 p.m., LVN A, who was providing resident care, was asked for COVID-19 testing results for residents and staff. LVN A provided a new census sheet for 1/7/21, indicating 13 new residents infected with COVID-19. LVN A stated the facility's Infection Preventionist was Administrative Staff C, who was on sick leave. During an observation on of the reconfigured COVID Unit II (Rooms 11-15) on 1/7/21, at 3:20 p.m., there was no PPE available at the entrance of the Unit. During an interview on 1/7/21, at 3:50 p.m., the MDS Coordinator was asked who was the facility's Infection Preventionist. She stated it was Administrative Staff C. She was asked what was her job at the facility and stated she was the MDS Coordinator. She was asked if she performed any other role or job at the facility. She stated, No. She stated she worked full time, 40 hours a week, at the facility as the MDS Coordinator. The Department did not see or talk with any Infection Preventionist staff on 1/7/21, while at the facility. No Infection Preventionist staff sought or introduced themselves to the Department or offered to speak with the Department, in that role. During an observation on 1/8/21, at 10 a.m., the PPE cart at the entrance of COVID Unit II was empty. On 1/8/21, at 3:30 p.m., the Department had a conference call with representatives of the National Guard, who indicated they were ready to deploy personnel at the facility to augment nursing staff at the facility. The National Guard indicated they needed to speak with a facility representative to learn about the residents, the facility and the care needs. The Nurse Consultant was the only administrative staff on site and was invited to attend the conference call. During the call, the National Guard asked the Nurse Consultant to provide an overview of the facility, including census, resident acuity, as well as answer questions about infection control and the COVID outbreak. The Nurse Consultant stated he was not in charge of nursing care in the facility, that he actually was the Director of Nursing of another facility and did not have the time to be the Director of Nursing of both facilities. He stated the best person to answer these questions was LVN A. During an interview, LVN A stated he was providing resident care and could not join the conference call for long. A little after joining the conference call, LVN A stated he had to leave to insert an intravenous line in a resident. LVN A did not return to the conference call. During the conference call, the National Guard asked about the availability of Personal Protective Equipment (PPE) in the facility. The Nurse Consultant stated the facility needed gowns. The National Guard stated they would bring gowns for the facility and would arrive at the facility on 1/9/21 at 9 a.m. The conference call ended at 5:30 p.m. On 1/8/21, at 5:40 p.m., the Director of Nursing, who was not at the facility in order to assess resident needs and staffing resources, informed the Department the facility had advised the National Guard their staffing help was no longer needed, and they had asked the National Guard to cancel their deployment, which was done. The Department did not see or talk with any Infection Preventionist staff on 1/8/21, while at the facility. No Infection Preventionist staff sought or introduced themselves to the Department or offered to speak with the Department, in that role. During an observation on 1/11/21, at 4:20 p.m., the PPE cart at the entrance of COVID Unit II was empty. There were no gowns, gloves, masks or face shields at the entrance of the Unit. The Department did not see or talk with any Infection Preventionist staff on 1/11/21, while at the facility. No Infection Preventionist staff sought or introduced themselves to the Department or offered to speak with the Department, in that role. During an interview on 1/12/21, at 10:45 a.m., the Interim Administrator stated Administrative Staff C, the facility's Infection Preventionist, was at the facility and available to meet with the Department. The Interim Administrator stated other nurses at the facility were trained in infection control. The Interim Administrator was asked to provide the names of these nurses and their certificates of training in infection prevention. This information and these records were not provided. During an interview on 1/12/21, at 10:50 a.m., Administrative Staff C stated he had been on sick leave since 1/4/21. He stated he came to the facility today specifically to meet with the Department but would officially only return to his role as the facility's Infection Preventionist on 1/15/21. During his absence, he stated the MDS Coordinator was the facility's Infection Preventionist and was responsible for infection control at the facility. Administrative Staff C was requested a copy of the MDS Coordinator's certificate in Infection Prevention Control training but stated he did not have it. He stated the Infection Preventionist was responsible for ensuring the facility followed CDC guidelines for Infection Prevention Control guidelines and ensuring PPE was readily available for staff in the facility. He stated facility staff, in the COVID Unit, should wear full PPE (gown, masks, gloves and face shields) and should perform hand hygiene before and after resident care. He said the Infection Preventionist was responsible for training staff and ensuring staff used PPE properly, performed hand hygiene, and followed all CDC Infection Prevention and Control guidelines. He stated the Administrator and the DON were responsible for ordering PPE, and the Infection Preventionist was responsible for ensuring the PPE carts were properly stocked and that PPE was available in resident care areas. He stated the Infection Preventionist was also responsible for updating the facility's, Line List (a master spreadsheet that tracks infection cases at the facility). He stated the Line List had not been updated by facility staff since 1/4/21. This was the first time since the Immediate Jeopardy on Infection Control was called at the facility on 1/5/21, that an Infection Preventionist staff met with the Department. During an interview on 1/12/20, at 2:30 p.m., the Interim Administrator stated the MDS Coordinator was the facility's Infection Preventionist. The Interim Administrator was requested of copy of her infection prevention training certificate, but it was not provided. During this interview, the Interim Administrator provided a written statement indicating: ORCHARD POST ACUTE . IP Coverage for last 7 days: (MDS Coordinator) provided IP coverage. During an interview on 1/13/21, at 1:30 p.m., Licensed Nurse F stated new resident COVID-19 test results arrived today. Licensed Nurse F stated these tests had been done on 1/11/21. Licensed Nurse F stated five additional residents tested positive for COVID-19. Licensed Nurse F stated these residents included Resident 10 (who had shared a room with two positive residents on 1/7/21), and Resident 38 (whose room was in the path of two COVID-19 positive residents transported without wearing masks, throughout the facility on 1/7/21), who were now positive for COVID-19. The Department did not see or talk with any Infection Preventionist staff on 1/13/21, while at the facility. No Infection Preventionist staff sought or introduced themselves to the Department or offered to speak with the Department, in that role. During an observation on 1/14/21, at 6 a.m., Licensed Nurse B was working in the COVID Unit (which now have been merged into one unit comprising Rooms 20-28). Licensed Nurse B had the following PPE: A face mask and gloves. Licensed Nurse B was not wearing a gown or a face shield. Licensed Nurse B went into room [ROOM NUMBER] without performing hand hygiene, before or after, and did not use a gown or a face shield. During an interview on 1/14/21, at 6:10 a.m., Resident 36, who was in room [ROOM NUMBER], stated: This nurse (Licensed Nurse B) comes into our rooms not wearing a gown and not cleaning his hands, he is going to infect us with something. A review of Infection Control In-Service records titled, Orchard Post-Acute Care, In-service Attendance Record (for staff assigned to Covid unit), Course Title: Use of PPE and Infection Control Practices, Date Started 1/6/21 . Presented by: (Nurse Consultant), did not list the name of Licensed Nurse B as having been in-serviced in use of PPE and hand hygiene. These in-service records were provided to the Department by the Nurse Consultant as evidence of compliance with the facility's IJ Removal Plan, in which the facility committed to training all staff assigned to the COVID Unit in CDC infection prevention and control guidelines. The Department did not see or talk with any Infection Preventionist staff on 1/14/21, while at the facility. No Infection Preventionist staff sought or introduced themselves to the Department or offered to speak with the Department, in that role. During an interview on 1/15/21, at 7 a.m., the MDS Coordinator was asked if she was the facility's Infection Preventionist or had exercised the role in the past week. She said she had a certification in infection control but was not actually doing the job of Infection Preventionist. She said she did not have time to do it. She said worked full time as the facility's MDS Coordinator. She stated she informed the facility that she did not have the time to be the Infection Preventionist. She was asked if she knew the symptoms of COVID-19. She stated, Fever, cough, SOB, GI symptoms and muscle pain. She was asked if she knew what a, Line List, was. She stated, No. She was asked if she knew how to access the facility's Line List and stated, No. A review of the CDC list of symptoms for COVID-19 indicated 11 symptoms: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and diarrhea. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html A review of the facility screening form for visitors, Visitor Questioner (sic), indicated the screening for seven of the 11 CDC symptoms for COVID-19: Fever, chill, cough, shortness of breath, sore throat, shaking with chills, chills, muscle pain, headache and loss of taste or smell. The facility's screening form for visitors was missing the symptoms of fatigue, congestion or runny nose, nausea or vomiting and diarrhea. On 1/15/21, at 2:17 p.m., the Department had an Exit Conference with the Owner, the Interim Administrator and the Administrator. The Department informed them of the deficiencies identified during the survey. They were informed the deficiency determinations were preliminary and subject to supervisory review. They were informed the Immediate Jeopardy was not lifted on 1/15/21. On 01/19/21, at 3:32 p.m., the state survey agency submitted, via email to the facility, a summary of the findings of the Focused Infection Control Survey completed on 01/15/21. The state survey agency attached a Directed Plan of Correction. On 01/20/21, at 4:45 p.m., the facility submitted its Plan of Correction, via email, to the state survey agency. On 01/21/21, at 11:38 a.m., the state survey agency notified the facility that its Plan of Correction was not accepted because it did not incorporate the elements of the Directed Plan of Correction. On 01/21/21 at 4:12 p.m., the facility submitted a revised allegation of removal of the Immediate Jeopardy, via email, to the state survey agency. On 01/21/21 at 4:30 p.m., the state survey agency notified the facility their revised submitted allegation of removal of the Immediate Jeopardy still did not incorporate all elements of the DPOC. Specifics on hours on-site for the DON or designee were not included. The plan also still lacked clarity on the location of the PPE and its availability to staff. On 01/21/21 at 4:58 p.m., the facility submitted another revision of the allegation of removal of the Immediate Jeopardy. On 01/22/21 at 11:31 a.m., the state survey agency notified the facility their revised allegation of removal of the Immediate Jeopardy was approved. The allegation of removal of the Immediate Jeopardy included elements outlined in the DPOC: Staffing for the facility would be one Licensed Nursing Staff and two Certified Nursing Assistants for every ten residents throughout the entire facility; the Administrator, Director of Nursing (DON), or their designees, would be physically present at the facility seven days a week from 8 a.m. to 5 p.m., and would have the authority to make all operational decisions; the DON would not have any other obligations or roles at facility; the DON or Licensed Nurse would visually inspect and assess each resident, at least daily, to ensure care needs were being met; residents rooms would be cleaned daily, and all other areas of the facility would be kept clean and free of trash, all meals would be served timely and hot, with sufficient staff to provide feeding assistance to residents; an Infection Preventionist would be on site at the facility at least 20 hours per week; would provide in-services on PPE usage, hand hygiene, and the specific requirements for COVID Positive Units, PUI Units, and Green Zone Units, to all staff; hand sanitizers would be installed inside and outside of residents rooms; PPE would be stocked and placed in the facility so that it was readily available to all staff. On 1/26/21, at 4:25 p.m., the Immediate Jeopardy was removed after an on-site verification that the facility's Plan of Correction was implemented, and the Administrator, Director of Nursing and Infection Preventionist were notified.

Based on observation, interview and record review, the facility failed to provide sufficient staffing to meet resident needs for 24 of 24 residents in the COVID Unit. This failure resulted in the residents not being assisted with Activities of Daily Living (cross-reference to F677), not having vital signs monitored and not receiving RNA Program (cross-reference to F684), not receiving treatments to prevent and heal pressure ulcers (cross-reference to F686), not having their pain assessed and treated (cross-reference to F697), not receiving scheduled medications (cross-reference to F755), not having laboratory exams done (cross-reference to F770), not receiving safe, timely and hot meals (cross-reference to F804, F809 and F812) and not having care and treatments correctly documented in their clinical record (F842). These failures placed the residents in the COVID Unit at risk of sickness, malnourishment, pressure ulcers, disability and death. Findings: During an interview on 1/5/21, at 9:30 a.m., the Receptionist was asked who was in charge of the facility. The Receptionist stated it was Licensed Vocational Nurse A (LVN A). During an interview on 1/5/21, 9:30 a.m., LVN A stated he was in charge of the facility. LVN A stated he was working as a floor nurse and had 31 residents. LVN A was asked to speak with the Administrator, Director of Nursing and Infection Preventionist (IP). LVN A stated all three were sick. LVN A stated there was no administrative staff at the facility. LVN A stated there were a total of 55 residents at the facility, 24 of which had COVID-19, and were isolated in the COVID Unit. The COVID Unit comprised Rooms 16 to 28. LVN A stated the COVID Unit was divided in two sections: the first comprising Rooms 20-28 with 16 residents (COVID Unit I), and the second comprising Rooms 16-19 (COVID Unit II) with eight residents (together the COVID Unit). During an observation of the non-COVID unit 1/5/21, at 9:40 a.m., there were five Certified Nursing Assistants (CNAs) working in the Unit: CNAs G, H, I, J and K. During an observation of the COVID Unit I on 1/5/21, at 10:10 a.m., there were two nursing staff working in the unit: Licensed Nurse L and Licensed Nurse B. There was a strong smell urine and feces in the hallway and in the rooms. Outside of room [ROOM NUMBER], there was an open garbage bag hanging from the handrail filled with food containers and other trash. Next to it, on the floor, there was an open trash bag overflowing with used gowns. Soiled linen was also on the floor. The call light of room [ROOM NUMBER] was activated. Inside room [ROOM NUMBER], Resident 18 was attempting to transfer herself from a wheelchair to the toilet. Resident 18 tried to pivot from the wheelchair to the toilet (which was dirty with feces) but her arms gave in and she fell back into the wheelchair. No staff came to assist or supervise her. Resident 18 asked if the Department could help her get to the toilet. Resident 18 also asked for water. Resident 18's breakfast container was untouched, as were the breakfast containers of her two roommates. The call light of room [ROOM NUMBER] was activated, and a resident voice could be heard asking for water. Observations of Rooms 21, 22, 27 and 28 indicated undisturbed breakfast containers. A review of Resident 18's face sheet, and Baseline Care Plan dated 12/4/20, indicated Resident 18 was [AGE] years-old, had [DIAGNOSES REDACTED]. During an interview on 1/5/21, at 10:15 a.m., Licensed Nurse L stated she was working as a nurse and Licensed Nurse B as a CNA. Licensed Nurse L stated they were the only two staff providing care for the whole COVID Unit. She stated they were overwhelmed and could not provide care to all the residents. She stated the residents in the COVID Unit were very dependent on staff for care, and more nursing staff was needed. Asked how many more nursing staff was needed to meet resident needs, she stated at least twice their current numbers: two nurses and two CNAs. She stated she was late on administering medications and that most residents had not had breakfast yet. Asked what other care was not being done for the residents, Licensed Nurse B answered, everything. He stated incontinent residents had not been changed or cleaned since the beginning of the shift at 7 a.m. He stated residents at risk for pressure ulcers had not been turned or repositioned and resident had not been helped eating breakfast. During an interview on 1/5/21, at 10:20 a.m. Licensed Nurse B stated he was, doing his best, but did not have time to feed, clean and help all residents. During an observation on 1/5/21, at 10:25 a.m., Resident 18 was on her wheelchair, in the hallway outside her room. Her wheelchair was facing the wall and was staring at the open trash bags, soiled gowns and linens on the floor in front of her. A review of the clinical records of the residents in the COVID Unit on 1/5/21, indicated the following resident profiles: RESIDENT 7 A review of Resident 7's face sheet and Interdisciplinary Team (IDT) report dated 12/15/20, indicated Resident 7 was [AGE] years-old, had [DIAGNOSES REDACTED]. for falls, dehydration and skin breakdown. RESIDENT 11 A review of Resident 11's face sheet and IDT report dated 7/16/20, indicated Resident 11 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 12 A review of Resident 12's face sheet and IDT report dated 7/20/20, indicated Resident 12 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 13 A review of Resident 13's face sheet and IDT report dated 7/02/20, indicated Resident 13 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 14 A review of Resident 14's face sheet and Baseline Care Plan dated 12/17/20, indicated Resident 14 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 15 A review of Resident 15's face sheet and IDT report dated 7/6/20, indicated Resident 15 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 16 A review of Resident 16's face sheet and IDT report dated 7/7/20, indicated Resident 16 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 17 A review of Resident 17's face sheet and Baseline Care Plan dated 12/20/20, indicated Resident 17 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 18 A review of Resident 18's face sheet, and Baseline Care Plan dated 12/4/20, indicated Resident 18 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 21 A review of Resident 21's face sheet and IDT report dated 12/7/2, indicated Resident 21 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 22 A review of Resident 22's face sheet and IDT report dated 6/15/20, indicated Resident 22 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 23 A review of Resident 23's face sheet and IDT report dated 8/10/20, indicated Resident 23 was [AGE] years-old, had generalized muscle weakness and need for assistance with personal care; required extensive assistance with ADLs, was incontinent of urine and was at risk for falls and skin breakdown. RESIDENT 25 A review of Resident 25's face sheet and Baseline Care Plan dated 12/16/20, indicated Resident 25 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 26 A review of Resident 26's face sheet and Baseline Care Plan dated 12/16/20, indicated Resident 26 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 27 A review of Resident 27's face sheet and IDT report dated 12/06/20, indicated Resident 27 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 29 A review of Resident 29's facesheet and IDT report dated 9/19/20, indicated Resident 29 was [AGE] years-old, had [DIAGNOSES REDACTED]. RESIDENT 31 A review of Resident 31's facesheet indicated Resident 31 was [AGE] years-old and had [DIAGNOSES REDACTED]. RESIDENT 33 A review of Resident 33's facesheet and IDT report and Care Plan Conference Summary dated 2/14/20, indicated Resident 33 was [AGE] years-old, had [DIAGNOSES REDACTED]. During an interview on 1/5/21, at 11 a.m., the Director of Nursing (DON) was informed via phone of the insufficient staffing in the COVID Unit. The DON stated he was at home, sick, but was responsible for, staffing at the facility. The DON's voice was weak, and he struggled to talk. The DON stated one CNA failed to show up for duty today in the COVID Unit. The DON stated he was working with nursing registry agencies to augment staff in the COVID Unit. The DON was asked if he had requested help from the Medical and Health Operational Area Coordination (MHOAC - a State program that can assist with staffing needs in healthcare facilities) and he stated he had not. The DON was asked if the COVID Unit would be sufficiently staffed for the following shift (7 p.m. to 7 a.m.). The DON stated yes, that he had one registry nurse scheduled to work the night shift (7 p.m. to 7 a.m.). The DON stated this person was Licensed Nurse B. The DON was informed Licensed Nurse B was working at this moment in the COVID Unit. The DON stated he did not know Licensed Nurse B was working the day shift (7 a.m. to 7 p.m.). The DON stated Licensed Nurse B scheduled to work tonight from 7 p.m. to 7 a.m., as the nurse in the COVID Unit. During an interview on 1/5/21, at 11:05 a.m., Licensed Nurse B stated he had been working since 11 p.m., last night and would stay as long as necessary. During an interview on 1/5/21, at 11:10 a.m., the facility's Administrator was called about the insufficient staffing in the facility. The Administrator was left a voicemail message to call back but no call back was received. During an observation of the COVID Unit I on 1/5/21, at 2:15 p.m., there was only one nursing staff working in the unit: Licensed Nurse L. During an interview, she stated she was by herself, that Licensed Nurse B had gone home, and there had been no replacement staff. An observation of the COVID Unit indicated it smelled of urine and feces, resident call lights were on, and residents could be heard asking for help. On 1/5/21, at 2:45 p.m., an Immediate Jeopardy (IJ) was called concerning insufficient staffing in the COVID Unit. There was no administrative staff on site to communicate the IJ and the non-compliance identified. During an interview on 1/5/21, at 2:59 p.m., the DON was notified of the IJ via telephone. The DON was provided details of the non-compliance regarding insufficient staffing in the COVID unit. The DON stated additional staff would be sent to the facility but provided no details. On 1/5/21, at 3:27 p.m., the IJ Template indicating the facility's non-compliance was sent via e-mail to the Owner. On 1/5/21, at 3:35 p.m., the Regional Director of Operations (RDO) was informed via telephone of the IJ and the non-compliance, and that he needed to submit an IJ Removal Plan. The RDO was asked if he was familiar with the IJ process and was offered help in responding to the IJ and submitting the IJ Removal Plan. The RDO stated he was familiar with the IJ process and declined assistance. On 1/5/21, at 3:50 p.m., the facility's Owner, RDO and DON were sent via email an amended version of the IJ Template. The only change in the IJ Template was the correction of a typographical error in the date. The year 2020, was changed to 2021. The recipients were asked to, Please submit to me by email a written IJ Removal a Plan with immediate actions the facility will take to address the noncompliance. During an observation of the COVID Unit 1/5/21, at 4:15 p.m., Licensed Nurse L was the only nursing staff providing care to the residents. She said she was administering medications to the residents in the COVID Unit II. She stated the residents were supposed to have received these medications at 9 a.m. today. She stated her shift would end at 7 p.m. and asked who would replace her. She asked for additional staff to assist her. While Licensed Nurse L was passing medications in COVID Unit II (rooms 16-19), there was no staff providing care or supervising residents in COVID Unit I (rooms 20-28). On 1/5/21, at 4:30 p.m., Administrative Staff E arrived at the facility. During an interview he stated he was the Acting Administrator of the facility and would assist the Department in that role. He further stated: (a) he had never been to the facility; (b) he was currently the Administrator of a sister facility, had started that role five days before and was still getting to know that facility when he was told to come to this facility; (c) he did not know the resident census at the facility; (d) he did not know the characteristics of the resident population; (e) he did not know an IJ had been called (when informed so by the Department) and (f) stated did not know what an IJ was, and did not know what he had to do about it. The Administrator then asked the Department to, fill him in, in these matters. When the Department started orienting him to the facility and the non-compliance identified in the IJ, he requested to stop the interview and asked if the Department could provide him with paper and a pen so he could take notes. On 1/5/21, at 4:58 p.m., the RDO emailed the Department a, Plan of Correction, dated 1/5/21. The, Plan of Correction, contained the following parts: Corrective action(s) to be accomplished for those residents found to have been affected by the deficient practice. Identify other residents having potential to be affected by the deficient practice / corrective actions to be taken. Measures / systemic changes to make to ensure that the deficient practice does not recur. Plans to monitor its performance to make sure the solutions are sustained, and Facility has developed a QAPI for COVID-19 Precautions. A review of the facility's, Plan of Correction, indicated it contained all the regulatory requirements of a Plan of Correction but none of requirements of an IJ Removal Plan. The only requirement of the IJ Removal Plan, which was the document facility was asked to submit, was for the facility to indicate, The immediate actions the facility will take to address the noncompliance. The only immediate action required was for the facility to immediately assign additional staff to the COVID Unit to ensure resident care needs were met. The facility's, Plan of Correction, instead, contained three pages of single space verbiage indicating administrative actions such as, Quality Assurance compliance and, staffing assessments. The core of the, Plan of Correction seemed to be the, staff assessment, also mentioned as, daily staff assessments and staffing status to prevent any decline of basic care needs, reportedly completed on 1/5/21, by the RDO, DON and Nurse Consultant. Neither the RDO, DON or Nurse Consultant, however, were or had been on site on 1/5/21, in order to complete an accurate staff or resident needs assessment. In addition, no such assessment was required, as the Department, who was on site, had already made this assessment and determined that the facility did not have sufficient staff in the COVID Unit to meet resident needs. The facility's only requirement in the IJ Removal Plan was to indicate how it would immediately provide additional staffing to the COVID Unit to meet resident needs. The closest action concerning additional staffing indicated in the, Plan of Correction was, There is a daily reaching out to new candidates that might apply on recruiting websites. During an interview on 1/5/21, at 7:10 p.m., the Acting Administrator was asked who would replace Licensed Nurse L in the COVID Unit, whose shift ended at 7 p.m. The Acting Administrator stated Licensed Nurse B would relieve Licensed Nurse L in the COVID Unit. The Acting Administrator stated Licensed Nurse B was supposed to be at the facility at 7 p.m. During an observation and interview on 1/5/21, at 8:15 p.m., Licensed Nurse L was still working in the COVID Unit by herself. She asked where was her replacement. She asked what the Department was doing about getting help to the residents. She stated she had been by herself since noon when Licensed Nurse B went home. She stated no one had come came to help her all day. Licensed Nurse L stated she had been working in the COVID Unit since 7 a.m., and stated she was exhausted. She was sitting down. She stated, Look at my legs, they are swollen and hurt and, I can't get up. There were resident call lights on in the COVID Unit. On 1/5/21, at 8:47 p.m., via e-mail, the Department informed the RDO that the, Plan of Correction, was rejected because it was not an, IJ Removal Plan, and it did not contain the facility's, immediate actions to address the non-compliance. On 1/5/21, at 9:02 p.m., the RDO replied stating it would resubmit an IJ Removal Plan according to the Department's, preference. On 1/5/21, the at 9:31 p.m., the RDO submitted a revised document called, IJ Removal Plan, dated 12/11/2020 (sic). A review of the facility's IJ Removal Plan, dated 12/11/2020 (sic), indicated an even longer document than the previously submitted, Plan of Correction. The IJ Removal Plan was four pages long and typed single space with additional verbiage of, staffing assessments, daily and weekly review to ensure compliance, and, presentation of monthly QA for compliance, and other non-immediate actions. The IJ Removal Plan also indicated the, Director of Nursing, the Regional Director and Nurse Consultant are reviewing all basic care needs of all residents but none of these staff members were on-site at the facility to make such assessments. It was not possible to assess if the care needs were being met without direct observations of residents and interviews with staff. The IJ Removal Plan further indicated, Over 100 nurses and 4 facilities that share transfer agreements were notified and the facility was able to obtain 2 nurses to fill-in for the unexpected call-off of nurses at the facility by 7:30 p.m. on 1/5/21. This was a statement the Department was unable to verify, but it did not address the acute staffing shortage in the COVID Unit on 1/5/21. As documented above, no additional staff had been deployed to the COVID Unit, not even the replacement of the lone nurse working (whose shift ended at 7 p.m.) had arrived as of 1/5/21 at 8:15 p.m. The facility's IJ Removal Plan contained no specific actions to immediately augment nursing staff in the COVID Unit. During an observation on 1/5/21, at 9:53 p.m., the Vacaville Fire Department (VFD) arrived at the facility. The VFD stated a family member called 911 concerned about the health and safety of a resident. During an observation on 1/6/21, at 9 a.m., the breakfast trays for the COVID Unit residents were on top a table in the courtyard, unattended and exposed to the elements. During an observation of the COVID Unit I on 1/6/21, at 9:05 a.m., there were three nursing staff in the unit: LVN A, Licensed Nurse L and Licensed Nurse M, who stated she was working as a CNA. LVN A and Licensed Nurse L were asked if there were enough staff to provide care to the residents. They stated, No, that they needed at least another CNA. They stated they needed at least two nurses and two CNAs and one housekeeper. They stated residents had not been served breakfast and incontinent residents had not been cleaned and toileted since the beginning of the shift at 7 a.m. The COVID Unit smelled of urine and feces. During an observation of the COVID Unit I on 1/6/21, at 9:05 a.m., Resident 14 was moaning loudly. Resident 14 was lying in sheets soaked in urine. During a concurrent interview, Licensed Nurse L stated Resident 14 needed pain medication. During an observation on 1/6/21, at 9:10 a.m., Resident 23 stated: I have tremors, I can't feed myself, I haven't had breakfast, please help me, no one helps me eat. During an observation on 1/6/21 at 9:15 a.m., Resident 14 was moaning loudly, and asking for help and could be heard throughout the unit. Another resident started yelling at Resident 14 saying, Shut up! Shut up! Shut up! and, Stop Complaining. During an observation on 1/6/21, at 9:20 a.m., there was a large yellow stain on the floor of room [ROOM NUMBER] covering the surface underneath two beds. Resident 23 stated it was urine and it had been there since last night. During an observation on 1/6/21, at 9:23 a.m., Resident 24 was lying in bed and her adult briefs were soiled with feces and urine. During an observation on 1/6/21, at 9:25 a.m., Licensed Nurse L went into Resident 14's room and stated she would provide Resident 14 with pain medications. This occurred 20 minutes after Resident 14 started asking for help. During an observation on 1/6/21, at 9:30 a.m., Resident 25 stated her breakfast was cold. She showed the breakfast tray and said: Look, I can't eat this. An observation of her breakfast tray showed gravy that appeared in a solid stated. She stated the facility always served cold meals, several hours late, like it was done today. She stated the facility did not offer them replacement or substitutes when they complained about the food. She stated residents had to eat cold and stale food or no food at all. During an observation on 1/6/21, at 9:35 a.m., LVN A was helping residents eat breakfast. During a concurrent interview, Resident 23 asked the Department: Nurse, can you help me eat? During an observation on 1/6/21, at 10:25 a.m., the Vacaville Fire Department (VFD) arrived at the facility. During a concurrent interview, LVN A stated 911 was called because a resident in the COVID Unit had a blood sugar of above 500 mg/dL (normal range <140). During an observation in COVID Unit I on 1/6/21, at 11:50 a.m., Licensed Nurse L stated she was now administering medications the residents were supposed to have received at 9 a.m. She stated she called 911 to take the resident to the hospital earlier in the morning because of a critically high blood sugar level. She stated the COVID Unit needed more staff to take care of the residents. During an interview on 1/6/21, at noon, the RDO submitted a revised IJ Removal Plan. On 1/6/21 at 4 p.m., the facility's IJ Removal Plan was approved. A review of the facility's approved IJ Removal Plan indicated the following: Facility will staff the Covid Unit with a minimum of 2 licensed nurses and 2 CNAs, for all shifts, and ensure all resident needs are met. During an interview on 1/7/21, at 10:45 a.m., the Long-Term Care Ombudsman stated they had received multiple complaints of poor care at the facility and insufficient staffing, especially in the COVID Unit. They stated the Ombudsman had received complaints of call lights not being answered, residents were not being fed, residents were served cold food, meals were served late, residents were not given their medications, residents were not being turned and repositioned, were not being cleaned and toileted, were not given showers and not being given care in general. The stated they received, a lot of complaints, and they received reports of residents being left soiled for up to eight hours. She stated they received reports of food being served cold or not at all. On 1/7/21, the Department received multiple complaints reporting residents were being left soiled for up to six hours, meals were not being served to residents, medications were not being given, and there was no Administrative Staff on-site to supervise resident care. During an interview on 1/7/21, at 3:05 p.m., Licensed Nurse F stated the facility's Administrator was Administrative Staff A, who had been out sick for the past ten days. During an observation on 1/8/21, at 10:13 a.m., in COVID Unit II, Licensed Nurse O was administering medications to residents. There was no CNA assisting her. During an interview, Licensed Nurse O stated she needed a CNA to help clean, toilet and assist the residents, which had not been done yet. During an observation on 1/8/21, 10:18 a.m., in COVID Unit I, Licensed Nurse N was administering medications. Licensed Nurse N stated she needed more help in the COVID Unit. She stated not all residents had had breakfast yet. She stated dietary staff left the trays outside and nursing staff brought the trays into the unit, and assisted the residents when they had the time. On 1/8/21, at 3:30 p.m., the Department had a conference call with representatives of the National Guard, who indicated they were ready to deploy personnel at the facility to augment nursing staff at the facility. The National Guard indicated they needed to speak with a facility representative to learn about the residents, the facility and the care needs. The Nurse Consultant was the only administrative staff on site and was invited to attend the conference call. During the call, the National Guard asked the Nurse Consultant to provide an overview of the facility, including census, resident acuity, as well as answer questions about the COVID outbreak. The Nurse Consultant stated he was not in charge of nursing care in the facility, that he actually was the DON of another facility and did not have the time to be the DON of both facilities. He stated the best person to answer these questions was LVN A. During an interview, LVN A stated he was providing resident care and could not join the conference call for long. A little after joining the conference call, LVN A stated he had to leave to insert an intravenous line in a resident. LVN A did not return to the conference call. During the conference call, the National Guard asked about staffing needs in the COVID Unit. The Nurse Consultant stated he was familiar with the unit, stating residents in the COVID Unit were heavy care, totally dependent on staff, and required a lot of help and assistance. The Nurse Consultant stated the COVID Unit needed the staffing help being offered by the National Guard. The National Guard stated they were ready to bring additional staffing for the facility, and their personnel were on their way to the facility. The National Guard stated they would arrive at the facility on 1/9/21 at 9 a.m. The conference call ended at 5:30 p.m. On 1/8/21, at 5:40 p.m., the Director of Nursing, who was not at the facility in order to assess resident needs and staffing resources, informed the Department the facility had advised the National Guard their staffing help was no longer needed, and they had asked the National Guard to cancel their deployment, which was done. During an interview on 1/11/21, at 1:40 p.m., Receptionist II stated the Administrator and the Director of Nursing were not at the facility and had not been here today. She stated there were no administrative staff on-site. A review of the facility census for 1/11/21, indicated there were 24 residents in the COVID Unit. During an interview on 1/11/21, at 1:45 p.m., LVN A stated there were two LVNs and three CNAs in the COVID Unit. During an observation of COVID Unit I on 1/11/21, at 1:50 p.m., only one nursing staff was working in the unit: Licensed Nurse N. During an interview, Licensed Nurse N stated there was a CNA helping her, CNA Q. Licensed Nurse N stated they were the only two staff in the COVID Unit, and they were responsible for the care of 24 residents. During an observation of the unit, there was a strong smell of urine in the facility; Resident 6 was lying on wet and soiled sheets that smelled of urine; and the call light on room [ROOM NUMBER] was activated and unanswered. There were untouched lunch trays in rooms 22, 25 and 26. During an interview on 1/11/21, at 1:55 p.m., Licensed Nurse N stated the COVID Unit needed more staff to meet resident needs. She stated they needed more CNAs to clean, toilet and feed the residents. During an interview on 1/11/21, at 2 p.m., CNA Q stated she was the only CNA working in the unit. She stated she needed more help to change, clean and feed the residents. She stated seven incontinent residents were soiled and had not been changed and cleaned yet. During an interview on 1/11/21, at 2:05 p.m., Resident 8 stated she had not had lunch yet. Resident 8 stated there was not enough staff to help residents eat. They need more help. During an observation of COVID Unit I on 1/12/20, at 9:55 a.m. there was only one nursing staff in the unit: Licensed Nurse N. A review of the facility's census indicated 13 residents in COVID Unit I. License Nurse N stated she had been there by herself since 7 a.m., but now that the Department arrived, a CNA was sent to help her. She stated there was another nurse at COVID Unit II. Licensed Nurse N stated the staffing needs for the COVID Unit was as follows: One nurse and two CNAs for COVID Unit I and one nurse and one CNA in COVID Unit II. Licensed Nurse N stated this was the minimum staff to clean, feed and take care of residents. She stated breakfast was being served now (9:55 a.m.) to the residents in COVID Unit I. She stated she had, no time to turn and reposition, feed residents and change(TRUNCATED)

Based on interview and record review, the facility improperly discharged home a resident (Resident 34) with one unstageable Pressure Ulcer on his sacrum (later diagnosed as a Stage 4 Pressure Ulcer) and one Deep Tissue Injury (DTI - a type of pressure ulcer) on his right heel. Resident 34 had been admitted to the facility three weeks prior for rehabilitation after an injury that left him completely paralyzed. Resident 34 did not have pressure ulcers upon admission. At discharge, the facility indicated in the Discharge Notice that Resident 34's health had improved sufficiently and he no longer needed the services of the facility. In reality, however, Resident 34 at discharge had acquired a life-threatening Stage 4 Pressure Ulcer caused by the facility's failure to provide him care to prevent pressure wounds (cross-reference to F686). In addition, the facility discharged Resident 34 without his medications, without providing the Representative Party and family the required Notice of Discharge and Post-Discharge Plan of Care, and without his personal belongings. The facility also failed to inform Resident 34's family the resident had pressure ulcers and failed to provide instructions to Resident 34's family on how to care for Resident 34 at home and treat his pressure ulcers (cross reference to F624). These failures delayed Resident 34's transfer to the Hospital to treat his pressure ulcer causing Resident 34 and his family unnecessary pain and suffering. Findings: A review of Resident 34's face sheet indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The face sheet did not list [DIAGNOSES REDACTED]. A review of Resident 34's record indicated he did not have pressure ulcers upon admission, was completely immobilized and totally dependent on staff for care (cross-reference to F686). A review of Resident 34's record indicated he was discharged on [DATE]. Resident 34's discharge records indicated three documents: 1) A NOTICE OF TRANSFER OR DISCHARGE, dated [DATE], indicating Resident 34 was being discharged because, The resident's health has improved sufficiently that the resident no longer needs the services provided by the facility. 2) A POST-DISCHARGE PLAN OF CARE, dated [DATE], with the following sections: a) WOUND/SKIN CARE (skin injury areas, treatment required, care instructions). This section was completely blank. b) EVERY FUNCTIONS (mobility and activities of daily living assessment): This section was completely blank. c) THERAPIES NEEDED (type, how often, reason, instructions): This section was completely blank. d) COMMUNITY RESOURCES (ombudsman, home health agencies, Medicaid office etc.): Completed with contact number of above persons. e) IMPORTANT NAMES AND NUMBERS (physician, pharmacy): This section was completely blank. f) medications: [REDACTED] g) SCHEDULED APPOINTMENTS: This section was completely blank. h) DIET: This section was completely blank. i) ACTIVITY: This section was completely blank. 3) DISCHARGE ORDERS. An undated order, in a standard discharged for m, signed by Physician A, indicating Resident 34 was to be discharged , HOME. The order form had a place for instruction for nursing needs titled, Wound Management. This section was completely blank. During interviews on [DATE] and [DATE], at 4 p.m., Resident 34's Representative Party and family indicated he arrived home from the facility via ambulance on [DATE], at noon. The family stated they were informed by the facility the day before that Resident 34 would be discharged the following day, on [DATE]. The family stated the facility did not inform them that Resident 34 had any skin wounds or pressure ulcers or any injuries or new health conditions. The family stated no instruction, education or orientation was provided to them on how to care for Resident 34 after his discharge. The family stated the facility only told them Resident 34 would be sent home by ambulance the following day. The family stated when Resident 34 arrived home on [DATE], at noon via ambulance he did not have his medications, did not have his personal belongings, and did not have any discharge documents or paperwork with him. The family stated about two hours later, the facility called the family and asked them to come to the facility to get Resident 34's medications and the Discharge Notice and Post Discharge Care Plan. The family stated, once they came to the facility, they were provided with a copy of the Notice of Discharge that indicated Resident 34 had been discharged because his health had improved sufficiently that he no longer needed the services of the facility; a Post Discharge Plan of Care indicating no health care needs, and the copy of the physician's discharge order indicating no nursing needs. There were no indication Resident 34 had pressure ulcers. The family said the facility did not give them Resident 34's personal belongings. The family stated Resident 34 was soiled and had encrusted food on him when he arrived home. The family stated, when they started cleaning him, they noticed he had a large wound on his sacrum area, and that it was all black. The family stated Resident 34 had a fever, was confused and could not recognize the family. The family stated Resident 34 was taken to the hospital the where he was diagnosed with [REDACTED]. A review of Review of Resident 34's Emergency Department record indicated, Arrival Time: 5:13 P.M. PST on [DATE], and he had a temperature of 103.4 F, blood pressure of ,[DATE], pulse of 76 and respirations of 23, urinary tract infection,[MEDICAL CONDITION] and, Large decubitus ulcer to sacrum with mild drainage (photo in media). A review of Resident 34's hospital's Inpatient Wound and Ostomy RN assessment of Resident 34's skin, dated [DATE], indicated Resident 34 had two pressure ulcers: A sacrococcygeal community acquired unstageable pressure injury measuring 9.5 x 12 centimeters showing 100% necrotic (dead) tissue and a community acquired Deep Tissue Injury (DTI) on his right heel. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure injury/ulcer is, localized damage to the skin and underlying soft tissue usually over a bony prominence . the injury can present as intact skin or an open ulcer . the injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (shear is stress/deformation of the skin from movement). Pressure injuries/ulcers are classified or, staged according to the degree of injury to tissue, from Stage 1 (least injury) to Stage 4 (greatest injury). Stage 2 pressure injuries/ulcers involve the loss of the first skin layer (epidermis), thus exposing the second skin layer (dermis). The wound appears pink and moist. Stage 3 pressure injuries/ulcers involve a wound with total loss of the skin, revealing the layer of fat underneath. Stage 4 pressure injuries/ulcers involve the total loss of the skin and the underlying fat tissue, revealing muscle, bones and other tissues. A pressure injury/ulcer may also be classified as, unstageable, which occurs when the wound is covered by slough or eschar (dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (2016) and www.npuap.org/wp-content/uploads/,[DATE]/Shear_slides.pdf). According to the National Pressure Ulcer Advisory Panel (NPUAP), a deep tissue injury is a, Pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. https://cdn.ymaws.com/npiap.com/resource/resmgr/white_papers/1g._dti-white-paper.pdf A review of Resident 34's hospital's Inpatient Wound and Ostomy RN assessment of Resident 34's skin, dated [DATE], at 10:58 a.m., after Resident 34's sacrum pressure ulcer was debrided (dead tissue removed from the wound), indicated Resident 34's sacrum pressure ulcer was a Stage 4 Pressure Ulcer measuring 11 x 11 centimeters in size (around 4 x 4 inches) and was 4 centimeters deep (around 1.5 inches). The medical literature indicates that: A Grade 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die (tissue necrosis). The underlying muscles, bone or joint may also be damaged, sometimes very severely. People with grade four pressure ulcers have a high risk of developing a life-threatening infection. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 88/#:~:text=People%20with%20grade%20four%20pressure,example%2C%20tendon%20or%20joint%20capsule During an observation on [DATE], at 4:15 p.m., the facility returned Resident 34's personal belonging, which consisted of a suitcase full of clothes. During an interview on [DATE], at 11:15 a.m., Licensed Nurse F stated she discharged Resident 34. She stated Resident 34 was discharged in the morning on [DATE], to his home. She stated it was busy at the facility, and Resident 34's discharge documentation and medications were not ready by the time he left. She stated an ambulance was called to take Resident 34 home, and the family was later asked to come to the facility to get his medications and discharge documentation. She stated prior to Resident 34's discharge, on [DATE], she checked Resident 34's sacrum area and, it was all black. She was asked to describe what she saw. She said she did not know, that it was just, all black. She was asked if she informed the physician and said, No. She said the physician signed the discharge order and the ambulance took him home. During an interview on [DATE], at 10:10 a.m., the facility's Nurse Consultant stated Resident 34's pressure ulcer was caused by poor care by the family after discharge from the facility. The Nurse Consultant stated: I just think when he got home the wife was not able to provide the necessary care . The resident was discharged home and the caregiver was not able to care for the resident. A review of Resident 34's Hospital record, Physician Note dated [DATE], indicated Resident 34 died at the hospital on [DATE].

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one resident (Resident 34), when the facility discharged Resident 34 to his home without informing Resident 34's Representative Party (RP) that Resident 34 had acquired one unstageable Pressure Ulcer on his sacrum (later diagnosed as a Stage 4 Pressure Ulcer) and one Deep Tissue Injury (DTI - a type of pressure ulcer) on his right heel while at the facility. Additionally, the facility failed to prepare and orient Resident 34's RP on how to care for a resident with pressure ulcers and how to treat his wound. This failure delayed Resident 34's transfer to the Hospital to treat his skin wounds causing Resident 34 and his family unnecessary pain and suffering. Findings: A review of Resident 34's face sheet indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The face sheet did not list [DIAGNOSES REDACTED]. A review of Resident 34's record indicated he did not have pressure ulcers upon admission, was completely immobilized and totally dependent on staff for care (cross-reference to F686). A review of Resident 34's record indicated he was discharged on [DATE]. Resident 34's discharge records indicated three documents: 1) A NOTICE OF TRANSFER OR DISCHARGE, dated [DATE], indicating Resident 34 was being discharged because The resident's health has improved sufficiently that the resident no longer needs the services provided by the facility. 2) A POST-DISCHARGE PLAN OF CARE, dated [DATE], with the following sections: a) WOUND/SKIN CARE (skin injury areas, treatment required, care instructions). This section was completely blank. b) EVERY FUNCTIONS (mobility and activities of daily living assessment): This section was completely blank. c) THERAPIES NEEDED (type, how often, reason, instructions): This section was completely blank. d) COMMUNITY RESOURCES (ombudsman, home health agencies, Medicaid office etc.): Completed with contact number of above persons. e) IMPORTANT NAMES AND NUMBERS (physician, pharmacy): This section was completely blank. f) medications: [REDACTED] g) SCHEDULED APPOINTMENTS: This section was completely blank. h) DIET: This section was completely blank. i) ACTIVITY: This section was completely blank. 3) DISCHARGE ORDERS. An undated order, in a standard discharged for m, signed by Physician A, indicating Resident 34 was to be discharged , HOME. The order form had a place for instruction for nursing needs titled, Wound Management. This section was completely blank. During interviews on [DATE] and [DATE], at 4 p.m., Resident 34's Representative Party and family indicated he arrived home from the facility via ambulance on [DATE], at noon. The family stated they were informed by the facility the day before that Resident 34 would be discharged the following day, on [DATE]. The family stated the facility did not inform them that Resident 34 had any skin wounds or pressure ulcers or any injuries or new health conditions. The family stated no instruction, education or orientation was provided to them on how to care for Resident 34 after his discharge. The family stated the facility only told them Resident 34 would be sent home by ambulance the following day. The family stated when Resident 34 arrived home on [DATE], at noon via ambulance he did not have his medications, did not have his personal belongings, and did not have any discharge documents or paperwork with him. The family stated about two hours later, the facility called the family and asked them to come to the facility to get Resident 34's medications and the Discharge Notice and Post Discharge Care Plan. The family stated once they came to the facility, they were provided with a copy of the Notice of Discharge that indicated Resident 34 had been discharged because his health had improved sufficiently that he no longer needed the services of the facility; a Post Discharge Plan of Care indicating no health care needs, and the copy of the physician's discharge order indicating no nursing needs. There were no indication Resident 34 had pressure ulcers. The family said the facility did not give them Resident 34's personal belongings. The family stated Resident 34 was soiled and had encrusted food on him when he arrived home. The family stated when they started cleaning him, they noticed he had a large wound on his sacrum area, and that it was all black. The family stated Resident 34 had a fever, was confused and could not recognize the family. The family stated Resident 34 was taken to the hospital the where he was diagnosed with [REDACTED]. A review of Review of Resident 34's Emergency Department record indicated, Arrival Time: 5:13 p.m PST on [DATE]. Resident 34 had a temperature of 103.4 F, blood pressure of ,[DATE], pulse of 76 and respirations of 23, urinary tract infection,[MEDICAL CONDITION] and had a, Large decubitus ulcer to sacrum with mild drainage (photo in media). A review of Resident 34's hospital's Inpatient Wound and Ostomy RN assessment of Resident 34's skin, dated [DATE], indicated two pressure ulcers: A sacrococcygeal community acquired, unstageable pressure injury measuring 9.5 x 12 centimeters showing 100% necrotic (dead) tissue and a community acquired Deep Tissue Injury (DTI) on his right heel. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure injury/ulcer is, localized damage to the skin and underlying soft tissue usually over a bony prominence . the injury can present as intact skin or an open ulcer . the injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (shear is stress/deformation of the skin from movement). Pressure injuries/ulcers are classified or, staged according to the degree of injury to tissue, from Stage 1 (least injury) to Stage 4 (greatest injury). Stage 2 pressure injuries/ulcers involve the loss of the first skin layer (epidermis), thus exposing the second skin layer (dermis). The wound appears pink and moist. Stage 3 pressure injuries/ulcers involve a wound with total loss of the skin, revealing the layer of fat underneath. Stage 4 pressure injuries/ulcers involve the total loss of the skin and the underlying fat tissue, revealing muscle, bones and other tissues. A pressure injury/ulcer may also be classified as, unstageable. which occurs when the wound is covered by slough or eschar (dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (2016) and www.npuap.org/wp-content/uploads/,[DATE]/Shear_slides.pdf). According to the National Pressure Ulcer Advisory Panel (NPUAP), a deep tissue injury is a, Pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. https://cdn.ymaws.com/npiap.com/resource/resmgr/white_papers/1g._dti-white-paper.pdf A review of Resident 34's hospital's Inpatient Wound and Ostomy RN assessment of Resident 34's skin, dated [DATE], at 10:58 a.m., after Resident 34's sacrum pressure ulcer was debrided (dead tissue removed from the wound), indicated Resident 34's sacrum pressure ulcer was a Stage 4 Pressure Ulcer measuring 11 x 11 centimeters in size (around 4 x 4 inches) and was 4 centimeters deep (around 1.5 inches). The medical literature indicates that: A Grade 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die (tissue necrosis). The underlying muscles, bone or joint may also be damaged, sometimes very severely. People with grade four pressure ulcers have a high risk of developing a life-threatening infection. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 88/#:~:text=People%20with%20grade%20four%20pressure,example%2C%20tendon%20or%20joint%20capsule During an interview on [DATE], at 11:15 a.m., Licensed Nurse F stated she discharged Resident 34 on [DATE], in the morning to his home. She stated it was busy at the facility and Resident 34's discharge documentation and medications were not ready by the time he needed to leave. She stated an ambulance was called to take Resident 34 home and the family was later asked to come to the facility to get his medications and discharge documents. She stated prior to Resident 34's discharge, on [DATE], she checked Resident 34's sacrum area and, it was all black. She was asked to describe what she saw. She said she did not know, that it was just, all black. She was asked if she informed the physician and said, No. She said the physician signed the discharge order and the ambulance took him home. During an interview on [DATE], at 10:10 a.m., the facility's Nurse Consultant stated Resident 34's pressure ulcer was caused by poor care by the family after discharge from the facility. The Nurse Consultant stated: I just think when he got home the wife was not able to provide the necessary care . The resident was discharged home and the caregiver was not able to care for the resident. A review of Resident 34's Hospital record, Physician Note dated [DATE], indicated Resident 34 died at the hospital on [DATE].

Based on observation, interview and record review, the facility failed to ensure 20 or 24 residents who were unable to carry out Activities of Daily Living (ADL) independently in the COVID Unit received the necessary services to maintain good nutrition and personal hygiene. ADLs comprised: eating, personal hygiene, toilet use, dressing and bathing. These failures affected the following residents: 1, 7, 11, 12, 13, 14, 15, 16, 17, 18, 21, 22, 23, 24, 26, 27, 29, 31, 33 and 36. These failures resulted in the residents not receiving baths or shower, and not being assisted with eating, toileting and personal hygiene. For Resident 1, these failures resulted in Resident 1 feeling humiliated by having to wear adult briefs and having to soil herself instead of being assisted to bathroom for bowel and bladder elimination. Findings: During the survey period, from 1/5/21 to 1/15/21, the Department received complaints that dependent residents were not being assisted with eating, were not receiving showers, incontinent residents were being left soiled for hours and not being cleaned, residents were not being toileted and assisted with personal hygiene. During an interview on 1/7/21, at 10:45 a.m., the Long-Term Care Ombudsman reported to the Department it had received the same complaints from families and residents in the COVID Unit. During observations of the COVID Unit on 1/5/21, 1/6/21 and 1/11/21, the unit smelled or urine and feces (cross-reference to F725). During interviews with licensed nurses and CNAs working in the COVID Unit on 1/5/21, 1/6/21, 1/11/21 and 11/21/21, the nursing staff indicated there was insufficient staff to provide care to the residents in the COVID Unit. During an interview on 1/15/21, at 10:50 a.m., Certified Nursing Assistant I (CNA I) stated CNAs were responsible for assisting residents with Activities of Daily Living (ADLs). She stated CNAs documented care on the ADL flowsheets. RESIDENT 1 A review Resident 1's face sheet indicated she had [DIAGNOSES REDACTED]. A review of Resident 1's Activities of Daily Living (ADL) Care Plan, date initiated 1/14/20, indicated the following interventions: DRESSING: - Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. - The resident requires (Extensive assistance) by (1) staff to dress; PERSONAL HYGIENE: - The resident requires (Extensive assistance) by (1) staff with personal hygiene and oral care; TOILET SCHEDULE: - Scheduled toileting: before breakfast, after getting up/morning, before lunch, before dinner, before bedtime, and per demand. A review of Resident 1's, IDT Conference Sheet, undated, indicated Resident 34 was on a, Scheduled Toileting Program. During an interview on 1/13/21, at 1:38 p.m., Licensed Nurse F reviewed Resident 1's, IDT Conference Sheet, and indicated a, Scheduled Toileting Program meant a resident was supposed to be transferred from the bed to toilet for bowel and bladder elimination every two hours. During an observation and interview on 1/12/21, at 10:10 a.m., Resident 1 was in her room, lying in her bed and wearing a gown. Resident 1 stated she used to go to the restroom for toileting but now facility staff told her she had to wear adult briefs and soil her herself and wait for staff to come change her because staff told her they do not have time to come and take her to the bathroom. She stated she accepted this because she had no other choice but felt humiliated by having to wear adult briefs and soil herself and wait to be changed. Resident 1 stated she wanted to be taken to the toilet for bowel and bladder elimination. Resident 1 also stated she wished she could wear her own clothes instead of a gown. Resident 1 stated: Look, I have a closet full of clothes in my closet, but they make me wear these gowns because they said they do not have time to help me dress. She stated it was humiliating. An observation of her closet indicated personal clothes. During an interview on 1/13/21, at 12:25 p.m., Resident 1's family stated the resident was not receiving the care she needed. The family stated Resident 1 had been left soiled in urine for several times, one time up to 5.5 hours and Resident 1 felt terrible about it. The family stated the facility did not have enough staff to meet resident care needs. During an observation and interview on 1/14/21, at 6:05 a.m., Resident 1 was in her room, lying in her bed and wearing a gown. Resident 1 stated she had been soiled for hours and no one had cleaned or changed her despite asking for assistance. Resident 1 stated she had been wearing the same dirty gown for three days. Resident 1 stated she needed to use the toilet. Resident 1's call light was on. During an observation on 1/14/21, at 6:35 a.m., Certified Nursing Assistant (CNA) T arrived to assist Resident 1. CNA T removed Resident 1's soiled adult briefs, cleaned her and placed new adult briefs on Resident 1. RESIDENT 7 A review of Resident 7's face sheet, and Interdisciplinary Team (IDT) report dated 12/15/20, indicated Resident 7 was [AGE] years-old, had [DIAGNOSES REDACTED]. for falls, dehydration and skin breakdown. A review of Resident 7's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Tuesdays and Fridays: No bathing provided to resident during period of 1/3/21 to 1/12/21 (bathing missed on 1/5/21, 1/8/21, 1/12/21). ADL - Eating: Resident not assisted/not done from 1/3/21 to 1/13/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/3/21 to 1/13/21. ADL - Toilet Use: Resident not assisted/not done from 1/3/21 to 1/13/21. RESIDENT 11 A review of Resident 11's face sheet and IDT report dated 7/16/20, indicated Resident 11 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 11's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Wednesdays and Saturdays: No bathing provided to resident during period of 1/2/21 to 1/12/21 (bathing missed on 1/2/21, 1/5/21, 1/9/21). ADL - Eating: Resident not assisted/not done from 1/2/21 to 1/12/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/2/21 to 1/12/21. ADL - Toilet Use: Resident not assisted/not done from 1/2/21 to 1/12/21. RESIDENT 12 A review of Resident 12's face sheet and IDT report dated 7/20/20, indicated Resident 12 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 12's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Monday and Thursdays: No bathing provided to resident during period of 1/1/21 to 1/12/21 (bathing missed on 1/4/21, 1/7/21, 1/11/21). ADL - Eating: Resident not assisted/not done from 1/1/21 to 1/12/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/1/21 to 1/13/21. ADL - Toilet Use: Resident not assisted/not done from 1/1/21 to 1/13/21. RESIDENT 13 A review of Resident 13's face sheet and IDT report dated 7/02/20, indicated Resident 13 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 13's ADL flowsheets indicated the following non-compliance: Bathing (showers/Bed Bath) on Monday and Thursdays: no bathing provided to resident during period of 1/1/21 to 1/6/21 (bathing missed on 1/4/21). ADL - Eating: resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Personal Hygiene: resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Toilet use: resident not assisted/not done from 1/1/21 to 1/5/21. RESIDENT 14 A review of Resident 14's face sheet and Baseline Care Plan dated 12/17/20, indicated Resident 14 was [AGE] years-old, had [DIAGNOSES REDACTED]. During an observation on 1/6/21, at 9:05 a.m., Resident 14 was lying in sheets soaked in urine. A review of Resident 14's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Friday and Tuesdays: No bathing provided to resident during period of 1/1/21 to 1/6/21 (bathing missed on 1/1/21 and 1/5/21). ADL - Eating: Resident not assisted/not done from 1/1/21 to 1/6/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/1/21 to 1/6/21. ADL - Toilet Use: Resident not assisted/not done from 1/1/21 to 1/6/21. RESIDENT 15 A review of Resident 15's face sheet and IDT report dated 7/6/20, indicated Resident 15 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 15's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Wednesdays and Saturdays: No bathing provided to resident during period of 1/1/21 to 1/5/21 (bathing missed on 1/2/21). ADL - Eating: Resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Toilet Use: Resident not assisted/not done from 1/1/21 to 1/5/21. RESIDENT 16 A review of Resident 16's face sheet and IDT report dated 7/7/20, indicated Resident 16 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 16's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Tuesdays and Fridays: No bathing provided to resident during period of 1/2/21 to 1/12/21 (bathing missed on 1/5/21, 1/8/21, and 1/12/21). ADL - Eating: Resident not assisted/not done from 1/2/21 to 1/10/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/2/21 to 1/10/21. ADL - Toilet Use: Resident not assisted/not done from 1/2/21 to 1/10/21. RESIDENT 17 A review of Resident 17's face sheet and Baseline Care Plan dated 12/20/20, indicated Resident 17 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 17's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Tuesdays and Fridays: No bathing provided to resident during period of 1/1/21 to 1/6/21 (bathing missed on 1/1/21 to 1/5/21). ADL - Eating: Resident not assisted/not done from 1/1/21 to 1/6/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/1/21 to 1/6/21. ADL - Toilet Use: Resident not assisted/not done from 1/1/21 to 1/6/21. RESIDENT 18 A review of Resident 18's face sheet and Baseline Care Plan dated 12/4/20, indicated Resident 18 was [AGE] years-old, had [DIAGNOSES REDACTED]. During observations in the COVID-19 Unit I on 1/5/21, at 10:10 a.m., there was a strong smell urine and feces in the hallway and in the rooms. Outside of room [ROOM NUMBER], there was an open garbage bag hanging from the handrail filled with food containers and other trash. Next to it, on the floor, there was an open trash bag overflowing with used gowns. Soiled linen was also on the floor. The call light of room [ROOM NUMBER] was activated. Inside room [ROOM NUMBER], Resident 18 was attempting to transfer herself from a wheelchair to the toilet. Resident 18 tried to pivot from the wheelchair to the toilet (which was dirty with feces) but her arms gave in and she fell back into the wheelchair. No staff came to assist or supervise her. Resident 18 asked if the Department could help her get to the toilet. Resident 18 also asked for water. Resident 18's breakfast container was untouched, as were the breakfast containers of her two roommates. A review of Resident 18's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Monday and Thursdays: No bathing provided to resident during period of 1/1/21 to 1/12/20 (bathing missed on 1/4/21, 1/7/21, 1/11/21). ADL - Eating: Resident not assisted/not done from 1/2/21 to 1/10/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/2/21 to 1/10/21. ADL - Toilet use: Resident not assisted/not done from 1/2/21 to 1/10/21. RESIDENT 21 A review of Resident 21's face sheet and IDT report dated 12/7/20, indicated Resident 21 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 21's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Tuesdays and Friday: No bathing provided to resident during period of 1/1/21 to 1/6/21 (bathing missed on 1/1/21, 1/5/21). ADL - Eating: Resident not assisted/not done from 1/1/21 to 1/7/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/1/21 to 1/7/21. ADL - Toilet Use: Resident not assisted/not done from 1/1/21 to 1/7/21. RESIDENT 22 A review of Resident 22's face sheet and IDT report dated 6/15/20, indicated Resident 22 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 22's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Tuesdays and Fridays: No bathing provided to resident during period from 1/1/21 to 1/5/21 (bathing missed on 1/1/21 and 1/5/21). ADL - Eating: Resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Toilet Use: Resident not assisted/not done from 1/1/21 to 1/5/21. RESIDENT 23 A review of Resident 23's face sheet and IDT report dated 8/10/20, indicated Resident 23 was [AGE] years-old, had generalized muscle weakness and need for assistance with personal care, required extensive assistance with ADLs, was incontinent of urine and was at risk for falls and skin breakdown. During an observation on 1/6/21, at 9:10 a.m., Resident 23 stated: I have tremors, I can't feed myself, I haven't had breakfast, please help me, no one helps me eat. A review of Resident 23's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Wednesdays and Saturdays: No bathing provided to resident during period from 1/4/21 to 1/10/21 (bathing missed on 1/6/21 and 1/9/21). ADL - Eating: Resident not assisted/not done from 1/5/21 to 1/10/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/5/21 to 1/10/21. ADL - Toilet Use: Resident not assisted/not done from 1/5/21 to 1/10/21. RESIDENT 24 During an observation on 1/6/21, at 9:23 a.m., Resident 24 was lying in bed and her adult briefs were soiled with feces and urine. RESIDENT 26 A review of Resident 26's face sheet and Baseline Care Plan dated 12/16/20, indicated Resident 26 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 26's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Monday and Thursday: No bathing provided to resident during period of 1/1/21 to 1/5/21 (bathing missed on 1/4/21). ADL - Eating: Resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Toilet Use: Resident not assisted/not done from 1/1/21 to 1/5/21. RESIDENT 27 A review of Resident 27's face sheet and IDT report dated 12/06/20, indicated Resident 27 was [AGE] years-old and had [DIAGNOSES REDACTED]. A review of Resident 27's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Tuesday and Fridays: No bathing provided to resident during period of 1/2/21 to 1/10/21 (bathing missed on 1/5/21 and 1/8/21). ADL - Eating: Resident not assisted/not done from 1/2/21 to 1/5/21 and from 1/7/21 to 1/10/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/2/21 to 1/10/21. ADL - Toilet Use: Resident not assisted/not done from 1/2/21 to 1/10/21. RESIDENT 29 A review of Resident 29's face sheet and IDT report dated 9/19/20, indicated Resident 29 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 29's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Mondays and Thursdays: no bathing provided to resident during period of 1/2/21 to 1/12/21 (bathing missed on 1/4/21, 1/7/21, and 1/11/21). ADL - Eating: Resident not assisted/not done from 1/2/21 to 1/8/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/2/21 to 1/8/21. ADL - Toilet Use: Resident not assisted/not done from 1/2/21 to 1/8/21. RESIDENT 31 A review of Resident 31's face sheet indicated Resident 31 was [AGE] years-old and had [DIAGNOSES REDACTED]. A review of Resident 31's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Wednesday and Thursdays: No bathing provided to resident during period of 1/2/21 to 1/12/21 (bathing missed on 1/2/21, 1/6/21, and 1/9/21). ADL - Eating: Resident not assisted/not done from 1/2/21 to 1/12/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/2/21 to 1/12/21. ADL - Toilet Use: Resident not assisted/not done from 1/2/21 to 1/12/21. RESIDENT 33 A review of Resident 33's face sheet and IDT report and Care Plan Conference Summary dated 2/14/20, indicated Resident 33 was [AGE] years-old, had [DIAGNOSES REDACTED]. A review of Resident 33's ADL flowsheets indicated the following non-compliance: Bathing (Showers/Bed Bath) on Mondays and Thursdays: No bathing provided to resident during period of 1/1/21 to 1/5/21 (bathing missed on 1/5/21). ADL - Eating: Resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Personal Hygiene: Resident not assisted/not done from 1/1/21 to 1/5/21. ADL - Toilet Use: Resident not assisted/not done from 1/1/21 to 1/5/21. RESIDENT 36 A review of Resident 36's face sheet and IDT report dated 12/15/20, indicated Resident 36 was [AGE] years-old, had [DIAGNOSES REDACTED]. During an interview on 1/14/21, at 6:10 a.m., in COVID Unit I, Resident 36 stated there was not enough staff at the facility. She stated, at best, there were only two staff in the Unit. She stated all of her meals were served cold. She stated staff did not offer replacements. She stated she could not get ice. She stated the day before she pressed her call light to go to the commode and waited six hours until a staff came to help her. She stated she was soiled for six hours. A review of facility Policy and Procedure titled, Activities of Daily Living (ADL) (Revised March 2018), indicated: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including a. Hygiene (bathing, dressing, grooming, and oral care); h. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks) .

Based on interview and record review, the facility failed to provide care consistent with standards of practice to prevent pressure ulcers and failed to provide the necessary treatments consistent with professional standards of practice to promote healing and prevent infection of new pressure ulcers, to 4 of 4 residents (Residents 14, 17, 21 and 34). For Resident 34, who was paralyzed, at a very high risk for pressure ulcers, and who was admitted to the facility without pressure ulcers, the facility failed to: (1) perform a skin assessment within 8 hours of admission to the facility; (2) failed to follow physician orders [REDACTED]. recommendations for prevention and treatment of [REDACTED]. For Residents 14, 17 and 21, the facility failed to turn and reposition these residents every two hours. Turning and repositioning residents at least every two hours is the most important intervention to prevent pressure ulcers. This failure placed these residents at risk for pressure ulcers. Findings: RESIDENT 34 During an interview on 1/14/21, at 9:05 a.m., the Medical Records Director was asked to provide copies of the following records for Resident 34: Face Sheet, all Progress Notes, all Care Plans, all Medication Administration Records, all Treatment Administration Records, all Activities of Daily Living flowsheets, all skin assessments, all nursing assessments, all Dietary and Registered Dietician assessments, all Intake and Output records, and all Physician Orders. A review of Resident 34's face sheet indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The face sheet did not list [DIAGNOSES REDACTED]. A review of Resident 34's Skilled Nursing Facility Orders, printed 12/18/20, at 6:30 p.m., indicated Resident 34 was admitted for rehabilitation after cervical fusion surgery at the hospital to correct a spinal injury. The document indicated Resident 34 was dependent on assistance and was flaccid throughout. The document indicated Resident 34 had two wounds: one surgical neck incision and one right knee wound. The Skilled Nursing Facility Orders did not list pressure ulcers. A review of Resident 34's hospital skin flowsheets for 12/18/21, did not indicate Resident 34 had pressure ulcers or skin injuries on his sacrum/coccyx area. A review of Resident 34's Baseline Care Plan, completed on 12/18/20, at 9:15 p.m., by Licensed Nurse V, indicated an admission [DIAGNOSES REDACTED]. The Baseline Care Plan contained a section for documentation of skin injuries, including a field for staff to describe them. This section of the documented was titled, Skin Risk: current skin integrity issues, specify skin integrity issue and did not indicate pressure ulcers or wounds on his sacrum/coccyx area. The Baseline Care Plan indicated only that Resident 34 had, surgical wounds. A review of Resident 3's New Admit Report, no date (presumably the admission date of [DATE]), time 7:05 p.m., under the section, Integumentary Wounds, indicated no pressure ulcers or wounds in Resident 34' sacrum/coccyx area. A review of Resident 34's record indicated two Pressure Ulcer Risk Assessments (assessments indicating how likely a resident is for developing pressure ulcers) for Resident 34: The first was the Braden Scale for Predicting Pressure Ulcer Score Risk, Effective Date 12/18/20, at 8:11 p.m. (signed on 12/19/20), and indicated the following assessment for Resident 34: (1) SENSORY PERCEPTION: completely limited; (2) MOISTURE: occasionally moist; (3) ACTIVITY: bedfast (confined to bed); (4) MOBILITY: completely immobile (5) NUTRITION: adequate; (6) FRICTION AND SHEAR: problem; SCORING: 12 - HIGH RISK. The second was the Braden Scale for Predicting Pressure Ulcer Score Risk, signed 1/9/20, at 8:12 pm., indicating the following assessment for Resident 34: (1) SENSORY PERCEPTION: very limited; (2) MOISTURE: occasionally moist; (3) ACTIVITY: bedfast (confined to bed); (4) MOBILITY: very limited; (5) NUTRITION: probably inadequate; (6) FRICTION AND SHEAR: problem; SCORING: 9 - VERY HIGH RISK. A review of Resident 34's record indicated the facility did not complete a skin assessment upon his admission to the facility on [DATE]. Resident 34's New Admission Assessment Checklist, dated 12/18/20 (no time), had 12 fields indicating documents and assessments to be completed at admission for Resident 34, such as completing the baseline care plan, the fall risk assessment, the bowel and bladder assessment and others. The boxes next to all 12 admission actions were checked, except for one: Admission/Re-Admission Resident Data Collection: Skin Assessment. A review of Resident 34's record indicated the first skin assessment was completed the day after his admission on 12/19/21. Resident 34's, Admission/Re-Admission Resident Data Collection: Skin Assessment, signed 12/19/20, indicated Resident 34 had acquired two skin injuries: a blister in the coccyx measuring 1.5 x 1.5 (measuring unit not indicated) and a, non-blanchable redness in the, sacrococcyx and, blanchable redness in bilateral heels. No pressure type skin injuries were documented. A second skin assessment was also completed on 12/19/21. A review of Resident 34's, Skin Integrity Sheet, Effective Date 12/19/20, at 10:15 a.m., (completed 15 hours after Resident 34's admission), indicated Resident 34 had by now acquired two skin injuries: a, Blister in coccyx measuring 1.5 x 1.5, Stage II and, non-blanchable redness in the sacrococcyx. This assessment also indicated: Fluid filled blister noted around coccyx, potential for skin opening. Will continue to monitor. Patient is bed bound, dependent, and needs complete care. A review of Resident 34's physician order [REDACTED]. A review of Resident 34's, Food & Nutrition Service Director Nutrition Chart Review and Interview, dated 12/22/20, and completed by the Dietary Supervisor, indicated under, Wounds that, he has wound on the knees from surgery. No pressure ulcers were noted. A review of Interdisciplinary Team Meeting (Admission) (IDT Admission), completed on 12/22/20, indicated the following: Here for rehab therapy to get stronger and medically stable in order to go home safely. GOAL: To reach his maximum potential & discharge to community safely .ADL REVIEW: Extensive assistance .SAFETY RISK: .skin tear bruising .skin breakdown . SKIN: Coccyx blister; Sacral-coccyx stg 1 (stage 1). A review of Resident 34's record indicated only one skin assessment done on Resident 34 after the initial skin assessment completed on 12/19/20. This document was a, Weekly Assessment, unsigned, dated 1/4/21, at 6:44 p.m., under, Skin Condition, indicated, Fair. The box for Pressure Ulcers was unchecked. The field for, Other Skin Issues, was blank. A review of Resident 34's MDS (Minimum Data Set - An Assessment Tool), dated 12/25/20, (One week after admission), indicated Resident 34 had one Stage I pressure ulcer and one Stage II pressure ulcer. A review of Resident 34's record indicated he was discharged on [DATE]. Resident 34's Notice of Transfer or Discharge, dated 1/9/21, indicated Resident 34 was discharged on [DATE], because, The resident's health has improved sufficiently that the resident no longer needs the services provided by the facility. A review of Resident 34's MDS (Minimum Data Set - An Assessment Tool), dated 1/9/21, the date of Resident 34's discharge, indicated on discharge Resident 34 one Stage II Pressure Ulcer. During an interview on 1/15/21, at 7 a.m., the MDS Coordinator stated she completed the discharge MDS dated [DATE]. She stated she did not visually inspect Resident 34's skin when she documented a Stage II Pressure Ulcer in the MDS but got that information from Resident 34's skin assessment dated [DATE]. During an interview on 1/13/21, a 4 p.m., the family of Resident 34 indicated he was discharged home on[DATE], and arrived home at noon via ambulance. The family stated when Resident 34 arrived home he had a large wound on his sacrum area and it was all black, had a high fever, was confused and could not recognize his family. The family stated Resident 34 was taken to the hospital the where he was diagnosed with [REDACTED]. A review of Review of Resident 34's Emergency Department record dated, Arrival Time: 5:13 P.M. PST on 1/9/21, indicated upon arrival Resident 34 had a temperature of 103.4 F, blood pressure of 107/57, pulse of 76 and respirations of 23, urinary tract infection,[MEDICAL CONDITION] and a, large decubitus ulcer to sacrum with mild drainage (photo in media). A review of the picture taken on admission indicated a large black area on Resident 34's sacrum. A review of the hospital's Inpatient Wound and Ostomy RN assessment of Resident 34's skin, dated 1/10/21, indicated two pressure ulcers: one sacrococcygeal community acquired unstageable pressure injury measuring 9.5 x 12 centimeters showing 100% necrotic (dead) tissue and one community acquired Deep Tissue Injury (DTI) on his right heel. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure injury/ulcer is, localized damage to the skin and underlying soft tissue usually over a bony prominence . the injury can present as intact skin or an open ulcer . the injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (shear is stress/deformation of the skin from movement). Pressure injuries/ulcers are classified or, staged according to the degree of injury to tissue, from Stage 1 (least injury) to Stage 4 (greatest injury). Stage 2 pressure injuries/ulcers involve the loss of the first skin layer (epidermis), thus exposing the second skin layer (dermis). The wound appears pink and moist. Stage 3 pressure injuries/ulcers involve a wound with total loss of the skin, revealing the layer of fat underneath. Stage 4 pressure injuries/ulcers involve the total loss of the skin and the underlying fat tissue, revealing muscle, bones and other tissues. A pressure injury/ulcer may also be classified as, unstageable, which occurs when the wound is covered by slough or eschar (dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (2016) and www.npuap.org/wp-content/uploads/2012/02/Shear_slides.pdf). According to the National Pressure Ulcer Advisory Panel (NPUAP), a deep tissue injury is a, Pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. https://cdn.ymaws.com/npiap.com/resource/resmgr/white_papers/1g._dti-white-paper.pdf A review of the hospital's Inpatient Wound and Ostomy RN assessment of Resident 34's skin, dated 1/15/21, at 10:58 a.m., after Resident 34's sacrum pressure ulcer was debrided (dead tissue removed from the wound), indicated Resident 34's sacrum pressure ulcer was a Stage 4 Pressure Ulcer measuring 11 x 11 centimeters in size (around 4 x 4 inches) and was 4 centimeters deep (around 1.5 inches). The medical literature indicates that, A Grade 4 pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die (tissue necrosis). The underlying muscles, bone or joint may also be damaged, sometimes very severely. People with grade four pressure ulcers have a high risk of developing a life-threatening infection. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 88/#:~:text=People%20with%20grade%20four%20pressure,example%2C%20tendon%20or%20joint%20capsule. During an interview on 1/14/21, at 10:10 a.m., the facility's Nurse Consultant stated Resident 34 was admitted with a blister on this sacrum and the pressure ulcer noted after his discharge from the facility was caused by poor care by the family at home. The Nurse Consultant stated: I just think when he got home the wife was not able to provide the necessary care . The resident was discharged home, and the caregiver was not able to care for the resident. During an interview on 1/15/21, at 11:05 a.m., License Nurse S stated she took care of Resident 34 for, several days, and stated she did not know he had a pressure ulcer on his coccyx/sacrum area. She stated the only skin wound Resident 34 had was a, blister on his coccyx, which she found out about on 1/9/21, when she checked Resident 34's record because a physician called her with questions about Resident 34. She stated she never visually checked Resident 34's back or sacrum area. She stated: I never checked his bottom or skin, because the CNAs (Certified Nursing Assistants) do that, and they let us know if there are any problems. During an interview on 1/15/21, at 11:15 a.m., Licensed Nurse F stated she discharged Resident 34 on 1/9/21, in the morning. She stated she checked Resident 34's coccyx/sacrum area on the day of discharge and that, it was all black. She was asked to describe what she saw. She said she did not know, that it was just, all black. She said the physician was not notified and stated the ambulance took Resident 34 home. During an interview on 1/15/21, at 9:40 a.m., The Interim Administrator was requested to make the facility's Director of Nursing or designee available for an interview and resident record review concerning Resident 34. The Interim Administrator stated the best person was the Nurse Consultant, who was on his way and would be at the facility shortly. During an interview on 1/15/21, at 11:25 a.m., the Administrator and Owner stated the Nurse Consultant was, diverted on his way to the facility but would be at the facility in the afternoon. An appointment was made to meet with the Nurse Consultant on 1/15/21 at 2 p.m., to review Resident 34's records and answer the Department's questions. During this interview the Administrator was also asked for shower sheets for Resident 34 (CNAs document resident skin wounds on shower sheets) for the period of his stay at the facility. The Administrator stated she had to review those records before supplying them to Department and would later provide them. These records were not provided. The Administrator also stated these records were part of the facility's quality records and therefore non-disclosable to the Department. During an interview on 1/15/21, at 2 p.m., the Interim Administrator informed the Department the Nurse Consultant was not at the facility and would not come. He stated he was available by phone but did not have access to Resident 34's records. The Department wanted to meet with the Nurse Consultant, or another nursing supervisor, to review records and ask questions about the care provided to Resident 34. A review of Resident 34's clinical record indicated a note, dated 1/13/21 (25 days after Resident 34's admission), signed by the Director of Nursing (DON), indicating as follows: The Resident . (was) admitted with pressure ulcer on Coocyx (sic) (stage2) and sarococcygeal (stage 1). Under, Date Initiated, the note indicated: 12/18/20. The DON's note, dated 1/13/21, is a late entry into Resident 34's record, added 25 days after Resident 34's admission to the facility and four days after his discharge. The note indicated it was created on 1/13/21. The hard copy placed in Resident 34's chart of this note indicated it was also printed on 1/13/21. This date, 1/13/21, coincidently was the date the family of Resident 34 met with the Department at the facility to report that Resident 34 had been discharged home with a pressure ulcer. Resident 34 was admitted on [DATE], at night, outside the regular business hours when the DON would be present at the facility. There is no indication in Resident 34's records the DON participated in the admission of Resident 34, or performed a skin assessment on him on 12/18/20, in order to remember, on 1/13/21, that Resident 34 was admitted with Stage I and Stage II pressure ulcers. The first indication in the clinical record Resident 34 had pressure ulcers was made the day after his admission, on 12/19/20, at 10:15 a.m., when it was documented that Resident 34 had injuries in the, cooccyx and sacrococcyx. A Review of Resident 34's Pressure Ulcer Care Plan indicated: The resident has potential for pressure ulcer development r/t immobility, admitted with pressure ulcer on Coocys (sic) (stage2) and sarococygeal (Stage 1). The Pressure Care Plan indicated it was created by Licensed Nurse V and the DON. The date of creation is not indicated. The Pressure Ulcer Care Plan indicated it was initiated on, 12/18/19. All the interventions of the Pressure Ulcer Care Plan, however, were initiated on 12/19/20. There is no indication in Resident 34 clinical record of a skin assessment done on 12/18/20, indicating Resident 34 had pressure ulcers on admission to the facility. A review of Resident 34's Pressure Ulcer Care Plan indicated the goals of, Pressure ulcer will show signs of healing and remain free from infection, and resident, will have intact skin, free of redness, blisters or discoloration . Resident 34's Care Plan interventions to reach the above goals, initiated on 12/19/20, included the following interventions: 1) ADMINISTER MEDICATIONS AS ORDERED. MONITOR/DOCUMENT FOR SIDE EFFECTS AND EFFECTIVENESS. 2) ADMINISTER TREATMENTS AS ORDERED AND MONITOR FOR EFFECTIVENESS. 3) ASSESS/RECORD/MONITOR WOUND HEALING (Q WEEK) MEASURE LENGTH, WIDTH AND DEPTH WHERE POSSIBLE. ASSESS AND DOCUMENT STATUS OF WOUND PERIMETER, WOUND BED AND HEALING PROCESS. REPORT IMPROVEMENTS AND DECLINES TO THE MD. 4) EDUCATE THE RESIDENT/FAMILY/CAREGIVERS AS TO CAUSES OF SKIN BREAKDOWN; INCLUDING: TRANSFER/POSITIONING REQUIREMENTS; IMPORTANCE OF TAKING CARE DURING AMBULATING/MOBILITY, GOOD NUTRITION AND FREQUENT REPOSITIONING. 5) FOLLOW FACILITY POLICIES/PROTOCOLS FOR THE PREVENTION/treatment of [REDACTED]. 6) INFORM THE RESIDENT/FAMILY/CAREGIVERS OF ANY NEW AREA OF SKIN BREAKDOWN. 7) INSTRUCT ASSIST TO SHIFT WEIGHT IN W/C Q 15 MINUTES. 8) MONITOR DRESSING (QD - EVERY DAY) TO ENSURE IT IS INTACT AND ADHERING. REPORT LOSE DRESSING TO THE TREATMENT NURSE 9) MONITOR NUTRITIONAL STATUS. SERVE DIET AS ORDERED, MONITOR INTAKE AND RECORD. 10) THE RESIDENT NEEDS . TO TURN/REPOSITION AT LEAST EVERY TWO HOURS, MORE OFTEN AS NEEDED OR REQUESTED. 11) THE RESIDENT NEEDS MOISTURIZER APPLIED (QD - EVERY DAY) TO MY (SIC) SKIN 12) THE RESIDENT REQUIRES PRESSURE RELIEVING/REDUCING DEVICE. 13) THE RESIDENT REQUIRES SUPPLEMENTAL PROTEIN, AMINO ACIDS, VITAMINS, MINERALS AS ORDERED TO PROMOTE WOUND HEALING. 14) WEEKLY TREATMENT DOCUMENTATION TO INCLUDE MEASUREMENT OF EACH AREA OF SKIN BREAKDOWN'S WIDTH, LENGTH, DEPTH, TYPE OF TISSUE AND EXUDATE. The Department's investigation indicated these interventions were not implemented by the facility, as follows: 1) ADMINISTER MEDICATIONS AS ORDERED. MONITOR/DOCUMENT FOR SIDE EFFECTS AND EFFECTIVENESS. A review of Resident 34's Medication Administration Record [REDACTED] [MEDICATION NAME] 20 mg [MEDICAL CONDITION] administered 1/2/21; [MEDICATION NAME] Tablet 10 mg for MAJOR [MEDICAL CONDITION] not administered 1/2/21; [MEDICATION NAME] 15 mg for MUSCLE SPASMS not administered 1/2/21; Vitamin D3 Tablet 540 mcg for SUPPLEMENT not administered 1/2/21; Acidophilus Tablet for PPX not administered 1/2/21 (two doses missed); Aspirin Tablet for [MEDICAL CONDITION]/[MEDICAL CONDITION] PPX not administered 1/2/21 (two doses missed) and 1/5/21; [MEDICATION NAME] Sodium 5000 for [MEDICAL CONDITION]/PPX not administered 1/2/21 (two doses missed) and 1/5/21; [MEDICATION NAME] Solution for PNA PPX not administered 1/21/21 (two doses missed) and 1/5/21; [MEDICATION NAME] 100 mg for CHRONIC PAI[DIAGNOSES REDACTED] not administered 1/2/21 (two doses) and 1/5/21; Xejanz 10 mg for [MEDICAL CONDITION] POLYARTHIRTIS not administered 1/2/21 (two doses) and 1/5/21; [MEDICATION NAME] 300 mg for PERIPHERAL [MEDICAL CONDITION] not administered 1/21/21 (three doses) and 1/5/21; [MEDICATION NAME] 5 mg for ORTHOSTATIC [MEDICAL CONDITION] not administered (three doses) and 1/5/21. 2) ADMINISTER TREATMENTS AS ORDERED AND MONITOR FOR EFFECTIVENESS. A review of Resident 34 MAR indicated [REDACTED] Incentive spirometer every 4 hours: not administered on 1/2/21 and 1/5/21; Cervical Collar on at times: not done on 1/2/21 and 1/5/21. A review of Resident 34 Treatment Administration Record (TAR) for December 2020 and January 2021, indicated the following orders and compliance: Monitor fluid filled blister to coccyx and notify MD of any changes; not done on 1/30/20 and 1/31/20, 1/1/21 and 1/2/21 (DAY) and 1/5/21 EVENING (this intervention was documented as being done even after Resident 34 had been discharged from the facility). Monitor non-blanchable redness to sacrococcyx and notify MD of any changes; not done on 1/30/20, 1/31/20, 1/1/21, 1/2/21 (DAY) and 1/5/21 EVENING (this intervention was documented as being done even after Resident 34 had been discharged from the facility). 3) ASSESS/RECORD/MONITOR WOUND HEALING (Q WEEK) MEASURE LENGTH, WIDTH AND DEPTH WHERE POSSIBLE. ASSESS AND DOCUMENT STATUS OF WOUND PERIMETER, WOUND BED AND HEALING PROCESS. REPORT IMPROVEMENTS AND DECLINES TO THE MD. A review of Resident 34's record indicated only one assessment of Resident 34 wound after the initial assessment when the wounds were detected on 12/19/21. The, WEEKLY ASSESSMENT, dated 1/4/21, at 6:44 p.m., indicated fair skin and no pressure ulcers. 4) EDUCATE THE RESIDENT/FAMILY/CAREGIVERS AS TO CAUSES OF SKIN BREAKDOWN; INCLUDING: TRANSFER/POSITIONING REQUIREMENTS; IMPORTANCE OF TAKING CARE DURING AMBULATING/MOBILITY, GOOD NUTRITION AND FREQUENT REPOSITIONING. During an interview on 1/13/20, at 4 p.m., Resident 34 family stated the facility did not inform them Resident 34 had a pressure ulcer, much less educate them on how to care for it. A review of Resident 34's, Post-Discharge Plan of Care, dated 1/9/21, and provided to the family after Resident 34's discharge, contained no instructions on how to care for pressure ulcers or indication Resident 34 had a pressure ulcer. 5) INFORM THE RESIDENT/FAMILY/CAREGIVERS OF ANY NEW AREA OF SKIN BREAKDOWN. During an interview on 1/13/20, at 4 p.m., Resident 34 family stated the facility did not inform them Resident 34 had a pressure ulcer. A review of Resident 34's record indicated no evidence the facility informed the family of the pressure ulcers. 6) INSTRUCT ASSIST TO SHIFT WEIGHT IN W/C Q 15 MINUTES. A review of Resident 34's records provided to the Department revealed no evidence this was done. 7) MONITOR DRESSING (QD - EVERY DAY) TO ENSURE IT IS INTACT AND ADHERING. REPORT LOSE DRESSING TO THE TREATMENT NURSE. A review of Resident 34's records provided to the Department revealed no evidence this was done. 8) MONITOR NUTRITIONAL STATUS. SERVE DIET AS ORDERED, MONITOR INTAKE AND RECORD. A review of Resident 34, NUTRITION - Amount eaten, flowsheet indicated it was not done on 1/1/21, 1/3/21, 1/4/21, and 1/8/21 at 6 p.m. A review of Resident 34, FLUIDS - flowsheet, indicated it was not done on 1/1/21, 1/3/21, 1/4/21, and 1/8/21 at 6 p.m. A review of Resident 34's INTAKE AND OUTPUT RECORD for 12/9/20 to 01/08/21, indicated the it was only fully and properly completed (with intake and output recorded for all three shifts) on three days: 12/26/21 - 12/28/21. A review of Resident 34's records provided to the Department revealed no additional evidence this was done. 9) THE RESIDENT NEEDS . TO TURN/REPOSITION AT LEAST EVERY TWO HOURS, MORE OFTEN AS NEEDED OR REQUESTED. A review of Resident 34's clinical record revealed no evidence Resident 34 was turned and repositioned every two hours in December 2020. The facility's Medical Records Director was requested the Activities of Daily Living flowsheets for December 2020 twice, on 1/14/21 at 9:05 a.m., and on 1/15/21 at 10:35 a.m., and on both occasions she stated there were not any. A review of Resident 34 ADL flowsheets for January 2021, MONITOR - Turn and Reposition Q2H flowsheet for January 2021, indicated Resident 34 was turned and repositioned from 1/1/21 to 1/9/21, as follows: 1/1/21: 3 times in 24 hours (turned average once every 8 hours) 1/2/21: 3 times in 24 hours (turned average once every 3.4 hours) 1/3/21: 4 times in 24 hours (turned average once every 6 hours) 1/4/21: 4 times in 24 hours (turned average once every 6 hours) 1/5/21: 5 times in 24 hours (average once every 4.8 hours) 1/6/21: 6 times in 24 hours (average once every 6 hours) 1/7/21: 9 times in 24 hours (average once every 2.6 hours) 1/8/21: 8 times in 24 hours (average once every 3 hours) 1/9/21: 8 times in 24 hours (average once every 3 hours) (two of these instances occurred after the resident had been discharged from the facility) 1/10/21: 1 time in 24 hours (this occurred 36 hours after the resident had been discharged from the facility on 1/9/21) 10) THE RESIDENT NEEDS MOISTURIZER APPLIED (QD - EVERY DAY) TO MY (SIC) SKIN A review of Resident 34's records provided to the Department revealed no evidence this was done. 11) THE RESIDENT REQUIRES PRESSURE RELIEVING/REDUCING DEVICE. A review of Resident 34's records provided to the Department revealed no evidence this was done. 12) THE RESIDENT REQUIRES SUPPLEMENTAL PROTEIN, AMINO ACIDS, VITAMINS, MINERALS AS ORDERED TO PROMOTE WOUND HEALING. A review of Resident 34's Medication Administration Record [REDACTED]. 13) WEEKLY TREATMENT DOCUMENTATION TO INCLUDE MEASUREMENT OF EACH AREA OF SKIN BREAKDOWN'S WIDTH, LENGTH, DEPTH, TYPE OF TISSUE AND EXUDATE. A review of Resident 34's records provided to the Department revealed no evidence this was done. 14) FOLLOW FACILITY POLICIES/PROTOCOLS FOR THE PREVENTION/treatment of [REDACTED]. The following facilities policies and procedure were not followed: Policy and Procedure titled, Nutrition and hydration to maintain skin integrity (revised October 2010): Ensure that the resident's intake of fluid is sufficient: Sufficient fluid means the amount of fluid needed to prevent dehydration. A review of Resident 34's records provided to the Department revealed no evidence this was done (See #8 above). The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. A review of Resident 34's records provided to the Department revealed no evidence this was done (See #8 above). Policy and Procedure titled, Prevention of Pressure Ulcers/Injuries (Revised July 2017): Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. A review of Resident 34's records provided to the Department revealed no evidence this was done. A review of Resident 34's clinical record indicated the first skin assessment (Skin Integrity Sheet) was completed on 12/9/20, at 10:15 a.m., more 15 hours after Resident 34's admission to the facility. Moisturize dry skin daily. A review of Resident 34's records provided to the Department revealed no evidence this was done (See #10 above). Monitor the resident for weight loss and intake of food and fluids. A review of Resident 34's records provided to the Department revealed no evidence this was done (See #8 above). At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. A review of Resident 34's records provided to the Department revealed no evidence this was done (See #9 above). A review of facility policy titled, Pressure Ulcers/Injuries Overview (Revised July 2017), indicated the following: Avoidable, means that the resident developed-a-pressure-ulcer/injury-and that one of more-of the following was not completed: Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate. The National Pressure Ulcer Advisory Panel (www.npuap.org) recommends the following interventions to prevent pressure ulcers: RISK ASSESSMENT 1. Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2. Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within 8 hours after admission). 3. Refine the assessment by including these additional risk factors: A. Fragile skin B. Existing pressure injury of any stage, including those ulcers that have healed or are closed C. Impairments in blood flow to the extremities from vascular disease, diabetes or tobacco use. D. Pain in areas of the body exposed to pressure. 4. Repeat the risk assessment at regular intervals and with any change in condition. Base the frequency of regular assessments on acuity levels: A. Acute care .Every shift B. Long term care .Weekly for 4 weeks, then quarterly. C. Home care .At every nurse visit 5. Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. SKIN CARE 1. Inspect all of the skin upon admission as soon as possible (but within 8 hours). 2. Inspect the skin at least daily for signs of pressure injury, especially non-blanchable [DIAGNOSES REDACTED].3. Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices. 4. When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature and tissue consistency compared to adjacent skin. Moistening the skin assists in identifying changes in color. 5. Cleanse the skin promptly after episodes of incontinence. 6. Use skin cleansers that are pH balanced for the skin.7. Use skin moisturizers daily on dry skin. 8. Avoid positioning an individual on an area of [DIAGNOSES REDACTED] or pressure injury. NUTRITION 1. Consider hospitalized individuals to be at risk for under nutrition and malnutrition from their illness or being NPO for diagnostic testing. 2. Use a valid and reliable screening tool to determine risk of malnutrition, such as the Mini Nutritional Assessment. 3. Refer all individuals at risk for pressure injury from malnutrition to a registered dietitian/nutritionist.4. Assist the individual at mealtimes to increase oral intake. 5. En(TRUNCATED)