Every finding on record at Victoria Care Center

Based on observation, interview, and record review, the facility failed to ensure to post the actual nurse staffing information at the beginning of each shift in a prominent location readily accessible to residents, visitors, and staff for viewing for two of three recertification survey days (4/7/2026 and 4/8/2026). These failures had the potential to mislead the residents, visitors, and staff of the actual staffing in the facility that may affect the quality of nursing care provided to the residents.Findings: During a concurrent observation in the facility's lobby, hallways, and reception area and interview on 4/7/2026 at 10:57 am with the Facility Receptionist (FR), there was no daily nurse staffing information posted in the lobby, hallways, and reception area. The FR stated the nurse staffing information was only posted in the nurse station. The facility had only one nurse station. During a concurrent observation in the nurse station and interview on 4/7/2026 at 11:00 am with Licensed Vocational Nurse 1 (LVN 1), the nurse staffing information was posted on the side of a shelf in the nurse station. There were two medication carts parked in front of the nurse station. The letter fonts used to print the nurse staffing information were not readable from the hallway. LVN 1 stated the residents and visitors would have a hard time seeing and reading the nurse staffing information on its current location. LVN 1 stated the residents and visitors could not move closer to the nurse station because of the parked medication carts. During a concurrent interview and record review on 4/8/2026 at 1:45 pm with the Director of Staff Development (DSD), the nurse staffing information dated 4/7/2026 and 4/8/2026 were reviewed. The DSD stated the hours indicated in the nurse staffing information for 4/7/2026 and 4/8/2026 were projected hours and not actual hours of staff working for each shift. The DSD stated the nurse staffing information should reflect the actual hours of staff working for each shift and posted in a visible and accessible location for the residents, visitors, and staff to see and know the facility had enough staffing to meet the nursing hours provided per patient care as reported to the Center for Medicare and Medicaid Services (CMS, a federal agency responsible for administering the Medicare and Medicaid programs) and to meet the residents' individual needs. During an interview on 4/9/2026 at 12:46 pm with the Director of Nursing (DON), the DON stated the nurse staffing information should be posted in a prominent location, visible and accessible for the residents, visitors, and staff to know the facility had sufficient staffing to provide appropriate care to the residents. The DON stated the nursing staff information should also reflect the actual hours of the licensed and unlicensed staff working for each shift to ensure the facility had enough staff to take care of the residents' needs in the facility. During a review of the facility's Policy and Procedure (P&P) titled, Nurse Staffing Posting Information revised 3/10/2025, the P&P indicated, The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. The facility will post the Nurse Staffing Sheet at the beginning of each shift. The information posted will be presented in a clear and readable format, in a prominent place readily accessible to the staff, residents, and visitors.

Based on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 6 and 51) Minimum Data Set (MDS- standardized assessment and care planning tool) reflected an accurate assessment by failing to: a. Ensure Resident 51, who was discharged to home under the care of home health (wide range of health care services that can be given at home for an illness or injury) service was coded in the MDS assessment accurately.b. Ensure Resident 6's hearing impairment was coded in MDS assessment. These deficient practices resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to result in Residents 6 and 51 not receiving interventions to address specific care concerns. Findings: a. During a review of Resident 51's admission Record (AR), the AR indicated the facility admitted Resident 51 on 11/28/2025 with diagnoses including difficulty in walking, hypertension (high blood pressure) and other symptoms and signs involving the musculoskeletal system. During a review of Resident 51's Order Summary Report (OSR) dated 2/19/2026, the OSR indicated to discharge Resident 51 to home under home health with Licensed Nurse for Medication reconciliation and Physical Therapy (PT)/Occupational Therapy (OT) for safety evaluation. During a review of Resident 51's Post Discharge Plan of Care and Summary (PDPOCS) dated 2/19/2026, the PDPOCS indicated Resident 51 would benefit from Home Health Services to safely transition to home environment. During a review of Resident 51's MDS dated [DATE], the MDS indicated Resident 51 was discharged to home/community instead of discharge home under care of organized home health service organization. During an interview on 4/8/2026 at 3:13 pm, with the facility's Minimum Data Set Nurse (MDSN), the MDSN stated Resident 51 was discharged to home on 2/20/2026 under home health with Licensed Nurse for medication reconciliation and PT/OT for safety eval. The MDSN stated Resident 51's MDS assessment was coded discharged to home/community. The MDSN stated Resident 51's MDS assessment should have been coded discharged to home under care of organized home health service organization and not just home/community. The MDSN stated Resident 51's MDS assessment should have been coded accurately to give accurate information to the Centers for Medicare and Medicaid services (CMS). During an interview on 4/9/2026 at 1:03 pm with Director of Nursing (DON), the DON stated MDS assessment needed to be coded accurately to give accurate information to CMS for CMS to know the care and services needed to provide to the residents. The DON stated Resident 51 was discharged to home under home health and should have been coded discharged to home under care of organized home health service organization in the MDS. During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessment- RAI, revised 12/19/2022, P&P indicated, The facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS. The assessment will include at least the following: Identification and demographic information. b. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 12/17/2021 with diagnoses including polyneuropathy (many nerves in the body were damaged, causing numbness, weakness, or pain) and hearing loss. During a review of Resident 6's History and Physical (H&P) dated 10/29/2025, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's Ear, Nose, and Throat Physician Progress Note (ENTPPN) dated 2/13/2026, the ENTPPN indicated Resident 6 had chronic hearing loss. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had adequate (no difficulty in normal conversation, social interaction, listening to television) hearing. The MDS indicated Resident 6 had severely impaired cognition (ability to understand). The MDS indicated Resident 6 was independent on eating. The MDS indicated Resident 6 was dependent (helper did all the effort) on staff with toileting hygiene, showering/ bathing, and bed-to-chair transferring. During a concurrent observation and interview with Resident 6 on 4/7/2026 at 11:05 AM, Resident 6 was pointing at Resident 6's ears and stated both of Resident 6's ears could not hear well. Surveyor had to remove facial mask and speak loudly next to Resident 6's ears. During a concurrent record review and interview with the MDS Coordinator (MDSC) on 4/8/2026 at 2:04 PM, Resident 6's MDS dated [DATE] was reviewed. The MDSC stated the MDS indicated Resident 6 had adequate hearing and it was not an accurate assessment. The MDSC stated the MDS nurse should have coded Resident 6's hearing assessment based on the MDS nurse's observation and the ENTPPN. The MDSC stated it was important to have accurate MDS assessment because the MDS assessment represented the residents' health information. The MDSC stated inaccurate MDS assessment would send inaccurate health information to CMS. During a review of the facility's P&P titled, Resident Assessment - RAI revised on 12/19/2022, the P&P indicated the facility should make a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by Centers for Medicare & Medicaid Services (CMS). During a review of the facility's P&P titled, Documentation in Medical Record revised on 12/19/2022, the P&P indicated the documentation should be accurate, relevant, and complete, containing sufficient details about the resident's care.

Based on observation, interview, and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans to meet the residents' needs for three of three sampled residents (Residents 6, 31 and 38) by failing to: a. Implement Resident 31's care plan of turning and repositioning schedule every two (2) hours. b. Developed a care plan to address Resident 6's hearing loss and use of Gabapentin (a medication for nerve pain and used to control seizures). c. Developed a care plan to address Resident 38's current gastrostomy tube (GT, a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications) feeding formula. These failures had the potential for Residents 6, 31, and 38 not to receive necessary care, treatment, and services specific to their needs. Findings: a. During a review of Resident 31's admission Record (AR), the AR indicated the facility admitted Resident 31 on 9/28/2009 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline of mental abilities), contracture (a stiffening/shortening at any point, that reduces the joint's range of motion) of the right hand, and generalized muscle weakness (reduced muscle strength). During a review of Resident 31's untitled Care Plan (CP) dated 8/19/2021, the CP indicated Resident 31 had activities of daily living (ADL) self-care performance deficit and Resident 31 required total care (dependent). The CP interventions included turning and repositioning Resident 31 every 2 hours and to keep skin clean and dry. During a review of Resident 31's Minimum Data Set (MDS, a resident assessment tool) dated 3/6/2026, the MDS indicated Resident 31 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 31 was dependent (helper did all the effort, resident did none) on staff with oral hygiene, toileting, shower, upper/lower body dressing and personal hygiene. The MDS indicated Resident 31 was at risk of developing pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bone prominence). During a review of Resident 31's Braden Scale Scoring (BSS, assessment tool that predicts a resident's risk of developing pressure injuries) dated 3/12/2026, the BSS indicated Resident 31 had a score of 9 (severe or very high risk of developing pressure injuries/sores). During an observation inside Resident 31's room on 4/8/2026 at 8:26 am, Resident 31 was lying on Resident 31's right side facing the door. During an observation inside Resident 31's room on 4/8/2026 at 9:42 am, Resident 31 was lying on Resident 31's right side facing the door. During an observation inside Resident 31's room on 4/8/2026 at 10:15 am, Resident 31 was lying on Resident 31's right side facing the door. During an observation inside Resident 31's room on 4/8/2026 at 11:15 am, Resident 31 was lying on Resident 31's right side facing the door. During an observation inside Resident 31's room on 4/8/2026 at 12:08 pm, Resident 31 was lying on Resident 31's right side facing the door. During a concurrent observation inside Resident 31's room and interview on 4/8/2026 at 12:56 pm with Certified Nurse Assistant 1 (CNA 1), Resident 31 was lying on Resident 31's right side facing the door. CNA 1 stated Resident 31 should have been turned and reposition every 2 hours to prevent bed sores. During an interview on 4/8/2026 at 2:00 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 31 was at risk for developing pressure ulcers and should be turned and repositioned every 2 hours to prevent skin breakdown and developing pressure injuries. During an interview on 4/9/2026 at 1:01 pm with the Director of Nursing (DON), the DON stated dependent and total care residents needed to be turned and repositioned every 2 hours and as necessary to prevent development or worsening of pressure injury. During a review of facility's Policy and Procedure (P&P) titled, Turning and Repositioning, revised 11/27/2023, the P&P indicated, Residents at risk of, or with existing pressure injuries, will be turned and repositioned, frequently, as tolerated, unless it is contraindicated due to a medical condition. In this case, small shifts in repositioning will be employed. The facility has established routine turning and repositioning schedules consisting of every 2-4 hours on the even hour. A maximum of thirty minutes before or after the scheduled time will be allotted for compliance with the schedule. b.1. During a review of Resident 6's AR, the AR indicated the facility admitted Resident 6 on 12/17/2021 with diagnoses including polyneuropathy (nerves in the body were damaged, causing numbness, weakness, or pain) and hearing loss. During a review of Resident 6's History and Physical (H&P) dated 10/29/2025, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's Ear, Nose, and Throat Physician Progress Note (ENTPPN) dated 2/13/2026, the ENTPPN indicated Resident 6 had chronic (long term) hearing loss. During a review of Resident 6's MDS dated [DATE], the MDS indicated Resident 6 had severely impaired cognition. The MDS indicated Resident 6 was independent on eating. The MDS indicated Resident 6 required moderate assistance (helper did less than half the effort) from staff with personal hygiene. The MDS indicated Resident 6 required maximal assistance (helper did more than half the effort) from staff with oral hygiene. The MDS indicated Resident 6 was dependent on staff with toileting hygiene, showering/ bathing, and bed-to-chair transferring. During an interview with Resident 6 on 4/7/2026 at 11:05 AM, Resident 6 stated both of Resident 6's ears could not hear well. During a concurrent record review and interview with the MDS Coordinator (MDSC) on 4/8/2026 at 2:04 PM, all of Resident 6's care plans (CP) were reviewed. The MDSC stated there was no specific CP initiated to address Resident 6's hearing loss. The MDSC stated the licensed nurse should initiate a CP as soon as the problem was identified. The MDSC stated the licensed nurse should have initiated the care plan to address Resident 6's hearing loss on 2/13/2026, following the ENTPPN indicating Resident 6 had chronic hearing loss. The MDSC stated it was important to have a specific resident-centered CP because the CP was individualized for each resident's problems/needs. The MDSC stated the CP was used to determine if the intervention was effective. b. 2. During a review of Resident 6's Order Summary Report (OSR) dated 4/8/2026, the OSR indicated Resident 6 had an active order of gabapentin (a medicine that helped calm nerves to reduce pain) for neuropathy. The order was dated 10/15/2024. During a concurrent record review and interview with the MDSC on 4/8/2026 at 2:36 PM, all of Resident 6's CPs were reviewed. The MDSC stated there was no specific CP initiated to address Resident 6's use of gabapentin for neuropathy. c. During a review of Resident 38's AR, the AR indicated the facility admitted Resident 38 on 3/18/2025 and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) and gastrostomy (a surgical opening fitted with a device to allow feedings/medication to be administered directly to the stomach). During a review of Resident 38's Physician Order (PO) dated 3/4/2026, the PO indicated continuous gastrostomy tube feeding (GTF) with Peptamen AF 1.2 (high-protein GTF that provided 1.2 kilocalorie [kcal, a unit of energy] per milliliter [ml, a unit to measure small volumes of liquid]) every shift for Resident 38. During a review of Resident 38's H&P dated 3/6/2026, the H&P indicated Resident 38 did not have the capacity to understand and make decisions. During a review of Resident 38's MDS dated [DATE], the MDS indicated Resident 38 had severely impaired cognition. The MDS indicated Resident 38 required maximal assistance from staff with oral and personal hygiene. The MDS indicated Resident 38 was dependent on staff with toileting hygiene, showering/ bathing, and bed-to-chair transferring. During an observation on 4/7/2026 at 10:59 AM, at Resident 38's bedside, Resident 38 was receiving GTF Peptamen AF 1.2 via GT while in bed. During a concurrent record review and interview with the MDSC on 4/8/2026 at 2:36 PM, Resident 38's CP for GT Feeding dated 4/7/2026 was reviewed. The CP indicated an intervention for licensed nursing staff to provide tube feeding as ordered. The MDSC stated the CP intervention was not specific and should indicate the specific GTF Peptamen AF 1.2. During an interview with the Director of Nursing (DON) on 4/9/2026 at 1:13 PM, the DON stated the resident's CP reflected the plan of care based on the resident's need. The DON stated the licensed nurses should develop specific and resident-centered CP. The DON stated the intervention of providing tube feeding as ordered was general and not specific to Resident 38. During a review of the facility's P&P titled, Comprehensive Care Plans, revised 12/2022, the P&P indicated the facility should develop and implement a comprehensive resident-centered CP for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. The P&P indicated the comprehensive CP should be developed within seven days after the completion of the comprehensive MDS assessment. The P&P indicated the CP should address the factors identified by the interdisciplinary team. The P&P further indicated the CP should have specific interventions that reflected the resident's needs and preferences.

Based on observation, interview, and record review, the facility failed to ensure safe food storage and handling practices in two of two facility kitchen refrigerators (Refrigerators 1 and 2), by failing to:a. Label a tray with four (4) heads of lettuce in Refrigerator 1 with received date.b. Discard an open plastic container of 2% milk, around one-fourth (1/4) full, past its use-by-date (relating to food safety) in Refrigerator 2.c. Discard an open plastic container of prune juice, around half (1/2) full, past its use-by-date in Refrigerator 2.These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.Findings:a. During an observation in the kitchen on 4/7/2026 at 9:22 am with the Dietary Supervisor (DS), a tray containing 4 heads of lettuce in Refrigerator 1 did not have a date when the lettuces were received. b. During an observation in the kitchen on 4/7/2026 at 9:24 am with the DS, an open plastic container of 2 % milk, around 1/4 full, had a preparation date of 3/31/2026 and a use-by-date of 4/4/2026 in Refrigerator 2.c. During an observation in the kitchen on 4/7/2026 at 9:24 am with the DS, an open plastic container of prune juice, around half full, had a preparation date of 2/24/2026 and a use-by-date of 3/24/2026 in Refrigerator 2.During an interview on 4/7/2026 at 9:32 am with DS, the DS stated all food items received should be labeled with a received date to determine when the food items were of highest quality and when they needed to be discarded to ensure foods served to the residents were safe and palatable.During an interview on 4/8/2026 at 12:56 pm with the Director of Nursing (DON), the DON stated all food, and beverages should be labeled with received date and not to be consumed past the best by date and use-by-date to prevent stomach reaction like diarrhea and vomiting.During a review of the facility's Reference Guide (RG) on Refrigerated Storage, dated 1/2026, the RG indicated that a washed and thoroughly drained head of lettuce should be kept in a crisper or moisture resistant wrap or bags and had a recommended storage time of three to five (3-5) days. The RG indicated that an opened liquid whole, or low-fat milk had a recommended storage time of one (1) week. The RG indicated that opened bottled, reconstituted, frozen, and canned juices had a recommended storage time of 1 week. During a review of the facility's Policy and Procedure (P&P) titled, Food Safety and Food Storage, revised 11/4/2024, the P&P indicated, Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food was received from the vendor and ends with delivery of the food to the resident. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded, and keeping foods covered or in tight containers.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving oxygen therapy (treatment that provided extra oxygen) in accordance with professional standards of practice for two of the two sampled residents (Residents 8 and 10) by failing to: a. Ensure Resident 10's nasal cannula tubing (a flexible plastic tubing used to deliver oxygen through the nostrils), oxygen humidifier (a small bottle that adds moisture to oxygen), and oxygen storage bag (a plastic bag that stores oxygen supplies for a resident) were properly labeled.b. Ensure Resident 8's nasal cannula tubing, oxygen humidifier, and oxygen storage bag were properly labeled. These failures placed Residents 8 and 10 at risk of complications related to the use of oxygen.Findings: a. During a review of Resident 10's admission Record (AR), the AR indicated the facility admitted Resident 10 on 1/23/2025 and readmitted on [DATE] with diagnoses including acute respiratory failure with hypoxia (sudden breathing problem when the lungs do not get enough oxygen) and dependence on supplemental oxygen. During a review of Resident 10's History and Physical (H&P) dated 6/9/2025, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool) dated 1/20/2026, the MDS indicated Resident 10 had severely impaired cognition (ability to understand and process information). The MDS indicated Resident 10 required supervision from staff with eating. The MDS indicated Resident 10 required maximal assistant (helper did more than half the effort) from staff with bed-to-chair transferring. The MDS indicated Resident 10 was dependent (helper did all the effort) on staff with oral hygiene, toileting hygiene, showering/ bathing, and personal hygiene. During a review of Resident 10's Order Summary Report (OSR) active as of 4/8/2026, the OSR indicated for nursing staff to change oxygen tubing as needed and administer oxygen to Resident 10 every shift. During a concurrent observation and interview on 4/7/2026 at 10:41 AM with the Director of Nursing (DON), Resident 10 was lying in bed, awake with ongoing oxygen at 2 liters per minute (LPM) via nasal cannula. The DON stated Resident 10's nasal cannula tubing, oxygen storage bag, and oxygen humidifier were dated 3/5/2026 and should be dated 4/5/2026. The DON stated the facility change resident's nasal cannula tubing, oxygen storage bag, and oxygen humidifier every Sunday of the week. During an interview on 4/9/2026 at 10:36 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated the oxygen nasal cannula tubing and oxygen storage bag needed to be changed and labeled by the registered nurse every Sunday of the week. LVN 4 stated it was not acceptable to see labels of 3/5/2026 instead of 4/7/2026 because the oxygen nasal cannula tubing and oxygen storage bag could not have been changed timely and placed the residents at risk of upper respiratory infection. LVN 4 stated the licensed nurse should make rounds during the shift to ensure the oxygen nasal cannula tubing and oxygen storage bag were labeled correctly and changed. LVN 4 stated nursing staff should have informed the registered nurse to change the oxygen nasal cannula tubing and oxygen storage bag if the labels were dated 3/5/2026. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, revised 5/20/2024, the P&P indicated staff should administer oxygen to residents consistent with professional standards of practice. The P&P indicated staff should change oxygen cannula tubing and humidifier bottle weekly for infection control. b. During a review of Resident 8's AR, the AR indicated the facility admitted Resident 8 on 2/11/2025 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- type of obstructive lung disease characterized by long-term poor airflow), chronic respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) and dependence on supplemental oxygen. During a review of Resident 8's Order Summary Report (OSR) dated 1/14/2026, the OSR indicated for staff to change Resident 8's oxygen tubing as needed. During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8 had intact cognition. The MDS indicated Resident 8 required partial/moderate assistance (helper did less than half the effort) from staff with toileting, shower, lower body dressing and putting on/taking off footwear. During a concurrent observation in Resident 8's room and interview on 4/7/2026 at 9:50 am with Licensed Vocational Nurse 3 (LVN 3), Resident 8 was lying in bed, awake with ongoing oxygen at two liters per minute (LPM) via nasal cannula. LVN 3 stated Resident 8's nasal cannula tubing, plastic bag and humidifier were dated 3/5/2026. LVN 3 stated the oxygen bag, nasal cannula tubing and humidifier should be changed every Sunday of the week or as needed for infection control. During an interview on 4/7/2026 at 2:13 pm, with Registered Nurse 1 (RN 1), RN 1 stated licensed nurses were responsible for changing the oxygen tubing, humidifier, and oxygen bag every Sunday of the week for infection control. During an interview on 4/8/2026 at 1:44 pm with the DON, the DON stated oxygen nasal cannula tubing, bag and humidifier needed to be changed every Sunday of the week or as needed by licensed nurses for infection control. The DON stated oxygen cannula tubing, bag and humidifier should be labeled with the date when it was changed. During a review of the facility's P&P titled, Oxygen Administration, revised 5/20/2024, the P&P indicated Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty, weekly or per facility policy.

Based on interview and record review, the facility failed to revise the care plans (CP) for two of two sampled residents (Residents 7 and 10) when:a. Resident 7's gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach) tube was removed.b. Resident 10 did not take medication for edema (swelling caused when extra fluid leaked from blood vessels and collected in body tissues). These deficient practices had the potential for Residents 7 and 10 to not receive appropriate care, treatment and/or services. Findings: a. During a review of Resident 7's admission Record (AR), the AR indicated the facility admitted Resident 7 on 12/12/2018 and readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive disease marked by tremor, muscular rigidity, and slow, imprecise movements) and dysphagia (difficulty swallowing). During a review of Resident 7's History and Physical (H&P) dated 2/16/2026, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Nursing Progress Notes (NPN) dated 2/23/2026, the NPN indicated the physician removed Resident 7's gastrostomy tube (GT) on 2/23/2026 at 3:03 PM. During a review of Resident 7's Minimum Data Set (MDS, a resident assessment tool) dated 2/27/2026, the MDS indicated Resident 7 had intact cognition (ability to understand and process information). The MDS indicated Resident 7 was dependent (helper does all the effort) on staff with oral hygiene, oral hygiene, toileting hygiene, showering/ bathing, personal hygiene, and bed-to-chair transferring. During a review of Resident 7's Order Summary Report (OSR) with active orders as of 4/8/2026, the OSR indicated Resident 7 did not have an active order of tube feeding nor water flushing. During a review of Resident 7's Care Plan (CP) for nutritional problems with target date of 6/11/2026, the CP indicated as of 9/11/2025, Resident 7 no longer had tube feeding and was taking meals orally. The CP intervention indicated for nursing staff to provide tube feeding and water flush as ordered. During a concurrent record review and interview with the MDS Coordinator (MDSC) on 4/8/2026 at 2:50 PM, Resident 7's CP for nutritional problem was reviewed. The MDSC stated the licensed nurse should have revised Resident 7's CP when the GT was removed to reflect Resident 7's current health condition and dietary needs. During an interview with Licensed Vocational Nurse 4 (LVN 4) on 4/9/2026 at 10:49 AM, LVN 4 stated it was not acceptable for Resident 7's CP intervention to provide GT feeding (GT) because Resident 7 did not have active GT or GT feeding. LVN 4 stated the licensed nurse should revise the CP when there was a change on the resident's medication and tube feeding. LVN 4 stated it was important to have specific and up-to-date CP for residents. b. During a review of Resident 10's AR, the AR indicated the facility admitted Resident 10 on 1/23/2025 and readmitted on [DATE] with diagnoses including cerebral palsy (a group of permanent disorders affecting a resident's ability to move, maintain balance, and manage posture) and hydronephrosis (the swelling of one or both kidneys caused by a buildup of urine). During a review of Resident 10's CP for edema dated 2/6/2025 with target date of 5/6/2026, the CP intervention indicated for licensed nursing staff to provide medication as ordered. During a review of Resident 10's H&P dated 6/9/2025, the H&P indicated Resident 10 did not have the capacity to understand and make decisions. During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 had severely impaired cognition. The MDS indicated Resident 10 required supervision from staff with eating. The MDS indicated Resident 10 required maximal assistant (helper did more than half the effort) from staff with bed-to-chair transferring. The MDS indicated Resident 10 was dependent on staff with oral hygiene, toileting hygiene, showering/ bathing, and personal hygiene. During a concurrent record review and interview with the MDSC on 4/8/2026 at 2:22 PM, Resident 10's OSR dated 4/8/2026 was reviewed. The MDSC stated the OSR indicated Resident 10 did not have an active medication order for edema. The MDSC stated the licensed nurse should have removed the intervention to provide medication in Resident 10's CP for edema because Resident 10 was not taking any medication for edema. The MDSC stated the licensed nurse should have revised the CP as soon as the physician discontinued the medication for edema. The MDSC stated inaccurate nursing intervention could affect the continuity of resident care. During an interview with the Director of Nursing (DON) on 4/9/2026 at 1:13 PM, the DON stated the resident's CP should reflect the plan of care based on the resident's current needs. The DON stated the licensed nurse should revise the CP when residents (in general) had a change in condition. During a review of the facility's Policy and Procedure (P&P) titled, Care Plan Revisions Upon Status Change, revised 12/19/2022, the P&P indicated the facility should reviewed and revised the comprehensive CP as necessary, when a resident experiences a status change. The P&P further indicated that the MDSC and designated staff would update the CP with the new or modified interventions as needed.

Based on interview and record review, the facility failed to ensure medication regimen review (MRR) irregularity identified by the facility's Pharmacy Consultant was acted upon for one of five sampled resident (Resident 5) in accordance to facility's policy and procedure Consultant Pharmacist Report.This deficient practice had the potential for harm due to the missed opportunity by the physician and the licensed staff to act upon the reported irregularities for Resident 5. Findings:During a review of Resident 5's admission Record (AR), the AR indicated the facility admitted Resident 5 on 11/24/2025 with diagnoses including encephalopathy (disease that affects the function or structure of the brain) and unspecified dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning).During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/28/2026, indicated, Resident 5 had severely impaire cognition (mental action or process of acquiring knowledge and understanding) for daily decision making The MDS indicated, Resident 5 needed maximum assistance (helper does more than half the effort) to staff for toileting, shower, lower and upper body dressing and putting on/taking off footwear.During a record review of Resident 5's Order Summary Report (OSR), dated 2/26/2026, the OSR indicated to administer diphenhydramine hydrochloride oral (used primarily to treat allergy symptoms [sneezing, itching, runny nose] and as a sleep aid due to its strong sedative [substance that includes sedation] effects) tablet 25 milligram (mg, unit of measurement) one tablet by mouth every six hours as needed for itchiness.During a review of a facility document titled, Note to Attending Physician/Prescriber, dated 3/6/2026, completed by the facility's pharmacist consultant, the note indicated Patient is on PRN (as needed) Benadryl. Federal guidelines can view the use of Diphenhydramine (Benadryl) as unnecessary due to its potential for anticholinergic (i.e. constipation, orthostasis, urinary retention) and sedative side effects. If appropriate and effective, topical instead of oral diphenhydramine should be considered. If an oral agent is clinically necessary for long term use, perhaps other alternatives (for example, Allegra or Claritin [used to relieve allergy symptoms]) could be considered. The Note indicated, physician agreed to discontinue Benadryl PRN.During a concurrent interview and record review on 4/8/2026 at 2:39 pm, with the facility's Director of Nursing (DON), of Resident 5's medical records (PointClickCare - PCC, a cloud-based software used in long-term and post-acute care facilities and chart), the DON stated, the MRR was a monthly recommendation from the pharmacy consultant that licensed nurses should carry out. The Facility's DON stated, the purpose of MRR was for the pharmacy consultant to review if residents were receiving proper medications and to eliminate unnecessary medication use. The DON stated, Medical Doctor (MD) agreed to discontinue Benadryl PRN as ordered. The DON stated, Diphenhydramine hydrochloride tablet 25 mg, one tablet by mouth every six hours as needed for itchiness was not discontinued as recommended by pharmacist. The DON stated, Licensed Nurse (LN) received the order from MD on 3/31/2026 to discontinue Benadryl order and LN might forgot to discontinue the order.During a review of the Policy and Procedure (P&P), titled, Medication Regimen Review, revised 12/19/2022, the P&P indicated The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on observation, interview, and record review, the facility staff failed to elevate the resident's head of the bed (HOB) while the resident was receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition/medication directly into the stomach) in accordance with the resident's care plan and physician's order for one of three sampled residents (Resident 32). This deficient practice had the potential to result in aspiration (inhalation of foreign materials) and respiratory complications for Resident 32. Findings: During a review of Resident 32's admission Record (AR), the AR indicated the facility admitted Resident 32 on 8/14/2025 with diagnoses including encounter for attention to gastrostomy (creation of an artificial external opening into the stomach for nutritional support), dysphagia (difficulty in swallowing) and dependence on supplemental oxygen. During a review of Resident 32's untitled Care Plan (CP) dated 9/2/2025, the CP indicated Resident 32 required tube feeding related to dysphagia and swallowing problem, The care plan interventions included for nursing staff to elevate Resident 32's HOB at least 30 to 45 degrees during and thirty minutes after tube feeding and to provide tube feeding to Resident 32 as ordered. During a review of Resident 32's Order Summary Report (OSR) dated 1/9/2026, the OSR indicated for staff to elevate Resident 32's HOB at 30 to 45 degrees at all times for aspiration precaution every shift for tube feeding. During a review of Resident 32's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 2/19/2026, the MDS indicated Resident 32 had severely impaired cognition (ability to understand). The MDS indicated Resident 32 was dependent (helper did all the effort) on staff for oral hygiene, toileting, shower, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. During a review of Resident 32's OSR dated 4/3/2026, the OSR indicated continuous GT feeding of Isosource 1.5 (formula) rate at 40 milliliters (ml, unit of measurement) per hour (hr.). Start at 2 pm, stop at 10 am or until 800 ml has been infused for Resident 32. During an observation on 4/7/2026 at 9:41 am, Resident 32 was lying flat in bed, in supine position with ongoing GT feeding formula running at 40 ml/hr. An unidentified Certified Nurse Assistant (CNA) was at Resident 32's bedside. During a concurrent observation and interview on 4/7/2026 at 9:43 am, together with Licensed Vocational Nurse 3 (LVN 3), Resident 32 was awake, lying in bed, in supine position with ongoing GT feeding and the resident's HOB was not elevated at 30 to 45 degrees. LVN 3 stated Resident 32's HOB should have been elevated at 30 to 45 degrees while receiving GT feeding to prevent aspiration. LVN 3 stated the licensed nurse should turn off the GT feeding if Resident 32 was flat on bed. During an interview on 4/7/2026 at 2:25 pm, with Registered Nurse 1 (RN 1), RN 1 stated Resident 32's HOB needed to be elevated while the resident was receiving GT feeding to prevent aspiration. During an interview on 4/8/2026, at 1:45 pm, with the Director of Nursing (DON), the DON stated Resident 32's HOB needed to be elevated at least 30 degrees while receiving GT feeding to prevent aspiration.

Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device to assist a resident when needed) was within reach for one of one sampled resident (Residents 45). This failure had the potential to delay meeting Resident 45's needs or result in a fall or accident/injury.Findings: During a review of Resident 45's admission Record (AR), the AR indicated the facility originally admitted Resident 45 on 1/23/2020 and readmitted on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, usually caused by damage to the brain) following cerebral infarction (part of the brain did not get enough blood, which caused brain cells to die) affecting left non-dominant side. During a review of Resident 45's fall risk care plan (CP) initiated on 2/23/2023, the CP intervention indicated for nursing staff to place the call light within Resident 45's reach. During a review of Resident 45's History and Physical (H&P) dated 10/29/2025, the H&P indicated Resident 45 did not have the capacity to understand and make decisions. The H&P indicated Resident 45 had right eye blindness and left eye cataract (a condition where the lens of the eye became cloudy and caused blurry vision). During a review of Resident 45's Minimum Data Set (MDS, a resident assessment tool) dated 1/28/2026, the MDS indicated Resident 45 had severely impaired cognition (ability to understand). The MDS indicated Resident 45 required setup assistance from staff with eating. The MDS indicated Resident 45 required supervision from staff with mobility. The MDS indicated Resident 45 required moderate assistance (helper did less than half the effort) from staff with oral hygiene, toileting hygiene, showering/ bathing, and personal hygiene. During a concurrent of observation and interview with Resident 45 on 4/7/2026 at 10:47 AM, at Resident 45's bedside, Resident 45 was awake and lying on bed. Resident 45's call light for was on the floor, positioned near the left side of the bed. Resident 45 stated Resident 45 needed help with the cellphone and was unable to locate the call light. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 4/8/2026 at 9:24 AM, LVN 2 stated the resident's call light should be within easy reach so the resident (in general) could call for help when needed. LVN 2 stated it was important to ensure the call lights were within residents' reach. During a concurrent picture review and interview with Certified Nurse Assistant 3 (CNA 3) on 4/9/2026 at 10:11 AM, the picture dated 4/7/2026 at 10:48 AM was reviewed. CNA 3 stated Resident 45's call light was on the floor and the resident could not reach. CNA 3 stated the call light should be placed on Resident 45's chest or very close to the resident so the resident could reach easily for safety. CNA 3 stated the call light was used for resident's safety and as a means to communicate between the residents and staff. During an interview with the Director of Nursing (DON) on 4/9/2026 at 1:13 PM, the DON stated it was important to ensure the call light was within the resident's reach for safety precaution and fall prevention. The DON stated staff could not attend to residents' needs timely if the residents needed to look for the call light. The DON stated the call light on the floor was not within Resident 45's reach. During a review of the facility's Policy and Procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised 12/2022, the P&P indicated the facility staff should ensure the call light was within reach of the resident while in bed.

Based on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for twelve (12) out of thirteen (13) resident rooms (Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14). This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.Findings: During an interview with the facility's Administrator (ADM) on 4/9/2026 at 12:14 PM, the ADM stated the facility would like to request a room waiver (a document recording the waiving of a right or claim) for Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14. The ADM stated nothing was changed and the number of bed occupancy in the 12 rooms. During a review of the facility's letter to request for room waiver dated 4/7/2026, the room waiver request indicated there was ample room to accommodate wheelchairs (a chair fitted with wheels for use as a means of transport by a person who was unable to walk as a result of illness, injury, or disability) and other medical equipment, as well as space for mobility and movement of ambulatory residents. The letter indicated there was adequate space for nursing care, and the health and safety of residents occupying these rooms were not in jeopardy. The letter further indicated these rooms were in accordance with the special needs of the residents, and did not have an adverse effect on the residents' health and safety or impedes the ability of any resident in the rooms to attain his or her highest practicable well-being. The room waiver letter indicated the following: Room Sq. Ft. Beds1 304 42 304 43 304 4 4 304 46 304 47 304 4 8 304 4 9 304 410 304 411 304 412 304 4 14 304 4 During the Health Recertification Survey conducted from 4/7/2026 to 4/9/2026, Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14 had adequate space, nursing care and comfort, and privacy was provided to the residents. The residents were observed to have enough space to move freely inside the rooms. There was adequate room for the operation and use of wheelchairs, walkers (a device that gave additional support to maintain balance or stability while walking), and Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place). Each resident inside the affected rooms had beds and bedside tables with drawers. The room size did not affect the care and services provided by the staff to the residents when staff were observed providing care to the residents. During a concurrent observation and interview with Resident 7 on 4/7/2026 at 10:38 AM, in Resident 7's room (room [ROOM NUMBER]), Resident 7 was sitting in wheelchair. Observed two certified nurse assistants (CNA, unidentified) were moving the Hoyer lift out of room [ROOM NUMBER] with no concerns. Resident 7 stated Resident 7 had enough space in the room to move around with no concerns. During an interview with CNA 3 on 4/9/2026 at 12:30 PM, CNA 3 stated CNA 3 had enough space to move around in all the rooms to provide resident care. CNA 3 stated she did not have any incident of bumping CNA 3 into any room furniture or getting hurt in the residents' rooms.

Based on interview and record review, the facility failed to ensure an accurate assessment was conducted for one of one sampled resident (Resident 1). Resident 1 did not have an accurate assessment for the resident's cognitive skills for daily decision making.This deficient practice resulted in inaccurate assessment for Resident 1's elopement risk and had the potential for delay in necessary care and services.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), diabetes mellitus (a disease that results in elevated levels of glucose in the blood), dysphagia (difficulty swallowing), hypertension (HTN-high blood pressure), and acquired absence of left leg below knee (a part of the left leg removed below the knee, due to an amputation, either surgically or traumatically). The AR indicated Resident 1's Responsible Person (RP) was a conservator/guardian (a public official appointed by the court to care for individuals who are deemed unable to care for themselves or their finances).During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 4/22/25, the MDS indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision making.During a concurrent review of Resident 1's Elopement Risk Assessment, dated 6/7/25, and interview with the Director of Nurse (DON) on 6/10/25 at 10:02 a.m., Resident 1's Elopment Risk Assessment indicated No on all 10 areas of the assessment. The DON stated all questions in Resident 1's assessment were answered No because the assessment tool assessed if the resident had a history of elopement or an attempt for elopement while at home. The DON stated Resident 1 was not at home and the questions would not apply to Resident 1 while the resident was at the facility. During a telephone interview on 6/12/25 at 9:17 a.m. with Resident 1's Public Guardian (PG), the PG stated Resident 1 has been under [NAME]-Petris-Short (LPS, a California law enacted in 1969 that regulates the involuntary commitment of individuals with mental health disorders) conservatorship (a legal process where a court appoints a person to make certain decisions for an individual who was deemed gravely disabled [unable to provide for basic needs] due to a mental health disorder) since 7/1/22 to present day (6/12/25) and Resident 1 cannot make any legal, financial, medical or care decisions. The PG stated Resident 1's elopement from the facility on 6/7/25 was considered absence without leave (AWOL, generally refers to a resident leaving the facility without proper authorization or supervisions).

Based on observation, interview, and record review, the facility failed to ensure a safe environment for two of three sampled residents (Resident 1 and Resident 2), as indicated in the facility's policy and procedures (P&P) titled, Accidents and Supervision, and Resident Right to Access and Visitation, by failing to ensure: 1. There was adequate resident visitation monitoring (continuous observation) at the facility's main front door entrance during the night shift (11 PM to 7 AM). This failure resulted in an unknown visitor walking inside the facility without staff awareness and entering Resident 1' and Resident 2's room. The failure had the potential to result in physical, emotional, and mental harm for Resident 1, Resident 2, and other residents residing at the facility. Findings 1. During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on [DATE] with diagnoses that included hemiplegia (total paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following unspecified cerebrovascular disease (stroke, loss of blood flow to part of the brain) affecting left non-dominant side, Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and difficulty walking. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's plan of care (CP), initiated on [DATE], the CP indicated Resident 1 had impaired cognitive function or impaired thought process related to hemiplegia/hemiparesis after a stroke. The CP's interventions indicated to communicate with the resident and resident's family members regarding the resident's capacities and needs and to reorient and supervise Resident 1 as needed. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated Resident 1's cognitive (ability to understand and process information) skills were moderately impaired. The MDS indicated Resident 1 did experience hallucinations (perceptual experience in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 1 required moderate assistance (helper does more than half the effort) to complete Resident 1's activities of daily living (ADL, term used in healthcare that refers to self-care activities). The MDS indicated Resident 1 required supervision with functional mobility (a person's ability to move safely and independently within their environment) such as turning left and right in bed, transferring from sitting to standing position, and transferring from bed to chair. During a review of Resident 1's Nursing Progress Notes (PN), dated [DATE], timed at 3:40 AM, Licensed Vocational Nurse (LVN) 2 indicated at 11 PM, there was a female visitor (unknown) in Resident 1's room. The PN indicated at 11:10 PM, the visitor was crying, and LVN 2 asked the visitor to leave the facility due to, suggested visiting hours are over. The PN indicated at 11:15 PM, Resident 2 (Resident 1's roommate) informed LVN 2, someone [was] in [Resident 1's] room [and] was using [Resident 1's] phone and talking to [Resident 1]. The PN indicated at 11:38 PM, Family Member (FM) 1 arrived at the facility inquiring who had visited Resident 1. The PN indicated at 12:28 AM, Police Officer 1 arrived at the facility and spoke to Resident 1 about the unknown visitor. The PN indicated at 3:30 AM, FM 2 requested to take Resident 1 home. During a review of FM 1's written notification to the facility, dated [DATE] at 3:34 AM, the notification indicated FM 1 notified the facility of FM 1's decision to remove Resident 1 from the facility due to an incident where a stranger was allowed into [Resident 1's] room, compromising not only [Resident 1's] safety but also the safety of other patients in the facility. 2. During a review of Resident 2's AR, the AR indicated the facility originally admitted Resident 2 on [DATE] with diagnoses that included DM 2 and hypertension (high blood pressure). During a review of Resident 2's H&P, dated [DATE], the H&P indicated Resident 2 did not have memory loss and had the capacity to make medical decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills were intact. The MDS indicated Resident 2 did not experience hallucinations or delusions. During an observation on [DATE] at 5:05 AM of the facility's main entrance, there was one security camera on the edge of the building facing the facility's parking lot and the front main entrance door. The facility's main entrance door was locked, and no receptionist was observed at the front desk. There was a doorbell at the front of the facility, the doorbell was pressed and was working. During an observation on [DATE] at 6:16 AM in the facility's lobby, Resident 1's room was the first immediate room past the double doors located in the first hallway and to the left side of the lobby. During an interview on [DATE] at 7:27 AM with the Administrator (ADM), the ADM stated, there was a security camera monitoring the main front entrance door that all facility staff and visitors must use to enter and exit the facility. During a concurrent observation and interview on [DATE] at 9:55 AM, with Resident 2, in Resident 2's room. Resident 2 stated, Resident 1's bed was located across from Resident 2's bed. Resident 2 stated there was an unknown visitor on [DATE] who visited Resident 1 around 11 PM. Resident 2 stated, Resident 2 felt unsafe because the facility was not aware how the unknown visitor entered the facility. Resident 2 stated, as the conversation between the stranger and Resident 1 continued, Resident 2 realized Resident 1 did not know the stranger. Resident 2 stated Resident 2 saw the back of the unknown visitor's head who stood at the foot of Resident 1's bed. Resident 2 stated, the unknown visitor had long black hair, was young, and was tearful while interacting with Resident 1. Resident 2 stated, Resident 2 heard Resident 1 tell the unknown visitor Resident 1 was not sure if Resident 1 knew the unknown visitor because Resident 1 did not remember the unknown visitor. During an interview on [DATE] at 11:02 AM with FM 2, FM 2 stated, FM 2 received a phone call from Resident 1 on [DATE] after 11 PM. FM 2 stated, when FM 2 answered the phone call, FM 2 heard someone crying horrifically and FM 2 thought [Resident 1) had died . FM 2 stated, FM 2 spoke to Resident 1 on the phone and Resident 1 told FM 2, I do not know who was the unknown visitor. FM 2 stated FM 2, I do not recognize the [unknown visitor's] voice. FM 2 stated, the unknow visitor said, it was not important, and it does not matter where [Resident 1 and the unknown visitor] met when FM 2 asked what the unknown visitor's relationship to Resident 1 was. FM 2 stated, Resident 1 told FM 2 the same nurse who brought the unknown visitor into Resident 1's room escorted the unknown visitor out of the room. FM 2 stated, I was worried for [Resident 1] because [the facility] let someone [unknown visitor] come in [the facility] unannounced. During an interview on [DATE] at 12:41 PM with Certified Nurse Assistant (CNA) 2, CNA 2 stated, the main entrance doors were always locked. CNA 2 stated, if there were visitors during the night shift, the visitors needed to ring the doorbell and the charge nurse, should be aware of who is coming in the facility. During an interview on [DATE] at 12:53 PM with FM 1, FM 1 stated, FM 1 received a phone call from FM 2 on [DATE] after 11 PM, and FM 2 stated there was an unknown visitor in Resident 1's room who was crying over the phone. FM 1 stated FM 2 did not think Resident 1 knew who the unknown visitor was because the unknown visitor initially told FM 2, she was Resident 1's neighbor then stated was Resident 1's niece. FM 1 stated, the facility put the entire facility in danger because the facility allowed an unknown visitor in, who did not have known family members in the facility, into the home of these residents. During an interview on [DATE] at 2:30 PM with CNA 3, CNA 3 stated, there should be no unknown visitors during the night shift. CNA 3 stated, we checked the logbook, and there were no visitor names during that time. CNA 3 stated CNA 3 did not know who opened the door for the unknown visitor and who showed [the unknown visitor Resident 1's] room. CNA 3 stated, it was scary if there were unknown visitors in the facility at night because unknown visitors might harm the residents by stealing their belongings or physically harming the residents. During an interview on [DATE] at 2:39 PM with LVN 2, LVN 2 stated on [DATE] there was a young unknown visitor in the facility near Resident 1's room. LVN 2 stated, LVN 2 did not know who the unknown visitor was and told the unknown visitor to leave the facility because visiting hours were over. LVN 2 stated, LVN 2 saw the unknown visitor come out of Resident 1 and Resident 2's room. LVN 2 stated the visitor did not sign the visitor logbook upon entering the facility. LVN 2 stated the unknown visitor should not be in a resident's room because it was dangerous. During an interview on [DATE] at 2:50PM with the ADM, the ADM stated no strangers, or unknown visitors should have entered the facility, especially during the night shift. The ADM stated it was important for all visitors entering the facility to sign the [visitor] logbook because it was important to keep track of who was in the facility. The ADM stated, there should not be unknown visitors in the facility because we do not want people who we do not know in[side] the building and it may be harmful to the staff and the residents. During a review of the facility's P&P titled, Accidents and Supervision, dated [DATE], the P&P indicated each resident will receive adequate supervision . to prevent accidents which include identifying hazards and risks and evaluating and analyzing hazards and risks. During a review of the facility's P&P titled, Resident Right to Access and Visitation, dated [DATE], the P&P indicated visitations will be person-centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life. The P&P indicated the facility will provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions. The P&P indicated there were reasonable clinical and safety restrictions to protect the health and security of all residents and staff which included keeping the facility locked at night with a system in place for allowing visitors approved by the resident.

Based on interview and record review, for two of five sampled residents (Residents 10 and 94), the facility failed to ensure: a. Resident 94's physician order for Lorazepam (medication used to treat anxiety disorders [a condition that involves excessive fear, worry, or dread that interferes with daily life]) had a stop date as indicated in the facility's policy and procedures (P&P) on the use of psychotropic medication (drugs that alter the brain chemistry and affect metal processes, emotions and behavior). b. Resident 10's target behavior was monitored for the use of Haloperidol (antipsychotic medication to treat serious mental disorder in which people interpret reality abnormally) as indicated in the facility's P&P on the use of psychotropic medication. These deficient practices had the potential to result in the use of unnecessary psychotropic medications, which may result in significant adverse (harmful) consequences to Residents 10 and 94. Findings: a. During a review of Resident 94's Admission Record, the AR indicated Resident 94 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm of the breast (breast cancer) and anxiety disorder. During a review of Resident 94's Order Summary Report (OSR) dated 2/15/2025, the OSR indicated Resident 94 had an order for Lorazepam oral tablet 0.5 milligram (mg), 1 tablet by mouth every six hours as needed (PRN) for anxiety. During an interview on 2/15/2025 at 11:56 am with the facility's Director of Nursing (DON), the DON stated, all PRN psychotropic medication order should have a duration of use. The DON stated, normally the first duration should be 14 days, and the ordering physician would reassess the effectiveness after 14 days to see if the medication order should be extended. The DON stated this measure was to prevent unnecessary psychotropic medication administered to residents which could affect their thought processing and safety. During a review of the facility's P&P titled Use of Psychotropic Medication, dated 12/19/2022, the P&P indicated PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and limited duration (i.e. 14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall documented their rational in the resident's medical record and indicated the duration for the PRN order. 42781 b. During a review of Resident 10's AR, the AR indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression (a feeling of severe sadness or hopelessness) and dependence on supplemental oxygen. During a review of Resident 10's History and Physical (H&P) dated 1/17/2025, the H&P indicated Resident 10 had the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/29/2025, the MDS indicated Resident 10 was dependent (helper did all the effort and lifted or held trunk or limbs) to staff for toileting hygiene, shower, lower body dressing and putting on/taking off footwear. During a review of Resident 10's OSR dated 2/4/2025, the OSR indicated Resident 10 had an order for Sertraline Hydrochloride Oral (antidepressant [medication to treat depression, mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning]) tablet 100 mg by mouth two times a day for depression manifested by inability to sleep. During an interview on 2/16/2025 at 9:16 am with the facility's Director of Nurses (DON), the DON stated the target behavior needed to be monitored and documented every shift as ordered to identify if the medication was effective or not. During a concurrent interview and record review on 2/16/2025 at 10:30 am with Licensed Vocational Nurse 1 (LVN 1) of Resident 10's medical record in PointClickCare (PCC, a cloud-based software used in long-term and post-acute care facilities), there was no documented monitoring for Resident 10's target behavior for depression manifested by inability to sleep from 2/5/2025 to 2/14/2025. LVN 1 stated, Resident 10's hours of sleep was not monitored for 10 days. LVN 1 stated it was important to monitor the target behavior of the residents to know if the medication was working or not. During a review of the facility's P&P titled, Use of Psychotropic Medication, revised 12/19/2022, the P&P indicated, the indications for initiating, withdrawing or withholding medications as well as the use of non-pharmacological approaches will be determined by assessing the resident's underlying condition, current signs, symptoms, expressions and preferences and goals for treatment. The P&P indicated, non-pharmacological interventions that have been attempted and the target symptoms for monitoring shall be included in the documentation.

Based on observation, interview, and record review, the facility failed to provide safe and sanitary environment to prevent the development and transmission of communicable diseases (one that is spread from one person to another) for two of five sampled residents (Residents 145 and 2) by failing to: a. Ensure Certified Nurse Assistant 3 (CNA 3) wore the required Personal Protective Equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing care to Resident 145 who was on Enhanced Barrier Precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs]). b. Ensure the Treatment Nurse (TN) who entered Resident 2's room and administered medication to Resident 2, wore a gown. Resident 2 was on EBP. These failures had the potential to result in the spread of infection from Residents 2 and 145 to staff members and other residents in the facility. Findings: a. During a review of Resident 145's Admission Record (AR), the AR indicated Resident 145 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (a slow progressive narrowing of the blood flow to the arms and legs) and ulcer (a small open sore or wound generally found in the stomach or on the skin) of bilateral lower extremity. During a review of Resident 145's Order Summary Report (OSR) dated 2/10/2025, the OSR indicated Resident 145 was placed on Enhanced Barrier Precautions related to wound/s. During a review of Resident 145's Care Plan (CP), dated 2/10/2025, the CP indicated Resident 145 was on EBP related to unhealed ulcers. The CP interventions included for staff to apply EBP to prevent the spread of infections for specific care activities such as toileting and changing incontinence briefs. During a review of Resident 145's Minimum Data Sheet (MDS, a resident assessment tool) dated 2/14/2025, the MDS indicated Resident 145 had intact cognition (ability to understand). The MDS indicated Resident 145 required setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating, oral and personal hygiene and dependent (helper did all of the effort, resident did none of the effort to complete the activity) with toileting, and shower. During an observation on 2/14/2025 at 7:17 pm inside Resident 145's room, Certified Nurse Assistant 1 (CNA 1) was cleaning and changing Resident 145. CNA 1 was only wearing gloves. CNA 1 was not wearing gown. During an interview on 2/14/2025 at 7:19 pm with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, Resident 145 was on EBP because of his wounds on both lower extremities. LVN 1 stated all staff should wear gown and gloves when providing care to residents on EBP to prevent the spread of infection. During an interview on 2/15/2025 at 4:05 pm with the facility's Director of Nursing (DON), the DON stated all staff should don (put on) gown and gloves before they enter the room of residents on EBP, when providing care, and doffed (remove PPE) before leaving the room, for infection control. 40037 b. During a review of Resident 2's AR, the AR indicated the facility admitted Resident 2 on 3/18/2022, with diagnoses that included dysphagia (difficulty swallowing) and Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control). During a review of Resident 2's OSR dated 6/24/2024, the OSR indicated the physician ordered EBP for Resident 2 due to gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment and screening tool) dated 12/26/2024, the MDS indicated Resident 2 had unclear speech, sometimes understood others, and sometimes made self-understood. The MDS indicated Resident 2 was dependent (helper does all of the effort) for personal hygiene and chair/bed-to-chair transfer. During an observation on 2/15/2025 at 8:03 am, outside Resident 2's room, there was a signage posted at the door indicating Resident 2 was on EBP. The Treatment Nurse (TN) entered Resident 2's room and administered medication to Resident 2 via GT. The TN did not wear a gown while in close contact with Resident 2. During an interview on 2/15/2025 at 8:52 am, the TN stated, the TN did not wear a gown while performing medication administration for Resident 2. The TN stated, EBP measure was to prevent Resident 2 from cross infections. The TN stated TN should have worn a gown as this measure was to protect both the resident and care givers. During an interview on 2/15/2025 at 10:43 am with the Infection Preventionist Nurse (IPN), the IPN stated, Resident 2 was on EBP due to GT, and the TN should wear a gown when administering medications which was in close contact care with Resident 2. The IPN stated, this was to prevent cross contaminations and protect both residents and care givers from infection. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, revised 6/17/2024, the P&P indicated, EBP/ESP are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Make gowns and gloves available prior to performing task. PPE for EBP is only necessary when performing high-contact care activities. High-contact resident care activities include dressing, bathing/shower, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting and device care or use.

Based on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bed rails/siderails (adjustable metal or rigid plastic bars attached to the bed) and grab bars (bars installed on the side of the bed) for two of two sampled residents (Residents 145 and 9). These failures placed Residents 145 and 9 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaces around the bed) and injury from the use of siderails and grab bars. Findings: a. During a review of Resident 145's Admission Record (AR), the AR indicated Resident 145 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (a slow progressive narrowing of the blood flow to the arms and legs) and ulcer (a small open sore or wound generally found in the stomach or on the skin) of bilateral lower extremity. During a review of Resident 145's Minimum Data Sheet (MDS, a resident assessment tool) dated 2/14/2025, the MDS indicated Resident 145 had intact cognition (ability to understand). The MDS indicated Resident 145 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, oral and personal hygiene and dependent (helper did all the effort, resident did none of the effort to complete the activity) with toileting, and shower. During a concurrent observation and interview on 2/14/2025 at 6:09 pm with Licensed Vocational Nurse 1 (LVN 1) inside Resident 145's room, Resident 145 was in bed, on his back with half siderail up on both sides of the bed. LVN 1 stated Resident 145 was alert and oriented. During a concurrent interview and record review on 2/15/2025 at 9:54 am with the Minimum Data Set Coordinator (MDS C), Resident 145's medical record (chart) and PointClickCare (PCC, a cloud-based software) were reviewed. The MDS C stated, there was no documented evidence that appropriate alternative interventions were attempted and did not meet the needs of Resident 145 before the installation of bilateral half siderails. b. During a review of Resident 9's AR, the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (muscle weakness on one side of the body that can affect the arms, legs, and facial muscles), and history of falling. During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9 had moderately impaired cognition. The MDS indicated Resident 9 required substantial/maximal assistance (helper did more than half of the effort) with eating and oral hygiene and dependent with toileting, shower and personal hygiene. During a concurrent observation and interview on 2/14/2025 at 6:16 pm with MDS C inside Resident 9's room, Resident 9 was sitting on the bed with grab bars on both sides of the bed. MDS C stated Resident 9 was alert with periods of confusion. During a concurrent interview and record review on 2/15/2025 at 9:33 am with the MDS C, Resident 9's chart and PCC were reviewed. The MDS C stated there was no documented evidence that appropriate alternative interventions used did not meet the needs of the resident before the installation of bilateral grab bars. The MDS C stated there was no copy of consent for the use of grab bars in the chart and in the PCC. The MDS C stated a consent should be obtained before the use of grab bars to ensure that risks and benefits on the use of grab bars were explained to the resident and/or family members and was understood. During an interview on 2/15/2025 at 4:05 pm with the facility's Director of Nursing (DON), the DON stated the least restrictive alternative interventions should have been attempted and failed to meet the needs of the resident before the use of siderails/bedrails or grab bars to prevent the potential of getting caught in between the bed and the rails or bars and to prevent injury to the resident. The DON stated a consent should be obtained before bedrails/siderails or grab bars were installed to ensure the resident/family member and/or responsible parties were informed of the risks and benefits on the use of bedrails/siderails or grab bars. The DON stated bedrails, siderails and grab bars belong to the same category. During a review of the facility's P&P titled, Proper Use of Bed Rails, revised 12/19/2022, the P&P indicated, The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bedrails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion.

Based on observation, interview, and record review, the facility failed to ensure to administer oxygen as ordered and in accordance with the facility's Policy and Procedure (P&P) on oxygen administration for two of two sampled residents (Residents 3 and 193). These failures had the potential to result in adverse consequences for Residents 3 and 193. Findings: a. During a review of Resident 3's Admission Record (AR), the AR indicated Resident 3 was readmitted to the facility on [DATE], with diagnoses that included acute respiratory failure (lung cannot adequately provide oxygen to the body) with hypoxia (low blood oxygen level) and immunodeficiency ( the body's ability to fight infection and other diseases is reduced or absent). During a review of Resident 3's Minimum Data Set (MDS, a resident assessment tool) dated 11/23/2024, the MDS indicated Resident 3 had clear speech, had the ability to understand others and to make self-understood. The MDS indicated Resident 3 was dependent (helper does all the effort) with toileting hygiene, shower, and chair/bed-to-chair transfer. During a review of Resident 3's Order Summary Report (OSR) for 2/2025, the OSR indicated Resident 3 was ordered continuous oxygen at 2 liters (L) per minute via nasal cannula (tube which on one end splits into two prongs, placed in the nostrils to deliver oxygen) to maintain oxygen saturation (the measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) above 92 percent (%). During an observation on 2/14/2025 at 5:51 pm, Resident 3 was sitting in a wheelchair in the hallway outside Resident 3' room. Resident 3 had NC tubing connected to an oxygen tank placed at the back of Resident 3's wheelchair. Resident 3's oxygen was off. During a concurrent interview, Licensed Vocational Nurse 2 (LVN 2) stated, Resident 3 was ordered continues oxygen at 2L per minute. LVN 2 stated, the oxygen for Resident 3 should not be turned off. LVN 3 stated, Resident 3 had history of desaturation (low blood oxygen level) which required licensed staff to administer continues oxygen to Resident 3 to maintain adequate oxygen saturation. LVN 3 stated, licensed nurses should follow the physician's order to provide continues oxygen to Resident 3. 42781 b. During a review of Resident 193's AR, the AR indicated Resident 193 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure (a condition when the lungs cannot get enough oxygen into the blood) with hypoxia and dependence on supplemental oxygen. During a review of Resident 193's OSR dated 1/28/2025, the OSR indicated for licensed staff to administer oxygen via NC at 2L/min, may titrate oxygen to maintain oxygen saturation greater or equal to 92 percent (%) every shift. During a review of Resident 193's MDS dated [DATE], the MDS indicated Resident 193 had intact cognition for daily decision making. The MDS indicated Resident 193 was dependent to staff for toileting hygiene, shower, lower body dressing and putting on/taking off footwear. During an observation in Resident 193's room on 2/14/2025 at 5:35 pm, Resident 193 was awake lying in bed with nasal cannula not placed on both nostrils. During a concurrent observation and interview on 2/14/2025 at 9:48 am, with the facility's Director of Staff and Development (DSD), the DSD stated Resident 193's nasal cannula was not placed in Resident 193's nostrils. The DSD stated, the resident's nasal cannula needed to be inside Resident 193's nostril for the resident to get adequate oxygen as ordered by the physician. The DSD stated, if the nasal prongs were not placed in both nostril, Resident 193 was getting less oxygen and the resident's oxygen saturation will drop. During an interview on 2/15/2024 at 4:04 pm with the facility's Director of Nursing (DON), the DON stated the resident's nasal cannula needed to be inside the resident's nostrils to get the right amount of oxygen needed. During a review of the facility's P&P titled, Oxygen Administration, revised 5/20/2024, the P&P indicated oxygen is administered to residents who need it, consistent with professional standards of practice.

Based on interview and record review, the facility failed to ensure an Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) was discussed and written information was provided to the resident and/or responsible party and a current copy of the AD was in the medical chart for two of two sampled residents (Residents 145 and 5), consistent with the facility's policy and procedure on AD. These failures had the potential for facility staff to provide medical treatment and services against the residents' will. Findings: a. During a review of Resident 145's Admission Record (AR), the AR indicated Resident 145 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control) and congestive heart failure (a heart disorder which causes the heart to not pump efficiently). During a review of Resident 145's Minimum Data Set (MDS, a resident assessment tool) dated 2/14/2025, the MDS indicated Resident 145 had an intact cognition (ability to understand). The MDS indicated Resident 145 required setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating, oral and personal hygiene and dependent with toileting, and shower. During a concurrent interview and record review on 2/14/2025 at 7:30 pm with the Director of Nursing (DON), Resident 145's Physician Orders for Life-Sustaining Treatment (POLST, a form that contains written medical records for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life), dated 2/7/2025, was reviewed. The DON stated, the POLST indicated Resident 145 had no AD. The DON stated, there was no AD Acknowledgement Form to indicate information was provided to Resident 145 and/or his family member/responsible party on his rights to accept or refuse treatment and how to formulate an AD. The DON stated, a copy of AD should be in the resident's chart in case of emergency and for the staff to be able to provide care according to the resident's wishes and preferences. 40037 b. During a review of Resident 5's AR, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included cardiomyopathy (a group of diseases that affect the heart muscle) and epilepsy (a chronic brain disorder characterized by involuntary body movements). During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had an impaired cognition and was dependent (helper does all the effort) with toileting hygiene, shower, and lower body dressing. During an interview on 2/14/2025 at 7:37 pm with Social Service Director (SSD), the SSD stated, Resident 5's AD Acknowledgement Form was completed incorrectly. The SSD stated Resident 5 did not execute an AD, but Resident 5's AD Acknowledgement Form indicated Resident 5 executed an AD. The SSD stated, an AD indicated resident's care and treatment choices, and it was important to follow the residents' wishes. The SSD stated, if the AD Acknowledgment Form was incorrectly completed, the nurses would not know the resident's choices during an emergency. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights Regarding Treatment and Advance Directive, revised 12/19/2022, the P&P indicated The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive.

Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 194) in accordance to facility's policy titled Call Lights: Accessibility and Timely Response. This failure had the potential for Resident 194 not to receive care or receive delayed services to meet the residents' needs and could result in a fall or injury. Findings: During a review of Resident 194's Admission Record (AR), the AR indicated Resident 194 was admitted to the facility on [DATE] with diagnoses that included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and dependence on supplemental oxygen. During a review of Resident 194's Fall Risk Assessment (FRA- method of assessing a patient's likelihood of falling) dated 1/23/2025, the FRA indicated Resident 194 was assessed as high risk for fall due to being chair bound, required the use of assistive devices, took three or more medications and presence of predisposing disease condition. During a review of Resident 194's Care Plan dated 1/24/2025, the Care Plan indicated Resident 194 was at risk for falls related to epilepsy. The Care Plan interventions indicated for nursing staff to anticipate and meet Resident 194's needs and follow facility fall protocol. During a review of Resident 194's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 1/27/2025, the MDS indicated Resident 194 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 194 was dependent (helper does all of the effort) to staff for toileting hygiene, shower, lower body dressing, and putting on/taking off footwear. During a review of Resident 194's Care Plan dated 2/6/2025, the Care Plan indicated Resident 194 had oxygen therapy related to respiratory illness. The Care Plan interventions indicated for the nursing staff to have an agreed method for the resident to call for assistance (e.g., call light, bell.) During a concurrent observation and interview on 2/14/2025 at 5:39 pm, Resident 194 was awake, lying in bed. Resident 194's call light was hanging on the left side of the bed. Resident 194 stated, I could not see my call light. During a concurrent observation and interview on 2/14/2025 at 5:42 pm, with the Director of Staff and Development (DSD), the facility DSD stated Resident 194's call light was hanging on the left side of the bed. The DSD stated Resident 194 could not reach the call light. The DSD stated the resident's call light needed to be within reach at all times so that if Resident 194 needed anything from the staff, Resident 194 could call for assistance. During an interview on 2/15/2025 at 4:05 pm with the facility's Director of Nursing (DON), the DON stated, residents call light needed to be within reach at all times for the residents to use for staff assistance. The facility DON stated the call light was the resident's mode of communication and to maintain resident's safety. During a review of the facility's Policy and Procedure (P&P) titled, Call Lights: Accessibility and Timely Response, dated 12/9/2022, the P&P indicated the facility staff will ensure the resident's call light was within reach of the resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to provide a resident on hemodialysis (a treatment to cleanse the blood of wastes through a machine when the kidneys failed) an emergency kit (E-kit, contains the main items needed in an emergency) at bedside for one of two sampled residents (Resident 15). This failure had the potential for Resident 15 not to receive or received delayed care and treatment for complications caused by unexpected bleeding from the hemodialysis access site. Findings: During a review of Resident 15's Admission Record (AR), the AR indicated Resident 15 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD, irreversible kidney failure) and dependence on hemodialysis. During a review of Resident 15's Care Plan (CP), dated 10/4/2024, the CP indicated Resident 15 needed hemodialysis related to renal failure. The CP goal indicated Resident 15 would have immediate intervention should any signs and symptoms of complications from dialysis occur. During a review of Resident 15's Order Summary Report (OSR) dated 12/17/2024, the OSR indicated Resident 15 had a tunneled catheter (a thin, flexible tube that's inserted into a vein and the tunneled under the skin) hemodialysis access site on the right femoral groin. Resident 15 was scheduled for hemodialysis every Monday, Wednesday and Friday. During a review of Resident 15's Minimum Data Set (MDS, a resident assessment tool) dated 1/8/2025, the MDS indicated Resident 15 had intact cognition (ability to understand). The MDS indicated Resident 15 required setup or clean-up assistance (helper sets up or cleans up, resident completes the activity) with eating and oral hygiene and substantial/maximal assistance (helper did more than half of the effort) with toileting, shower and personal hygiene. During an observation on 2/14/2025 at 5:54 pm with the Minimum Data Set Coordinator (MDS C) inside Resident 15's room, Resident 15 just came back from dialysis treatment. Resident 15 had a tunneled catheter hemodialysis access site on the right femoral groin. The MDS C stated, Resident 15 had no E-kit at bedside. The MDS C stated all dialysis residents needed to have an E-kit at bedside to use in case of bleeding from the hemodialysis access site. During an interview on 2/15/2025 at 4:05 pm with the facility's Director of Nursing (DON), the DON stated all dialysis residents should have an E-kit at bedside for the staff to use to stop and control the bleeding in case bleeding from the hemodialysis access site occurs. During a review of the facility's Policy and Procedure (P&P) titled, Hemodialysis, revised 6/5/2023, the P&P indicated, The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice to include ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices.

Based on observation, interview, and record review, the facility failed to provide resident rooms that measured at least 80 square feet per resident for 12 of 13 multiple resident bedrooms. Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14, did not meet the minimum square footage of 80 square feet per resident. This deficient practice had the potential to result in insufficient space to deliver care and services to the residents, affecting their quality of life. Findings: During an initial tour of the facility on 2/14/2025 from 5:30 pm to 9:00 pm, 12 of 13 resident rooms (Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14) did not meet the minimum requirement of 80 square feet of useable living space per resident in a multiple resident bedroom. The following were observed: For Rooms 1 - 2, four beds were occupied with four residents. For Rooms 3, four beds were occupied with three residents. For room [ROOM NUMBER], three of four beds were occupied with three residents. For room [ROOM NUMBER] - 7, four beds were occupied with four residents. For room [ROOM NUMBER], one of four beds was occupied with one resident. For room [ROOM NUMBER] - 12, four beds was occupied with four residents. For room [ROOM NUMBER], two of four beds were occupied with two residents. The above rooms had sufficient space for the residents and staff to move in and out of the room during delivery of care and there was enough space to store the resident's personal items. The residents in these rooms were able to move their wheelchairs while inside the room. There was enough space for the beds, dresser, closets, and other medical equipment. During an interview on 2/15/2025 at 8:11 am, the facility Administrator (ADM) stated the facility had 12 of 13 resident rooms that did not meet the 80 square feet per resident requirement and will continue to request a room waiver for the 12 rooms (Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14). During a review of the facility's room waiver request dated 2/14/2025, the request indicated the facility was requesting a waiver for Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14. The room waiver request indicated the 12 rooms had four (4) beds to a room and all rooms measure 304 square feet each room. The room waiver request indicated although these rooms do not meet the current Federal requirements, their sizes do not adversely affect the resident's health and safety. The room waiver request indicated the special needs of the resident in these rooms were being met. The room waiver request indicated the rooms allow for adequate space for nursing care, comfort and privacy of the residents and there were sufficient rooms for the resident to maneuver around the rooms and there was enough space to enter and exit the room without hazard and despite the room requirements not being met, the residents care and comfort will not be compromised. The room waiver request indicated the residents were able to keep personal possession in their rooms, the room allowed for adequate space to ensure proper infection control measures and isolation issues of this nature should occur. The room waiver request indicated if a resident status should change, basic medical equipment or appliance such as suction machine, oxygen, intravenous poles, walkers, wheelchairs can be accommodated, and in case the resident required more medical equipment that the room can hold, they will be transferred to a room that will accommodate their needs. The room waiver request indicated the rooms were large enough to allow residents to have visitors, watch television, etc., therefore allowing them non-sleeping hours in their room if they wish. During a review of the Client Accommodations Analysis dated 2/15/2025, the analysis indicated the following: Room Sq. Ft. Beds 1 304 4 2 304 4 3 304 4 4 304 4 6 304 4 7 304 4 8 304 4 9 304 4 10 304 4 11 304 4 12 304 4 14 304 4 During an interview on 2/15/2025 at 1:49 pm with Resident 36 in room [ROOM NUMBER], Resident 36 was able to wheel himself with ease. Resident 36 stated, he had no complaint regarding the room space. During an interview on 2/15/2025 at 1:53 pm with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated, she was able to move wheelchairs, shower chair and Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place) around the rooms with ease. During an interview on 2/15/2025 at 2:46 pm with Resident 8 in room [ROOM NUMBER], Resident 8 was awake and sitting on her wheelchair next to her bed. Resident 8 stated, Resident 8 was able to wheel herself in and out of the room with no concerns or issues. Resident 8 stated the room space was enough for her. During an interview on 2/15/2025 at 2:57 pm with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated the room space was adequate and there were no issues with the staff and residents. LVN 3 stated, LVN 3 was able to provide care and move wheelchairs, walker and Hoyer lifts inside the room with no issues.

Based on interview and record review, the facility failed to follow its policy and procedure on Medication Orders, to prevent significant medication errors (medication errors that causes the resident discomfort or jeopardizes the resident health and safety) for one of three sampled residents (Resident 1) by failing to: 1. Ensure Registered Nurse 1 (RN 1) checked Resident 1's name on the Physician Admission Order (medication list) when she transcribed (to make a written copy)13 of the medication list into the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 entered the medication list that belonged to Resident 2 (another hospice [a special kind of care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness] resident who was not a resident at the facility) into the PCC system for Resident 1. 2. Ensure RN 1 verify Resident 1's Physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, for 4 days (from admission on 5/27/2022 to discharge on 5/31/2022), Resident 1 received 13 medications that were not prescribed to him {1. [MEDICATION(S)] (medication to treat high blood pressure); 2. [MEDICATION(S)] (medication to treat blood pressure); 3 [MEDICATION(S)] (medication to treat high blood sugar) 4. [MEDICATION(S)] (mediation to treat high blood pressure); 5. [MEDICATION(S)] (medication to treat chest pain for [CONDITION(S)]); 6. [MEDICATION(S)] (medication to treat high blood sugar). 7. [MEDICATION(S)] (medication to reduce extra fluid in the body to treat high blood pressure); 8 [MEDICATION(S)] (medication to treat underactive [CONDITION(S)]); 9. [MEDICATION(S)] (medication to treat memory loss); 10. [MEDICATION(S)] (blood thinner); 11. [MEDICATION(S)] (medication to lower the amount of cholesterol in the blood and to prevent stroke and [CONDITION(S)]); 12. FeroSul (an iron supplement to treat or prevent low blood level of iron), 13. Pepcid (medication to prevent and treat heart [CONDITION(S)] and other symptoms caused by too much acid in the stomach)} that were not prescribed for the resident. Resident 1 also did not receive 6 medications that were prescribed for him {1. [MEDICATION(S)] Silver Multivitamin (supplement); 2. [MEDICATION(S)] (medication to treat high blood pressure; 3. Magnesium (supplement); 4. Metamucil (medication to help with bowel movement), 5. [MEDICATION(S)] (medication to treat high blood pressure); 6. Senna (medication to relieve occasional constipation)}. These deficient practices placed Resident 1 at risk to experience adverse side effects (unintended pharmacologic effects that occur when a medication is administered incorrectly) from these significant medication errors. The Department called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, impairment, or death to a resident) situation on 8/3/2022 at 7:21pm, in presence of the Administrator (ADM) and the Director of Nursing (DON). The ADM and DON were informed of the facility's failure to have a system in place to ensure Resident 1 received scheduled and as needed (PRN) medications as prescribed by the resident's Physician. The ADM and the DON were made aware that the deficient practices resulted in potential serious harm that threatened the health and safety for Resident 1 and other potential new admitted residents due to significant medication errors. On 8/4/2022, 4:30 pm the facility submitted an acceptable plan of action (POA, a list of steps taken to correct the deficient practices), and the surveyor verified the implementation of the POA by observation, interview, record review and confirmed the removal of the immediate jeopardy on 8/4/2022 at 6 pm in the presence of the ADM and the DON. The ADM and the DON provided an acceptable plan of action as follows: A. The DON provided a re-education to all licensed nurses regarding admission checklist, verification of physician orders, medication management and medication order policies and procedures emphasizing on verification of residents' name and calling and verifying orders with the attending physician on 8/3/2022. B. On 8/4/2022, the hospice licensed nurses wrote admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . C. On a daily basis, the Licensed Nurse receiving admission will inform the attending Physician of Admission and verify the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . D. On a daily basis, the facility's Interdisciplinary Team (IDT, healthcare team members from different disciplines working together to share knowledge and skills to impact on the resident care) will review new admissions chart to ensure orders are verified true and correct by comparing the list with the transferring order medication listings. Any discrepancy will be reported to the Attending Physician for corrective action. Findings: A review Resident 1's Admission Record indicated the facility admitted the resident on 5/27/2022 from home with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Clinical Admission Evaluation dated 5/27/2022 and timed at 2 pm, indicated Resident 1 was admitted to the facility for respite care (temporary care given to a person who is unable to care for himself or herself so that the usual caregivers can have a break). The evaluation indicated Resident 1 had clear speech, usually understand others, and usually made self-understood. Resident 1 had unsteady gait and was able to move all extremities with no impairment. A review of Resident 1's Baseline Care Plan and Summary dated 5/27/2022 and timed at 2 pm, indicated Resident 1 required set up help only for eating, one-person physical assist for personal hygiene, toilet use, dressing, transfer and walk in room. Resident 1 was alert upon admission. Resident 1 had impaired cognitive status manifested by confusion and forgetfulness. A review of the facility's Order Summary Report dated 5/27/2022, indicated Resident 1 was prescribed: 1. Acetaminophen Suppository (medication to treat mild to moderate pain), 650mg, inserted rectally (insert into the rectum), every 4 hours as needed for pain or temperature greater than 100 Fahrenheit (F). 2. [MEDICATION(S)] tablet (medication to treat anxiety and induce sleep), 5mg, give 1 capsule by mouth at bedtime for inability to sleep. 3. [MEDICATION(S)] [MEDICATION(S)] (HCI, class of medication know as diuretics/water pills), 20mg, give 1 tablet by mouth in the morning for [CONDITION(S)] (hypertension, increased blood pressure). 4. [MEDICATION(S)] Suppository (medication to treat constipation), insert 10mg, rectally every 24 hours as needed for constipation. 5. [MEDICATION(S)] HCI tablet (medication to treat high blood pressure), 0.1mg, give1 tablet by mouth one time a day for hypertension. 6. [MEDICATION(S)] patch 72-hour (medication to treat severe pain), 50mcg/hr (microgram per hour) apply 1 patch transdermal (through skin) in the afternoon every 3 days for pain management. 7. FeroSul tablet 325mg, give 1 tablet by mouth two times a day for [CONDITION(S)] (lack enough healthy red blood cells to carry oxygen to body). 8. [MEDICATION(S)] (medication to treat urinary problem caused by an enlarged prostate), 0.4mg, give 1 capsule by mouth at bedtime for enlarged prostate gland. 9. [MEDICATION(S)] tablet, 5mg, give 1 tablet by mouth one time a day for DM2 (type 2 diabetes mellitus, a chronic condition that affects the way your body metabolizes sugar). 10. [MEDICATION(S)] tablet, 12.5mg, give 1 tablet by mouth in the morning for high blood pressure/fluid retention. 11. [MEDICATION(S)] Sulfate (medication to treat stomach problem such as cramps) tablet 0.125mg give 1 tablet by mouth every 4 hours as needed for increase secretions. 12. Isosorbides [MEDICATION(S)] tablet give 30mg by mouth in the morning for [CONDITION(S)], [MEDICATION(S)] tablet 25mg give 1 tablet by mouth in the morning for DM2. 13. [MEDICATION(S)] tablet 20mg give 1 tablet by mouth in the morning for fluid retention. 14. [MEDICATION(S)] Sodium tablet give 100mg by mouth one time a day for [CONDITION(S)] (a condition where the [CONDITION(S)] doesn't create and release enough [CONDITION(S)] hormone into your bloodstream). 15. [MEDICATION(S)] tablet (medication to treat anxiety), 0.5mg give 1 tablet by mouth every 2 hours as needed for anxiety, [MEDICATION(S)] HCI tablet 5mg give 1 tablet by mouth in the morning for Alzheimer's. 16. [MEDICATION(S)] tablet (mediation to treat moderate to severe pain), 7.5-325 mg, give 1 tablet by mouth every 4 hours as needed for pain. 17. Pepcid Tablet, 20mg, give 1 tablet by mouth two times a day for gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach causing burning sensation). 18. [MEDICATION(S)] tablet, 75mg, give 1 tablet by mouth in the morning for [CONDITION(S)] (DVT, blood clot in a vein) prophylaxis. 19. [MEDICATION(S)] tablet, 40mg, give 1 tablet by mouth at bedtime for [CONDITION(S)] (HLD, too much fat in the blood). 20. [MEDICATION(S)] tablet (medication to prevent nausea and vomiting), 4mg, give 1 tablet by mouth every 8 hours as needed for nausea/vomiting. A review of Hospice Nurse 1 (HN 1's) medication list (List 1) faxed to the facility on [DATE] with fax stamp timed at 3:47pm, indicated Resident 1 was prescribed the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)], 360mg, 1 tab, oral, once daily for Afib ([CONDITION(S)], a type of arrhythmia or abnormal heartbeat); 3. Magnesium, 500mg, 1 tab, oral, once daily for supplement; 4. Metamucil (fiber supplement), 1 table spoon (tsp), oral, once daily for laxative; 5. [MEDICATION(S)] 7.5mg/325mg, 1 tab, oral, every 4 hours as needed for pain; 6. [MEDICATION(S)], 40mg, 1 tab, oral, twice a day for hypertension; 7. Senna, 8.6mg, 2 tablets, orally daily for prevent constipation; 8. [MEDICATION(S)], 0.4mg, 1 capsule, oral, daily for BPH; 9. [MEDICATION(S)] Advance (medication to treat diarrhea), 2mg-125mg, 2mg 1-2 tablets, oral, for diarrhea; 10. [MEDICATION(S)] 50mcg/hr, transdermal (through skin) patch, 50mcg film ER (extended release), every 72 hours for pain; 11. [MEDICATION(S)], 5mg, 1 tablet, oral, once daily at bedtime as needed for [CONDITION(S)] (difficulty sleep); 12. [MEDICATION(S)]'s [MEDICATION(S)] and [MEDICATION(S)] Sulfate 0.5mg/3mg/3ml, 1 unit, via mask, every 4 hours as needed for shortness of breath/wheezing (breathing with a whistling or rattling sound in the chest)/congestion; 13. [MEDICATION(S)] ([MEDICATION(S)]), 0.5mg, 1 tablet, oral, every 2 hours as needed for anxiety/dyspnea (difficulty breathing). A review of the facility's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 4 doses of [MEDICATION(S)], 20 milligrams (mg, unit of measurement). 2. 4 doses of [MEDICATION(S)], 0.1mg. 3. 4 doses of [MEDICATION(S)], 5mg. 4. 4 doses of [MEDICATION(S)], 12.5mg. 5. 4 doses of [MEDICATION(S)], 30mg. 6. 4 doses of [MEDICATION(S)], 25mg. 7. 4 doses of [MEDICATION(S)], 20mg. 8. 4 doses of [MEDICATION(S)], 100mg. 9. 4 doses of [MEDICATION(S)], 5mg. 10. 4 doses of [MEDICATION(S)], 75mg. 11. 4 doses of [MEDICATION(S)], 40mg. 12. 8 doses of FeroSul, 325mg. 13. 8 does of Pepcid, 20mg. 14. 4 doses of [MEDICATION(S)], 5mg. 15. 4 doses of [MEDICATION(S)], 0.4mg. 16. 11 doses of [MEDICATION(S)], 0.5mg as needed for anxiety. 17. 9 doses of [MEDICATION(S)] 7.5-325mg as needed for pain. 15. 1 patch of [MEDICATION(S)] Patch 72-hour 50mcg/hour (hr) on 5/28/2022. A review of Resident 1's closed medical record (paper pack) provided by the DON on 8/3/22, there was Resident 2's medication list (list 2) inside Resident 1's closed medical record. A review of List 2 indicated Resident 2 was prescribed: 1. Acetaminophen Suppository, 650mg, inserted rectally, every 4 hours as needed for pain/temperature greater than 100 Fahrenheit (F); 2. [MEDICATION(S)] tablet, 5mg, 1 capsule, oral, at bedtime for [CONDITION(S)]; 3. [MEDICATION(S)] HCI, 20mg, 1 tablet, oral, twice daily for hypertension, increased blood pressure; 4. [MEDICATION(S)] Suppository, 10mg, insert rectally, 1 daily if no bowel movement for 3 days every 24 hours as needed for constipation; 5. [MEDICATION(S)] tablet, 0.1mg, 1 tablet oral, one time a day for hypertension; 6. Ferosul, tablet 325mg, 1 tablet by mouth, two times a day for supplement; 7. [MEDICATION(S)], 0.4mg, 1 capsule, oral, daily for enlarged prostate gland; 8. [MEDICATION(S)] tablet, 5mg, 1 tablet, oral, daily for [CONDITION(S)] (increased blood sugar); 9. [MEDICATION(S)], 12.5mg, 1 tablet, oral, daily for fluid retention; 10. [MEDICATION(S)], 0.125mg, 1 tablet, oral/sublingual (under tongue,) every 4 hours as needed for increase secretions; 11. Isosorbides [MEDICATION(S)], 30mg ER (extended release), 1 tablet, oral, daily for hypertension; 12, [MEDICATION(S)], 25mg, 1 tablet, oral, daily for [CONDITION(S)]; 13. [MEDICATION(S)], 20mg, 1 tablet, oral, daily for fluid retention; 14. [MEDICATION(S)], 100mcg, 1 tablet, oral, daily for [CONDITION(S)] (a condition where the [CONDITION(S)] doesn't create and release enough [CONDITION(S)] hormone into your bloodstream); 15. [MEDICATION(S)] ([MEDICATION(S)]) 0.5mg 1 tablet oral every 2 hours as needed for anxiety/shortness of breath); 16. [MEDICATION(S)] HCI 5mg tablet 1 tablet oral daily for Alzheimer's (a brain disorder that slowly destroys memory and thinking skills); 17. Pepcid, 20mg, 1 tablet, oral, two times a day for GERD (gastroesophageal reflux disease, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach causing burning sensation); 18. [MEDICATION(S)], 75mg, 1 tablet, oral, daily for anticoagulant (medicines that help prevent blood clots); 19. [MEDICATION(S)], 40mg, 1 tablet, oral, daily for HLD ([CONDITION(S)], too much fat in the blood); 20. [MEDICATION(S)], 4mg, 1 tablet, oral, 8 hours as needed for nausea/vomiting; 21. [MEDICATION(S)] [MEDICATION(S)] and [MEDICATION(S)] Sulfate 0.5mg/3mg/3ml, 1 unit, via mask, every 4 hours as needed for shortness of breath/wheezing (breathing with a whistling or rattling sound in the chest)/congestion; 22. [MEDICATION(S)] Sulfate IR (immediate release) 20mg/ml 0.25ml oral every 2 hours as needed for breakthrough pain/short of breath). During an interview on 8/3/2022 at 11:20 am, Licensed Vocational Nurse 2 (LVN 2) stated she was taking care of two hospice residents on 8/3/2022. LVN 2 stated when hospice transferring a resident to the facility, hospice nurse would come to the facility upon admission and hand over the resident's medication list to the facility's nurses. LVN 2 stated if the hospice nurses were not at the facility, they would fax the resident's medication list to the facility. The facility's admission nurse would enter the resident's medication list into the facility's PCC system after checking the lists for accuracy. LVN 2 stated if the facility staff had a question about the medication list, they needed to call the hospice physician for clarification. LVN 2 stated if the facility's staff did not have a concern, staff would not call the hospice physician to verify the Physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/3/2022 at 11:40am, RN 1 stated upon admitting a hospice resident to the facility, the facility staff would review the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated the facility's staff would page the hospice physician to verify the orders. RN 1 stated staff would verify order before administering any medications. RN 1 stated if the hospice nurse onsite upon resident's admission and gave the medication list to facility's staff in person, facility's staff would just verify order with the hospice nurse onsite without calling the hospice physician for verification. RN 1 stated she was working on 5/27/2022 when Resident 1 was admitted to the facility. RN 1 stated HN 1 was onsite in the facility to admit Resident 1. RN 1 stated HN 1 handed her some papers including a medication list (list 2), HN 1 told RN 1 don't worry, our pharmacy will send you medications. During an interview and concurrent review of Resident 1's closed record on 8/3/2022, at 12:50 pm, the DON stated HN 1 was at the facility when Resident 1 was admitted on [DATE] around 2 pm. The DON stated HN 1 provided the facility a medication list (List 2) for Resident 1. A concurrent review of medication list 2 indicated List 2 had Resident 2's name on it. The DON stated RN 1 did not check the resident's name (Resident 2) on List 2 and transcribed medications on List 2 into the facility's PCC system under Resident 1's. The DON pointed at List 2 and stated, this list did not belong to Resident 1, it was Resident 2's medication list. The DON stated, we made a mistake here, my nurse (RN 1) did not check the resident's name on the medication list from hospice nurse before entering medications from the list into the facility's PCC system. The DON stated the wrong medications were given to Resident 1 during his 4 days stay in this facility. The DON stated after receiving any medication order, nurses need check the order for the resident's name, birthday, and allergies. During an interview and concurrent review of Resident 2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated HN 1 handed over preprinted medication list (List 2) for Resident 1. RN 1 stated she did not realize the medication list (List 2) received from HN 1 belonged to Resident 2. RN 1 pointed at List 2 and stated it was the medication list she received from HN 1 for Resident 1 with Resident 2's name. RN 1 stated she did not check the resident name on List 2 when HN 1 handed to her and before transcribing the orders into the facility's PCC system. RN 1 stated she entered the medications on that list one by one into the facility's PCC system under Resident 1 name. RN 1 stated admitting nurse should verify resident's name while transcribing medications to prevent medication errors. RN 1 stated even though HN 1 provided a medication list with the wrong name, she was responsible to double check the names to pick up the errors. RN 1 stated Resident 1 did not receive part of his own medications, instead, Resident 1 received medications that were prescribed to Resident 2 for 4 consecutive days from admission to discharge (5/27/2022 to 5/31/2022). RN 1 stated Resident 1 did not have diabetes (chronic disease that cause abnormal blood sugar) but was administered anti-diabetic medications to lower blood sugar level, this could cause Resident 1's sugar to be too low, RN 1 stated this was very dangerous. During an interview on 8/3/2022 at 4:42 pm with the ADM and the DON, the DON stated all medication orders (telephone orders or paper orders) needed to be verified with the prescribing physician. The DON stated when in doubt, staff should clarify the orders with the physician. A review of the facility's policy and procedure, titled Medication Orders, updated in August 2019, indicated The prescriber is contacted to verify or clarify an order.

Based on interview and record review, the facility failed to immediately notify the resident's physician and resident's family representative after one of 29 sampled residents (Resident 47) sustained an unwitnessed fall that occurred on 10/26/21, which resulted in the resident to experience severe pain, and a delay in timely treatment after twelve (12) hours. As a result, Resident 47 was transferred to the GACH (General Acute Care Hospital) where an x-ray (a photographic or digital image) report, indicated the resident had a comminuted (the bone breaks into several pieces) intertrochanteric fracture (breaks of the femur between the greater and the lesser trochanters [overhang toward the near end of the thighbone]). On 10/28/21, (two days after the resident fell ) the resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] Cross Reference F689 Findings: A review of Resident 47's Admission Record, indicated, the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 47's Care Plan, dated 9/8/2021, indicated the resident was at risk for falls related to gait/balance problems. The care plan interventions included to anticipate and meet resident's needs and to follow facility fall protocol. A review of Resident 47's Care Plan, dated 9/9/2021, indicated the resident had behavior problem of standing, transferring, and walking without asking for assistance. The care plan interventions included to anticipate and meet the resident's needs. A review of Resident 47's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/5/2021, indicated, Resident 47 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident 47 required limited assistance with one-person physical assist for toileting. The MDS indicated Resident 47 was assessed not steady and only able to stabilize with staff assistance moving on and off toilet and moving from seated to standing position. The MDS indicated Resident 47 was assessed needing to use a walker and wheelchair for mobility. A review of Resident 47's Fall Assessment, dated 10/18/21, indicated Resident 47 was assessed being at risk for falls due to intermittent confusion, balance problem while standing and walking and use of assistive device (walker/wheelchair). A review of Resident 47's untimed Situation Background Appearance Review and notify (SBAR) form, completed by Licensed Vocational Nurse 5 (LVN 5) and dated 10/27/2021 indicated the resident complained of severe pain on her left hip. Resident 47 told LVN 5 she was in pain because she fell in the resident's restroom. LVN 5 noted left hip swelling on Resident 47 and very tender to touch. LVN 5 notified the physician on 10/27/21 and the physician ordered to send Resident 47 to the GACH Emergency Department for further evaluation and possible treatment. A review of Resident 47's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 47's Transfer Form dated 10/27/2021, timed at 4:40 am, indicated the resident was transferred to GACH due to uncontrolled pain. A review of Resident 47's GACH Emergency Department (ED) Visit Summary General assessment dated [DATE] at 5:30 am, indicated Resident 1 had limited range of motion (ROM, refers to how far a person can move or stretch a part of the body, such as a joint or a muscle), of the left hip and the left lower leg was shorter than the right lower leg. A review of Resident 47's GACH ED Hip/Pelvis X-ray (a photographic or digital image) report, dated 10/27/2021, timed at 5:50 am, indicated Resident 1 had a comminuted (the bone breaks into several pieces) intertrochanteric fracture (breaks of the femur between the greater and the lesser trochanters [overhang toward the near end of the thighbone]) on the left was seen. A review of Resident 47's GACH History and Physical dictated on 10/27/21 at 10:03 p.m., indicated the resident had multiple medical problems and the facility sent the resident to GACH secondary to a mechanical fall (an external force caused the resident to fall). The resident was found to have left hip intertrochanteric fracture. A review of Resident 47's GACH Operative Report dictated on 10/28/2021 at 3:11 pm indicated the resident had treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's untimed investigation report of Resident 47's fall incident, dated 11/3/2021, indicated on 10/26/2021 at 4:30 pm, CNA 1 and Resident 47 were in the resident's restroom. The report indicated CNA 1 stepped out of the resident's restroom to retrieve a shower chair and upon her return, CNA 1 found Resident 47 sitting on the floor in the restroom. The report indicated CNA 1 immediately reported to the licensed nurse (unidentified) and the licensed nurse (unidentified) assessed Resident 47. The report indicated on 10/27/2021 at 4:30 am 12 hours after the resident was found on the floor, Resident 47 complained of pain on her left hip, had swelling and tenderness to touch. Pain medication (unidentified) was administered to Resident 47. The physician and Resident 47's representative were notified. The physician ordered to transfer Resident 47 to the GACH for further evaluation. Resident 47 was transferred to the GACH and was found to have a fracture. A review of Resident 47's clinical record did not indicate LVN 1 documented the resident's unwitnessed fall on 10/26/2021 at 4:30 pm Resident 47's clinical record did not indicate LVN 1 documented an assessment (unidentified) was done to the resident after the unwitnessed fall on 10/26/21. Resident 47's clinical record did not indicate LVN 1 reported Resident 47's unwitnessed fall on 10/26/2021 to the DON and Administrator as soon it was discovered. Resident 47's clinical record did not indicate LVN 1 notified the resident's physician and the resident's family representative. This information was confirmed with the DON and LVN 1. During an interview on 10/27/2021 at 8:50 am Registered Nurse 1 (RN 1), stated Resident 47 fell inside the resident's restroom on 10/26/21 at 4:30 pm, and was transferred to the GACH on 10/27/21 at 4:40 am for an evaluation. During an interview on 10/28/2021 at 1 pm, the facility's Director of Nursing (DON) stated CNA 1 reported Resident 47's fall to Licensed Vocational Nurse 1 (LVN 1) on 10/26/21 at 4:30 pm, but LVN 1 did not document the fall incident in Resident 47's clinical record. During a phone interview on 10/28/2021 at 1:45 pm, LVN 1 stated on 10/26/21 at approximately 4:30 pm, CNA 1 asked him and LVN 2 to accompany her to Resident 47's room and they found Resident 47 sitting on the floor in the resident's restroom. LVN 1 stated LVN 2 and himself assisted Resident 47 from the floor to the shower chair. LVN 1 stated CNA 1 wheeled Resident 47 to the shower room and showered the resident. LVN 1 stated Resident 47's fall was unwitnessed, and the resident was by herself in the restroom when she fell . LVN 1 stated he was responsible for Resident 47's care and was supposed to document Resident 47's unwitnessed fall on 10/26/2021. LVN 1 stated he failed to notify the physician of Resident 47's unwitnessed fall. LVN 1 stated he failed to notify Resident 47's family representative after the unwitnessed fall on 10/26/21. LVN 1 stated he failed to notify the Administrator or the DON of Resident 47's unwitnessed fall on 10/26/2021 as soon as the fall was discovered. During an interview on 10/28/2021 at 4:20 pm, the DON stated LVN 1 who was assigned to Resident 47 was supposed to assess the resident after the resident fell on [DATE] at 4:30 pm, complete an incident report, document the fall incident in the resident's clinical record and notify the physician and the resident's family representative about the fall. During an interview on 10/28/2021 at 4:32 pm, LVN 2 stated on 10/26/2021, CNA 1 called him and LVN 1 to accompany her to Resident 47's room and they found Resident 47 sitting on the resident restroom's floor with the resident's back against the wall. LVN 2 stated he assisted LVN 1 to pick up Resident 47 off the floor and into the shower chair. LVN 2 stated Resident 47 was unsteady and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 2 stated after a fall incident, licensed nurses (in general) needed to call the RN Supervisor to assess the resident, and to notify the physician and the resident's representative about the fall. LVN 2 stated licensed nurses should notify the Administrator and the DON regarding the resident's fall and document the fall incident in the resident's clinical record. LVN 2 stated after a fall incident, licensed nurses (in general) needed to call the RN Supervisor to assess the resident, and to notify the physician and the resident's representative about the fall. LVN 2 stated licensed nurses should notify the Administrator and the DON regarding the resident's fall and document the fall incident in the resident's clinical record. A review of the facility's policy and procedure titled, Accidents and Incidents-Investigating and Reporting, revised on 4/16, indicated, regardless of how minor an accident or incident may be, it must be reported to the DON and Administrator as soon as an accident or incident is discovered or when information of an accident/incident is learned. The physician and the resident representative will be notified as soon as possible. The licensed nurse shall examine the resident and document the findings on the Incident/Accident Report form; conduct a neurological assessment of resident who had an unwitnessed fall. The licensed nurse will document information regarding the accident or incident in the licensed nurse's progress notes. A review of the facility's policy and procedure, titled, Change in a Resident's Condition or Status, revised 1/12, indicated, the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status. The nurse supervisor/charge nurse will notify the physician and the resident's representative of any accident or incident involving the resident. The nurse supervisor/charge nurse will document in the resident's medical record the information relative to changes in the resident's medical/mental condition. Assessment related to the change in condition will be documented for 72 hours unless the condition requires continued documentation or the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to provide supervision with toileting (how a resident uses the toilet room) to prevent one of 29 sampled residents (Resident 47) from sustaining an unwitnessed fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force). Resident 47 was at risk for falls due to intermittent confusion (not being able to think clearly or quickly, feeling disorientated, and struggling to pay attention, make decisions), balance problems while standing and walking, and required limited assistance (resident highly involved in activity, staff to provide guided maneuvering of limbs or other non-weight bearing assistance) with toileting. On 10/26/2021 at 4:30 pm, Certified Nursing Assistant 1 (CNA 1) left Resident 1 inside Resident 1's restroom unsupervised sitting on the toilet by herself while CNA 1 went to grab a shower chair (waterproof wheelchair). CNA 1 found Resident 47 sitting on the floor inside the resident's restroom upon her return. This deficient practice resulted for Resident 47 to sustain an unwitnessed fall and was transferred to a General Acute Care Hospital (GACH) on 10/27/2021 at 4:40 am and resulted for Resident 47 to sustain a fracture (break in the bone) of the femur (upper bone of the leg) and underwent surgery using intermediate nail device (metal is inserted into the bone and across the fracture to provide a solid support for the fractured bone) on 10/28/2021. Cross Reference F580 Findings: A review of Resident 47's Admission Record, indicated, the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including [CONDITION(S)] (medical condition in which a person's kidneys cease functioning on a permanent basis), need for assistance with personal care and abnormalities of gait (manner of walking) and mobility (ability to move). A review of Resident 47's Care Plan, dated 9/8/2021, indicated the resident was at risk for falls related to gait/balance problems. The care plan interventions included to anticipate and meet resident's needs and to follow facility fall protocol. A review of Resident 47's Care Plan, dated 9/9/2021, indicated the resident had behavior problem of standing, transferring, and walking without asking for assistance. The care plan interventions included to anticipate and meet the resident's needs. A review of Resident 47's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/5/2021, indicated, Resident 47 was assessed with severely impaired cognition (ability to understand). The MDS indicated Resident 47 required limited assistance with one-person physical assist for toileting. The MDS indicated Resident 47 was assessed not steady and only able to stabilize with staff assistance moving on and off toilet and moving from seated to standing position. The MDS indicated Resident 47 was assessed needing to use a walker and wheelchair for mobility. A review of Resident 47's Fall Assessment, dated 10/18/21, indicated Resident 47 was assessed being at risk for falls due to intermittent confusion, balance problem while standing and walking and use of assistive device (walker/wheelchair). A review of Resident 47's untimed Situation Background Appearance Review and notify (SBAR) form, completed by Licensed Vocational Nurse 5 (LVN 5) and dated 10/27/2021 indicated the resident complained of severe pain (disabling; unable to perform daily living activities) on her left hip. Resident 47 told LVN 5 she was in pain because she fell in the resident's restroom. LVN 5 noted left hip swelling on Resident 47 and very tender to touch. LVN 5 notified the physician on 10/27/21 and the physician ordered to send Resident 47 to the GACH Emergency Department for further evaluation and possible treatment. A review of Resident 47's Physician's Order dated 10/27/2021, timed at 4:12 am, indicated to transfer the resident to GACH for further evaluation after a fall. A review of Resident 47's Transfer Form dated 10/27/2021, timed at 4:40 am, indicated the resident was transferred to GACH due to uncontrolled pain (unidentified pain level). A review of Resident 47's GACH Emergency Department (ED) Visit Summary General assessment dated [DATE] at 5:30 am, indicated Resident 1 had limited range of motion (ROM, refers to how far a person can move or stretch a part of the body, such as a joint or a muscle), of the left hip and the left lower leg was shorter than the right lower leg. A review of Resident 47's GACH ED Hip/Pelvis X-ray (a photographic or digital image) report, dated 10/27/2021, timed at 5:50 am, indicated Resident 1 had a comminuted (the bone breaks into several pieces) intertrochanteric fracture (breaks of the femur between the greater and the lesser trochanters [overhang toward the near end of the thighbone]) on the left was seen. A review of Resident 47's GACH History and Physical dictated on 10/27/21 at 10:03 p.m., indicated the resident had multiple medical problems and the facility sent the resident to GACH secondary to a mechanical fall (an external force caused the resident to fall). The resident was found to have left hip intertrochanteric fracture. A review of Resident 47's GACH Operative Report, dictated on 10/28/2021 at 3:11 pm indicated the resident had treatment of left intertrochanteric femur fracture using intermediate nail device on 10/28/21. A review of the facility's untimed investigation report of Resident 47's fall incident, dated 11/3/2021, indicated on 10/26/2021 at 4:30 pm, CNA 1 and Resident 47 were in the resident's restroom. The report indicated CNA 1 stepped out of the resident's restroom to retrieve a shower chair and upon her return, CNA 1 found Resident 47 sitting on the floor in the restroom. The report indicated CNA 1 immediately reported to the licensed nurse (unidentified) and the licensed nurse (unidentified) assessed Resident 47. The report indicated on 10/27/2021 at 4:30 am 12 hours after the resident was found on the floor, Resident 47 complained of pain on her left hip, had swelling and tenderness to touch. Pain medication (unidentified pain relief medication) was administered to Resident 47. The physician and Resident 47's representative were notified. The physician ordered to transfer Resident 47 to the GACH for further evaluation. Resident 47 was transferred to the GACH and was found to have a fracture. During an interview on 10/27/2021 at 8:50 am Registered Nurse 1 (RN 1), stated Resident 47 fell inside the resident's restroom on 10/26/21 at 4:30 pm, and was transferred to the GACH on 10/27/21 at 4:40 am for an evaluation. During an interview on 10/28/2021 at 1 pm, the facility's Director of Nursing (DON) stated CNA 1 reported Resident 47's fall to Licensed Vocational Nurse 1 (LVN 1) on 10/26/21 at 4:30 pm, but LVN 1 did not document the fall incident in Resident 47's clinical record. During a phone interview on 10/28/2021 at 1:45 pm, LVN 1 stated on 10/26/21 at approximately 4:30 pm, CNA 1 asked him and LVN 2 to accompany her to Resident 47's room and they found Resident 47 sitting on the floor in the resident's restroom. LVN 1 stated LVN 2 and himself assisted Resident 47 from the floor to the shower chair. LVN 1 stated CNA 1 wheeled Resident 47 to the shower room and showered the resident. LVN 1 stated Resident 47's fall was unwitnessed, and the resident was by herself in the restroom when she fell . During an interview on 10/28/2021 at 4:20 pm, the DON stated according to CNA 1's statement, she left Resident 47 sitting on the toilet by herself to get the shower chair. The DON stated it was not safe for CNA 1 to leave Resident 47 on the toilet by herself because the resident had episodes of confusion and occasionally got up by herself without assistance. During an interview on 10/28/2021 at 4:32 pm, LVN 2 stated on 10/26/2021, CNA 1 called him and LVN 1 to accompany her to Resident 47's room and they found Resident 47 sitting on the resident restroom's floor with the resident's back against the wall. LVN 2 stated he assisted LVN 1 to pick up Resident 47 off the floor and into the shower chair. LVN 2 stated Resident 47 was unsteady and had a history of getting out of her wheelchair without assistance. On 10/28/2021 at 2 pm and at 3:15 pm, the Surveyor tried to contact CNA1 by telephone, but CNA1 did not answer the call. A review the facility's Policy and Procedure titled Accident and Incident Prevention, dated 5/24/2021 indicated the facility will have a Safety Training program to prevent accidents and incidents and eliminate preventable occurrences, practices, or systems, which negatively impact residents and/or resident care and environment hazards over which the facility has control over. Any fall risk factor identified will be addressed with interventions that will be documented on the resident's plan of care. A review of the facility's Policy and Procedure titled Fall Risk Assessment, revised 3/2018 indicated staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. A review of the facility's Assessing Falls and their Causes policy and procedure with a revised date of March 2018 indicated the following: 1.If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2.Obtain and record vital signs as soon as it is safe to do so. 3.If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. 4.If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. 5.Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. 6.When a fall does not result in significant injury or a condition change, notify the practitioner routinely (e.g., by fax or by phone the next office day). Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing. The same policy indicated Identifying Causes of a Fall or Fall Risk were the following: 1.Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident, refer to resident specific evidence including medical history, known functional impairments, etc, 2. Evaluate chains of events or circumstances preceding a recent fall, including: a. Time of day of the fall. b. Time of the last meal. c. What the resident was doing. d. Whether the resident was standing, walking, reaching, or transferring from one position to another. e. Whether the resident was among other persons or alone. f. Whether the resident was trying to get to the toilet. g. Whether any environmental risk factors were involved. h. Whether there is a pattern of falls for this resident. 3.Continue to collect and evaluate information until the cause of falling is identified or it is determined that cause cannot be found. 4.Consult with the attending physician or medical director to confirm specific causes from among multiple possibilities, When possible, document the basis for identifying specific factors as the cause, 5.If the cause is unknown but no additional evaluation is done, the physician or nursing staff should note why (e.g., workup already done, finding a cause would not change the approach, etc.). A review of the same policy and procedure indicated the Performing a Post-Fall Evaluation were the following: After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results of this effort.

Based on interviews, record reviews and observations the facility failed to maintain an infection prevention and control program (IPCP) to include these elements: 1). ) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted and following accepted national standards. 2). A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. 3). Maintain an infection prevention and control program designed to provide a safe, and sanitary practices to help prevent the development and transmission of communicable diseases and infections. The facilities failed IPCP practices was evident by: 1). On 7/21/2020-7/22/2020 surveyor identified the facility failed to identify three dietary staff that were COVID-19 positive since June 2020. As a result the positive COVID-19 test data was not reported to the Federal, State, and Public Health Department. 2). The facility also failed to conduct infection control surveillance for June and July until requested on 7/21/2020. In addition March 2020, April 2020, and May 2020 infection control surveillance were incomplete. The facility failed to identify patients and contagious disease in order to prevent potential outbreaks or the transmission of infectious diseases. Currently the facility has five residents and undetermined number of employees who are COVID 19 positive. The entire census of 41 residents have been expose to COVID 19 and are under droplet precautions. 3). Multiple direct care staff failed to use PPE appropriately per Center for Disease Control (CDC) guidelines by not changing gowns, gloves, and wash hands between patients who are on droplet precaution. Findings include: 1). During the Kitchen tour on 07/21/2020 at 11:00 AM interviewed Dietary Staff #11 while questioning her about the sick call process, she mentioned the three dietary staff member who were out sick with Coronavirus Disease COVID 19. On 07/21/2020 at 11:45 AM interview conducted with Admin Staff #1 when asked about the total number of staff that were COVID 19 positive in the facility she indicated, Two. When questioned about the dietary staff she indicated, None. Surveyor informed her of the three dietary staff that were tested positive with COVID 19, she stated, According to her data the facility currently only have two nursing staff members out sick with COVID 19. On 07/21/2020 at 11:50 PM conducted a phone interview with the Infection Preventions Nurse (IPN) Staff 7, she indicated being out sick with a fever and cough today and was feeling sick at home Saturday (07/18/20) and Sunday (07/19/20). She stated her completed infection control work was in the infection control binder. When inquired where about the June and July infection control data were placed she stated, All I have is what you see in the infection control binder. Surveyor informed her that June and July data was not in the binder she replied, I do not know. When I questioned her about March, April, and May 2020 infection control data being incomplete she again replied, I do not know. When questioned if she was aware of the three dietary staff with COVID-19 + test results she stated, NO. On 07/21/2020 at 12:30 PM interview conducted concurrent with record review with Admin Staff 2 she indicated the nursing and administration leadership team were not aware of the three dietary staff with positive COVID-19 results and will do an investigation promptly. Admin Staff 2 acknowledged, not knowing all employees with positive COVID-19 results can contribute to the spread of the infections among residents and employees. Admin staff indicated the IPN Staff 7 usually collects and enter all the infection control data in the surveillance log and she was not able to locate any infection control report data for June and July. Admin Staff #2 confirmed although she provides oversight for the IPN Staff 7, she was not aware of the Infection Control Surveillance Log missing data for June and July. On 07/21/2020 at 1:30 PM interview conducted with Admin Staff 3, he further confirmed the facility leadership were not aware of the COVID 19 positive dietary staff. He stated, the Dietary Manager (DM) Staff 5 informed him of the COVID-19 results on 07/21/2020. Admin Staff 3 explained the COVID-19 positive results data are reported weekly and daily per CDC guidelines. He confirmed the information he reported for the past few weeks were inaccurate because he had no prior knowledge of the three dietary staff positive results. Admin Staff 3 acknowledged, not knowing all employees with positive COVID-19 results can contribute to the spread of the infections among residents and employees. Admin Staff 3 stated he is very concern and will conduct an investigation promptly and provide a narrative to surveyor. Additional Admin Staff 3 stated he will also contact the Department of Health and State to report the dietary staff COVID-19 positive results. Conducted a second interview concurrent with record review on 07/24/2020 with Admin Staff 3, he confirmed the COVID-19 and Respiratory Outbreak Line List for LTC, staff COVID-19 positive results began on or near June 20, 2020. The residents COVID-19 positive results began on or near July 3, 2020. Since the start of the pandemic the facilities final count for COVID-19 positive are at 12 residents and 13 staff members. During a 2nd interview on 07/23/20 at 11:45 AM with Admin Staff 2 she confirmed not being aware of the dietary staff COVID-19 positive results until surveyor requested information on 07/21/2020. Additionally she indicated being in the process of completing all the March - July infection control surveillance data. Admin Staff 2 further explained, the facility expectation is for license staff and IPN Staff 7 to collect data and log the information daily in the infection control surveillance log. Admin Staff 2 stated she cannot explain why the infection control surveillance information was not documented for June/July and incomplete for March, April and May 2020. During a 2nd telephonic interview on 07/22/2020 at 4:40 PM with IPN Staff 7, she acknowledged not completing the surveillance log per policy. She explained that she had been extremely busy with the COVID 19 positive cases in the facility and failed to complete the data. IPN Staff 7 stated, I am trying to get someone to bring me the books at home and will complete the infection control surveillance log immediately. On 07/23/2020 at 3:00 PM interview conducted with DM Staff 5 she acknowledged being aware of a staff with COVID-19 positive exposure on June 23, 2020. On June 29, 2020 the dietary staff began to experience COVID-19 like symptoms and was tested along with another relative dietary staff. On July 1, 2020 both dietary staff reported a positive COVID-19 test result. The other one dietary staff received her COVID-19 test result on July 2, 2020. DM Staff 7 stated, I reported the dietary staff COVID-19 symptom concerns on June 29, 2020 and the positive test results on July 1 and 2, 2020 to the corporate manager. The corporate manger said he would communicate with the facility administrator. This is the process always. If I have a problem I report it to the corporate office manager and he talks to the administrator. DM staff 7 further explained, I know how contagious COVID-19 is, that why I reported the information immediately to the corporate office manager and he was supposed to call the administrator. When questioned about when she communicated with the facility administrator regarding the three staff that tested COVID-19 positive, she stated, Tuesday July 21, 2020. 2). During a medication administration observation on 07/21/2020 at 12:10 AM LVN Staff 8 observed performing blood glucose test for three residents and administering insulin to one resident. LVN Staff 8 did not wash her hands between the three residents on droplet precaution isolation. LVN Staff 8 acknowledged not washing her hands between resident was not appropriate infection control practice and can contribute to the spread of infections. 3). During the dinning observation on 07/21/2020 at 12:15 PM C.N.A Staff 9 observed delivering trays to six residents on droplet precaution isolation. C.N.A Staff 9 observed setting up the bedside tables, turning and repositioning the residents. C.N.A Staff 9 did not changed his gloves and gown between the six residents. The DON was present in the hall way when she also witnessed the concerns with C.N.A Staff 9 infection control practices. DON intervened and educated C.N.A Staff 9 promptly. C.N.A Staff 9 acknowledged using improper infection control practices with proper use of Personal Protective Equipment (PPE). On 07/21/2020 1:15 PM with Admin Staff 2 she acknowledged LVN Staff 8 and C.N.A Staff 9 used improper infection control practices per policy. She stated, I will retrain the all staff immediately. She further explained the facility expectation is for hand washing between all residents when doing blood glucose monitoring. She provided evidence of the staff in-service with the use of PPE and hand washing practices. On 07/23/2020 reviewed the facility policy titled Infection Control and it revealed: 1). Outcome Surveillance Examples: Collection of sign and symptoms as well as laboratory data and comparing to standard written definitions (criteria) of infections. Review data to detect clusters and trends Review of antibiotics orders and laboratory antibiograms Review newly admitted residents Tracking of prevalence of infections monthly Reporting communicable disease according to the local State and Federal requirements. 2). Standard Precaution: Hand Hygiene - Before and after resident contact and personal care Gloves - Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Wash Hands immediately to avoid transfer of microorganisms to other residents or environments. Hand Washing - Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after performing invasive procedure (finger stick blood sampling) Before and after entering an isolation precaution setting. Before and after assisting a resident with meals On 07/23/2020 reviewed the facility policy title Temporary Updates to Sick Employee Policy- COVID 19 updated on 3/11/2020 and it revealed: Employees are encouraged to notify their supervisor and stay home if they are sick. Notify us if you develop respiratory symptoms while at work. All employees will be required to have their temperature checked when entering the facility and be required to use hand sanitizer or wash their hands when entering or leaving the facility Practice proper hand washing hygiene. On 07/23/2020 reviewed the dietary contractor infection control policy titled Infection Control Policy and Overview and it revealed: Investigate, Control and prevent infections in the facility Maintain a record of incidents and corrective action plans related to infections by reporting incidents through the facility proper chain of command.

Based on observations, interviews, and record reviews, the facility failed to thoroughly assess and treat 1 of 5 sample residents (Resident 1), for the presence of skin rashes and itching. Resident 1 was found to have scabies (a condition of very itchy skin caused by tiny mites that burrow into the skin which is easily spread from person to person by close contact, touching one's skin, sharing towels, linens, clothing and other personal items). This deficient practice prolonged Resident 1's discomfort due to a scabies infestation and had the potential of spreading to other residents, staff and visitors. Findings: A review of the admission record indicated that Resident 1 was admitted to the facility 9/2/16, with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), a standardized assessment tool dated 12/7/16, Resident 1 had the ability to make self-understood and had the ability to understand others. The MDS functional status (activities of daily living), under Section G indicated Resident 1 required extensive assistance for dressing, personal hygiene, bathing, and toilet use. The MDS indicated Resident 1 had no skin problems present. At 10:30 a.m., on 2/23/17, Resident 1 was observed scratching his left hand vigorously. Resident 1 was observed with dry, scaly and crusted skin between his fingers. During a concurrent interview, with the assistance of Certified Nurse Assistant (CNA) 1, Resident 1 stated he had been scratching his hands for several weeks. Resident 1 was asked by the Surveyor for permission to visually assess Resident 1's skin in the resident's room. Resident 1 was observed to have several raised reddened spots and black pinpoint scabs on the chest, back and shoulders. According to CNA 1, Resident 1's skin has been so dry that she had been applying body lotion to keep the skin moistened. CNA 1 also stated she was not aware if Resident 1 was receiving any skin treatments. On 2/23/17, at 11 a.m., the Surveyor accompanied by the Registered Nurse (RN) supervisor, Licensed Vocational Nurse (LVN) 1 and CNA 2, examined Resident 1. The RN Supervisor and LVN 1 confirmed that Resident 1's front and back of the left ring and little fingers had a heavy encrustation and one point open sore covered with dried blood. The RN Supervisor and LVN 1 described Resident 1's chest, back, and shoulders as having, raised reddened spots, red papules (small rounded bumps rising from the skin) and black pinpoint scabs. LVN 1 further described the skin on the chest, back and shoulders as, covered with raised red papules with tracking (blisters and bumps caused by the bites and burrows from the mite). Further observation indicated encrustation on Resident 1's right foot. At this time LVN 1, who was also the treatment nurse, stated that Resident 1 was currently receiving antibiotic (drugs that kill bacteria or slow their growth) treatment for [REDACTED]. LVN 1 stated that Resident 1 was not on any skin or wound treatment other than the oral (by mouth) antibiotics. In addition, both the RN Supervisor and LVN 1 stated that they did not know what a scabies infestation looked like. They both stated a physician or a Dermatologist (skin diseases specialist) had not seen Resident 1's skin condition. The RN supervisor agreed to arrange for an immediate physician consultation and had implemented isolation precaution (used to help stop the spread of germs from one person to another) for Resident 1. A review of Resident 1's Weekly Summary, from 12/11/16 to 2/5/17, indicated Resident 1's skin was assessed as clear and intact. A review of Resident 1's Weekly Summary, dated 2/8/17, indicated Resident 1 was assessed to have a bluish discoloration to the left lower eye area, left cheek bone redness, and a superficial scratch to left lower face secondary to an altercation with another resident. On 2/15/17, Resident 1's Weekly Summary, indicated that the skin was clear and intact, no new skin problems noted. A review of Resident 1's Nurses' Notes, from 12/11/16 to 2/23/17, no documentation was found which indicated that Resident 1 had a rash or had been complaining of itching or scratching himself. During an interview with LVN 2 on 2/23/17, at 12 p.m., LVN 2 stated that skin assessments include a direct observation and assessment of the resident's skin condition from head to toe and should be documented in the weekly summary. On 2/27/17, at 3 p.m., during a follow up visit to the facility, the Director of Nursing (DON) and Administrator stated that a skin scraping (test used to detect the presence of scabies) was done on Resident 1. On 2/28/17, at 10 a.m., during a telephone interview, the Administrator stated that Resident 1's skin scraping was positive for scabies. He also stated that they have been in communication with the Public Health Nurse. On 3/1/17, the facility faxed the Physician's Progress Notes dated 2/28/17, that indicated Resident 1 had scabies. The Physician's Progress Notes, indicated multiple treatment modalities (treatment methods that cause a resident's symptoms to improve or worsen) that included [MEDICATION NAME] (medication to be taken by mouth to treat scabies), [MEDICATION NAME] cream every week, wash clothes and linens, scabies [MEDICATION NAME] (a measure taken to maintain health and prevent the spread of disease) to roommates and follow up assessment in two (2) weeks. On a follow up visit on 3/2/17, at 2:30 p.m., during an interview with the DON, she stated that Resident 1 always had a skin rash since admission. The DON was not able to provide any documentation which indicated the facility's staff had assessed Resident 1 as having a rash prior to the Surveyor's visit. The facility's policy and procedure titled, Resident Examination and Assessment, dated 04/2007, indicated, The purpose of the procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. It also stated, Notify the physician of any abnormalities such as, but not limited to: wounds or rashes on the resident's skin. According to Prevention and Control of Scabies in California Long-Term Care Facilities California Department of Public Health Division of Communicable Disease Control in Consultation with Licensing and Certification, March 2008 (guidelines and recommendations by the California Department of Public Health), Confirmation of Symptomatic Case(s): The [DIAGNOSES REDACTED]. Their skin is generally dry and scaly and there may be pre-existing, chronic dermatological conditions for which oral or topical steroids have been prescribed. Usually, the first indication that a scabies infestation is evolving is complaints of itching and new onset of a rash by one or more residents within a period of 5-12 days. Exposed health care workers, volunteers and frequent visitors may also complain of itching and rash at about the same time. Skin scrapings, when performed properly, will almost always be positive in persons suspected of having atypical or crusted scabies. However, newly infested persons are more likely to have typical scabies and skin scrapings, even when repeated several time at different sites, may be negative.