Every finding on record at Villa las Palmas Healthcare Center

Based on observations, interviews, and record review the facility failed to treat one of 12 sampled residents (Resident 1) with dignity during toileting and brief care.This failure could lead to the emotional and psychosocial trauma of Resident 1.Findings:A review of the admission Record for Resident 1 indicated, Resident 1 was admitted on [DATE] for diagnoses which included: Polyneuropathy (condition characterized by damage to multiple peripheral nerves throughout the body simultaneously, often resulting in weakness, numbness, and burning pain, typically starting in the hands and feet) and Osteomyelitis of the Vertebrae (infection of the vertebrae[backbones] and intervertebral discs[cushion located between each vertebra in the spine]). A review of the Minimum Data Set (MDS- a federally mandated, standardized clinical assessment tool used to evaluate resident functional capabilities, health conditions, and preferences ) Section C-Cognitive (thinking processes) Patterns dated 2/20/26 indicated, Resident 1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. On 4/1/126 at 10:15 A.M., an interview with Certified Nursing Assistant 1(CNA) was conducted. CNA 1 stated Resident 1 is nice, gets up early, very active, always goes to dining room and activities. Alert and oriented, and can make her needs known. Resident 1 is making good progress with her rehab, can stand and turn, and start to use restroom by herself. Resident 1 is able to make her needs known and is very compliant. Resident 1 is minimum assist and is pretty independent, and can turn by herself. On 4/1/26 at 10:25 A.M., an observation and interview with Resident 1 was conducted. Resident 1 was in her wheelchair in her room freshly showered. Resident 1 was alert and oriented and agreeable to the interview. Resident 1 stated she felt safe in the facility at this time. Resident 1 stated that on the morning of 3/17/26 at 3 A.M., she used her call light to let her CNA know her brief was wet and she needed to be changed. Resident 1 stated she waited until 5 A.M. for the light to be answered by CNA 5. Resident 1 stated she was frustrated and asked CNA 5 for an explanation as to why it took 2 hours to answer the light. Resident 1 stated CNA 5 did not provide her an answer. Resident 1 stated that she may have raised her voice to CNA 1 out of frustration. Resident 1 stated that CNA 5 told her, Don't yell at me. When you are ready for me to change you, I will change you. Resident 1 stated that CNA 5 went to change the other residents in the room despite the resident being the one who called to be changed. Resident 1 stated that CNA 5 came back to her after she finished changing the other two residents in the room and asked, Are you ready now? Resident 1 stated she replied, Yes. Resident 1 stated that CNA 5 asked, Are you ready now? and Resident 1 stated, Yes a second time. Resident 1 stated she felt belittled and angry after the interaction because she felt she was in a vulnerable position, and unable to care for herself independently. On 4/1/26 at 11:45 A.M., an interview with CNA 2 was conducted. CNA 2 stated Resident 1 was sweet, has a routine, likes coffee, can make her needs known, alert and oriented, is compliant, no problems, typically very easy going resident. Resident 1 will come back to her room and tell you when she needs to get changed, is very good about letting staff know if she needs something or to be changed. On 4/1/26 at 11:55 A.M., an interview with CNA 3 was conducted. CNA 3 stated Resident 1 is alert and oriented, makes her needs known with staff. Easy going resident. On 4/1/26 at 12:05 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the expectation was to answer call lights immediately and to change residents as soon as possible, if residents requested a brief change. The DSD stated that a resident waiting two hours to be changed was not acceptable, and that they should be changed promptly after call light was answered. The DSD also stated that not changing a resident immediately was disrespectful of their needs and constituted a dignity issue. The DSD stated she expects staff to treat residents with the same respect they would show their own family, because it could affect the residents' psychosocial well-being. On 4/1/226 at 4:56 P.M., a phone interview was conducted with CNA 4. CNA 4 stated she did not work on Tuesday, 3/17/26 with Resident 1. CNA 4 stated Resident 1 was compliant, alert and oriented, and had no issues with her. CNA 4 stated that when a resident requested a brief changed, she does change them immediately. CNA 4 stated that if she worked with another resident, she would inform the resident that she will return after she finished her current task. CNA 4 stated she had not worked with Resident 1 for a long time. On 4/2/26 at 5:26 P.M. a phone interview was conducted with CNA 5. CNA 5 stated she remembered the incident with Resident 1. CNA 5 stated she went to check on the resident about 4 AM and remembered that the Licensed Nurse (LN) asked who had Resident 1's room. CNA 5 stated Resident 1 was very angry when she entered the room and was yelling at her. CNA 5 stated she told Resident 1 she would give her a few minutes to calm down, stating that she had been hit by a resident before. CNA 1 stated while she was in the room for Resident 1, she offered to change the roommates while Resident 1 calmed down. CNA 5 stated that she was unaware of how Resident 1 was feeling, because she had never been in her situation before. CNA 5 also stated that changing the other residents in the room before attending to the angry resident could be considered disrespectful to Resident 1. CNA 5 stated she likes to treat people like the way she wants to be treated. CNA 5 stated the importance of treating residents with respect when caring for them was to maintain their dignity. On 4/14/26 at 12 P.M., an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated the expectation for call lights was to be answered them as soon as possible, and that soiled briefs must be changed immediately. The ADON stated, failure to change promptly could lead to infection, skin breakdown, or falls. The ADON stated that all residents should be treated with respect and dignity, as this was the standard of care and helps maintain residents' psychosocial well-being. Review of facility policy titled Dignity dated 2001, indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self worth and self-esteem.5. When assisting with care, residents are supported in exercising their rights.d. allowed to choose.and conduct activities of daily living.8.Staff speak respectfully to residents at all times.12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example:.b. promptly responding to a resident's request for toileting assistance.

Based on interview and record review, the facility failed to report an allegation of sexual abuse for one of three sampled residents (Resident 1) to the Department of Public Health (DPH) within twenty-four (24) hours from the time the facility learned of the allegation.This deficient practice had the potential for Resident 1 to experience continued abuse and negative psychosocial outcomes. Findings:On 12/19/25 at 12:45 P.M., an unannounced visit was conducted at the facility to investigate a complaint regarding an allegation of abuse.During a record review on 12/19/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included alcoholic cirrhosis of liver (severe scarring of the liver caused by alcohol abuse), major depressive disorder, anxiety disorder, and unspecified dementia.During a record review on 12/19/25, the Minimum Data Set (MDS-an assessment tool) indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) of 9, which indicated Resident 1 had impaired cognition.During an interview with the Assistant Director of Nursing (ADON) on 12/19/25 at 12:45 P.M., the ADON stated on 12/18/25 around 1 P.M., the police arrived at the facility after Resident 1 called 911 to report an allegation of abuse. The ADON stated she was present during the police's interview with Resident 1. The ADON stated during the interview, Resident 1 stated that a staff member, .asked him, 'how are you honey' and touched his shoulder and touched his butt. The ADON further stated Resident 1 felt sexually harassed by a staff member. The ADON stated Resident 1 did not report this allegation to any staff member.During an interview with Licensed Nurse (LN) 1 on 12/19/25 at 1:30 P.M., LN 1 stated he was present during Resident 1's interview with the police officer. LN 1 stated, [Resident 1] told the cop his nurse was flirtatious with [Resident 1], [the nurse] was overly nice.[Resident 1] said he felt like it was sexual harassment. LN 1 stated Resident 1 identified Licensed Nurse (LN) 2 as the alleged perpetrator. LN 1 stated Resident 1's comments were an allegation of abuse.During an interview with the Director of Nursing (DON) on 12/19/25 at 2:02 P.M., the DON stated Resident 1 accused LN 1 of harassment and, any type of harassment is abuse. The DON stated the facility did not report the abuse allegation to the State Licensing Agency or the Ombudsman. The DON stated she did not initiate the investigation, or report the incident because she was training the ADON to investigate allegations of abuse. The DON stated, I wanted [the ADON] to train and take initiative over the incident. The DON stated it was her expectation that any allegation of abuse was reported to the State Licensing Agency.During an interview with Resident 1 on 12/19/25 at 3:22 P.M., Resident 1 stated, About 12 days ago, one of the male nurses was flirtatious with me. It started with 'hey honey, how's it going?' I blew it off and [the flirtatious behavior] increased . Resident 1 further stated, [LN 1] stroked my face and he put his fist in my [vulgar word for buttocks]. Resident 1 stated he called the police, but does not remember whether he told staff about LN 1's actions.During an interview with the Director of Operations (DO) on 12/19/25 at 3:31 P.M., the DO stated he was the designated abuse coordinator for the facility. The DO stated as abuse coordinator, his responsibility was to ensure all allegations of abuse were reported to the State Agency per policy. The DO acknowledged Resident 1's allegations were not reported to CDPH.During a record review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised September 2022, the policy indicated, All reports of resident abuse.are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services.e. Law enforcement officials; f. The resident's attending physician; and g. The facility's medical director.Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

The following reflects the findings of the California Department of Public Health during an investigation of two complaints. Complaint Number: 2564745Complaint Number: 2566052 The inspection was limited to the complaints investigated and does not represent the findings of a full inspection of the facility. One deficiency was identified for the complaint number: 2564745 and Complaint Number: 2566052 (Refer to Ftag 694).Resident 1 was readmitted to the facility on [DATE] with diagnoses which included pneumonia (lung infection), per the facility's admission Record. A review of Resident 1's clinical record was conducted. Resident 1's physician's order dated 7/16/23, indicated Resident 1 was to receive an antibiotic (anti-infective) medication and PIV line care. The physician's order was for the Licensed Nurses (LNs) to flush the PIV line every shift (three shifts in a day). A review of Resident 1's IV medication administration record (MAR) was conducted. Resident 1's IV MAR for July 2023 indicated, the License Nurses (LNs) missed documentation for PIV line flushing on 7/18/23 in evening shift, and 7/19/23 night shift. On 7/29/25 at 12:38 P.M., a joint review of Resident 1's clinical record and an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 was to get an antibiotic medication from 7/16/23 to 7/22/23 for urinary tract infection (UTI). The DON stated there was also an order for PIV line flush for Resident 1. The DON stated there were missed entries for PIV flush for Resident 1. The DON stated there were two missed opportunities. The DON stated she had no answer as to why the documentation was missing. The DON stated, It could have been given, it could have been not. The DON stated it was important to flush Resident 1's PIV to prevent clogging and to ensure there was no infiltration of the site. A review of the facility's policy titled, Intravenous Administration of Fluids and Electrolytes, revised 6/25, indicated, The purpose of this procedure is to provide guidelines for the safe and aseptic administration of intravenous fluids.General Guidelines. 1. Resident should be monitored frequently.for signs and symptoms.catheter patency, insertion site complications.

Based on interview and record review, the facility failed to revise and implement a preventative fall risk plan of care for 1 of 3 sampled residents (1) with a known history of falls and severe cognitive impairment. Resident 1 sustained an unwitnessed fall which had the potential to be prevented. Findings: An unannounced visit was conducted at the facility on 6/2/25. Resident 1 was no longer in the facility. A review of Resident 1's admission record indicated she was admitted to the facility on [DATE] with diagnoses that included vascular dementia (decreased blood flow to the brain leading to reduced cognitive function), metabolic encephalopathy (a brain dysfunction characterized by changes in thinking), muscle weakness and gait instability (an abnormal walking pattern). On 6/2/25 at 12 P.M. a concurrent record review and interview were conducted with the Director of Nursing (DON). Resident 1 had two falls in the facility, one on 5/1/25 and another on 5/24/25. Resident 1's fall risk evaluations indicated a score of 20 (high risk) for falls. A review of Resident 1's Minimum Data Set (MDS) section C (an assessment that evaluates a patient's memory) dated 5/1/25 indicated a Brief Interview for Mental Status (BIMS) score of 2 (severe cognitive impairment, (a significant decline in mental abilities such as memory, impacting daily life). A review of Resident 1's fall care plan initiated on 8/9/24 indicated, .history of self-transferring and getting out of bed with no assistance. Interventions: anticipate and meet needs. Educate/ remind resident to call for assistance with all transfers . , monitor for changes in condition affecting risk for falls and notifying physician if observed. Additional interventions added to Resident 1's fall care plan on 2/24/25 indicated, Anticipate needs due to dementia and poor safety awareness. Resident 1 was found on the floor in her room by staff at approximately 9:45 PM on 5/24/25 with a one-inch skin tear on the back of her head. The facility's fall care plan for Resident 1 indicated staff were to anticipate and meet Resident 1's needs however, the interventions were not individualized for specific fall prevention in regards to Resident 1's severe cognition impairment.

Based on observation, interview, and facility policy review, the facility failed to ensure food items stored in the residents' refrigerator were labeled and dated and discarded within two days per the facility policy. This deficient practice had the potential to affect who stored items in the residents' refrigerator. Findings included: An undated facility policy titled, Bringing In Food For Our Residents, revealed, Food or beverages should be labeled and dated to monitor for food safety. The policy revealed, Food or beverage items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away two days after the date marked. Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored and the resident's name. Per the policy, Opened foods or beverages that require refrigeration should be marked with the date food was opened and resident's name. Refrigeration can occur in a personal room refrigerator, nurses station food refrigerator, or food service refrigerator. Unused food will be discarded within 2 days and if kept frozen, 30 days. During a concurrent interview and observation of the residents' refrigerator on [DATE] at 2:52 PM, with Registered Nurse (RN) #3, the surveyor noted in the freezer there was a pizza with a gray substance on top of it stored in a black plastic container that was not sealed, labeled or dated. In the refrigerator there was what appeared to the chicken and rice that had a gray substance on top of the food with a date of [DATE] and a container of spaghetti labeled with a room number but no date. Also noted in the refrigerator was a blue bowl that contained beans, which was not labeled or dated. RN #3 stated the food items should be labeled and dated. According to RN #3, the kitchen and dietary staff were responsible for keeping the refrigerator clean. During an interview on [DATE] at 8:38 AM, RN #3 stated he was not sure what the gray substance was on top of the pizza, but it could have been freezer burn. RN #3 stated that was mold growing on top of the chicken and rice. During an interview on [DATE] at 7:30 AM, the Dietary Director (DD) stated she expected foods to be labeled with a resident's name and date. The DD stated the dietary aides were supposed to check the resident refrigerator. The DD stated staff should throw away everything in the refrigerator that had been opened for three days. During an interview on [DATE] at 7:47 AM, the Director of Nursing (DON) stated food stored in the refrigerator and freezer should be labeled with the date the food was opened and the date the food expired and be thrown away in two days. The DON stated the DD was supposed to ensure the refrigerator and freezer were clean and the items were dated and labeled with residents' names. During an interview on [DATE] at 9:05 AM, the Director of Operations (DOO) stated the refrigerator and freezer should be checked daily, and the food should be labeled, dated, and free of mold. The DOO stated that staff should throw away anything that was more than a couple of days old. The DOO stated the management staff should hold staff accountable for the cleanliness of the refrigerator and freezer.

Based on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #134) of 5 residents reviewed for unnecessary medications was free of significant medication errors. Specifically, facility staff failed to hold spironolactone (a diuretic/water pill which promotes the removal of fluid [edema] from the body) when Resident #134's systolic blood pressure (SBP) was below 120 millimeters mercury (mmHg) as outlined in the physician's order. Findings included: A facility policy titled, Administering Medications, dated 04/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. The policy indicated, 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. An Admission Record indicated the facility admitted Resident #134 on 01/08/2025. According to the Admission Record, the resident had a medical history that included diagnoses of acute on chronic systolic (congestive) heart failure (CHF), pulmonary hypertension, and essential (primary) hypertension. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/14/2025, revealed Resident #134 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident received a diuretic during the seven-day look-back period. Resident #134's Care Plan Report, included a focus area initiated 01/09/2025, that indicated the resident required the use of a diuretic medication, spironolactone, related to heart failure. Interventions directed staff to administer medications as ordered (initiated 01/09/2025). Resident #134's Order Summary Report, which contained active orders as of 05/06/2025, revealed an order dated 01/27/2025, for spironolactone oral tablet 25 milligrams (mg), give one tablet by mouth one time a day for CHF and hold if the resident's systolic blood pressure (SBP) was less than 120 millimeters of mercury (mmHg). Resident #134's medication administrator record (MAR) for the timeframe 04/01/2025 - 04/30/2025, revealed spironolactone was administered to the resident when their SBP was less than 120 mmHg on the following days: - On 04/01/2025, the resident's SBP was listed as 116 mmHg. - On 04/05/2025, the resident's SBP was listed as 112 mmHg. - On 04/06/2025, the resident's SBP was listed as 111 mmHg. - On 04/10/2025, the resident's SBP was listed as 104 mmHg. - On 04/18/2025, the resident's SBP was listed as 117 mmHg. - On 04/22/2025, the resident's SBP was listed as 117 mmHg. - On 04/23/2025, the resident's SBP was listed as 118 mmHg. - On 04/24/2025, the resident's SBP was listed as 114 mmHg. - On 04/26/2025, the resident's SBP was listed as 118 mmHg. - On 04/27/2025, the resident's SBP was listed as 114 mmHg. - On 04/29/2025, the resident's SBP was listed as 111 mmHg. Resident #134's MAR for the timeframe 05/01/2025 - 05/31/2025, revealed spironolactone was administered to the resident when their SBP was less than 120 mmHg on the following days: - On 05/03/2025, the resident's SBP was listed as115 mmHg - On 05/05/2025, the resident's SBP was listed as118 mmHg. - On 05/06/2025, the resident's SBP was listed as118 mmHg. During an interview on 05/07/2025 at 9:40 AM, Licensed Vocational Nurse #1 stated she administered spironolactone to Resident #134 when the resident's SBP was less than 120 mmHg on 05/06/2025 because she did not see the order to hold the medication for a SBP less than120 mmHg. During an interview on 05/07/2025 at 10:55 AM, Registered Nurse (RN) #2 stated when administering medications with parameter orders, she checked the resident's blood pressure (BP) and if it was below the ordered parameter, she held the medication. RN #2 stated she administered medications to Resident #134 when the resident's SBP was less than120 mmHg; however, she stated that she checked the resident's BP later that day and it was fine. According to RN #2, she knew Resident #134 and knew the resident was okay. During an interview on 05/07/2025 at 10:24 AM, the Nurse Consultant stated it was important to hold a medication if there was a BP parameter specified in the order. The Nurse Consultant stated if a medication was given when a resident's BP was outside the accepted parameters it could cause a resident to become dizzy, develop other symptoms, or worsen their condition. During an interview on 05/07/2025 at 10:34 AM, the Pharmacist stated it was important to monitor a resident's BP when administering diuretics to maintain a stable BP. The Pharmacist stated nursing staff should follow BP parameters as specified in the physician's orders because if a diuretic was given when a resident's BP was low, their BP could fall even more, which could cause falls or unresponsiveness. During an interview on 05/07/2025 at 10:10 AM, the Physician stated diuretics affected electrolyte balance, and if it was administered to a resident when their vital signs were outside the specified parameters, it could adversely affect their kidney or cardiac function. The Physician stated spironolactone was used for the treatment of heart failure and helped to reduce edema and should be held if a resident's BP was already low to prevent any adverse effects. During an interview on 05/07/2025 at 2:47 PM, the Director of Nursing (DON) stated she expected nursing staff to follow vital sign parameters included in a physician's order when they administered medications. The DON stated it was important to follow orders for vital sign parameters for resident safety. During an interview on 05/08/2025 at 8:48 AM, the Director of Operations stated he expected nursing staff to follow what was specified in a physician's order for vital sign parameters when they administered medications.

Based on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASRR) when the resident was diagnosed with a new mental illness diagnosis for 1 (Resident #134) of 3 sampled residents reviewed for PASRR. Findings included: An undated facility policy titled, PASRR (Pre-Admission Screening & Resident Review), indicated, To ensure each patient in the facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. An Admission Record indicated the facility admitted Resident #134 on 01/08/2025. According to the Admission Record, the resident had a medical history that included diagnoses of generalized anxiety disorder and post-traumatic stress disorder. Per the Admission Record, the resident received a diagnosis of major depressive disorder on 04/14/2025. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/12/2025, revealed Resident #134 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS revealed the resident had active diagnoses to include anxiety disorder and post-traumatic stress disorder. Resident #134's medical record revealed no evidence to indicate a level II PASRR was resubmitted after the resident was diagnosed with major depressive disorder on 04/14/2025. During an interview on 05/07/2025 at 9:55 AM, the Admissions Director stated if a resident had a change in condition or if a new diagnosis or psychiatric medication was added, the facility completed another PASRR for the resident. Per the Admissions Director, the Director of Nursing (DON) was responsible for completing the PASRR screening. The Admissions Director stated that she checked the PASRR portal and Resident #134's most recent PASRR was completed in January 2025. During an interview on 05/07/2025 at 3:22 PM, the MDS Coordinator stated the facility should have identified that Resident #134's diagnosis of major depressive disorder was not on the resident's level I screening and another screening should have been completed. During an interview on 05/07/2025 at 2:47 PM, the DON stated if she had noticed that the resident's depression diagnosis was not listed on the initial PASRR, another PASRR should have been completed. The DON stated it was important for the PASRR to be accurate because the diagnosis could qualify the resident for a level II screening and to ensure the resident was appropriate for the facility. During an interview on 05/08/2025 at 8:48 AM, the Director of Operations (DOO) stated facility staff reviewed residents' level I PASRRs upon admission to ensure the resident was appropriate for the facility. The DOO stated he expected the level I PASRR to accurately reflect a resident's condition, and if a pertinent diagnosis was missing, a status change should be submitted.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was free from verbal and mental abuse when: Certified Nursing Assistant (CNA) 2 yelled at Resident 1 and made disparaging comments to the resident about their ability to perform bed mobility while also making humiliating comments to the resident regarding their weight and size. Cross reference F607. As a result: Resident 1 cried, experienced depressed mood, psychosocial (the influence of social factors on an individual's mind or behavior) distress, and felt unsafe in the facility and worthless. Findings: A review of Residents 1 ' s Admission Record dated 5/1/25, indicated the resident was readmitted to the facility on [DATE]. On 5/1/25 at 9:05 A.M., an onsite visit was conducted to investigate an allegation of abuse between CNA 2 and Resident 1. On 5/1/25 at 10:15 A.M., an observation and interview were conducted with Resident 1 while inside the resident ' s room. Resident 1 ' s husband was also present. Resident 1 stated there was an incident that occurred around 11 P.M. (on 4/22/25) after she had requested help to be pulled up in bed. Resident 1 stated CNA 1 was her assigned CNA and CNA 1 went to get assistance. Resident 1 stated CNA 1 entered her room with CNA 2. Resident 1 stated CNA 2 told her, Oh, it ' s you. You been here long enough and should be able to pull yourself up. Resident 1 stated CNA 2 laughed and pointed at her while saying, Look at you, you ' re four times bigger than me. Resident 1 stated CNA 2 told her she did not want to break her back by pulling her up and that the resident was too big. Resident 1 was observed wiping her tears away during the interview. Resident 1 stated after the incident occurred, she called her husband on the phone and told him what had happened. Resident 1 stated, I just want to go home with my family. Resident ' s 1 husband stated they had been married for [AGE] years, and that this incident had a bad effect on his wife. Resident 1 stated when the incident occurred, she was in disbelief at first and then she felt bad and it made her feel worthless. Resident 1 stated the incident felt like abuse because CNA 2 had been yelling at her, it happened at night, and she was alone and in a helpless state. Resident 1 stated, I didn ' t feel safe. Resident 1 further stated, Everyone knows [CNA 2] is rude. Even housekeepers know [this]. On 5/1/25 at 10:35 A.M., an interview was conducted with the Housekeeper (HK). The HK stated when she was cleaning a resident ' s room on another unit, about three to four weeks ago, a resident told her CNA 2 was rude to them. The HK stated she did not report what the resident told her to anyone. A review of CNA 2 ' s employee file indicated: -Employee Counseling Form dated 5/6/24, and signed by CNA 2 indicated, .2. Employee was rude to a family member -Employee Disciplinary Action Form dated 4/2/25, indicated, .concerns regarding your ongoing comments about resident [sic] and staff. It has been observed and reported that you have repeatedly spoken about residents in a negative manner .Corrective Action Plan [:] Speak about residents respectfully at all times, regardless of frustrations or concerns. Bring up any care-related concerns to management or nursing leadership privately CNA 2 refused to sign the form. -Employee Disciplinary Action Form dated 4/10/25, indicated, .This disciplinary action is being issued due to ongoing unprofessional conduct that is detrimental to team cohesion and the overall work environment CNA 2 refused to sign the form. -(Facility Name) Notice of Termination of Employment dated 4/28/25, indicated, .Following a resident ' s [Resident 1] complaint, an internal investigation determined that verbal comments were made which in turn negatively affected the resident ' s emotional well-being, causing her significant distress On 5/1/25 at 12:11 P.M., a telephone interview was conducted with CNA 2. CNA 2 stated CNA 1 had asked for assistance to pull Resident 1 up in bed and, She ' s overweight this patient. CNA 2 stated she did not want to hurt her back and that, This lady [Resident 1] is more than 400 pounds. I can get hurt. CNA 2 denied making any comments about Resident 1 in front of the resident. CNA 2 was asked about her training on how to pull up a resident in bed and CNA 2 did not answer the question. CNA 2 spoke non-stop and frequently did not answer interview questions. CNA 2 was asked about the disciplinary actions in her employee file. CNA 2 changed the topic. CNA 2 was again asked about the contents of her employee file and CNA 2 denied there being any disciplinary actions in her file. CNA 2 stated she did go back to Resident 1 ' s room with the charge nurse and a different CNA and assisted in pulling Resident 1 up in bed. CNA 2 stated the resident was fine. CNA 2 further stated, I never called [Resident 1] fat. On 5/1/25 at 3:15 P.M., a telephone interview was conducted with CNA 1. CNA 1 stated around 11:00 P.M., on 4/22/25, at the start of her shift, she asked CNA 2 for help to pull Resident 1 up in bed. CNA 1 stated they were in the hallway outside of Resident 1 ' s room when CNA 2 stated she was not going to break her back. CNA 1 stated CNA 2 continued talking loudly and stated, The resident ' s 500 times my weight. CNA 1 stated CNA 2 followed her into Resident 1 ' s room while stating, How could someone let themselves get that big? CNA 1 stated that CNA 2 told Resident 1, We ' re not going to do this, you ' re going to do it. [NAME] ' t you see how big you are? CNA 1 stated Resident 1 started crying while CNA 2 kept talking about how big Resident 1 was. CNA 1 stated CNA 2 would not stop talking about the resident ' s weight and the resident kept crying. CNA 1 stated, I couldn ' t take it anymore and told [CNA 2] she was rude and to get out of my resident ' s room. CNA 1 stated this was the first time she had worked with CNA 2. CNA 1 stated she had reported the incident to the Charge Nurse (CN) 3 and she also emailed the Director of Staff Development (DSD) about the incident. CNA 1 stated she was emotional after witnessing the incident and had to take a break. CNA 1 stated based on her facility-provided abuse prevention training, the incident was emotional abuse. CNA 1 stated the incident was, Emotionally damaging [to] the resident. CNA 1 stated Resident 1 was very sweet, never got mad, and was considerate. CNA 1 stated Resident 1 was not the type to complain and if she had not spoken up, the resident would have kept it inside and not said anything about it. On 5/1/25 at 3:42 P.M., a telephone interview was conducted with CN 3. CN 3 stated she was in charge of the building during the night shift (11 P.M. to 7 A.M.). CN 3 stated around the start of the shift on 4/22/25, CNA 1 reported to her that CNA 2 was rude to Resident 1 and had made the resident cry. CN 3 stated she asked CNA 2 what had happened, and CNA 2 stated that she did not say anything to Resident 1. CN 3 stated she spoke to Resident 1 about the incident and the resident did not want to talk about what had occurred. CN 3 was informed of what Resident 1 and CNA 1 said had happened on 4/22/25. CN 3 stated, Oh no, that ' s abuse. CN 3 stated based on her facility-provided abuse prevention training, the incident on 4/22/25 that occurred between CNA 2 and Resident 1 was verbal, emotional, and mental abuse. A review of Resident 1 ' s progress notes titled IDT [Interdisciplinary Team-different disciplines who meet and discuss resident care issues] Note dated 4/23/25, indicated when the IDT interviewed Resident 1 regarding the incident that occurred on 4/22/25, the resident had cried for 10 seconds. The IDT referred Resident 1 to the psychiatrist and psychologist for evaluation. On 5/5/25 at 10:12 A.M., an interview was conducted with the DSD. The DSD stated she was involved in investigating the incident that occurred on 4/22/25 between Resident 1 and CNA 2. The DSD stated it had been determined that verbal abuse had occurred, and that Resident 1 had suffered emotional distress. The DSD stated Resident 1 frequently became teary-eyed since the incident. The DSD stated prior to the incident Resident 1 seemed happier. The DSD stated this incident affected Resident 1 and, It was verbal and mental abuse. The DSD stated Resident 1 was a two-person assist to pull up in bed. The DSD stated CNA 2 received training on how properly move and position a resident. On 5/5/25 at 11:00 A.M., an interview was conducted with the Director of Operations (DOO) and the Director of Nursing (DON). The DOO stated initially they did not think what happened on 4/22/25 to Resident 1 was as bad as it was. The DOO stated the incident was abuse considering how Resident 1 perceived the incident and how it made her feel. The DON stated what happened was, Verbal abuse as [Resident 1] experienced emotional distress from it. A review of the facility ' s policy titled Identifying Types of Abuse revised September 2022, indicated, .1. Abuse of any kind against residents is strictly prohibited .1. Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 2. Verbal abuse may be considered to be a type of mental abuse . 3. Examples of mental and verbal abuse include but are not limited to: a. Harassing a resident; b. Mocking, insulting, ridiculing; c. Yelling or hovering over a resident, with the intent to intimidate A review of facility ' s policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program revised April 2021, indicated, Residents have the right to be free from abuse

Based on interview and record review, the facility failed to ensure a baseline care plan was developed for two of three residents (Resident 6 and 7), reviewed for fall care plans. This failure to develop the baseline care plan for fall risk within 48 hours of admission placed Resident 6 and 7 at risk for falls. Findings: Resident 6 was admitted to the facility on [DATE] with diagnoses which included unsteadiness on feet per the facility's Admission Record. A review of Resident 6 ' s Fall Risk Observation/assessment dated [DATE], documented a score of 22, which indicated the resident was identified as being high risk for falls. Resident 7 was admitted to the facility on [DATE] with diagnoses which included repeated falls per the facility's Resident Admission Record. A review of Resident 7 ' s Fall Risk Observation/assessment dated [DATE], documented a score of 26, which indicated the resident was identified as being high risk for falls. On 5/5/25 at 8:50 A.M., an interview was conducted with Licensed nurse (LN) 4. LN 4 stated the purpose of completing an admission fall risk assessment was to identify a resident who was a high fall risk and to develop interventions to prevent falls. LN 4 stated the fall care plan was used to communicate to the staff that a resident was a high fall risk and identified interventions to prevent falls. On 5/5/25 at 10:47 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the purpose of doing a fall risk assessment on admission was to identify residents who were at high risk for falls so that interventions could be developed to prevent falls. The DON stated interventions to prevent falls should have been in place immediately for Residents 6 and 7. On 5/5/25 at 11:02 A.M., a joint interview and record review was conducted with the DON. The DON stated there was no baseline care plan for fall risk in Resident 6 and Resident 7 ' s clinical record. The DON stated it was important to initiate a fall care plan within 48 hours of admission based on the fall risk assessment, so interventions regarding the residents' care could be communicated to the care team. A review of the facility policy titled Care Plan - Baseline revised March 2022, indicated, A baseline plan of care to meet the resident ' s immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission

Based on observation, interview, and record review, the facility failed to ensure staff were fully trained to correctly identify mental, emotional, and verbal abuse when: 1. Certified Nursing Assistant (CNA) 2 yelled at Resident 1 and made disparaging comments to the resident about their ability to perform bed mobility while also making humiliating comments to the resident regarding their weight and size. Staff considered CNA 2 ' s behavior as rudeness instead of abuse. 2. Charge Nurse (CN) 3 was not adequately trained to collect pertinent information to make an accurate determination of abuse during the incident regarding CNA 2 and Resident 1. As a result, CNA 2 was permitted to finish her eight-hour shift providing care to residents after the incident involving Resident 1. This failure had the potential for other residents to experience abuse. Cross reference F600. Findings: A review of Residents 1 ' s Admission Record dated 5/1/25, indicated resident was readmitted to the facility on [DATE]. On 5/1/25 at 9:05 A.M., an onsite visit was conducted to investigate an allegation of abuse between CNA 2 and Resident 1. On 5/1/25 at 10:15 A.M., an interview and observation was conducted with Resident 1 while inside the resident ' s room. Resident 1 ' s husband was also present. Resident 1 stated there was an incident that occurred around 11 P.M. (on 4/22/25) after she had requested help to be pulled up in bed. Resident 1 stated CNA 1 was her assigned CNA, and CNA 1 went to get assistance. Resident 1 stated CNA 1 entered her room with CNA 2. Resident 1 stated CNA 2 told her, Oh, it ' s you. You been here long enough and should be able to pull yourself up. Resident 1 stated CNA 2 laughed and pointed at her while saying, Look at you, you ' re four times bigger than me. Resident 1 stated CNA 2 told her she did not want to break her back by pulling her up and that the resident was too big. Resident 1 was observed wiping her tears away during the interview. Resident 1 stated she called her husband on the phone and told him what had happened. Resident 1 stated, I just want to go home with my family. Resident 1 ' s husband stated they had been married for [AGE] years, and this incident had a bad effect on his wife. Resident 1 stated when the incident occurred, she was in disbelief at first and then she felt bad and it made her feel worthless. Resident 1 stated the incident felt like abuse because CNA 2 had been yelling at her, it happened at night, and she was alone and in a helpless state. Resident 1 stated, I didn ' t feel safe. Resident 1 further stated, Everyone knows [CNA 2] is rude. Even housekeepers know [this]. On 5/1/25 at 10:35 A.M., an interview was conducted with the Housekeeper (HK). The HK stated when she was cleaning a resident ' s room on another unit, about three to four weeks ago, a resident told her CNA 2 was rude to them. The HK stated she did not report what the resident told her to anyone. On 5/1/25 at 3:15 P.M., a telephone interview was conducted with CNA 1. CNA 1 stated at the start of her shift around 11:00 P.M., on 4/22/25, she asked CNA 2 for help to pull Resident 1 up in bed. CNA 1 stated they were in the hallway outside of Resident 1 ' s room when CNA 2 stated she was not going to break her back. CNA 1 stated CNA 2 continued talking loudly and stated, The resident ' s 500 times my weight. CNA 1 stated CNA 2 followed her into Resident 1 ' s room while stating, How could someone let themselves get that big? CNA 1 stated that CNA 2 told Resident 1, We ' re not going to do this, you ' re going to do it. [NAME] ' t you see how big you are? CNA 1 stated Resident 1 started crying while CNA 2 kept talking about how big Resident 1 was. CNA 1 stated CNA 2 would not stop talking about the resident ' s weight and the resident kept crying. CNA 1 stated, I couldn ' t take it anymore and told [CNA 2] she was rude and to get out of my resident ' s room. CNA 1 stated this was the first time she had worked with CNA 2. CNA 1 stated she had reported the incident to the Charge Nurse (CN) 3 and she also emailed the Director of Staff Development (DSD). CNA 1 stated she was emotional after witnessing the incident and had to take a break. CNA 1 stated based on her facility-provided abuse prevention training, the incident was emotional abuse. CNA 1 stated the incident was, Emotionally damaging [to] the resident. CNA 1 stated Resident 1 was very sweet, never got mad, and was considerate. CNA 1 stated Resident 1 was not the type to complain and if she did not speak up the resident would have kept it inside. On 5/1/25 at 3:42 P.M., a telephone interview was conducted with CN 3. CN 3 stated she was in charge of the building during the night shift (11P.M. to 7 A.M.) that started on 4/22/25. CN 3 stated around the start of the shift CNA 1 reported to her that CNA 2 was rude to Resident 1 and had made the resident cry. CN 3 stated she asked CNA 2 what had happened, and CNA 2 stated that she did not say anything to Resident 1. CN 3 stated she spoke to Resident 1 about the incident and the resident did not want to talk about what had occurred. CN 3 stated what CNA 1 told her was vague and that she had not clarified what was told to her. CN 3 was informed of what Resident 1 and CNA 1 stated had happened on 4/22/25. CN 3 stated, Oh no, that ' s abuse. CN 3 stated based on her facility-provided abuse prevention training, the incident on 4/22/25 that occurred between CNA 2 and Resident 1 was verbal, emotional, and mental abuse. CN 3 stated if she had known all the details of what had happened, she would have sent CNA 2 home. CN 3 stated CNA 2 had worked the whole night shift providing care to residents. On 5/5/25 at 8:50 A.M., an interview was conducted with CN 5. CN 5 stated there were times she was in charge of the building. CN 5 stated if an incident of staff rudeness to a resident was reported to her, she would have to, Get all the facts. CN 5 stated she would contact the Director of Operations (DOO) and Director of Nursing (DON) to get guidance to determine if the incident was considered rudeness or abuse. CN 5 stated if staff rudeness looked like abuse took place, she would send the staff home. CN 5 stated she received abuse training here at the facility but had received extra training in her role as a CN while employed at a hospital. CN 5 stated this extra training involved following up on allegations and asking pertinent questions to determine if abuse had occurred. On 5/5/25 at 10:12 A.M., an interview and record review was conducted with the DSD. The DSD stated she was involved in investigating the incident that occurred on 4/22/25 between Resident 1 and CNA 2. The DSD stated it had been determined that verbal abuse had occurred, and that Resident 1 had suffered emotional distress. The DSD stated this incident affected Resident 1 and, It was verbal and mental abuse. The DSD stated CNA 2 had a history of negatively talking about residents, constantly complaining about management and staff, and speaking loudly where everyone could hear. The DSD stated on 4/2/25 and 4/10/25, CNA 2 was given written warnings about her behavior. The DSD stated she had received an email from CNA 1 after midnight (4/23/25) indicating that unnecessary comments were made by CNA 2 to Resident 1. The DSD stated, In my head, I thought [CNA 2] was being negative again and I could address it the morning. The DSD stated there should have been additional training provided to Licensed Nurses in the CN position on how to gather all the facts and to report to the DOO and the DON for additional guidance to determine if abuse had occurred so appropriate action could take place. The DSD reviewed the lesson plan for identifying different types of abuse, reporting, and documentation dated 4/24/25. The DSD stated this was the same lesson plan used during in-services related to abuse. The lesson plan indicated, .mental/emotional abuse-actions or words that inflict psychological abuse or trauma. Examples: A staff member tells a resident ' You ' re useless, ' causing the resident to cry .verbal abuse- The use of words to cause emotional pain, fear, or distress. Examples: A nurse yells at a resident in front of others: ' You ' re a burden to everyone here! ' The DSD stated rudeness should be covered in the abuse prevention training. The DSD stated staff needed to be able to tell the difference between rudeness and abuse and report it. On 5/5/25 at 11:00 A.M., an interview was conducted with the DOO and DON. The DOO stated initially they did not think what happened on 4/22/25 to Resident 1 was as bad as it was. The DOO stated considering how Resident 1 perceived the incident and how it made her feel was abuse. The DON stated what happened was, Verbal abuse as [Resident 1] experienced emotional distress from it. The DOO stated during the incident the CN 3 could have asked more questions and tried to gather more details of the situation and dig deeper. The DOO stated gathering more details would have provided CN 3 with enough information to make the decision to send CNA 2 home. The DOO stated the CN should have reached out to the DOO and the DON for guidance in identifying CNA 2 ' s behavior as abuse. The DOO stated the facility abuse prevention training should include more focused training to ask more thorough questions to understand the full scope of the situation for staff in charge of the building. The DOO stated all staff should be trained and capable of identifying verbal and mental abuse. A review of the facility ' s policy titled Identifying Types of Abuse revised September 2022, indicated, As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. 1. Abuse of any kind against residents is strictly prohibited .1. Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 2. Verbal abuse may be considered to be a type of mental abuse . 3. Examples of mental and verbal abuse include, but are not limited to: a. Harassing a resident; b. Mocking, insulting, ridiculing; c. Yelling or hovering over a resident, with the intent to intimidate .4. Staff are trained on abuse reporting and investigation A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021, indicated, .5. Establish and maintain a culture of compassion and caring for all residents .6. Provide staff orientation and training/orientation programs that include .identification and reporting of abuse .10. Protect residents from any further harm during investigations

Based on interview and record review, the facility failed to employ a qualified Social Services Director (SSD) on a full- time basis that met the qualifications specified in the regulation. This deficient practice placed all 151 residents at risk of not receiving medically-related social services necessary to attain their highest practicable well-being. Findings: An anonymous complaint regarding the SSD not meeting job qualifications was received by the California Department of Public Health. On 4/17/25, an unannounced site visit was conducted. An interview was conducted with the Director of Nursing (DON) on 4/17/25 at 2:10 P.M. The DON stated there had been some staff turnover in the SW department. Per the DON, the current SSD had been in the role for about one year. A concurrent record review and interview was conducted with the DON on 4/17/25 at 3 P.M. The DON reviewed the employment file for the SSD and stated the SSD had an associates degree in nursing, but was not a licensed nurse. The DON reviewed the facility job description for the Social Services Director, signed on 4/4/24 and stated, The SSD does not have a degree in Social Work or any other related area of study. She does not qualify to be in the role. The DON stated having an unqualified SSD may put residents at risk for not getting the social services they needed. A concurrent interview and record review was conducted with the Human Resources Administrator (HRA) on 4/17/25 at 4 P.M. The HRA stated all job descriptions include the education and/or experience required for the role. The HRA reviewed the job description for the SSD, and stated the job required a bachelor ' s degree in social work or related field, and the current SSD did not have the required degree. The HRA stated it was the role of the administrator or hiring manager to ensure the job candidate had the required education. An interview was conducted with the SSD on 4/17/25 at 4:10 P.M. The SSD stated she had interviewed with the former Administrator of the facility, who told her she was qualified for the job and placed her in the position. The SSD stated she did not have a degree in Social Work. The SSD stated she had a current Certified Nursing Assistant (CNA) certification, and had completed an associates degree in nursing, but had not taken the nursing board exam. The former Administrator no longer worked at the facility. The current Administrator was unavailable for interview. Per a facility job description, dated March 2017 and titled Job Description: Social Services Director, .Education and/or Experience: Bachelor ' s Degree in Social Work or in Human Services and 2 years of supervised social work experience in a health care setting .MSW [masters in social work] preferred .

Based on interview and record review, the facility failed to address the nutrition and hydration need of one of three residents (Resident 1) when: Resident 1's nutrition and hydration need, as recommended by the registered dietician (RD), was not implemented. The interdisciplinary team (IDT - team of individual with different specialties) did not address Resident 1's weight loss. As a result, Resident 1 was found lethargic (lack of mental and physical energy) and hard to arouse (wake up). Resident 1 was sent to the hospital and diagnosed with acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), metabolic acidosis (a condition when the body produces too much acid) and dehydration (when a body does not have as much fluids as it needs; can lead to kidney damage, brain damage and even death). Resident 1 died , three days after admission to the hospital, due to septic shock (a widespread infection causing organ failure and dangerously low blood pressure), acute kidney failure, and severe dehydration. Findings: A record review of Resident 1's undated Admission Record (a record which contains resident personal information) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included a history of moderate protein-calorie malnutrition (an energy deficit due to deficiency of all macronutrients, but primarily protein). Resident 1's historical record reviews did not include a diagnosis of kidney failure. A record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool that is used to develop a plan of care), dated [DATE], indicated a Brief Interview for Mental Status (BIMS - use to measure a resident's mental status) score of 5 points out of 15 possible points which indicated Resident 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits (problems). A record review of Resident 1's Nutritional Risk Assessment, completed by the RD, dated [DATE], was conducted. According to the assessment, Resident 1's nutritional needs and hydration needs included the following: ,d+[DATE] total calories (unit of energy) per day ,d+[DATE] milliliters (ml) of liquids per day A record review of Resident 1's care plan, dated [DATE], indicated that the resident had a nutritional problem due to inadequate nutrient intake related to decrease appetite . The care plan indicated that one of the interventions included, RD to evaluate and make diet change recommendations PRN (as needed). An interview with certified nurse assistant (CNA) 1 was conducted on [DATE] at 12:56 P.M. CNA 1 stated that she had taken care of Resident 1 and was familiar with her care needs. CNA 1 stated that Resident 1 required encouragement to eat during meals. CNA 1 stated at times, she would sit with Resident 1 to physically assist her with her meals. CNA 1 stated, If she [Resident 1] didn't eat, I would encourage her, and she would eat. I don't think the other CNAs did that with her, cause (because) they probably thought she would eat on her own. CNA 1 stated she notified the nurses when Resident 1 did not eat well. CNA 1 stated that CNAs documented the residents' meal intakes in the electronic medical record. CNA 1 stated that meal intakes were documented as, 0 for intakes of ,d+[DATE]%; 1 for intakes of ,d+[DATE]%; 2 for intakes of ,d+[DATE]%; 3 for intakes of ,d+[DATE]%. CNA 1 stated that if the resident ate 50% or less, an alternative meal or snack would be offered to the resident and documented on the meal intake electronic record. CNA 1 stated that an NA documentation would indicate that the alternate meal or snack was not offered, and a RR documentation would indicate that the resident refused the alternate meal or snack. CNA 1 also stated that a 0 documentation would indicate that the resident did not eat the alternate meal or snack. CNA 1 stated that Resident 1's fluid intake was documented in the electronic medical record. A record review of Resident 1's electronic meal intake documentation, from [DATE] to [DATE], was conducted. The dates listed below were dates when Resident 1 ate 50% or less: [DATE] - dinner: 1 (,d+[DATE]%); NA - alternate or snack not offered [DATE] - lunch: 1; NA [DATE] - lunch: 1; NA [DATE] - breakfast: 0 (,d+[DATE]%); NA [DATE] - lunch: 1; NA [DATE] - lunch: 1; NA [DATE] - lunch: 1; NA [DATE] - dinner: 1; NA [DATE] - lunch: 1; NA [DATE] - lunch: 1; NA [DATE] - lunch: 0; NA [DATE] - lunch: 1; NA [DATE] - lunch: 1; NA [DATE] - dinner: 0; 0 - did not eat alternate or snack [DATE] - dinner: 1; NA [DATE] - dinner: 1; NA [DATE] - lunch: 0; 0 [DATE] - dinner: 0; 0 [DATE] - lunch: 1; NA [DATE] - lunch: 1; NA [DATE] - dinner: 1; NA [DATE] - lunch: 1; NA [DATE] - breakfast: RR (resident refused); NA [DATE] - lunch: RR; RR [DATE] - dinner: RR; NA [DATE] - breakfast: RU (resident unavailable); 0 [DATE] - lunch: NA; 0 [DATE] - breakfast: 1; NA [DATE] - lunch: 0; NA [DATE] - dinner: RR; 0 [DATE] - breakfast: 0; NA [DATE] - lunch: 1; NA [DATE] - lunch: 0; NA [DATE] - dinner: RR; 0 [DATE] - breakfast: RR; RR [DATE] - lunch: 1; NA [DATE] - dinner: 1; NA [DATE] - breakfast: 0; NA [DATE] - lunch: no documentation [DATE] - dinner: no documentation [DATE] - breakfast: 0; NA [DATE] - lunch: RR; RR [DATE] - dinner: 0; NA [DATE] - dinner: 0; NA [DATE] - dinner: 1; NA [DATE] - breakfast: RR; RR [DATE] - lunch: 0; NA [DATE] - breakfast: RR; 0 [DATE] - lunch: RR; RR [DATE] - breakfast: 1; NA [DATE] - dinner: 0; NA [DATE] - breakfast: RR; 0 [DATE] - breakfast: 1; NA [DATE] - lunch: 1; NA [DATE] - breakfast: 0; NA [DATE] - dinner: no documentation [DATE] - dinner: 1; NA [DATE] - breakfast: 1; NA [DATE] - lunch: 1; NA [DATE] - dinner: RR; 0 [DATE] - dinner: RR; 0 [DATE] - dinner: RR; 0 [DATE] - dinner: RR; 0 [DATE] - dinner: RR; NA [DATE] - breakfast: RR; RR [DATE] - lunch: RR; RR [DATE] - dinner: no documentation [DATE] - breakfast: 0; NA [DATE] - lunch: RR; RR [DATE] - dinner: RR; 0 [DATE] - breakfast: RR; NA [DATE] - lunch: RR; NA [DATE] - dinner: RR; 0 [DATE] - breakfast: RR; RR [DATE] - lunch: RR; RR [DATE] - dinner: RR; 0 A record review of Resident 1's electronic fluid intake documentation, from [DATE] to [DATE], was conducted. The dates listed below were dates when Resident 1 did not meet the recommended daily fluid intake per RD's recommendation: [DATE]: 720 ml/day [DATE]: 720 ml/day [DATE]: 840 ml/day [DATE]: 880 ml/day [DATE]: 800 ml/day [DATE]: 680 ml/day [DATE]: 880 ml/day [DATE]: 720 ml/day [DATE]: 480 ml/day [DATE]: 640 ml/day [DATE]: 920 ml/day [DATE]: 480 ml/day [DATE]: 820 ml/day [DATE]: 940 ml/day [DATE]: 860 ml/day [DATE]: 880 ml/day [DATE] 910 ml/day [DATE]: 460 ml/day [DATE]: 240 ml/day [DATE]: 190 ml/day [DATE]: 620 ml/day [DATE]: 540 ml/day ,d+[DATE]: 720 ml/day [DATE]: 760 ml/day [DATE]: 720 ml/day [DATE]: 480 ml/day [DATE]: 840 ml/day [DATE]: 240 ml/day [DATE]: 600 ml/day [DATE]: 630 ml/day [DATE]: 380 ml/day [DATE]: 240 ml/day [DATE]: 360 ml/day [DATE]: 360 ml/day [DATE]: 680 ml/day [DATE]: 840 ml/day [DATE]: 930 ml/day [DATE]: 240 ml/day [DATE]: 720 ml/day [DATE]: 730 ml/day [DATE]: 840 ml/day [DATE]: 600 ml/day [DATE]: 860 ml/day [DATE]: 600 ml/day [DATE]: 880 ml/day [DATE]: 590 ml/day [DATE]: 120 ml/day [DATE]: 498 ml/day [DATE]: 520 ml/day [DATE]: 280 ml/day A record review of Resident 1's weight from [DATE] to [DATE] was conducted. The record indicated the following weights: [DATE]: 139.6 lbs. (pounds) [DATE]: 133.6 lbs. - 6 lbs. weight loss in a month or 4.8% weight loss in a month [DATE]: 124.6 lbs. - 9 lbs. weight loss in a month or 6.7%. weight loss in a month A record review of Resident 1's IDT Note, dated [DATE] at 3:25 P.M. indicated, weight loss of Wt (weight) hx (history) [sic]: (,d+[DATE]) 133.6lbs; (,d+[DATE]) 139.6 lbs; (,d+[DATE]) 138lbs. Noted -6lbs/-4.3% clinically insignificant wt loss x1 mo (in/over the course of one month). Average PO (oral) intake mostly ,d+[DATE]% per tasks .Recommend: continue diet as ordered, texture per SLP (speech-language pathologist; expert who works with individuals in the treatment of communication and swallowing problems), monitor weekly weights x4 (over the course of four) weeks, continue fortified (extra calorie) foods at meals . A record review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated [DATE] at 12:53 P.M., indicated, .Resident lost weight 9lbs [sic] in one month due to not eating and drinking enough . A record review of Resident 1's weight loss care plan developed on [DATE] and revised on [DATE] indicated, Weight Loss: Resident has an actual significant weight loss of 9 lbs. 6.7%, which was unintended weight loss x1 month; Goal: will show a desirable weight gain of ,d+[DATE] lbs in a month. An interview and joint record review of Resident 1's medical record was conducted with licensed nurse (LN) 1 on [DATE] at 1:15 P.M. LN 1 stated she was aware that Resident 1 had episodes of poor meal and fluid intake. LN 1 stated she was aware that Resident 1 had weight loss. LN 1 could not find documentation that the resident's poor intake (meal and fluid) and weight loss were addressed. LN 1 was not able to find documentation that staff attempted to identify the cause of resident's poor meal and fluid intake. LN 1 reviewed Resident 1's weight record and stated that the resident's weight loss started on [DATE]. LN 1 stated the care plan for weight loss was not developed until [DATE]. On [DATE] at 8:33 A.M., an interview was conducted with the Speech Therapist (ST). The ST stated that Resident 1 was seen by ST from admission until the resident transitioned to restorative nursing assistant (RNA) program (acquire special knowledge skills, and techniques in rehabilitation) in October for exercises. The ST stated she was not aware of Resident 1's poor intake and weight loss. The ST stated if the IDT notified her of the resident's poor intake, they could have collaborated and identified interventions that could have helped address the resident's needs. The ST stated she would have recommended for Resident 1 to be placed on a RNA feeding program since the resident needed encouragement to eat and drink. An interview and joint record review of Resident 1's medical record was conducted with the RD on [DATE] at 9:27 A.M. The RD reviewed Resident 1's electronic meal and fluid intake documentation from [DATE] to [DATE]. The RD stated she was aware of Resident 1's poor meal and fluid intake. The RD stated Resident 1's poor meal and fluid intake was not addressed timely. The RD stated staff should be offering other meal options and snacks, especially when a resident had a weight loss, to help encourage the resident to eat. The RD stated that she was aware of Resident 1's weight loss and that the resident's weight loss was not addressed timely. The RD stated that Resident 1's weight should have been monitored weekly x 4 weeks, as recommended by the IDT on [DATE]. According to the RD, this recommendation was not implemented. An interview with the Assistant Director of Nursing (ADON) was conducted on [DATE] at 10:20 A.M. The ADON stated Resident 1's poor meal and fluid intake should have been addressed timely to avoid weight loss. The ADON acknowledged that the recommended nutritional intake including fluid intake for Resident 1, was not implemented. The ADON stated Resident 1's weight loss should have been addressed timely to prevent a decline in resident's health. A record review of Resident 1's nurse's notes, dated [DATE] was conducted. According to the nurse's notes, Resident 1 was found lethargic and unresponsive at 9:30 P.M. The nurse's notes indicated Resident 1 was picked-up by ambulance at 10 P.M. and was taken to the hospital. A record review of Resident 1's hospital lab (laboratory) results indicated the following: [DATE] Sodium: 153 H (high) BUN (measures amount of nitrogen in the blood): 117 H (high) Creatinine (waste product produced by muscles and excreted by the kidneys): 6.3 H (high) Total Protein: 5.8 L (low) Albumin (a type of protein in the blood): 3.3. L (low) eGFR CKD-EPI (a measure that helps assess how well your kidneys are working): 6 L (low) Lactic Acid (provides insights into the body's metabolism): 3.3 L (low) Blood Gases (refers to the levels of oxygen and carbon dioxide in the blood for lung function) indicated Acidosis (may result from kidney issues. Occurs when there's too much acid in the body) [DATE] Lactic Acid: 9.8 C (critical) A record review of Resident 1's hospital emergency note, dated [DATE], was conducted. The emergency note indicated, Patient presents to the hospital with complaints of dyspnea (difficulty breathing), rapid respiratory rate.She initially had some hypotension (low blood pressure) which was improved with IV (intravenous - fluids administered through the vein) fluid. I was initially concerned for sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection ) and treated the patient with broad-spectrum antibiotics along with 30 cc/kg (cubic centimeters/kilograms) IV fluid bolus (single dose) . Reviewing her laboratory tests I see that she had normal laboratory test back in June of this year, and yet now she has significant kidney disease with a creatinine of 6.3. She has hyponatremia (occurs when the concentration of sodium in your blood is abnormally low) without hyperkalemia (potassium in blood is abnormally high), I feel this is the cause of her elevated troponin (a protein that's released into the bloodstream during a heart attack) as her EKG (measures the heart's electrical activity) does not show ischemic (decrease blood flow) findings.I am concerned based on the patient's evaluation that she is quite dry and then acute kidney injury is related to volume loss which is why I treated with IV fluid . A record review of Resident 1's hospital History and Physical, dated [DATE], indicated, . In the ED (emergency department) the patient was intubated (inserting a tube through a person's mouth or nose) and placed on mechanical ventilation (machine breathing for the person) .Assessment . Acute Kidney Injury, Severe Dehydration . A record review of Resident 1's hospital Admission, Transfer/Discharge Note, dated [DATE], indicated, Date/Time of Death pronouncement: [DATE] 02:23 (2:23AM). A record review of Resident 1's Death Certificate, dated [DATE], indicated that Resident 1's cause of death was septic shock, aspiration pneumonia (complication from inhaling of food or liquid into the lungs), severe dehydration, and acute kidney failure. On [DATE] at 2:51 P.M., a telephone interview was conducted with medical doctor (MD) 1. MD 1 stated that he was not aware that the RD's recommendations for weekly weights were not implemented. MD 1 stated that Resident 1's hospital lab results indicated dehydration and malnutrition (lack of proper nutrition). MD 1 stated Resident 1 was not given IV therapy at the facility. MD 1 stated that Resident 1's hospital lab results indicated decreased nutrition and hydration which resulted in acute renal failure. A telephone interview with the Director of Nursing (DON) was conducted on [DATE] at 3:02 P.M. The DON stated Resident 1's poor meal and fluid intake should have been addressed. The DON stated the CNAs should have offered alternate meals and snacks, as well as fluids that the resident preferred to eat and drink, to prevent weight loss and dehydration. The DON acknowledged that the RD's recommendation for Resident 1's caloric and fluid intake was not followed. The DON stated that Resident 1's weight loss should have been addressed as soon as the resident started losing weight to avoid further weight loss. The DON stated that a weight loss care plan should have been developed as soon as the weight loss was identified. The DON acknowledged that Resident 1's poor meal and fluid intake, as well as the resident's weight loss, were not addressed by the interdisciplinary team. The DON stated the RD should have identified and addressed Resident 1's poor intake to prevent weight loss. The DON stated that when Resident 1 started to lose weight, the RD should have intervened to prevent further weight loss. The DON stated the IDT, to include the direct staff, should have collaborated to identify possible interventions, such as 1:1 feeding assist and for family member to bring meals Resident 1 preferred to eat. The DON acknowledged that Resident 1's poor intake of food and fluids, and the resident's weight loss, were not addressed. A document review of the facility's policy and procedure titled Nutrition (impaired)/Unplanned Weight Loss-Clinical Protocol, revised [DATE], indicated .1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. 2. The staff and physician will define the individual's current nutritional status (weight, food/fluid intake, and pertinent laboratory values) and identify individuals with anorexia (eating disorder), weight loss or gain, and significant risk for impaired nutrition; for example, high risk residents with acute symptoms such as vomiting, diarrhea, fever and infection, or those taking medications that may be causing weight gain or increasing the risk of anorexia or weight loss. A document review of the facility's policy and procedure titled Hydration-Clinical Protocol, revised [DATE], indicated, .Assessment and Recognition 1. The physician and staff will help define the individual's current hydration status (fluid and electrolyte balances or imbalances [too much or not enough minerals in the body]). a. The physician will distinguish various types of fluid and electrolyte imbalance (for example hyponatremia, hypernatremia, pre-renal azotemia [too much waste product in the blood], etc.) from true hydration (clinically significant loss of total body water) . Treatment/Management . For more severe or complicated fluid and electrolyte imbalance, . intravenous hydration may be needed . A document review of the facility's policy and procedure titled Weight Assessment and Intervention revised on ,d+[DATE], indicated, . Weight assessment: . 5. The threshold for significant unplanned and undesired weight loss will be based on the following: a. 1 month - 5% weight loss is significant .

Based on observation, interview, and record review, the facility failed to ensure two of three residents ' (Resident 1 and Resident 3) written care plans were developed and implemented, when: 1. Resident 1 did not have an individualized care plan developed to address his multiple wounds. 2. Resident 3 ' s written care plan for activities of daily living (ADL, self-care activities) which required two staff to perform bed mobility (how a resident moves in bed) was not implemented. As a result of these failures, there was a potential for Resident 1 ' s wounds to deteriorate and for Resident 3 to experience discomfort and possible injury during care. Findings: 1. A review of Resident 1 ' s Admission Record indicated the resident was admitted on [DATE] with diagnosis to include encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (beneath the first layer of skin), second degree (extends into subcutaneous tissue) burn of the right thigh and foot, and pressure ulcer stage three (injury from sustained pressure extending into subcutaneous tissue) of the sacrum (area above tailbone). A review of Resident 1 ' s physician ' s orders indicated the following: - Cleanse left bunion (a bony bump on the joint at the base of the big toe) with soap and water, pat dry, apply bacitracin (antibacterial ointment) and cover with dry dressing (order dated 10/20/23). -Empty [brand name] drain (used to remove liquid accumulating in a wound) every shift (order dated 10/20/23). -Cleanse open wound to right dorsum (top of foot) with normal saline, pat dry, apply santyl (ointment that removes dead tissue) and cover with dry dressing (order dated 10/29/23). -Cleanse pressure wound to sacrum with normal saline, pat dry, apply medihoney (ointment to promote wound healing), followed by calcium alginate (medicated pad) and cover with foam dressing (order dated 10/27/23). -Cleanse right groin open area with normal saline, pat dry and leave open to air (order dated 10/20/23). -Cleanse open wound to right medial foot with normal saline, pat dry, apply triad paste (promotes wound healing) and cover with dry dressing (order dated 10/19/23). A review of Resident 1 ' s clinical record indicated there were no written care plans to guide the nursing care of the resident ' s wounds and nursing interventions to promote healing and prevent wound deterioration. On 12/26/23 at 2:28 P.M., a joint interview and record review was conducted with the infection prevention nurse (IPN). The IPN reviewed Resident 1 ' s clinical record and stated there were no written care plans developed to address the resident ' s multiple wounds. The IPN stated there should have been a care plan to address each wound. The IPN stated written care plans communicated the expectations for care and what to do for the best outcome. On 12/26/23 at 3:05 P.M., a joint interview and record review was conducted with the director of nursing (DON). The DON reviewed Resident 1 ' s clinical record and stated Resident 1 ' s wounds should have had an individualized written care plan developed to address each one. 2. A review of Resident 3 ' s Admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include a stage 4 pressure ulcer (injury extends into the muscle and/or bone) of the sacrum. A review of Resident 3 ' s Minimum Data Set assessment (MDS, a comprehensive assessment) dated 9/23/23, indicated the resident required extensive assistance (staff to provide weight bearing support) from two or more staff to perform bed mobility. A review of Resident 3 ' s undated ADL care plan indicated bed mobility was to be provided by two staff. On 12/26/23 at 1:20 P.M., an observation of Resident 3 ' s stage 4 pressure ulcer wound treatment was conducted with LN 1. LN 1 positioned Resident 3 onto her side and placed a clean pad underneath the resident and on top of used bed pads and bed linens. Resident 3 was unable to maintain the side lying position and rolled backward onto her back. LN 1 had to position the resident again on her side. Resident 3 moaned while being repositioned and LN 1 told the resident Sorry, sorry, and explained to the resident that he had to turn her to get to the wound. LN 1 removed the soiled dressing from Resident 3 ' s sacral wound. Resident 3 rolled backward onto the bed pad. LN 1 attempted to cleanse Resident 3 ' s wound with a wound cleanser spray but was unable to fully clean Resident 3 ' s wound due to the resident ' s bottom being in close proximity to the mattress. LN 1 positioned Resident 3 onto her side and again the resident rolled backward onto her bottom. LN 1 repositoned Resident 3 onto her side and placed a square shaped calcium alginate with silver (a medicated treatment pad) approximately three by three inches onto Resident 3 ' s sacral wound. Resident 3 rolled backward again. LN 1 repositioned Resident 3 onto her side and the calcium alginate with silver was no longer on the wound and appeared to have been lost in the bed pads and bed linens. LN 1 took another square shaped calcium alginate with silver that was approximately six by six inches and folded it in half and then again in half. Resident 3 rolled backward onto her bottom. LN 1 slid the calcium alginate with silver between the resident ' s bottom and the used pad on the bed, touching the medicated pad with the resident skin and used pads/linens. On 12/26/23 at 1:52 P.M., an interview was conducted with Resident 3 while inside the resident ' s room. Resident 3 stated she was unable help out very much with turning in bed and could not remain laying on her side. Resident 3 stated usually when her wound treatment was performed, it was provided by two staff with one staff holding her. Resident 3 stated the wound care she had been provided today with one staff had been uncomfortable. On 12/26/23 at 2:05 P.M., an interview was conducted with LN 1. LN 1 stated he should have had another staff present to hold the Resident 3 ' s position so he could maintain proper infection control and be able to fully clean the resident ' s wound, apply treatment, and ensure the resident ' s comfort. On 12/26/23 at 4:20 P.M., a joint interview and record review was conducted with the DON. The DON reviewed Resident 3 ' s written ADL care plan and stated the resident ' s bed mobility during wound care should have been provided by two staff. The DON stated it was her expectation for care plans to be fully implemented. A review of the facility ' s policy titled Care Plans, Comprehensive Person-Centered revised 3/2022, indicated, .1. A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs. 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident The policy did not provide guidance related to care plan implementation.

Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 3) was provided privacy during wound care when the resident's privacy curtain was not closed all the way. During Resident 3's wound treatment, a staff member came into the room when the resident ' s private areas were exposed. As a result, Resident 3 was not provided care in a private and dignified manner which had the potential to cause the resident emotional distress. Findings: A review of Resident 3 ' s Admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include a stage 4 pressure ulcer (injury resulting from prolonged pressure to the skin and underlying tissues including muscle and/or bone) of the sacrum (area directly above the tailbone). On 12/26/23 at 1:20 P.M., an observation of Resident 3 ' s stage 4 pressure ulcer wound treatment was conducted with licensed nurse (LN) 1. Resident 3 was positioned in the middle bed of a three-bed room. LN 1 secured Resident 3 ' s privacy curtain along the window side of the resident ' s bed. Resident 3 ' s roommate ' s privacy curtain was closed along the door side of the bed, providing privacy between Resident 3 and her roommate. There was an approximate eight foot gap in between the privacy curtains at the foot of Resident 3 ' s bed. LN 1 positioned Resident 3 onto her side facing the door. Resident 3 ' s buttocks were exposed for the purpose of the treatment procedure. While in a side lying position, Resident 3 ' s gown slid forward exposing the resident ' s right breast. During the treatment procedure, a staff knocked on the resident ' s door and then entered the room. The staff member came to LN 1 and took a set of keys from LN 1 ' s pocket and then left the room. The staff member had been able to visualize the resident ' s body. On 12/26/23 at 1:52 P.M., an interview was conducted with Resident 3 while inside the resident ' s room. Resident 3 stated nursing staff usually provided care to her with her privacy curtains open. Resident 3 stated, Would you like that? Resident 3 stated she did not like being exposed during care. Resident 3 stated, That ' s why I hate it here. On 12/26/23 at 2:05 P.M., an interview was conducted with LN 1. LN 1 stated he should have provided full privacy to Resident 3 during the treatment procedure. LN 1 stated he would not have liked being exposed during care if it were to have happened to him. On 12/26/23 at 2:28 P.M., an interview was conducted with the infection prevention nurse (IPN). The IPN stated Resident 3 ' s privacy curtains should have been completely closed during treatment. The IPN stated Resident 3 should have been provided privacy, it ' s a matter of dignity. On 12/26/23 at 3:05 P.M., an interview was conducted with director of nursing (DON). The DON stated privacy should have been provided to Resident 3 during care and treatment. A review of the facility ' s policy titled Resident Rights revised 2/2021, indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: a. A dignified existence .b. Be treated with respect, kindness, and dignity . t. Privacy and confidentiality

Based on observation, interview, and record review, the facility failed to ensure two of three residents (Resident 2 and 3) reviewed for pressure injuries (damage to the skin and underlying tissues as a result of sustained pressure over long periods of time), had: - Physicians ' orders for pressure injury wound treatments that were followed. -Infection control practices that were adhered to during pressure injury treatments. As a result, there was the potential for Resident 2 and Resident 3 ' s pressure injuries to deteriorate and/or become infected. Findings: 1. A review of Resident 2 ' s Admission Record indicated the resident was readmitted to the facility on [DATE] with diagnosis to include pressure induced deep tissue damage to the left ankle. On 12/26/23 at 11:30 A.M., an observation of Resident 2 ' s left ankle wound treatment was conducted with licensed nurse (LN) 1. A certified nursing assistant (CNA) was also present to help position the resident. The CNA, wearing gloves, proceeded to position Resident 2 and adjust the resident ' s blankets. LN 1 removed Resident 1 ' s dressing from her left ankle and then asked the CNA to give him one of the individually packaged NS wipes set out on the bedside table. The CNA opened one NS wipe and removed it from the package and handed it to LN 1. LN 1 used the NS wipe to soak off a medicated treatment pad that adhered to the resident ' s wound. The CNA held the resident ' s hand. LN 1 performed hand hygiene (washing hands or using an alcohol-based hand rub and putting on clean gloves). Resident 2 ' s ankle wound was open (non-intact skin) and was approximately the size of a pencil eraser with a red-colored wound base resembling granulation tissue (new connective tissue that fills in a wound). LN 1 asked the CNA to provide him with another NS wipe. The CNA let go of the resident ' s hand and opened another individual package of NS wipes and removed the NS wipe. LN 1 ' s N95 (respirator) slid down exposing his nose and nostrils. LN 1 took the NS wipe and wiped the wound bed (open area with non-intact skin) and around the wound edges. LN 1 adjusted his N95 with his gloved hand and then applied a foam dressing to Resident 2 ' s wound. On 12/26/23 at 11:50 A.M., an interview was conducted LN 1. LN 1 stated it was not within the scope of practice for the CNA to know at which step in wound care hand hygiene should be performed. LN 1 stated since the CNA was following his directions, he should have asked the CNA to perform hand hygiene again before providing him with NS wipes, or he should have reached for the NS wipes himself. LN 1 further stated he should not have touched his N95 in the middle of performing Resident 2 ' s treatment. LN 1 stated there was potential cross contamination of Resident 2 ' s wound. On 12/26/23 at 12:40 P.M., an interview was conducted with the infection prevention nurse (IPN). The IPN stated when the CNA touched Resident 2 and the resident ' s environment with her gloved hands and then opened and handed LN 1 the NS wipes, there was cross contamination. The IPN stated when LN 1 pulled up his N95 in the middle of the treatment procedure there was cross contamination. The IPN stated cross contamination could cause Resident 2 ' s wound to develop an infection. A review of Resident 2 ' s treatment orders dated 12/19/23, indicated, Treatment: Left medial malleolus [inner ankle]: Cleanse with NS [normal saline], pat dry, and apply [brand name] skin prep [follow with] silver alginate [medicated pad] then cover with foam dressing . On 12/26/23 at 2:05 P.M., a joint interview and record review was conducted with LN 1. LN 1 reviewed Resident 2 ' s left ankle treatment order dated 12/19/23 and stated that the order had not been followed. LN 1 stated he did not pat Resident 2 ' s wound dry, apply skin prep, and apply calcium alginate. On 12/26/23 at 3:05 P.M., an interview was conducted with the director of nursing (DON). The DON stated infection control practices for gloving, hand hygiene, and masking had not been followed during Resident 2 ' s wound treatment. The DON stated it was her expectation for infection control practices to be followed. The DON further stated Resident 2 ' s treatment order should have been followed. 2. A review of Resident 3 ' s Admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include a stage 4 pressure ulcer (injury extends into the muscle and/or bone) of the sacrum (area directly above the tailbone). On 12/26/23 at 1:20 P.M., an observation of Resident 3 ' s stage 4 pressure ulcer wound treatment was conducted with LN 1. LN 1 positioned Resident 3 onto her side and placed a clean pad underneath the resident and on top of used bed pads and bed linens. Resident 3 was unable to maintain the side lying position and rolled backward onto her back. LN 1 had to position the resident again on her side. Resident 3 moaned while being repositioned and LN 1 told the resident Sorry, sorry, and explained to the resident that he had to turn her to get to the wound. LN 1 removed the soiled dressing from Resident 3 ' s sacral wound. The wound was round and approximately the size of a half dollar coin and about an eighth of an inch deep. The wound bed resembled granulation tissue. Resident 3 rolled backward onto the bed pad. LN 1 attempted to cleanse Resident 3 ' s wound with a wound cleanser spray but was unable to fully clean Resident 3 ' s wound due to the resident ' s bottom being in close proximity to the mattress. LN 1 positioned Resident 3 onto her side and again the resident rolled backward onto her bottom. LN 1 repositioned Resident 3 onto her side and placed a square shaped calcium alginate with silver (a medicated treatment pad) approximately three by three inches onto Resident 3 ' s sacral wound. Resident 3 rolled backward again. LN 1 repositioned Resident 3 onto her side and the calcium alginate with silver was no longer on the wound and appeared lost among the used bed pads and bed linens. LN 1 took another square shaped calcium alginate with silver that was approximately six by six inches and folded it in half and then again in half. Resident 3 rolled back onto her bottom. LN 1 slid the calcium alginate with silver between the resident ' s bottom and the used pad on the bed, touching the medicated pad with the resident skin and used pads/linens. LN 1 placed the calcium alginate with silver against Resident 3 ' s wound bed and pressed it into the wound to fill in the wound depth and then covered it with a foam dressing. A review of Resident 3 ' s physician ' s orders dated 10/24/23, indicated, Treatment: Sacrum -Cleanse wound with wound cleanser or normal saline, gently pat dry, apply collagen dressing followed by calcium alginate to wound bed and cover with silicone foam dressing On 12/26/23 at 2:05 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated the calcium alginate with silver pad made contact with Resident 3 ' s skin and the used pad on the bed before being placed on the resident ' s wound. LN 1 stated this was an infection control concern. LN 1 stated there was potential contamination of Resident 3 ' s wound. LN 1 reviewed Resident 3 ' s physician ' s orders dated 10/24/23 and stated he had not followed the order. LN 1 stated he did not pat the wound dry and apply collagen dressing followed by calcium alginate to the wound bed. LN 1 stated the treatment order should have been followed. LN 1 further stated he should have had another staff present to hold the resident ' s position so he could maintain proper infection control and be able to fully clean the resident ' s wound and apply treatment. On 12/26/23 at 2:28 P.M., an interview was conducted with the IPN. The IPN stated LN 1 should have had another staff present to hold Resident 3 ' s position so the resident ' s wound could be fully cleaned. The IPN stated sliding the medicated treatment pad against the resident ' s skin and bed pads/linens before placing it on the wound had potentially contaminated the wound. The IPN stated Resident 3 ' s treatment orders should have been followed. The IPN further stated calcium alginate should have been cut to fit the wound bed as folding it made it thicker and could place added pressure on the wound. On 12/26/23 at 3:05 P.M., an interview was conducted with the DON. The DON stated it was her expectation for infection control practices to be followed. The DON stated Resident 3 ' s treatment orders should have been followed. A review of the facility ' s policy titled Prevention of Pressure Injuries revised 4/2020, did not provide guidance related to treatment of pressure injuries. A review of the facility ' s policy titled Wound Care revised 10/2010, indicated, . The purpose of this procedure is to provide guidance for the care of wounds to promote healing .Steps in the Procedure 1 . Arrange the supplies so they can be easily reached . 7. Use no-touch technique A review of the facility ' s policy titled Handwashing/Hand Hygiene revised 10/2023, indicated, . This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections .1. Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task . d. after touching a resident; e. after touching the resident ' s environment A review of the facility ' s policy titled Personal Protective Equipment- Contingency and Crisis Use of N-95 Respirators (COVID-19 Outbreak) revised 9/2021, indicated, .a. Front of mask/respirator is contaminated -DO NOT TOUCH. If your hands get contaminated during the mask/respirator removal, immediately wash your hands or use an alcohol-based hand sanitizer

Based on observation, interview, and record review, the facility failed to ensure licensed nurse (LN) 1 performed wound care/treatment in a competent manner. In addition, the facility did not assess LN 1 ' s competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) prior to LN 1 providing wound treatment to two residents (Resident 2 and Resident 3). This failure had the potential to cause the residents ' wounds to worsen and/or become infected. Findings: A review of Resident 2 ' s Admission Record indicated the resident was readmitted to the facility on [DATE] with diagnosis to include pressure induced deep tissue damage to the left ankle. A review of Resident 3 ' s Admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis to include a stage 4 pressure ulcer (pressure injury extending into the muscle and/or bone) of the sacrum (area directly above the tailbone). On 12/26/23 at 11:30 A.M., an observation of Resident 2 ' s left ankle wound treatment was conducted with LN 1. A certified nursing assistant (CNA) was also present to help position the resident. The CNA, wearing gloves, proceeded to position Resident 2 and adjust the resident ' s blankets. LN 1 removed Resident 1 ' s dressing from her left ankle and then asked the CNA to give him one of the individually packaged NS wipes set out on the bedside table. The CNA opened one NS wipe and removed it from the package and handed it to LN 1. LN 1 used the NS wipe to soak off a medicated treatment pad that adhered to the resident ' s wound. The CNA held the resident ' s hand. LN 1 performed hand hygiene (washing hands or using an alcohol-based hand rub and putting on clean gloves). Resident 2 ' s ankle wound was open (non-intact skin) and was approximately the size of a pencil eraser with a red-colored wound base resembling granulation tissue (new connective tissue that fills in a wound). LN 1 asked the CNA to provide him with another NS wipe. The CNA let go of the resident ' s hand and opened another individual package of NS wipes and removed the NS wipe. LN 1 ' s N95 (respirator) slid down exposing his nose and nostrils. LN 1 took the NS wipe from the CNA and wiped the wound bed (open area with non-intact skin) and around the wound edges. LN 1 adjusted his N95 with his gloved hand and then applied a foam dressing to Resident 2 ' s wound. On 12/26/23 at 11:50 A.M., an interview was conducted LN 1. LN 1 stated it was not within the scope of practice for the CNA to know at which step in wound care hand hygiene should be performed. LN 1 stated since the CNA was following his directions, he should have asked the CNA to perform hand hygiene again before providing him with NS wipes, or he should have reached for the NS wipes himself. LN 1 further stated he should not have touched his N95 in the middle of performing Resident 2 ' s treatment. LN 1 stated there was potential cross contamination of Resident 2 ' s wound. On 12/26/23 at 1:20 P.M., an observation of Resident 3 ' s stage 4 pressure ulcer wound treatment was conducted with LN 1. LN 1 positioned Resident 3 onto her side and placed a clean pad underneath the resident and on top of used bed pads and bed linens. Resident 3 was unable to maintain the side lying position and rolled backward onto her back. LN 1 had to position the resident again on her side. Resident 3 moaned while being repositioned and LN 1 told the resident Sorry, sorry, and explained to the resident that he had to turn her to get to the wound. LN 1 removed the soiled dressing from Resident 3 ' s sacral wound. The wound was round and approximately the size of a half dollar coin and about an eighth of an inch deep. The wound bed resembled granulation tissue. Resident 3 rolled backward onto the bed pad. LN 1 attempted to cleanse Resident 3 ' s wound with a wound cleanser spray but was unable to fully clean Resident 3 ' s wound due to the resident ' s bottom being in close proximity to the mattress. LN 1 positioned Resident 3 onto her side and again the resident rolled backward onto her bottom. LN 1 repositioned Resident 3 onto her side and placed a square shaped calcium alginate with silver (a medicated treatment pad) approximately three by three inches onto Resident 3 ' s sacral wound. Resident 3 rolled backward again. LN 1 repositioned Resident 3 onto her side and the calcium alginate with silver was no longer on the wound and appeared lost among the bed pads and bed linens. LN 1 took another square shaped calcium alginate with silver that was approximately six by six inches and folded it in half and then again in half. Resident 3 rolled back onto her bottom. LN 1 slid the calcium alginate with silver between the resident ' s bottom and the soiled pad on the bed, touching the medicated pad with the resident skin and used pads/linens. LN 1 placed the calcium alginate with silver against Resident 3 ' s wound bed and pressed it into the wound to fill in the wound depth and then covered it with a foam dressing. On 12/26/23 at 2:05 P.M., a joint interview and record review was conducted with LN 1. LN 1 reviewed Resident 2 and Resident 3 ' s treatment orders. LN 1 reviewed Resident 2's treatment orders dated 12/19/23, Treatment: Left medial malleolus [inner ankle]: Cleanse with NS [normal saline], pat dry, and apply [brand name] skin prep [follow with] silver alginate [medicated pad] then cover with foam dressing . LN 1 stated that the order had not been followed. LN 1 stated he did not pat Resident 2 ' s wound dry, apply skin prep, and apply calcium alginate. LN 1 reviewed Resident 3 ' s treatment order dated 10/24/23, Treatment: Sacrum -Cleanse wound with wound cleanser or normal saline, gently pat dry, apply collagen dressing followed by calcium alginate to wound bed and cover with silicone foam dressing LN 1 stated he had not followed the order. LN 1 stated he did not pat the wound dry and apply collagen dressing followed by calcium alginate to the wound bed. LN 1 stated the treatment order should have been followed. LN 1 stated the calcium alginate with silver pad made contact with Resident 3 ' s skin and the used pad on the bed before being placed on the resident ' s wound. LN 1 stated this was an infection control concern. LN 1 stated there was potential contamination of Resident 3 ' s wound. LN 1 stated he should have had another staff present to hold the resident ' s position so he could maintain proper infection control and be able to fully clean the resident ' s wound and apply treatment. LN further stated it had been a long time since he did wound treatments for residents. LN 1 stated the wound treatment nurses were currently absent and he was asked to perform wound treatments. LN 1 stated he did not feel comfortable or competent doing wound care. LN 1 stated the last time he was assessed for competency in wound care/treatment was about four years ago. On 12/26/23 at 2:28 P.M., an interview was conducted with the infection prevention nurse (IPN). The IPN stated nurses should be assessed annually for competency in doing wound care. On 12/26/23 at 3:05 P.M., an interview was conducted with the director of nursing (DON). The DON stated the wound treatments LN 1 provided to Resident 2 and Resident 3 did not meet acceptable standards of nursing practice and was not competent care. The DON stated assessing a nurse ' s competency involved observation and evaluation of the demonstrated skill and the result should be documented. The DON stated attending an in-service was not the same as assessing competency. The DON stated nursing competency should be determined before the nurse performed wound care on a resident. The DON stated, Care should be competent. The DON stated it was her expectation for nursing competency assessments to be done annually. On 12/26/23 at 4:20 P.M., an interview was conducted with the DON. The DON stated there was no documentation LN 1 had his competency in wound care/treatment assessed. The DON stated LN 1 had attended some in-service trainings on wound care but there were no knowledge checks or competency assessments done. A review of the facility ' s policy titled Staffing, Sufficient and Competent Nursing, revised 8/2022, indicated, .3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: .i. Skin and wound care .l. Infection control

Based on observation, interview and record review, the facility failed to implement infection control standards of practice when: 1. A dedicated blood pressure cuff, stethoscope and thermometer were not available for eight residents who were on contact isolation precautions for a multi-drug resistant organism (MDRO-bacteria that developed resistance to one or more classes of antibiotics). 2. Face shields or eye protection were not available for staff to use upon entering a resident room with a diagnosis of Coronavirus (COVID-19 an infectious respiratory infection). These failures had the potential to expose other residents, staff, and visitors to infection. Findings: 1. An interview was conducted with the Infection Preventionist (IP) on 9/29/23, at 10:07 A.M. The IP stated the residents in rooms 123 (with three residents), 128 (with two residents) and room [ROOM NUMBER] (with three residents) were in contact isolation precautions. The IP stated the residents in room [ROOM NUMBER] had the diagnosis of candida auris (C. Auris- an MDRO, a multidrug resistant yeast that can cause severe infections, a county-reportable infectious disease). The IP further stated the residents in rooms [ROOM NUMBERS] had the diagnosis of carbapenem-resistant Acinetobacter baumannii (CRAB- a county-reportable infectious disease, an MDRO which makes infections very difficult to treat). An observation of the facility ' s [NAME] Wing 3 and [NAME] Wing 4 was conducted on 9/29/23 at 10:59 A.M. Rooms 123, 128 and 129 had a sign on the wall next to the door which indicated, Stop, and to check with the nurse before entering. Outside the rooms were plastic carts with three drawers. room [ROOM NUMBER] cart included disposable gloves, disposable yellow gowns and one white blood pressure cuff inside the drawers. A tub of hydrogen peroxide (chemical that kills certain bacteria) disinfectant wipes on top of the cart. room [ROOM NUMBER] ' s cart included gloves, gown, one white blood pressure cuff with yellow stethoscope in a sealed plastic bag. A tub of disinfectant wipes was on top of the cart. A stop sign was also posted on the wall next to the door. room [ROOM NUMBER] ' s cart included gloves, gown, one yellow disposable stethoscope and one blood pressure cuff. CNA 2 was observed entering room [ROOM NUMBER] with an N-95 mask, gown and gloves on 9/29/23 at 11:19 A.M. During an interview with CNA 2 after exiting the room, CNA 2 stated the three residents in room [ROOM NUMBER] had the diagnosis of CRAB or C. Auris. CNA stated the residents were on isolation because the bacteria was contagious to the skin, and gown with gloves were needed to protect the residents and staff. CNA 2 stated blood pressure cuffs should be in the cart and each resident should have a dedicated equipment. A joint observation of rooms [ROOM NUMBERS] was conducted with CNA 2. CNA 2 stated the carts did not have dedicated blood pressure cuffs and stethoscopes for each resident. During an interview with CNA 3 on 9/29/23, at 11:50 A.M., CNA 3 stated residents on isolation had their own vital sign machine which was kept at the nurse ' s station. During an interview with LN 1 on 9/29/23, at 11:52 A.M., LN 1 stated there were no vital signs machine for resident on isolation. LN 1 stated rooms on isolation had carts outside the room with a blood pressure cuff in the drawer. LN 1 stated she was unsure if the BP cuff was per room or per resident. An interview and concurrent observation was conducted with LN 2, on 9/29/23, at 11:58 A.M. LN 2 stated rooms with a stop sign should have disposable blood pressure cuff and stethoscope in the isolation cart outside the room or inside the room on a rack by the door. LN 2 checked the isolation carts for rooms 123, 128 and 129 and did not find dedicated blood pressure cuffs, stethoscopes, or thermometers in the isolation cart. In addition, LN 2 also checked inside the residents ' rooms and did not find dedicated blood pressure cuffs, stethoscopes, or thermometers inside the residents ' rooms. LN 2 stated each resident should have a dedicated vital sign equipment because they had an infection which could spread to others. During an interview with the Director of Nursing (DON) on 10/5/23, at 1:56 P.M., the DON stated residents with the diagnosis of CRAB and C. Auris should have dedicated vital signs equipment. The DON stated it was important for residents to have their own vital signs equipment to prevent the spread of infection to other residents. A review of the facility ' s policy and procedure (P&P) titled, Multidrug-Resistant Organisms, dated August 2019 was conducted. The P&P indicated, .Dedicate non-critical medical items to use on individual residents known to be infected or colonized with an MDRO . 2. An observation and interview was conducted on 10/3/23, at 9:34 A.M. with the IP. [NAME] wing 2 was observed with a barrier leading to rooms 111, 112 and 114. The IP stated rooms 111, 112 and 114 had residents who were positive for COVID-19. During a concurrent observation and interview with CNA 5 on 10/3/23, at 9:40 A.M., CNA 5 stated he was assigned to the residents with COVID-19. CNA 5 stated he wore an N-95 mask (a tight-fitting mask that filters airborne particles), goggles, gown, and gloves upon entering a room with COVID-19. Isolation carts outside rooms 111, 112 and 114 did not have goggles or face shields. An interview was conducted with the DON on 10/5/23, at 2:37 P.M. The DON stated staff should use a face shield when caring for residents with COVID-19. The DON further stated face shields were worn as protection since COVID-19 can be transmitted from a resident coughing. During a review of the facility ' s undated P&P titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities, the P&P indicated, .Use safety glasses (e.g. face shields, trauma glasses, goggles) that have extensions to cover the side of the eyes when caring for resident with COVID-19 .

Based on observation, interview and record review the facility did not notify the attending physician in a timely manner regarding weight loss for three of three sampled residents. (Resident 10, 5 and 12). This failure had the potential to result in delayed care for the residents and were not given appropriate interventions to correct weight loss. Findings: Resident 10 was admitted to the facility on [DATE] with the diagnoses including moderate protein-calorie malnutrition (lack of proper nutrition) according to the facility's Admission Record. On 10/3/23, at 10:17 A.M., Resident 10 was observed sitting up in bed with eyes closed. An overbed table was in front of Resident 10 with an opened and unconsumed milk carton and juice. An interview was conducted with CNA 6 on 10/3/23, at 10:21 A.M. CNA 6 stated Resident 10 did not talk much and required set-up with meals. CNA 6 stated Resident 10 was able to feed herself, however needed to be monitored due to episodes of not eating. During an interview and concurrent record review on 10/5/23, at 11:18 A.M. with Licensed Nurse (LN) 6, LN 6 stated Resident 10 weighed 103.4 pounds (lbs) on 8/31/23, then 90.6 lbs on 10/1/23. LN 6 stated Resident 10 had a weight loss of 12.8 lbs since admission. LN 6 stated Resident 10's physician was not notified of Resident 10's weight loss. Resident 5 was admitted to the facility on [DATE] with the diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (disrupted blood flow to the brain) according to the facility's Admission Record. During an interview with Resident 5 on 10/3/23, at 9:52 A.M., Resident 5 stated he did not eat well when he was on a puree diet. Resident 5 stated he knew he had lost weight and it was unplanned. A review of Resident 5's weight record was conducted. Resident 5's recorded weights in the facility's electronic medical record were as follows: 8/15/23 249.5 lbs, 9/1/23 239 lbs, 9/10/23 234.5 lbs, 9/16/23 223.5 lbs, 9/23/23 230 lbs and 10/1/23 226.4 lbs. An interview and concurrent record review was conducted with LN 6 on 10/5/23, at 11:32 A.M. LN 6 stated Resident 5 had a weight loss of 10.5 lb on 9/1/23. LN 6 reviewed Resident 5's progress notes and stated the attending physician was not notified of the weight loss. LN 6 stated Resident 5 continued to have weight loss. Resident 12 was admitted to the facility on [DATE] with the diagnoses including Parkinson's Disease (a brain disorder causing uncontrolled movements, difficulty with balance and coordination). A review of the Registered Dietician's (RD) progress note dated 7/1/23 was conducted. The RD's note indicated Resident 12 was malnourished (poor nutrition). Additional progress note dated 8/18/23 indicated weight goals of 160 lbs to 175 lbs. An interview and concurrent record review was conducted with LN 6 on 10/5/23, at 11:41 A.M. LN 6 stated Resident 12 was on monthly weights. LN 6 reviewed Resident 12's weight record and stated Resident 12's weight on 8/1/23 was 165.5 lbs. LN 6 stated Resident 6's weight on 9/1/23 was 152.8 lb which was a 12.7 lbs weight loss in one month. Upon further review of Resident 6's progress notes, LN 6 stated Resident 6's physician was not notified of the weight loss. During an interview with the Director of Nursing (DON) on 10/18/23, at 12:45 P.M., the DON stated a resident's weight loss was considered a change of condition and it was important to notify the physician. The DON further stated the physician will the resident's medical record and provide orders to prevent further weight loss. A review of the facility's policy and procedure (P&P) titled, Guidelines for Notifying Physicians of Clinical Problems, dated September 2017 was conducted. The P&P indicated, .medical care problems are communicated to the medical staff in a timely, efficient, and effective manner .).

Based on observation, interview, and record review the facility failed to ensure residents' nutritional status were monitored and meal intakes were accurately maintained for three residents with weight loss when: 1. Resident's weights were not taken weekly. (Resident 10, Resident 5 and Resident 12) 2. Staff did not know how to take and record residents' meal percentage. These failures had the potential for residents to experience further weight decline and risk for functional decline, pressure sores and infection. Findings: 1. An interview was conducted with the Restorative Nurse Assistant (RNA- nurse assistants who help residents regain their ability to perform daily activities) on 10/5/23, at 11:05 A.M. The RNA stated residents who required weekly weights were taken on Saturdays and monthly weights were taken at the beginning of the month. The RNA stated a list of residents who required weekly weights were provided by a licensed nurse (LN). Resident 10 was admitted to the facility on [DATE] with the diagnoses including moderate protein-calorie malnutrition according to the facility's Admission Record. A review of Resident 10's physician orders, titled, Order Summary Report, dated 10/6/23, the physician's orders indicated, weekly weights x 4, dated 9/20/23. During an interview and concurrent record review on 10/5/23, at 11:18 A.M. with Licensed Nurse (LN) 6, LN 6 stated weekly weights were completed upon admission, weekly for four weeks until stable. Upon review of Resident 10's weight record, LN 6 stated Resident 10 was not weighed weekly for the month of September 2023. LN 6 stated Resident 10 weighed 103.4 pounds (lbs- a unit of measurement) on 8/31/23, then 90.6 lbs on 10/1/23. LN 6 stated Resident 10 had a weight loss of 12.8 lbs since admission. Resident 5 was admitted to the facility on [DATE] with the diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (disrupted blood flow to the brain) according to the facility's Admission Record. A review of Resident 5's weight record was conducted. Resident 5's recorded weights in the facility's electronic medical record were as follows: 8/15/23 249.5 lbs 9/1/23 239 lbs 9/10/23 234.5 lbs 9/16/23 223.5 lbs 9/23/23 230 lbs and 10/1/23 226.4 lbs. An interview and concurrent record review was conducted with LN 6 on 10/5/23, at 11:32 A.M. LN 6 stated Resident 5 was not weighed the week after 8/15/23 and the next weight was taken on 9/1/23 which showed a weight loss of 10.5 lbs. Resident 12 was admitted to the facility on [DATE] with the diagnoses including Parkinson's Disease (a brain disorder causing uncontrolled movements, difficulty with balance and coordination). A review of the Registered Dietician's (RD) progress note dated 9/25/23 was conducted. The RD's note indicated weekly weights was recommended. An interview and concurrent record review was conducted with LN 6 on 10/5/23, at 11:41 A.M. LN 6 stated Resident 12 was weighed monthly. LN 6 reviewed Resident 12's weight record and stated Resident 12's weight on 8/1/23 was 165.5 lbs. LN 6 stated Resident 6's weight on 9/1/23 was 152.8 lbs which was a 12.7 lbs weight loss in one month. An interview was conducted with the RD on 10/5/23, at 11:51 A.M. The RD stated residents' weights were taken on admission, weekly for four weeks, then monthly if stable. The RD further stated residents who were at risk or with unintended weight loss also required weekly weights. The RD further stated weekly weights upon admission to the facility was important because residents were in a new environment and needed time to adjust, then the resident's baseline weight can be assessed. During an interview with the Director of Nursing on 10/5/23, at 2:04 P.M., the DON stated residents were weighed initially upon admission weekly for four weeks. The DON stated the RD determined if residents will be added to their weight variance meetings. The DON further stated weekly weights were changed to monthly if residents were stable. A review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated March 2022 was conducted. The P&P indicated, .Resident weights are monitored for undesirable or unintended weight loss . 2. An interview was conducted with CNA 6 on 10/3/23, at 10:21 A.M. CNA 6 stated resident's meal percentage was determined based on what was served on the plate and the soup. CNA 6 stated soup was 10% or 15% of the meal. An interview was conducted with LN 4 on 10/3/23, at 10:36 A.M. regarding how meal percentages were determined. LN 4 stated percentage of resident's meal was determined by looking at the tray and what the resident ate. LN 4 stated she was not sure how else to calculate meal percentages. During an interview on 10/5/23, at 11:00 A.M. with CNA 7, CNA 7 stated resident's meal percentage depended on the portions of the main meal and three portions of the meal eaten would be 75%. An interview was conducted with the Director of Nursing on 10/18/23, at 12:45 P.M. The DON stated residents' meal percentages should be accurate to ensure accuracy of weight variances and follow up as needed. The facility did not provide a policy and procedure regarding residents' meal percentages.

Based on interview and record review the facility failed to provide notice of bed-hold policy for 1 of 3 sampled residents (Resident 1) upon admission to the facility or transfer to the hospital. As a result, Resident 1 was not allowed to return to the facility upon hospital discharge. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included compression fractures of the vertebrae (small breaks bones that form the spine) and chronic obstructive pulmonary disease (COPD, a disease that restricts airflow into the lungs and makes it hard to breath). A review of Resident 1 ' s admission record indicated, Resident 1 had insurance coverage that included Medicare b (federal health insurance that covers healthcare for people over 65) and medi-cal (health insurance for that covers medical services for children and residents with limited income in California). A review of the facility ' s discharge records indicated Resident 1 was transferred to the hospital on 5/21/23 at 4:26 P.M. On 6/1/23 at 11:11 A.M. an interview was conducted with the case management assistant (CMA). CMA stated Resident 1 was at the facility for three weeks before being transferred to the hospital. CMA stated she was responsible for communicating with insurance groups who pay for resident bed holds when they are transferred to the hospital. CMA stated she had reviewed Resident 1 ' s insurance authorization record which showed no indication a bed hold was authorized. CMA stated a bed hold notification should have been submitted for Resident 1. CMA stated the admissions director (AD) was responsible for obtaining bed holds on admission. On 6/1/23 at 11:11 A.M. an interview was conducted with the Admissions Director (AD). The AD stated she was not working on 5/21/23 when Resident 1 was transferred to the hospital. AD stated she did not know if Resident 1 was offered a bed hold on transfer to the hospital. AD stated residents who have bed holds were listed on the facility census following the date of transfer to the hospital. AD stated she did not see Resident 1 with a bed hold on the facility census when she returned to work. AD stated the nurses were responsible for obtaining the bed hold authorization at transfer. AD stated the business office manager (BOM) was responsible for submitting the bed hold authorization to the insurance company. On 6/1/23 at 12:02 P.M. an interview was conducted with the Business Office Manager (BOM). The BOM stated she ran reports in the morning that indicated resident admissions, room changes, transfers, and discharges. The BOM stated Resident 1 should have been offered a bed hold upon transfer to the hospital. The BOM stated nursing staff should have provided Resident 1 with a written bed hold notice. The BOM stated if nursing had offered Resident 1 a bed hold BOM would have sent the insurance group an authorization form for payment. In addition, the BOM stated she did not send a bed hold authorization form for payment to Resident 1 ' s insurance group. On 6/1/23 at 1:58 P.M. an interview was conducted with licensed nurse (LN) 1. LN 1 stated the bed hold notice procedure was to provide a resident written notification of bed hold policy upon admission and transfer to the hospital. LN 1 stated the bed hold notice would be signed by the resident and the nurse and then placed in the resident paper chart. LN 1 stated if the resident did not want a bed hold, the notice should still be signed as rejected and placed in the medical chart. On 6/1/23 at 2:30 P.M. an interview and record review of Resident 1 ' s medical chart was conducted with the director of medical records (DMR). A blank bed hold form was observed in the chart. The MRD stated the bed hold notice should have been filled out and signed by Resident 1 and a nurse and placed back in the chart. MRD stated there was also no bed hold notice in the electronic medical record. On 7/12/23 at 2:37 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated all residents should be offered a written bed hold notice by nursing upon transfer to the hospital. The DON stated the BOM is responsible for submitting the bed hold authorization form to the insurance group. The DON stated the bed hold notice should be signed by the resident and kept in the medical chart. Resident 1 ' s nursing discharge note, dated 5/21/23 at 4:30 P.M. indicated Resident 1 or their representative was not given a written bed hold notice. The facility census dated 5/22/23 indicated Resident 1 had been discharged and Resident 1 was not listed underneath the Bed hold Updates section. A review of the facility policy titled Bed-Holds and Returns revised October 2022 indicated, Policy Statement: Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed hold policies. Policy Interpretation and Implementation: 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident ' s bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at the time of transfer (or if the transfer was an emergency, within 24 hours).