Every finding on record at West Shore Post Acute

Based on interview and record review, for one of two sampled residents (Resident 1) reviewed for pressure ulcer (also called a bedsore, or pressure injury, is localized damage to the skin and/or underlying tissue caused by constant or prolonged pressure, often combined with shear [mechanical force that causes deep tissue damage when layers of skin and underlying tissues slide in opposite directions] or friction), the facility failed to notify the physician and Resident Representative (RR 1) when Resident 1 developed a Stage 3 pressure ulcer (a full thickness skin loss injury in which the damage extends through the epidermis, outermost layer of the skin, and dermis, below the epidermis, into the fat layer, but does not expose muscle, tendon, ligament, cartilage, or bone. May include slough, a yellow, tan, green, or brown devitalized tissue; or eschar, dry, black or brown dead tissue) on the sacrum (large, triangular bone at the base of the spine, located just above the tailbone) representing a significant change in condition that required timely medical consultation and notification.This failure resulted in Resident 1's pressure ulcer worsening, transfer to an acute care hospital (ACH) related to the delayed treatment interventions, lack of physician oversight, and missed opportunities to prevent deterioration of the wound. This failure prevented RR 1 from advocating for timely medical evaluation and intervention. Resident 1 had subsequent acute medical complications including lethargy (abnormal drowsiness and an unusual lack of energy, alertness, or mental responsiveness), acute kidney injury (abrupt loss of kidney function, leading to accumulation of toxins, fluid and electrolyte imbalance) and sepsis (a life-threatening medical emergency in which the body's response to an infection becomes extreme and dysregulated, causing injury to its own tissues and organs) from a Stage 3 pressure ulcer and eventually passed on 8/1/26.Findings:During a review of Resident 1's admission Record (AR, a formal document created at the time a resident is admitted into a healthcare facility) printed on 8/17/26, the AR indicated Resident 1 was admitted to the facility in February 2026 with diagnoses that included Stage 4 chronic kidney disease (long-term condition in which the kidneys are damaged or have abnormal structure and cannot filter blood properly), asthma (chronic lung condition that makes it hard to breathe), emphysema (chronic lung disease in which the air sacs in the lungs become damaged, resulting in reduced ability to breathe and impaired oxygen exchange), weakness and chronic lymphocytic leukemia (slow growing cancer of the blood and bone marrow in which the body makes too many abnormal lymphocytes (a type of white blood cell, WBC, that don't function normally and can't fight infection effectively). The AR indicated RR 1 was listed as Resident 1's Responsible Party/Agent.During a telephone interview on 08/13/26 at 2:39 p.m., RR 1 stated that while Resident 1 was hospitalized , sometime after 07/20/26, the ACH physician told RR 1 that Resident 1 had been admitted with a severe sacral pressure ulcer. RR 1 stated the facility never notified them that Resident 1 had developed a pressure ulcer. RR 1 further stated that had they been informed, they would have requested additional evaluation from the attending physician.During a review of Resident 1's care plans titled, Potential for Impaired Skin Integrity and Risk for Skin Breakdown dated 2/6/26, the care plans interventions that included the following; assisting Resident 1 with turning and repositioning in bed, observing skin integrity during routine care, referring Resident 1 to the Registered Dietician (RD) for nutritional needs, and reporting any skin integrity changes to the Attending Physician (AP) as indicated. During a concurrent interview and record review on 8/17/26 at 11:09 a.m. with Treatment Nurse (TN) 1 and TN 2, Resident 1's Electronic Health Record (EHR) for Weekly Pressure Ulcer Assessment (WPUA) and IDT (Interdisciplinary team, a group composed of individuals representing different departments of the facility)-Pressure Ulcer notes from 2/6/26 through 7/20/26 were reviewed. TN 1 stated Resident 1 had a Stage 2 pressure ulcer (a partial thickness loss of skin presenting as a shallow open ulcer) on the sacrum upon admission on [DATE], IDT-Pressure Ulcer notes dated 3/2/26 indicated that Resident 1's sacral pressure ulcer was documented as healed. TN 2 stated the same sacral area later re-opened but she was not sure of the date of re-opening. TN 1 stated it might have re-opened when Resident 1 returned from a recent hospital stay from 4/26/26 to 4/27/26. Both TN 1 and TN 2 could not find the documentation when it re-opened.During a review of Resident 1's CoC: Change of Condition Fall dated 4/26/26, the CoC indicated Resident 1 was transferred to the hospital after an unwitnessed fall on 4/26/26.During a review of Resident 1's Nursing Daily Skilled (NDS, nursing documentation completed to record resident's condition, nursing intervention, and response to treatment) dated 4/27/26, the NDS indicated Resident 1 returned to the facility from the hospital on 4/27/26, Resident 1's skin was clear and no pressure ulcer was observed.During a concurrent interview and record review on 8/17/26 at 11:25 a.m. with the Director of Nursing (DON), Resident 1's EHR for Physician's Orders, IDT-Pressure Ulcer notes and Change of Condition (CoC) notes from 2/6/26 through 7/20/26 were reviewed. The DON stated Resident 1 was admitted on [DATE] with a Stage 2 pressure ulcer on the sacrum, was treated with normal saline (a sterile solution commonly used as wound cleanser) cleansing, Triad paste (moisture barrier wound dressing used to protect skin and treat wounds that are shallow or moisture-related) with foam dressing at that time. The DON stated the pressure ulcer was documented on the IDT-Pressure Ulcer note dated 3/18/26 as healed on 3/18/26. The DON stated Resident 1's pressure ulcer re-opened on 7/10/26, months after returning from the hospital, as evidenced by a treatment order initiated on 7/11/26, to wash the open area with normal saline and apply barrier cream via a telephone order signed by AP on 7/15/26. The DON stated the re-opened pressure ulcer was Stage 3. The DON stated she was unable to state the size of Resident 1's sacral pressure ulcer as of 7/10/26 as facility did not complete a pressure ulcer assessment. The DON further stated identification of a pressure ulcer warrants a CoC assessment, as this would have triggered a comprehensive pressure ulcer assessment, physician recommendation for treatment, and required notifications to the physician and Resident 1's Representative (RR 1). The DON also stated the CoC would have guided nursing interventions and wound management. The DON stated nursing staff should have completed Weekly Pressure Ulcer Assessments (WPUAs) on 7/10/26 and 7/17/26, however; the only assessment in the record was dated 7/21/26, which was a day after Resident 1 was taken to the ACH. The DON stated WPUAs were essential to monitor healing and identify changes requiring intervention. The DON stated facility completed only one Nursing Weekly Skin Review (NWSR) assessment (on 7/12/26) during a period of 07/1/26 till 7/20/26, The DON stated, even that assessment did not indicate the presence of a pressure ulcer, though it should have. The DON stated there should have been another NWSR on 7/19/26, but that too was not completed. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status last revised December 2025, the P&P indicated, the facility must notify the attending physician and the resident representative whenever there is a significant change in the resident's condition. A significant change is defined as a decline or improvement that will not resolve without staff intervention and require changes to the resident's medical treatment. During an interview on 8/17/26 at 2:03 pm with TN 2, TN 2 stated she did not complete a CoC on 7/10/26, as she assumed the charge nurses were expected to complete the CoC. TN 2 stated, however, she did not confirm whether Resident 1's charge nurses were even aware that Resident 1's sacral area had re-opened. TN 2 stated that protocols at the facility had been frequently changing, contributing to confusion about their responsibilities.During an interview on 8/17/26 at 2:23 p.m. with DON, the DON stated, on 7/10/26, TN 2 informed her that she might want to look at Resident 1's open area, and she just instructed TN 1 and TN 2, to follow facility's pressure ulcer protocol. The DON stated it was her oversight for not verifying if and which protocol TN 1 and TN 2 followed to treat Resident 1's pressure ulcer, as she assumed they were familiar with the correct procedures. The DON stated she should have reviewed facility's protocol and expectations with TN 1 and TN 2, to ensure appropriate wound-care management applicable for Resident 1.During a review of Resident 1's Order Audit Report (OAR) dated 7/10/26, created by TN 2, the OAR indicated coccyx (tailbone) Stage 3 pressure ulcer treatment as: cleanse with normal saline, pat dry, apply barrier cream and cover with foam dressing every dayshift and as needed if soiled or dislodged. The OAR indicated that TN 2 entered the order in Resident 1's clinical record and later signed by AP on 7/15/26.During a telephone interview on 8/20/26 at 11:08 a.m. with the DON, the DON stated the barrier cream used on Resident 1 was not an appropriate treatment for a Stage 3 pressure ulcer, noting that its use could worsen the wound. The DON stated facility did not have any pressure ulcer protocol in place to guide treatment nurses on which interventions were appropriate for different stages of pressure ulcer. The DON also stated Resident 1's Attending Physician (AP) was not aware that Resident 1's pressure ulcer had re-opened or that barrier cream was being applied for 10 days. The DON further stated facility did not conduct any IDT reviews to discuss Resident 1's health condition related to re-opening of pressure ulcer. The DON stated, had an IDT review been completed, it would have warranted more appropriate interventions to treat the wound.During a review of Resident 1's Treatment Administration Record (TAR) for July 2026, the TAR indicated Resident 1's Stage 3 pressure ulcer was treated with barrier cream and covered with foam dressing daily for 10 days from 7/11/26 to 7/20/26.During a telephone interview on 8/20/26 at 11:38 a.m. with Advice Nurse (AN, nurse who relays information between facility nurses and Attending Physician (AP) over the phone to determine urgency and needed interventions based on protocols and physician orders. AN stated that the advice line received two calls in July 2026, one dated 7/9/26, which did not come from the facility and was placed by an outside party, and the other was dated 7/20/26, which occurred when Resident 1 became difficult to arouse that resulted in a 911 transfer to the hospital. AN also stated the advice line did not record any calls received concerning Resident 1 developing a pressure ulcer.During a telephone interview on 8/20/26 at 1:42 p.m. with Resident 1's AP, the AP stated neither he was aware nor facility made him aware of Resident 1's pressure ulcer. AP stated had he been notified, he would have evaluated the treatment that had been initiated by facility staff. AP stated that barrier cream may be appropriate for a Stage 3 ulcer, only if the wound was without slough and maceration (softening, whitening, and breakdown of skin caused by prolonged exposure to moisture) of the peri-wound (surrounding) skin. AP stated if the wound already had macerated surrounding tissue or slough on the wound bed, then barrier cream would not be appropriate because it would not help debride (break down dead tissue in wounds so healthy tissue can form) the wound. AP stated, in such situation, he would have ordered either Santyl (prescription enzymatic debriding ointment) or Medi honey (medical grade honey with strong antibacterial properties) as more appropriate treatment options, or could have done debridement (removal of dead, devitalized, or infected tissue from a wound so healthy tissue can grow and healing can occur) sooner.During a telephone interview on 8/20/26 at 1:42 p.m. with AP, AP stated he was not aware Resident 1 had a pressure ulcer and had not been notified of its presence. AP stated had he been notified, AP would have evaluated the treatment that had been initiated by facility staff. AP stated that barrier cream may be appropriate for a Stage 3 ulcer, only if the wound is without slough and without maceration of the peri-wound (surrounding) skin. AP stated if the wound already had macerated surrounding tissue or slough on the wound bed, then barrier cream would not be appropriate because it would not help debride (break down dead tissue in wounds so healthy tissue can form) the wound. AP stated, in such situation, he would have ordered either Santyl (prescription enzymatic debriding ointment) or Medi honey (medical grade honey with strong antibacterial properties) as more appropriate treatment options.During a review of the facility's undated P&P titled Pressure Ulcers-Clinical Protocol, undated, the P&P indicated, nursing staff must assess residents for pressure injury risk on admission (BSA), quarterly, and whenever there is a significant change in condition. The protocol required notifying the physician of any newly identified pressure injuries and providing treatment according to physician's orders. Treatment may include pressure redistribution, repositioning, wound care, pain management, nutritional support, and other appropriate interventions.During a review of Resident 1's CoC dated 7/20/26, the CoC indicated, on 7/20/26 at 10:22 a.m., Resident 1 was difficult to arouse despite performing sternum (breastbone) rub, 911 was called and Resident 1 was transferred to the acute care hospital (ACH).During a review of Resident 1's [Emergency Department] ED Transfer Form (EDTF, a form filled out sent with the resident during transfer to the hospital with resident information including skin status) dated 7/20/26, the EDTF indicated, under Skin Assessments, that Resident 1 did not have any current skin condition (e.g. pressure ulcer).During a review of Resident 1's Wound Ostomy Progress Note (WOPN) from ACH, dated 7/21/26, the WOPN indicated an unstageable pressure ulcer (a full thickness pressure injury in which the base of the wound is completely covered by slough or eschar, making it impossible to determine the true depth of tissue damage until enough of that dead tissue is removed) on Resident 1's sacral/coccyx (tailbone) area. The WOPN indicated Resident 1's wound had sanguineous (bright red and consists primarily of fresh blood, with syrup-like consistency indicating bleeding from the wound bed or damaged blood vessels) discharge, maceration (softening, whitening, and breakdown of the skin caused by prolonged exposure to moisture) on the surrounding skin, and the wound bed was covered with 75-100% black eschar (dead tissue that forms a thick, dry, hard, black covering over a wound). During a review of Resident 1's Discharge Summary Notes (DSN) from ACH, dated 8/1/26, the DSN indicated that Resident 1 had developed metabolic acidosis (dangerous acid-base imbalance in which the blood contains too much acid or too little bicarbonate, or alkali) and Acute Kidney Injury (AKI, a sudden decline in kidney function). The AKI was believed to be caused by Acute Tubular Nephrosis (ATN, a severe form of acute kidney injury) resulting from sepsis. The DSN further indicated Resident 1's medical status did not improve with ceftriaxone (a powerful antibiotic). As a result, Resident 1 remained at high risk for recurrent infection and sepsis related to the sacral ulcer. The DSN further indicated that source control for infection/sepsis, specifically debridement (removal of dead, devitalized, or infected tissue from a wound so healthy tissue can grow and healing can occur) of the sacral ulcer, was recommended but declined by the family. Resident 1 was subsequently placed on comfort care (medical care that focuses on relieving pain, easing symptoms, and maximizing quality of life, rather than curing or controlling a disease) only on 7/27/26 and passed away on 8/1/26.

Based on interview and record review, the facility failed to ensure appropriate preventative measures were implemented for one of two sampled residents (Resident 1) who had a known history of sacral (tail bone) pressure ulcer (a pressure injury characterized by localized damage to the skin and/or underlying tissue caused by prolonged pressure, often combined with shear or friction) when the facility failed to do the following:Complete Braden Scale for Predicting Pressure Ulcer (BSPP, a standardized, evidence based nursing assessment tool used to determine a patient's risk for developing pressure ulcers) assessment as scheduled to evaluate Resident 1's risk for pressure ulcer development for a period over more than four months from 2/13/26 to 7/20/26.Implement Resident 1's potential for skin impairment care plan, including failing to ensure regular turning and repositioning, routine skin inspections, and prompt physician notification when a pressure ulcer was identified on Resident 1's sacrum on 7/10/26.Conduct a comprehensive pressure ulcer assessment, including its characteristics and wound measurement when Resident 1 developed a Stage 3 pressure ulcer (a full thickness skin loss injury in which the damage extends through the epidermis, outermost layer of the skin, and dermis, below the epidermis, into the fat layer, but does not expose muscle, tendon, ligament, cartilage, or bone. May include slough, a yellow, tan, green, or brown devitalized tissue; or eschar, dry, black or brown dead tissue) on the sacrum.Revise/update skin care plan to reflect development and management of pressure ulcer, after the Stage 3 ulcer was observed on 7/10/26.Accurately document pressure ulcer status in the Nursing Weekly Summary Reviews (NWSR). The NWSR dated 7/12/26 did not reflect the identified Stage 3 ulcer, and no NWSR was completed on 7/19/26.Complete Weekly Pressure Ulcer Assessments (WPUA) for the week of 7/10/26 through 7/20/26.Conduct an Interdisciplinary Team (IDT, a group composed of individuals representing different departments of the facility) evaluation to assess the pressure ulcer, determine contributing factors, or evaluate the appropriateness of treatment.Provide evidence based wound treatment, as the facility applied barrier cream (a topical skin protectant that forms a protective layer over the skin) -an intervention not appropriate for a Stage 3 pressure ulcer. These failures resulted in Resident 1's pressure ulcer worsening from Stage 3 with slough to unstageable sacral pressure ulcer with 75-100% eschar (possibly Stage 4, most severe stage of pressure ulcer, involves full thickness tissue loss where muscle, ligament, tendon or even bone is visible, may also include eschar and slough tissue), transfer to an acute care hospital (ACH, medical facility that provides short term, intensive treatment for serious injuries, sudden illnesses, urgent medical conditions) and subsequent acute medical complications including lethargy (abnormal drowsiness and an unusual lack of energy, alertness, or mental responsiveness), acute kidney injury (abrupt loss of kidney function, leading to accumulation of toxins, fluid and electrolyte imbalance), and sepsis (a life-threatening medical emergency in which the body's response to an infection becomes extreme and dysregulated, causing injury to its own tissues and organs) from a Stage 3 pressure ulcer and eventually passed on 8/1/26.(Cross-Reference F580) Findings:During a review of Resident 1's admission Record (AR, formal document created at the time a resident is admitted into a healthcare facility) printed on 8/17/26, the AR indicated Resident 1 was admitted to the facility in February 2026 with diagnoses that included Stage 4 chronic kidney disease (long-term condition in which the kidneys are damaged or have abnormal structure and cannot filter blood properly), asthma (chronic lung condition that makes it hard to breathe), emphysema (chronic lung disease in which the air sacs in the lungs become damaged, resulting in reduced ability to breathe and impaired oxygen exchange), weakness and chronic lymphocytic leukemia (slow growing cancer of the blood and bone marrow in which the body makes too many abnormal lymphocytes (a type of white blood cell, WBC, that don't function normally and can't fight infection effectively). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/15/26, under Section GG (functional abilities with daily living activities), the MDS indicated Resident 1 required maximal assistance (helper provides more than half the effort) from staff with turning and repositioning, to roll from lying on back to left and right side and return to lying on back while in bed.During a review of Resident 1's BSPPU dated 2/6/26, the BSPPU indicated Resident 1 had a moderate risk of developing pressure ulcer, related to prolonged pressure, exposure to moisture, movement ability and overall skin integrity. The BSPPU indicated staff was to complete the assessment upon admission for four weeks and quarterly thereafter.During a review of Resident 1's care plan titled, Potential for Impaired Skin Integrity and Risk for Skin Breakdown dated 2/6/26, the care plans indicated interventions that included the following: assisting Resident 1 with turning and repositioning in bed, observing skin integrity during routine care, referring Resident 1 to the Registered Dietician (RD) for nutritional needs, and reporting any skin integrity changes to the Attending Physician (AP) as indicated.During a concurrent interview and record review on 8/17/26 at 11:09 a.m. with Treatment Nurse (TN) 1 and TN 2, Resident 1's Electronic Health Record (EHR) for WPUA and IDT-Pressure Ulcer notes from 2/2/26 through 07/20/26 were reviewed. TN 1 stated Resident 1 had a Stage 2 pressure ulcer (a partial thickness loss of skin presenting as a shallow open ulcer) on the sacrum upon admission on [DATE], and the IDT notes dated 3/2/26 indicated that pressure ulcer was documented as healed. TN 2 stated the same sacral area later re-opened but she was not sure of the date of re-opening. TN 1 stated it might have re-opened when Resident 1 returned from a recent hospital stay. Both TN 1 and TN 2 could not find the documentation when it re-opened.During a review of Resident 1's CoC: Change of Condition Fall assessment dated [DATE], the CoC indicated Resident 1 was transferred to the hospital after an unwitnessed fall on 4/26/26.During a review of Resident 1's Nursing Daily Skilled (NDS, nursing documentation completed to record resident's condition, nursing intervention, and response to treatment) dated 4/27/26, the NDS indicated Resident 1 returned to the facility from the hospital on 4/27/26, Resident 1's skin was clear and no pressure ulcer was observed.During a concurrent interview and record review on 8/17/26 at 11:25 a.m. with the Director of Nursing (DON), Resident 1's EHR for Physician's Orders, IDT-Pressure Ulcer notes and Change of Condition (CoC) from 2/6/26 till 7/20/26 were reviewed. The DON stated Resident 2 was admitted with a Stage 2 pressure ulcer on the sacrum, was treated with normal saline (a sterile solution commonly used as wound cleanser) cleansing, Triad paste (moisture barrier wound dressing used to protect skin and treat wounds that are shallow or moisture-related) with foam dressing (a soft, absorbent wound dressing made of polyurethane or silicone foam) at that time. The DON stated the IDT-Pressure Ulcer note dated 3/18/26 indicated the pressure ulcer was healed by 3/18/26. The DON stated Resident 1's pressure ulcer re-opened on 7/10/26, months after returning from the hospital, as evidenced by a treatment order initiated on 7/11/26. The DON stated treatment order indicated staff was to wash the open area with normal saline and apply barrier cream. The DON stated the re-opened pressure ulcer was Stage 3. The DON stated she was unable to state the size of Resident 1's sacral pressure ulcer as of 7/10/26 as facility did not complete a pressure ulcer assessment. The DON further stated treatment and condition of a pressure ulcer warrants a Change of Condition (CoC) assessment, as this would have triggered a comprehensive pressure ulcer assessment, physician recommendation for treatment, and required notifications to the physician and Resident 1's Representative (RR 1). The DON also stated completion of a CoC assessment would have guided the staff to take appropriate nursing interventions and wound management. The DON stated nursing staff should also have completed Weekly Pressure Ulcer Assessments (WPUAs) on 7/10/26 and 7/17/26, however; the only assessment in the record was dated 7/21/26, which was a day after Resident 1 was taken to the acute care hospital (ACH). The DON stated WPUAs were essential to monitor healing and identify changes requiring intervention. The DON stated facility completed only one Nursing Weekly Skin Review (NWSR) assessment (on 7/12/26) during a period of 07/1/26 till 7/20/26. The DON stated, even the NWSR dated 7/12/26 did not indicate the presence of a pressure ulcer, though it should have. The DON stated there should have been another NWSR on 7/19/26, but that too was not completed. During a review of Resident 1's IDT-Pressure Ulcer (documentation completed by the Interdisciplinary Team (IDT) for the purpose of documenting the ulcer's status, healing progress, treatment plan, and any updates) from February 2026 to July 2026, the IDT-Pressure Ulcer indicated the last IDT-Pressure Ulcer was dated 3/18/26, there were no subsequent IDT that addressed Resident 1's re-opened sacral pressure ulcer.During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status last revised December 2025, the P&P indicated, the facility must notify the attending physician and the resident representative whenever there is a significant change in the resident's condition. A significant change is defined as a decline or improvement that will not [be] resolve[d] without staff intervention and require changes to the resident's medical treatment.During a concurrent interview and record review on 8/17/26 at 12:20 p.m. with Nurse Supervisor (NS) 1, Resident 1's BSPPU dated 2/6/26 and pressure ulcer care plans dated 2/6/26 and 2/11/26 were reviewed. NS 1 stated potential risk for skin breakdown care plan dated 2/6/26 was documented in the clinical record, but facility did not develop a care plan addressing an actual sacral pressure ulcer identified on 7/10/26. NS 1 stated she was not even aware if Resident 1 had a pressure ulcer; charge nurses did not perform wound treatments as these are completed by the treatment nurses. NS 1 also stated she did not participate in IDT meetings to address Resident 1's sacral pressure ulcer. During an interview on 8/17/26 at 2:00 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 did not have a regular CNA assigned on day shift, and care was provided by floating staff in that unit who were not familiar with Resident 1's care needs. CNA 1 stated he recalled Resident 1's routine care as: bringing Resident 1 a breakfast tray, then a brief change, returning at lunchtime to deliver Resident 1's lunch tray, followed by completing a second brief change for the shift. CNA 1 stated he did not recall assisting Resident 1 with turning and repositioning every two hours when he provided care to Resident 1.During an interview on 8/17/26 at 2:03 p.m. with TN 2, TN 2 stated she did not complete a CoC on 7/10/26, as she assumed the charge nurses were expected to complete the CoC. TN 2 stated, however, she did not confirm whether Resident 1's charge nurses were even aware that Resident 1's sacral area had re-opened. TN 2 stated that protocols at the facility had been frequently changing, contributing to confusion about their responsibilities.During an interview on 8/17/26 at 2:23 p.m. with DON, the DON stated, on 7/10/26, TN 2 informed the DON that she might want to look at Resident 1's open area, the DON instructed TN 1 and TN 2, to follow facility's pressure ulcer protocol. The DON stated it was her oversight for not verifying if and which protocol TN 1 and TN 2 followed to treat Resident 1's pressure ulcer, as she assumed they were familiar with the correct procedures. The DON stated she should have reviewed facility's protocol and expectations with TN 1 and TN 2, to ensure appropriate wound-care management applicable for Resident 1.During an interview on 8/17/26 at 3:45 p.m. with CNA 2, CNA 2 stated she noticed that Resident 1's health status was declining in July 2026 when Resident 1 started to stay in bed most of the time. CNA 2 stated it was around beginning of July 2026 when Resident 1 had the pressure ulcer developed. CNA 2 stated that prior to the development of the pressure ulcer, Resident 1 was able to turn and reposition independently bed. CNA 2 stated she did not provide any assistance with turning and frequently until Resident 1's health condition declined.During a review of Resident 1's Order Audit Report (OAR) dated 7/10/26, the OAR indicated, coccyx (tailbone) Stage 3 pressure ulcer treatment as: cleanse with normal saline, pat dry, apply barrier cream and cover with foam dressing every dayshift and as needed if soiled or dislodged. The OAR indicated that TN 2 entered the order in Resident 1's clinical record.During a review of Resident 1's Treatment Administration Record (TAR) for July 2026, the TAR indicated Resident 1's Stage 3 pressure ulcer was treated with barrier cream and covered with foam dressing daily for 10 days from 7/11/26 to 7/20/26.During a telephone interview on 8/20/26 at 11:08 a.m. with the DON, the DON stated the barrier cream used on Resident 1 was not an appropriate treatment for a Stage 3 pressure ulcer, noting that its use could worsen the wound. The DON stated facility did not have any pressure ulcer protocol in place to guide treatment nurses on which interventions were appropriate for different stages of pressure ulcer. The DON also stated Resident 1's Attending Physician (AP) was not aware that Resident 1's pressure ulcer had re-opened or that barrier cream was being applied for 10 days. The DON further stated facility did not conduct any Inter-disciplinary Team IDT reviews to discuss Resident 1's health condition related to re-opening of pressure ulcer. The DON stated, had an IDT review been completed, it would have warranted more appropriate interventions to treat the wound.During a telephone interview on 8/20/26 at 11:38 a.m. with Advice Nurse (AN, nurse who relays information between facility nurses and Attending Physician (AP) over the phone to determine urgency and needed interventions based on protocols and physician orders), AN stated that the advice line received two calls in July 2026, one dated 7/9/26, which did not come from the facility and was placed by an outside party, and the other was dated 7/20/26, which occurred when Resident 1 became difficult to arouse that resulted in a 911 transfer to the hospital. AN also stated the advice line did not record any calls received concerning Resident 1 developing a pressure ulcer.During a telephone interview on 8/20/26 at 1:42 p.m. with Resident 1's AP, the AP stated neither he was aware nor facility made him aware of Resident 1's pressure ulcer. AP stated had he been notified, he would have evaluated the treatment that had been initiated by facility staff. AP stated that barrier cream may be appropriate for a Stage 3 ulcer, only if the wound was without slough and maceration (softening, whitening, and breakdown of skin caused by prolonged exposure to moisture) of the peri-wound (surrounding) skin. AP stated if the wound already had macerated surrounding tissue or slough on the wound bed, then barrier cream would not be appropriate because it would not help debride (break down dead tissue in wounds so healthy tissue can form) the wound. AP stated, in such situation, he would have ordered either Santyl (prescription enzymatic debriding ointment) or Medi honey (medical grade honey with strong antibacterial properties) as more appropriate treatment options, or could have done debridement (removal of dead, devitalized, or infected tissue from a wound so healthy tissue can grow and healing can occur) sooner.During a review of the facility's undated P&P titled Pressure Ulcers-Clinical Protocol, the P&P indicated, nursing staff must assess residents for pressure injury risk on admission (BSA), quarterly, and whenever there is a significant change in condition, when a pressure ulcer is identified, a licensed nurse must assess and document the ulcer's location, size, appearance, drainage, surrounding skin, and any signs of infection- a physician, physician assistant, or wound clinician may assist with diagnosis or staging. The protocol required notifying the physician of any newly identified pressure injuries and providing treatment according to physician's orders. Treatment may include pressure redistribution, repositioning, wound care, pain management, nutritional support, and other appropriate interventions. The IDT care plan must address pressure injury risks, treatments, and prevention strategies. Pressure injuries must be monitored and documented at intervals appropriate to the resident's condition and treatment plan, and the care plan must be reviewed and revised as needed.During a review of Resident 1's CoC dated 7/20/26, the CoC indicated, on 7/20/26 at 10:22 a.m., Resident 1 was difficult to arouse despite performing sternum (breastbone) rub, 911 was called and Resident 1 was transferred to the acute care hospital (ACH).During a review of Resident 1's [Emergency Department] ED Transfer Form (EDTF, a form filled out sent with the resident during transfer to the hospital with resident information including skin status) dated 7/20/26, the EDTF indicated, under Skin Assessments, that Resident 1 did not have any current skin condition (e.g. pressure ulcer).During a review of Resident 1's Wound Ostomy Progress Note (WOPN) from ACH, dated 7/21/26, the WOPN indicated an unstageable pressure ulcer (a full thickness pressure injury in which the base of the wound is completely covered by slough or eschar, making it impossible to determine the true depth of tissue damage until enough of that dead tissue is removed) on Resident 1's sacral/coccyx area. The WOPN indicated Resident 1's wound had sanguineous (bright red and consists primarily of fresh blood, with syrup-like consistency indicating bleeding from the wound bed or damaged blood vessels) discharge, maceration (softening, whitening, and breakdown of the skin caused by prolonged exposure to moisture) on the surrounding skin, and the wound bed was covered with 75-100% black eschar.During a review of Resident 1's Discharge Summary Notes (DSN) from ACH, dated 8/1/26, the DSN indicated that Resident 1 had developed metabolic acidosis (dangerous acid-base imbalance in which the blood contains too much acid or too little bicarbonate, or alkali) and Acute Kidney Injury (AKI, a sudden decline in kidney function). The AKI was believed to be caused by Acute Tubular Nephrosis (ATN, a severe form of acute kidney injury) resulting from sepsis. The DSN further indicated Resident 1's medical status did not improve with ceftriaxone (a powerful antibiotic). As a result, Resident 1 remained at high risk for recurrent infection and sepsis related to the sacral ulcer. The DSN further indicated that source control for infection/sepsis, specifically debridement of the sacral ulcer, was recommended but declined by the family. Resident 1 was subsequently placed on comfort care (medical care that focuses on relieving pain, easing symptoms, and maximizing quality of life, rather than curing or controlling a disease) only on 7/27/26 and passed away on 8/1/26.

Based on observation, interview and record review, for one of four sampled residents (Resident 3), the facility failed to provide Activities of Daily Living (ADL) care for a dependent resident, when staff did not maintain Resident 3's personal hygiene, did not provide nail care and showers, or provide needed assistance during meals. This failure had the potential to result in inadequate nutrition, good grooming, hygiene, and the ability to eat safely. Resident 3 had long fingernails with visible dark matter underneath.During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was re admitted to the facility on [DATE] with multiple medical conditions, including muscle weakness (reduced strength that limits movement and physical function), need for assistance with personal care (requiring staff support for hygiene and daily tasks), dysphagia (difficulty swallowing that can increase the risk of choking or aspiration), glaucoma (an eye disease that damages the optic nerve, often causing vision loss), and dependence on renal dialysis (a treatment that filters waste and excess fluid from the blood when the kidneys are not functioning properly). During a concurrent observation and interview on 8/18/26 at 1:07 p.m. with Certified Nursing Assistant (CNA) 1, in the middle hallway, lunch trays were collected from resident rooms as CNA 1 entered and exited assigned rooms. CNA 1 stated he was assigned to 10 residents during the morning shift, and although manageable, the workload was difficult as he tried to complete all required care. CNA 1 stated residents were to receive three showers weekly, CNA 1 stated he had provided three showers earlier during the shift. Resident 3 was in his room, did not make attempts to touch the tray that was set in front of him. The tray contained minced and moist food (texture modified diet, finely chopped into very small, soft pieces designed for residents who have dysphagia) and ice cream, Resident 3 fell in and out of sleep.During an interview on 8/18/26 at 1:40 p.m. with CNA 3, CNA 3 stated the facility has been short staffed. CNA 3 stated sometimes, CNA 3 got assigned 11 residents, and on busier days up to 12 residents, making it difficult to complete all tasks. CNA 3 stated focusing on essential care needs, such as keeping residents safe and changing their briefs to maintain comfort, when staffing levels are low. During another concurrent observation and interview on 8/18/26 at 1:47 p.m. with CNA 4, Resident 3 still did not receive assistance with lunch meal and remained unable to begin eating. CNA 4 stated he was the assigned CNA for Resident 3 but did not place the lunch tray and believed it had been left on the overbed table while CNA 4 provided care to another assigned resident. During a concurrent observation and interview on 8/18/26 at 2:17 p.m. with Resident 3, Resident 3 had not touched his lunch tray, and stated he needed help to eat and had been waiting for staff assistance. Resident 3's fingernails were long with visible black matter underneath, and hair looked unkempt and oily. During an interview on 8/18/26 at 2:19 p.m. with Nurse Supervisor (NS), NS stated Resident 3's fingernails required trimming and that she would notify CNA 4, who was providing care to another resident at the time. NS stated Resident 3's nails should be kept clean regardless of medical conditions such as diabetes.During an interview on 8/18/26 at 2:25 p.m. with CNA 4, CNA 4 stated he was assigned to 10 residents that day. CNA 4 stated when he became occupied with providing care to other residents, CNA 4 prioritized tasks based on immediate need and resident safety, returning to assist with meals as time permits, especially during busy lunch hours.During an interview on 8/18/26 at 3:13 p.m. with CNA 5, CNA 5 stated that staff sometimes must prioritize care tasks based on immediate resident needs before returning to other duties such as trimming fingernails and cleaning hands when time allows. CNA 5 stated that managing 10 to 11 residents during an 8 hour shift makes it difficult to complete all hygiene related tasks consistently. He stated that CNAs do as much as they can and often work together or team up with other CNAs, who also have large resident assignments, to complete necessary care. During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/21/26, the MDS indicated Resident 3 needed supervision or touching assistance (helper provides verbal cues and/or touching and/or contact guard assistance as resident completes activity) with meals. The MDS also indicated Resident 3 also needed moderate assistance with oral hygiene and was dependent on staff with toileting hygiene. During a review of Resident 3's Order Summary Report (OSR) as of 8/25/26, the OSR indicated a physician order dated 8/11/26 for 1:1 feeding assistance three times daily. During a review of Resident 3's Nutritional/Dietary Progress Notes (NPN) dated 7/29/26, the NPN indicated Resident 3 triggered for significant weight loss, showing a decline of six pounds (-3.6%) over one week, which the dietician indicated was related to inadequate oral intake, as evidenced by Resident 3 consuming only 0-75% of meals during that period. During a review of Resident 3's ADL care plan dated 7/4/26, the care plan indicated interventions, all dated 7/4/26, that included assisting Resident 3 at mealtimes, with bathing and grooming as needed. During a review of Resident 3's Shower/Bathing from 8/6/26 to 8/18/26, the Shower/Bathing indicated Resident 3 received one shower over 13 days. During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (Supporting) last revised April 2025, the P&P indicated residents who are unable to perform activities of daily living (ADLs) independently must receive the care and assistance needed to maintain adequate nutrition, grooming, and personal and oral hygiene, in accordance with the facility's ADL policy. Interventions designed to improve a resident's functional abilities or to prevent or minimize functional decline must align with the resident's assessed needs, preferences, stated goals, and established standards of practice. The resident's response to these interventions is continuously monitored, evaluated, and revised as needed to ensure the care plan remains appropriate and effective.

Based on interview and record review, for two of five sampled residents (Resident 2 and Resident 3) the facility failed to provide a variety of fresh fruit options when only bananas were available for residents who requested fruits. This failure had the potential to result in not meeting the nutritional needs and compromising the nutritional status of the residents.A review of Resident 2's admission Record, printed on 6/1/26, indicated Resident 2 was admitted to the facility with diagnoses that included fracture of the left femur (a break on the thighbone), dislocation of the right hip, depression, and anxiety disorder. A review of Resident 2's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 4/25/26 indicated Resident 2 has a Brief Interview of Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember) score of 15 to indicate intact cognition. A review of Resident 2's Nutritional Evaluation, dated 4/27/26, indicated Resident 2 was on regular diet with thin liquid consistency. Nutritional recommendations included snacks in between meals, supplements, and others. Nutritional Evaluation Comments indicated, Resident 2's estimated nutritional needs likely not met due to poor meal intake. Inadequate food intake in relation to food preferences. During an interview on 6/1/26, at 3:19 p.m., with Resident 2, Resident 2 stated the facility only served bananas, no oranges, no apples, and no fresh lettuce, or tomatoes, when asked for other fresh fruits or salads. Resident 2 further stated she had to request her family to bring food from outside in relation to lack of fresh fruits and vegetable options available at the facility. During an interview on 6/1/26, at 11:32 a.m., with Resident 5, Resident 5 stated food served in the facility was crappy. Resident 5 also confirmed there were no fresh fruits available. During a concurrent interview and record review on 6/2/26, at 11:12 a.m., with Dietary Manager (DM), facility's weekly menu titled, Week At A Glance, dated 2026, indicated the week of 5/31/26, fresh fruit salad was only scheduled and served once, during dinner on Monday, 6/1/26. The weekly menu also indicated fresh green salad will be served twice during the week, during lunch on Thursday, 6/4/26, and dinner on Friday, 6/5/26. DM confirmed the facility only had bananas to offer when residents requested fresh fruit options. DM stated there was lack of variety in fresh fruit options and how she wished the facility used a different set of menus. A review of the facility's weekly menu titled, Week At A Glance, dated and initialed by DM for the week of 5/24, indicated no fresh fruits or fresh salads in the week's menu. Further review of the facility's weekly menu titled, Week At A Glance, dated and initialed by DM for the week of 5/17, indicated fresh vegetables were served during lunch and dinner on Tuesday, 5/19/26, on Thursday, 5/21/26, and dinner on 5/22/26, with no fresh fruits served at all in the week's menu. A review of the facility's Food Supplier receipts titled, Invoice, indicated on the weekly orders dated 5/11/26, 5/14/26, 5/22/26, and 5/25/26, the facility's only fresh fruit item ordered and delivered during the above-mentioned weeks were fresh bananas.

Based on observation, interview, and record review, the facility failed to provide maintenance services in two of seven shower rooms (Shower Room E and Shower Room F) when both shower rooms were found unclean and not well maintained. These failures resulted in the lack of comfortable sanitary environment for the residents of the facility who used Shower Rooms E and/or F.During an interview on 6/1/26, at 11:30 a.m., with Housekeeping 1 (Hskg 1), Hskg 1 stated shower rooms were routinely cleaned by the janitors usually during the afternoon (PM) shift. During a concurrent observation and interview on 6/1/26, at 11:45 a.m., with Janitor 1 (J 1), inside Shower Room F, J 1 stated scattered areas of the floor and walls had grouts that were moldy and with brown-colored stains. J 1 also stated the doorknob and steel door frame from inside the shower room were rusty, and the base part of the door frame had peeled white paint and was not in good repair. J 1 also confirmed that the red, round, metal frame attached to the wall that was a soap holder was rusty and with peeled red paint. During a concurrent observation and interview on 6/1/26, at 11:50 a.m., with J 1, inside Shower Room E, J 1 stated steel door frame from inside the shower room was rusty with peeled white paint. The base of the door frame had corroded which left a brown smudge on the tiled floor surface. J 1 also stated scattered areas of the wall either had peeled grout or was moldy with brown-colored stains. J 1 stated both Shower Rooms E and F needed cleaning and repair. During a concurrent observation and interview on 6/1/26, at 11:56 a.m., with the Environmental Services Manager (ESM), ESM stated facility did not have a Shower Room Cleaning Log nor records of daily shower room rounds. ESM also stated Shower Rooms E & F, and all the shower rooms in the facility should be kept clean and in good repair because this is an essential part of the home of the residents. During an interview on 6/1/26, at 12:22 p.m., with the new Maintenance Director (MD), MD stated the facility needed a preventative maintenance program to identify maintenance and repair needs in a timely manner. During an interview on 6/1/26, at 3:19 p.m., with Resident 2, Resident 2 stated her last shower was yesterday afternoon. Resident 2 stated the shower rooms were moldy, dirty, and were unpleasant to use. During a telephone interview on 6/2/26, at 12:10 p.m., with J 2, J 2 confirmed he worked in the afternoon shift who was responsible for keeping Shower Rooms E and F cleaned daily and well maintained. J 2 stated wheelchairs were often stored in the shower rooms making it difficult to keep the shower rooms clean and free of mold. J 2 also stated he had repeatedly given verbal reports to the previous Maintenance Supervisor regarding the rusty soap holder in Shower Room F, but nothing was done. A review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated February 2021, indicated, Residents are provided with a safe, clean, comfortable and homelike environment.to the extent possible. A review of the facility's P&P titled, Maintenance Service, revised December 2009, indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment.The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards.Establishing priorities in providing repair service. Providing routinely scheduled maintenance service to all areas.

Based on interview and record review, the facility failed to maintain an effective Pest Control Program (measures to eradicate and contain common household pests [e.g., bed bugs, lice, cockroaches [roaches], ants, mosquitos, flies, mice, and rats]) when there were continuous multiple sightings of roaches in the different parts of the facility despite scheduled weekly services from Pest Control Company. This failure created a nuisance for residents and had the potential to result in transfer of diseases such as salmonella, e. coli (bacteria known to cause food-borne illness), and other pathogens (microorganisms that can cause diseases).During an interview on 6/1/26, at 10:55 a.m., with Resident 3, inside resident's room, Resident 3 stated she had seen roaches twice since her admission to the facility two weeks ago. Resident 3 stated it was the first thing she saw when she woke up in the morning. During an interview on 6/1/26, at 11:10 a.m., with Resident 4 (Resident 3's roommate), inside resident's room, Resident 4 denied seeing cockroaches in her room but stated last month she saw roaches down the hallway. Resident 4 stated the facility was a dump (dirty, disorganized, and run-down) and was unpleasant to live in. During an interview on 6/1/26, at 11:32 a.m., with Resident 5 (Resident 2's roommate), inside resident's room, Resident 5 denied sightings of roaches but mentioned that Resident 2 saw the insects on Resident 2's side of the bed. During an interview on 6/1/26, at 3:19 p.m., with Resident 2, inside resident's room, Resident 2 confirmed she had seen roaches crawling on the floor. Resident 2 stated she was uncomfortable and disgusted, and reported this to the facility. During an interview on 6/1/26, at 11:45 a.m., with Janitor 1 (J 1), J 1 stated it was the janitor and housekeeping staff's responsibility to take care of reported insects in the rooms. J 1 stated Issues like these were brought to the attention of the Environmental Services Manager (ESM). During an interview on 6/1/26, at 11:56 a.m., with ESM, ESM stated she oversaw the facility's Pest Control Program. ESM stated Pest Control Company's scheduled visit was once a week. ESM further stated facility occasionally received resident complaints about roaches, with the most recent one on 5/25/26 from Resident 2. ESM mentioned the Pest Control Company had dealt with the presence of roaches in the past in the facility but had not totally resolved the situation over time. A review of the facility's Pest Services Notes, titled Pest Services, dated 4/13/26, indicated room [ROOM NUMBER] and room [ROOM NUMBER], with low level activity of cockroach identified. A review of the facility's Pest Services Notes, titled Pest Services, dated 4/20/26, again indicated room [ROOM NUMBER] and room [ROOM NUMBER]. room [ROOM NUMBER] this time had medium level cockroach activity identified in comparison to 4/13/26, last week's visit. room [ROOM NUMBER] continued to have low level cockroach activity. Also identified this week was room [ROOM NUMBER] with low level activity of cockroach identified. A review of the facility's Pest Services Notes, titled Pest Services, dated 5/18/26, indicated room [ROOM NUMBER], with low level activity of cockroach identified. A review of the facility's Pest Services Notes, titled Pest Services, dated 5/27/26, indicated room [ROOM NUMBER], with low level activity of cockroach identified. A review of the facility's Policy & Procedure (P&P) titled, Pest Control, revised May 2008, indicated, Our facility shall maintain an effective pest control program.The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interviews and record reviews, the facility failed to ensure the Registered Dietitian (RD) and Dietary Services Manager (DSM) carried out the functions of the dietetic services in the food & nutrition services department when multiple issues in food safety, sanitation, and clinical nutrition care for residents with weight loss or weight gain were identified, according to facility policy and standards of practice. This failure had the potential to expose residents to unsafe contaminated food and unsanitary equipment and utensils, leading to foodborne illness and altered nutrition status among 114 residents who consume food from the kitchen. Cross reference F802, F803, F804, and F812 Findings: According to the 2019 California Retail Food Code, CHAPTER 3. Management and Personnel, Article 2 Employee Knowledge, Section 113947, (a) The person in charge and all food employees shall have adequate knowledge of, and shall be properly trained in, food safety as it relates to their assigned duties. (b) The person in charge shall comply with both of the following: . (2) Educate the employees at the food facility .(c) For purposes of this section, person in charge means a designated person who has knowledge of safe food handling practices and the major food allergens as they relate to the specific food preparation activities that occur at the food facility . During an interview in the kitchen with the RD at 4/28/25 11:24 AM, the RD stated she does not do any kitchen sanitation checks because the DSM does them monthly. The RD further stated the DSM reports the findings of deficient practices to the Quality Assurance (QA) Committee. The RD stated she does not discuss the findings from the kitchen sanitation checks with the DSM. The RD and DSM stated they do not regularly meet to discuss the food service and safety operations in the kitchen when the RD is at the facility. During a concurrent record review and interview with the DSM of the facility's Dietary Manager's Reports from 1/7/25 through 3/25/25, the DSM stated these reports were used as kitchen sanitation checks. The report dated 2/20/25 identified improper cool down procedures with tuna salad by kitchen staff and ongoing reeducation was needed. The DSM acknowledged the kitchen checklist reports did not include food sanitation and food safety topics regarding the red bucket sanitizer testing, ice machine cleaning, the cool down process for cooked foods, and three compartment sink creation for emergency use. During an interview in the kitchen with the RD on 4/29/25 at 1:21 PM, stated she was not at the facility all the time, and only worked part-time, twice a week, up to sixteen hours a week. The RD stated she started working at the facility in January 2025 and the previous RD was virtual and never worked onsite. The RD stated she may need to spend more time in the kitchen and doing the kitchen sanitation checks with the DSM. During an interview in the kitchen with the RD and DSM on 4/30/25 at 12:57 PM, the RD and DSM stated they do not do regular test trays evaluations at the facility. After the test tray evaluation of the regular diet and pureed diet lunch meals with the Surveyor, RD and DSM stated the pot roast, and spinach could have used more seasoning. The RD further stated she expected the Cooks to follow the recipes because they've already been tested. During a record review of the facility created weights reports dated 4/30/25, the weight report indicated Resident 66 experienced a 10-pound weight gain in 1 month from 331 pounds in March 2025 to 344 pounds in April 2025. During an interview on 4/30/25 at 10:03 AM with Resident 66, the resident was sitting up in her bed watching T.V. The resident stated she wanted Asian foods, and sometimes they don't follow the menu. During a concurrent interview with the RD on 5/01/25 at 12:15 PM and record review of Resident 66's Nutrition assessment dated [DATE] completed by the RD, the assessment indicated the resident was not on a Physician Ordered Diet for weight gain or weight loss, and the Nutrition Goal was to maintain while meeting metabolic needs with adequate fluid for hydration. The RD acknowledged she did not discuss weight gain with the resident during her interview and nutrition assessment because she wanted to know how she liked the food. The RD further stated she should have included a goal weight for the resident in the assessment because continuous weight gain overtime could cause future health problems. During an interview with the RD on 5/1/25 at 12:18 PM, the RD stated she does not attend the weekly weight Interdisciplinary team (IDT) meetings with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The RD stated she writes a daily report of the residents she does nutrition assessments and follow-ups evaluations on, then she sends it to the Administrator (ADM), DSM, and DON. The RD also stated she runs weekly and monthly weight reports from the medical record system, then calculates residents' weight gains or losses. The RD stated she sends the weight report calculations to the DON, the ADON, and waits for feedback, but the RD acknowledged she does not reach out to the DON and ADON and the DON and ADON don't consistently reach out to her to discuss the weights. The RD stated she should be more involved in weight monitoring IDT meetings to have a greater impact on the resident's weight condition and nutrition status. The RD further acknowledged there were at least five residents with significant weight loss or gain, and she did not discuss topics like food substitutions and appropriate options with these residents during her nutrition assessments and evaluations. During an interview on 5/1/25 at 1:49 PM with the ADM, the ADM stated she expected the RD to work with the DON and DSM to ensure the residents receive the appropriate nutrition to prevent weight loss issues and receive healthy foods. During a record review of the facility's undated Job description titled Clinical Registered Dietitian, the job description indicated, .the Clinical Dietitian provides medical nutrition therapy and works with the Dietary Manager to ensure that quality food, service and nutritional care are being provided to residents .a. Is responsible for identifying the nutritional needs of the facility patient, providing support to the Dietary Manager in food and nutrition . d. Participates in interdisciplinary care conference meetings, weight meetings . e. Review and approve menus to meet all guidelines and nutritional therapy to patients . 2) Conducts meal rounds and interviews staff and residents to ensure residents are receiving foods in the amount, type, consistency, and frequency required to maintain or improve nutritional status. 3) Routinely inspects the food service areas and practices for compliance with company policies, procedures, standards, and applicable federal, state, and local regulations .5) Conducts nutrition in-services training for dietary .staff related to nutrition . During a record review of the facility's Job description titled FNS Director, dated 2018, the job description indicated, .DUTIES AND RESPONSIBILITIES: .2. Schedule and supervise the Food & Nutrition Service Staff providing in-service training . 3. Is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed.5. Test cooked food by taste to determine if properly cooked and seasoned. 6. Is responsible for maintaining cleanliness of kitchen equipment and follows all department of health regulations.8. Make menu adjustments as needed .with final approval of the Dietitian. During a record review of the facility's P&P titled Staff Development, dated 2018, the P&P indicated Food and Nutrition Services staff will be in-serviced .by the FNS Director and Consultant Dietitian.In-services will be scheduled monthly, on a variety of subjects, including .infection control, safety .food safety .and therapeutic diets.FNS Director and the Consultant Dietitian will periodically ask .staff questions .to demonstrate knowledge and techniques from recommended in-services to ensure staff has continued understanding of kitchen procedures. During a record review of the facility's P&P titled Nutritional Screening/ Assessments/Resident Care Planning, dated 2018, indicated .The resident's nutritional needs will be assessed. A nutrition program specific to his needs will be planned and implemented and then reassessed periodically for progress.the information .will come from a variety of sources .1. Direct resident interview .3. The medical record .5. Resident care conference .All residents will be reviewed quarterly and annually .Change in eating habits .weight and other problems will be recorded in the dietary progress notes and resident care plan .

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. Two Cooks (CK 1 and CK 2) did not properly verbalize or demonstrate the correct two-step cool down process used to prevent contamination in a cooked beef pot roast. 2. A Diet Aide (DA 1) did not know how to correctly calibrate a food thermometer. 3. A Diet Aide (DA 3) did not know how to test the sanitizer concentration in a red bucket. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The census was 114. Cross reference F801 and F812 Findings: 1. During an interview on 4/29/25 at 9:10 AM in the kitchen with the morning [NAME] (CK 1), CK 1 stated sometimes they have leftover foods they serve at a later date. CK 1 stated the leftover foods and large meats like a beef roast and turkey cooked from scratch, are cooled down using a cool down process. CK 1 stated the cool down process included lowering the food to a temperature of 100 degrees by using an ice bath method, and checking the food every four (4) hours to make sure it reached 100 degrees or near it, before it is placed in the refrigerator overnight. CK 1 stated he was trained years ago on the cool down process by a previous [NAME] who worked at the facility. During a kitchen observation on 4/29/25 at 2:45 PM, a large metal pan with a cooked beef roast was labeled roast beef 4-29-25 use by 5-1-25 and stored on a rack in the walk-in refrigerator. The surveyor's digital thermometer was placed in the roast and it read 141.8 degrees F. During an interview on 4/29/25 at 2:50 PM with the evening [NAME] (CK 2) and Dietary Services Manager (DSM), CK 2 was asked to describe the cool down foods process. CK 2 stated the cool down process for cooked meats like roast beef, pork, and turkey was to cool the meat down to 40 degrees in 4 hours. CK 2 stated the total cool down process time should be 4 hours. The surveyor asked CK 2 if she cooked the beef roast in the refrigerator, and she stated No, the morning [NAME] cooked it about an hour ago. CK 2 further stated CK 1 asked her to monitor the cool down process for the pot roast because it's for tomorrow's lunch. The DSM acknowledged CK 2 and CK 1 did not correctly the cool down process for cooked meats, and stated they should know it is a two-step method that takes six hours. The DSM stated the final step is for the temperature to reach 41 degrees F or below within four hours. The DSM stated they would restart the cooking process for the beef roast to ensure it was cooked and cooled down safely. A review of the facility's menu titled Daily Spreadsheet Wednesday - Day 25 Week 4- Day 4 .Spring/Summer 2025 indicated .Lunch .Regular diet .3-ounces of Tomato Braised Pot Roast, 1/2 cup of Lyonnaise potatoes, 1/2 cup steamed spinach, 1 Bread or Roll & butter packet, 1 cup of choice of beverage, and a slice of yellow 7-up cake. During a review of the facility's Job Description for the [NAME] position, dated 2018, the job description indicated .1. Responsible for the preparation of food for breakfast and noon meals to be served .4. Knowledge of basic principles of quantity food cooking . According to the 2022 Food & Drug Administration (FDA) Federal Food Code, section 3-501.15, titled Cooling Methods, .Cooling shall be accomplished in accordance with the time and temperature criteria specified under 3-501.14 by using one or more of the following methods .:(1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods . During a review of the facility policy titled Cooling Monitor for Hazardous Foods dated 5/20/2020 indicated Procedure. 1. Transfer cooked products to a container(s) with a depth no greater than two inches. 2. Label and date the container(s). 3. Leave container uncovered or loosely covered during the cooling process. 4. Place container(s) in the refrigerator for cooling. 5. Using the Cooling Monitoring Form (FORM 406) or other designated form record temperature of food every hour. The food should be cooled from 140* to 70* within 2 hours and cooled from 70* to 41* in an additional 4 hours. If a prepared product is initially at (less than or equal to) 41*F there is no need to record this on the Cooling Monitoring form but cover tightly and store in the refrigerator. 6. If the temperature is not dropping adequately consider using an ice bath, if it is roast, cut into smaller pieces, make sure you are using shallow (2 inches or less in depth) pans, etc. Record action taken to achieve proper temperature on the Cooling Monitoring form. 7. When the temperature reaches 41*F, cover tightly and store in the refrigerator or freezer. 8. If temperature does not reach 70*F in 2 hours, reheat to 165*F and try cooling process again. 2. During a concurrent observation and interview on 4/29/25 at 11:57 AM with Diet Aide (DA 2, DA 2 stated he did not know how to calibrate the bi-metal food thermometer, but he used the thermometer to take food temperatures during trayline. The DSM acknowledged DA 2 did not know how to calibrate a thermometer, and then she began to instruct him on how to do it by preparing a cup of ice water. The Diet Aide then asked, Should the thermometer read 20 degrees for calibration? The DSM told him No, it should be 32 degrees Fahrenheit (F) and stated he needs more training on thermometer calibration. The DSM further stated it was important to have accurate temperatures to confirm the food is safe. According to 2022 Federal Food Code, section 4-204.112 titled Temperature Measuring Devices, .The importance of maintaining time/temperature control for safety foods at the specified temperatures requires that temperature measuring devices be easily readable. The inability to accurately read a thermometer could result in food being held at unsafe temperatures. Temperature measuring devices must be appropriately scaled per Code requirements to ensure accurate readings. During a review of the facility's policy and procedures (P&P) titled Thermometer Use and Calibration, dated 2018, indicated .Food thermometers are to be used properly and calibrated to ensure accurate temperature reading .Checking the Accuracy and Calibrating .1. Fill a large glass with crushed ice and add clean tap water until slush is formed .2. Put thermometer's stem into the ice water so that the sensing area is completely submerged .do not let the stem touch the bottom or sides of the glass .3. If the thermometer does not read 32 degrees F, then the thermometer must be calibrated .follow manufacturer's instructions . 3. During a concurrent observation and interview on 4/30/25 at 8:33 AM with Diet Aide (DA 3) and the DSM, DA 3 tested the sanitizer concentration in the red buckets by taking a test strip from a container and dipping it in a red bucket full of sanitizer solution, then comparing it to the color grid on the container after dipping it for 1 second. The test strip was a faint yellow color and DA 3 said it needed to be 100-200 PPM (parts per million). DA 3 tested it again and dipped the test strip for 3 seconds then tested it against the strip container, and it was light green color. The DA stated it was still not the correct color. The DSM stated DA 3 did not hold the test strip in the sanitizer for 10 seconds, which would then indicate the correct color and solution concentration. The DSM acknowledged the DA did not know to immerse the test strip for 10 seconds in the solution and further stated she needed to be trained on how to test the sanitizer. During a review of the test strip container, the instructions indicated .Remove one strip .Allow 5-10 seconds to develop, then compare to color chart below . During a review of the facility's Job Description for the Diet Aide position, dated 2018, the job description indicated .b. Prepare juices, milk, water, and other beverages e. Cleaning as assigned on cleaning schedule.g. Assist with trayline .3. Keep work area clean . During a review of the facility's Dietary Services department kitchen staff In-services from May 2024-April 2025, the in-services indicated the topics covered did not include the cool down process, thermometer calibration, or red bucket sanitizer testing. During a review of the facility's policy and procedure (P&P) titled Sanitation, dated 2018, the P&P indicated .21. The FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service for training employees to use appropriate techniques .23. Do not use .sanitizer in the food preparation .areas in any way that could result in contamination of exposed food . During a review of the facility's P&P titled Staff Development, dated 2018, the P&P indicated Food and Nutrition Services staff will be in-serviced .by the FNS Director and Consultant Dietitian.In-services will be scheduled monthly, on a variety of subjects, including .infection control, safety .food safety .and therapeutic diets.FNS Director and the Consultant Dietitan will periodically ask .staff questions .to demonstrate knowledge and techniques from recommended in-services to ensure staff has continued understanding of kitchen procedures.

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation measures were maintained in the kitchen according to standards of practice and facility policy when: 1. An ice machine had pinkish gray slime debris on the drain panel and ice tray, and brown discoloration stains and debris inside the ice making grid, chute and on the right and left walls of the ice machine. 2. The kitchen did not have a three (3)-compartment sink station to wash, rinse, and sanitize dishes in the event of an emergency, if the dish machine was nonoperational. 3. Fourteen white colored plates on a dish rack had blackish dark gray stains on them. 4. Three cutting boards had deep cuts, and large white patches were used during food preparation in the kitchen. These failures had the potential to place residents at risk to develop foodborne illness by exposing residents to contaminated food and unsanitary practices. The facility census was 114. Cross reference F801 and F802 Findings: 1. During a concurrent kitchen observation and interview on 4/29/25 at 10:34 AM with the ice machine vendor technician, the vendor technician stated he last cleaned the ice machine in May 2024. The ice machine did not have a water filter attached. The technician removed the ice machine water tray and curtain covering ice making grid parts to clean them. The technician wiped pink and gray colored slime debris off with warm water and a clear solution in an unlabeled plastic spray bottle. The technician stated the clear solution was a mixture of Zep brand cleaner and water. The technician also had another clear spray bottle with a clear solution labeled bleach and the technician stated he planned to use it to clean other internal ice machine making parts. The technician further stated he had a gallon of Manitowoc cleaner in his car that he may use at the end. The DSM stated she requested the previous cleaning records from last year in May 2024 from the ice machine vendor who cleaned it, but they have not provided them. The DSM acknowledged the pinkish gray slimy substances and brown stained buildup and debris on all the ice machine internal parts that touch the ice. The DSM stated the ice machine should be cleaned correctly with the appropriate chemicals, according to the manufacturer's instructions, so it could make clean ice. The DSM further stated the ice machine should have a filter attached to clean the water used to make the ice. During a review of the undated ice machine manufacturer's instruction manual, Section 4 titled Maintenance the instructions indicated, Cleaning and Sanitizing .An extremely dirty ice machine must be taken apart for cleaning and sanitizing. Manitowoc Ice Machine Cleaner and Sanitizer are the only products approved for use in Manitowoc ice machines . Wash the sink, drip tray, grill and Drain Basin and Manifold with the sanitizer solution. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 4-204.17 titled, Ice Units, Separation of Drains, FDA Food Code indicated, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines .The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin. All equipment will be operated and maintained according to the manufacturer's specifications for cleaning and sanitizing and safe operating condition. During a review of the facility's policy and procedure (P&P) titled Ice Machine Cleaning Procedures, dated 2018, the P&P indicated .The ice machine (bin and internal components) needs to be cleaned monthly and the recorded when cleaned .3. Clean the inside of ice machine with a sanitizing agent per the manufacturer's instructions . 2. During a concurrent observation and interview on 4/30/25 at 11:43 AM with Diet Aide (DA) 4 and the DSM in the kitchen, DA 4 stated the two-compartment sink at the end of the clean side of the dish machine was used for washing and rinsing dishes if the dish machine didn't work. DA 4 did not know where the dishes would be sanitized. The DSM stated the kitchen should have a third compartment created for sanitizing clean dishes from the 2-compartment sink. During a review of the 2022 Federal Food and Drug Administration Food Code (FDA Food Code), Section 3-601.11 titled, Food Labels, FDA Food Code indicated, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . 3. During a concurrent observation and interview on 4/28/25 at 9:38 AM with Diet Aide (DA) 1 in the kitchen dish area, DA 1 stated a rack with fourteen white plates in them, were washed, clean and dry. DA 1 stated the fourteen white plates had blackish gray colored stains on them for a while but they were still clean. The DSM stated the dishes should be clean and of good quality. According to the Food and Drug Administration (FDA) Food Code 2022 Cleaning of Equipment and Utensils, section 4-601.11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch . 4. During a concurrent observation and interview in the kitchen on 4/28/25 at 9:58 AM with [NAME] (CK) 1, CK 1 stated the three cutting boards, a red, blue, and green one, stacked in a rack in the food preparation area were used to chop vegetables and meats. Each of the cutting boards had a large white stain with several cuts, grooves and scratches on them and were severely worn. The DSM stated the cutting boards should be of higher quality and not severely scratched. According to the Food and Drug Administration (FDA) Food Code 2022, Section 4-501.12, titled Cutting Surfaces, .surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized or discarded if they are not capable of being resurfaced. During a review of the facility's policy and procedure (P&P) titled, Sanitation dated 2018, the P&P indicated, .9. All utensils .and equipment shall be kept .maintained in good repair and shall be free from breaks .cracks and chipped areas .12. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner .17. Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized 19. Correct temperatures for the storage and handling of foods are used. Thermometers will be used to check the temperatures of refrigerators, freezers and in food storeroom. Thermometers will be used to check the food at mealtimes .

Based on interview and record review, the facility failed to maintain two out of two sampled clothes dryers according to the facility's policy when facility staff documented lint trap (help to reduce the lint and fabric particles that can build up and clog the exhaust hose) was cleaned prior to scheduled time. This failure had the potential for the clothes dryer to be in an unsafe operating condition. Findings: During a concurrent interview and record review on 4/29/25 at 8:52 a.m. with Laundry Personnel (LP) and Housekeeping Supervisor (HKS), in the laundry room, the Lint Trap Cleaning Log, dated 4/29/25 was reviewed. The Lint Trap Cleaning Log indicated, initial after cleaning. The Lint Trap Cleaning Log also indicated, 10:00 a.m., 12:00 p.m. and 2:00 p.m. had written letters LA. The LP stated, the letters LA was her initials. The HKS stated, laundry staff initials the log early because sometimes they forgot to initial. During a review of facility's undated policy and procedure (P&P) titled Interior Maintenance: Laundry, the P&P indicated, 3a. Laundry personnel are cleaning clothes dryer filters every two hours . d. Check exhaust ducts to ensure they are free of lint.

Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for three out of 25 final sampled residents (Residents 4, 47 and 94). This had potential for the facility to provide treatment and services against the residents' wishes. Findings: 1. Review of Resident 4's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (Muscle wasting, also known as muscle atrophy, refers to the loss of muscle mass and strength). During a review of Resident 4's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/25/25 under Section C, indicated a score of 15, meaning Resident 4 was cognitively intact . During a review of Resident 4's Physician Orders for Life-Sustaining Treatment (POLST) form, dated 1/3/16, under information and signatures, it showed the resident had no adv directives. (A POLST is a form that gives instructions for the resident's care in life-threatening medical situations). 2. Review of Resident 47's Facesheet indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses that included depression ( a mood disorder that causes persistent feelings of sadness), and adult failure to thrive (a syndrome where an adult experiences a decline in overall health, often marked by weight loss, decreased appetite, reduced energy, and a progressive decline in their ability to perform daily activities). During a review of Resident 47's MDS dated [DATE] under Section C, it indicated a score of 7, meaning Resident 47 had severe cognitive impairment . Review of Resident 47's medical records showed a POLST dated 2/18/22, under information and signatures, it showed the resident had no advanced directive. 3. Review of Resident 94's Facesheet indicated, Resident 94 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity). During a review of Resident 94's MDS dated [DATE] under Section C, it indicated a score of 6, meaning Resident 94 had severe cognitive impairment . During a review of Resident 94's POLST form, dated 12/20/23, under information and signatures , it showed the resident's advanced directives was not available. During a concurrent interview and record review on 4/29/25, at 11:24 a.m., with the Social Service Director Assistant (SSDA), SSDA reviewed Resident 4,47 and 94's medical records and there were no documentation found that indicated the advance directives were discussed with Residents 4, 47 and 94 and their responsible parties. SSDA also stated that the importance of having an advanced directive was so that the residents' wishes regarding their medical care were respected when the residents could not communicate anymore. During an interview on 4/30/25, at 3:28 p.m., with the Director of Nursing (DON), DON stated that she was not aware of the facility's policy regarding advanced directives. During a review of the facility's policy and procedure ( P&P) titled (Advanced Directives),revised 2008, the P&P indicated, Advanced directives will be respected in accordance with state law and facility policy .3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .7. The interdisciplinary team will review annually with the resident his or her advanced directives to ensure that such directives are still the wishes of the resident . The CMS Interpretive Guidance states that facilities are required to obtain a written record of resident advance directives upon admission and maintained in the medical record. Importantly, residents have a right to refuse to create an advance directive so the advance directive or the refusal to create an advance directive must be documented.

Based on observation, interview, record review, the facility failed to maintain a safe, clean, comfortable and homelike environment when: 1. The linoleum flooring in Resident 112's bathroom was discolored with areas of black stains that looked like dirt. 2. The toilet seat and toilet cover had multiple gray and black linear scratch marks, and the linoleum flooring was discolored with areas of black stains that looked like dirt in Resident 113's bathroom. This failure placed Residents 112 and 113 at risk for safety and may negatively impact the residents' psychological health when they had to use an unmaintained bathroom that was not homelike. Findings: 1.During an initial tour on 4/28/25 at 11:20 a.m. Resident 112 was lying in bed. Resident 112 expressed concerns regarding the dirty floor in her bathroom. Resident 112 also stated she was not using the bathroom, but she could see the bathroom floor when the door opened while she was lying in bed, and the dirty floor made her feel uncomfortable. During an observation on 4/28/25 at 11:27 a.m., the linoleum flooring in Resident 112's bathroom was discolored with areas of black stains that looked like dirt. The linoleum flooring of the bathroom appeared old and worn, discolored with some areas with black stains. Review of Resident 112's Minimum Data Set (MDS, an assessment tool) dated 3/18/25, indicated she had a Brief Interview for Mental Status or BIMS of 15 (BIMS score of 13-15 suggests intact cognition). 2. During an interview on 4/28/25, at 1:25 p.m., with Resident 113, the resident was lying in bed with a bedside commode by her bedside. Resident 113 stated she did not want to use the bathroom because the bathroom was dirty and gross. During an observation on 4/28/25 at 1:30 p.m., in Resident 113's bathroom, the linoleum flooring of the bathroom appeared old and worn, discolored with some areas with black stains. The toilet seat and cover had multiple gray and black linear scratch marks. Review of Resident 113's MDS dated [DATE], indicated she had a BIMS of 15 (intact cognition). During an interview on 4/29/25 at 12:12 p.m. with the Housekeeping Supervisor (HKS) , HKS acknowledged that Resident 112 and 113's bathroom did not appear homelike. HKS agreed that the linoleum flooring in Resident 112 and 113's bathrooms were old and worn and further stated that the housekeepers tried to scrub the scattered black discoloration in the floor with disinfectants but was unsuccessful in removing them. Also stated she knew of the gray and black scratch marks in Resident 113's bathroom toilet seat and cover but was not reported yet to the Maintenance Supervisor (MS). During an interview on 4/30/25 at 10:17 a.m. with the MS, MS stated he was not aware of the multiple gray and black scratch marks in Resident 113's bathroom toilet bowl seat and cover. Acknowledged that Resident 113's bathroom did not provide a homelike environment. Further stated that housekeeping department was assigned to the facility bathrooms' linoleum floorings. During an interview on 4/30/25 at 10:53 a.m. with the Administrator (Adm), Adm stated resident 113's bathroom toilet bowl will be replaced and the linoleum flooring in Resident 112 and 113's bathroom will be replaced. During a review of the facility's undated policy and procedure (P&P) titled, Homelike Environment, the P&P indicated, Residents are provided with a safe, clean, comfortable and home like environment .1. Staff shall provide person-centered care that emphasizes the residents comfort, independence and personal needs and preferences. 2. The facility and management maximizes, to the extent possible , the characteristics of the facility that reflect a personalized homelike setting. These characteristics include a. clean sanitary and orderly environment .c. inviting colors and décor .

Based on observation interview and record review the facility failed to ensure two of 25 sampled residents were free from physical restraints when the facility staff installed bed foam bolsters to Residents 63 and 77's bilateral bedrails, which inhibited the residents' freedom to get in and out of their beds (Bed foam bolsters are elongated foam that are designed to prevent residents from falling off the bed). This deficient practice had the potential to cause injury and decline in the residents' quality of life. Findings: a. During an observation on 5/1/2025 at 12:08 p.m., with Registered Nurse (WCN), Resident 63 was awake, lying in bed, appeared agitated and did not want to be bothered. Resident 63's bed had foam bolsters to bilateral side rails, strapped to the bed frame on bilateral sides. There were two straps across the mattress connecting both bolster pads, one strapped on the upper part of the mattress and the other below the mattress. Resident 63 was lying on top of these two straps, with no flat sheet on the mattress. The mattress only had a draw sheet on it. Resident 63 was non interviewable, not responding to questions. The WCN attempted to take Resident 63's blanket off his feet and Resident 63 was yelling and agitated. The WCN stated the foam pads are used for fall risk and that Resident 63 cannot get out of bed when bolster pads are in place. During an interview and observation on 4/30/2025 at 12:14 p.m., with the primary License Vocational Nurse (LVN 3), for Resident 63, LVN 3 stated the foam pads, placed on bilateral sides rails of resident 63's bed are called bolster pads, and they are used for fall risk residents. Resident 63's roommate in the B bed or middle bed had a floor pad in place, instead of foam pads (bolster pad) on his bedside rails. LVN 3 stated the facility did not use bolster pad for the roommate, they instead used a floor pad was the roommate would not attempt to exit his of bed, but for Resident 68, he would try to exit his bed. During an interview on 5/1/2025 at 12:57 a.m., with Registered Nurse (LN 3), LN 3 stated the bolster pads are for fall risk and the facility uses these pads on most residents who are assessed to be a fall risk. LN 3 stated when Residents are not able to remove the bolster pads or exit their bed when bolster pads are in place. LN 3 also stated the bolster pads can only be removed by staff. b. During an observation on 4/29/25, at 8:45 a.m., in Resident 77's room, resident was observed to be lying in bed awake, with bed foam bolsters installed in the bilateral bedrails of her bed . the foam bolsters were tied to the sides of the bed frame of Resident 77's bed. Review of Resident 77's Facesheet (information containing contact details, brief medical history at-a-glance) indicated she was admitted to the facility on [DATE] with diagnoses that included hemiplegia of left dominant side (severe weakness affecting the left side of the body, resulting from damage to the right side of the brain), need for assistance with personal care and adult failure to thrive (a syndrome where an adult experiences a decline in overall health, often marked by weight loss, decreased appetite, reduced energy, and a progressive decline in their ability to perform daily activities). Review of Resident 77's Minimum Data Set (MDS, an assessment tool) dated 3/13/25, indicated she had a Brief Interview for Mental Status or BIMS of 11 (BIMS score of 8-12 suggests mildly impaired cognition). The MDS Section GG titled, Functional Abilities indicated, Resident 77 was not steady, and was only able to stabilize with staff assistance when moving from seated to standing position and during surface-to-surface transfer (such as when transferring between bed and chair or wheelchair). Review of Resident 77's Physician Orders (PO), dated 12/25/22, the PO indicated, an order of Bolstered mattress to enable and support turning and repositioning when in bed related to diagnosis of cerebrovascular accident with left hemiplegia (cerebrovascular accident with left hemiplegia is brain injury, causing weakness on the left side of the body). During a concurrent observation and interview on 4/30/25, at 12:45 p.m., with the Director of Staff Development (DSD) , in the Resident 77's room, DSD stated the bolster siderail pads were used to keep the resident from falling from her bed. During an interview on 5/1/25, at 10:00 a.m., with Certified Nursing Assistant (CNA) 4, stated Resident 77 was a fall risk and was trying to get out of bed. Stated the bolster side rail pads were used to prevent the resident from getting out of bed and falling. Further stated, because the resident had left side body weakness, the bolster pads only helped the resident to reposition when she was using the right side of her body. During an interview on 5/1/25 at 2:32 p.m., with Assistant Director of Nursing (ADON), ADON acknowledged that the bolster pads were preventing the resident from getting in and out of her bed. During a review of the undated facility's policy and procedure (P&P) titled, Restraints, the P&P indicated, .Definitions .2. Convenience-any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest .6. Physical restraints-any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .Restraints: .may not be used for purposes of discipline or convenience .

Based on observation, interview and record review, the facility failed to ensure two of 25 sampled residents (Residents 47 and 370), received the necessary services of bathing when the residents were not offered a shower as scheduled. This failure had the potential to affect the residents' dignity and their quality of life. Findings: a. During a concurrent observation and interview on 4/28/25, at 10:56 a.m., Resident 47 was observed to be lying in bed. Resident 47's family member who was at the resident's bedside stated resident did not get showers as scheduled. Review of Resident 47's Facesheet (information containing contact details, brief medical history at-a-glance) indicated he was admitted to the facility on [DATE] with diagnoses that included muscle weakness, need for assistance for personal care and depression (a persistent feeling of sadness). Review of Resident 47's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 1/24/25 under Section C, indicated a score of 7, meaning Resident 47 had severe cognitive impairment. The MDS Section GG titled, Functional Abilities indicated Resident 47 needed partial to moderate physical assistance from one person in taking showers or bathing. Review of Resident 47's Activities of Daily Living (ADL) care plan dated 1/24/25 indicated a goal for the resident to be clean and be free from skin breakdown with the intervention for the staff to assist the resident with showers per schedule and as needed. During a joint concurrent interview and record review on 4/30/25 at 10:23 a.m., with Certified Nursing Aid (CNA) 5 and Assistant Director of Nursing (ADON) , Resident 47's shower schedule was reviewed and the ADON confirmed that the resident's shower days were supposed to be on Mondays, Wednesdays and Fridays in the morning shift (7 a.m. to 3 p.m.). Resident 47's Shower Day Body Check Sheets (or called shower sheets were the forms used by the CNAs to document the residents' showers),for April 2025 were reviewed with CNA 5 and the ADON. The shower sheets indicated Resident 47 only had showers on 4/7/25, 4/10/25, 4/13/25, 4/19/25 and 4/15/25. Resident 47 had no shower sheets on his scheduled shower days on Mondays, Wednesday and Fridays on the following dates: 4/2, 4/4, 4/9, 4/11, 4/14, 4/16, 4/18, 4/21, 4/23, 4/25 and 4/28 of 2025. CNA 5 stated she gave the resident showers on some of the mentioned dates and the resident refused showers on some of the other mentioned dates, but CNA 5 was unable to provide documentation. The ADON stated the risks for Resident 47 in not getting showers as scheduled were body odor and infection. b. During an interview on 4/28/25 at 10:51 a.m., Resident 370 was observed awake in his room lying in his bed. When asked about his showers, the resident stated he was not getting showers and that he never refused a shower. Review of Resident 370's Facesheet indicated he was admitted to the facility on [DATE] with diagnoses that included weakness and need assistance with personal care. Review of Resident 370's MDS dated [DATE] under Section C, indicated a score of 15, meaning Resident 370 was cognitively intact. The MDS Section GG titled, Functional Abilities indicated Resident 370 needed partial to moderate physical assistance from one person in taking showers or bathing. Review of resident's ADL care plan dated 4/21/25 indicated a goal for the resident to be clean and be free from skin breakdown with the intervention for the staff to assist the resident with showers per schedule and as needed. During a concurrent interview and record review on 4/30/25 at 4:13 p.m., with the Director of Staff Development (DSD), Resident 370's shower schedule was reviewed and the DSD confirmed that the resident's shower days were Tuesdays, Thursdays and Saturdays in the evening shift (3:00 p.m. to 11:00 p.m.). Resident 370's shower sheets for April 2025 were also reviewed with the DSD. The shower sheets indicated Resident 370 only had showers on the following dates: 4/15, 4/19, 4/22, 4/24 and 4/26 of 2025. Resident 370 had no shower sheets on 4/17/25 and 4/29/25. There was no documentation that the resident refused. DSD stated the resident should have had a shower on 4/17/25 and 4/29/25. Stated the risks for Resident 370 in not getting showers as scheduled were bedbugs, scabies and loss of dignity. During a review of the facility's policy and procedure (P&P) titled, shower bath, revised October 2010, the P&P indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1.The date and time the shower/tub bath was performed .5. if the resident refused the shower/tub bath, the reason(s) why and the intervention taken . Notify the supervisor if the resident refuses the shower/ tub bath .

Based on observation, interview and record review , the facility failed to provide an ongoing program of activities to meet the interests and psychosocial well-being for two of 25 sampled residents (Residents 112 and 115). These deficient practices had the potential to affect the quality of life of the residents by placing the residents at risk of sensory deprivation and social isolation. Findings: a. During an interview on 4/28/25, at 12:44 p.m., with Resident 112, the resident stated she was not being offered activities. On observation, the resident only had a TV and her cellphone. Review of Resident 112's Facesheet (information containing contact details, brief medical history at-a-glance) indicated she was admitted to the facility on [DATE]. Review of Resident 112's Minimum Data Set (MDS, an assessment tool) dated 3/18/25, indicated she had a Brief Interview for Mental Status or BIMS of 15 (BIMS score of 13-15 suggests intact cognition). Review of Resident 112's Activities care plan dated 3/12/25 indicated that one of the resident's interests included listening to radio, and the care plan also indicated to offer Resident 112 various activity supplies such as books, puzzles, reading materials and magazines. During a concurrent observation and interview on 5/1/25, at 10:45 a.m., with the Activity Director (AD), in Resident 112's room, Resident had no books, no radio or magazines at bedside. AD acknowledged the radio, books and magazines should have been offered to the resident. During a concurrent interview and record review on 5/1/25 at 11:00 a.m., AD stated Resident 112 refused to attend the activities offered but AD was unable to provide documentation of the resident's refusals or any activity progress notes for Resident 112. There was also no plan of care found on Resident 112's refusal of activities. b. During an interview on 4/28/25 at 9:31a.m., with Resident 115, the resident stated she was not being offered any activities to do. On observation, the resident only had a TV in her room. Review of Resident 115's Facesheet indicated she was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a persistent feeling of sadness). Review of Resident 115's MDS dated [DATE] indicated she had a BIMS of 13 (BIMS score of 13-15 suggests intact cognition). During a concurrent observation and interview on 5/1/25, at 11:05 a.m., with Activity Director (AD), in Resident 115's room, Resident had no books, no radio or magazines at bedside. AD acknowledged the radio, books and magazines should have been offered to the resident. During a concurrent interview and record review 5/1/25 at 11:10 a.m., with the AD, AD was unable to provide documentation of Resident 115's activities. Review of Resident 115's Activities care plan dated 3/24/25 indicated that Resident 115 had a depressive disorder and needed encouragement from the staff for participation in activity program. One of the interventions was to encourage attendance and participation with activities of choice as tolerated. During a concurrent interview and record review on 4/30/25 at 2:32 p.m., with the Assistant Director of Nursing (ADON), there were no activity progress notes found in Resident 112 and 115's medical records. ADON stated that the risks for the residents in not having activities were decreased quality of life and depression. During a review of the facility's policy and procedure (P&P) titled, Activity Evaluation, revised April 2013, the P&P indicated, .In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident

Based on observation interview and record review the facility failed to provide care and services to six of 25 sampled residents who were dependent on the staff for their care when their call lights were not answered by the facility staff on a timely manner (Residents 4,8, 48,88,113 and 370). This deficient practice had the potential to negatively affect the residents' physical comfort and psychosocial well-being Findings: a. During a concurrent observation and interview on 4/28/25 at 12:30 p.m., Resident 4 was lying in bed and resident stated his call lights took an hour or more to be answered. Stated his needs were sometimes not met. Review of Resident 4's Facesheet (information containing contact details, brief medical history at-a-glance) indicated, Resident 4 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (muscle wasting, also known as muscle atrophy, refers to the loss of muscle mass and strength). During a review of Resident 4's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/25/25 under Section C, indicated a score of 15, meaning Resident 4 was cognitively intact . b. During a concurrent observation and interview on 4/28/25 at 1024a.m., Resident 8 was lying in bed, and the resident stated her call lights were always not answered on time. Stated it took a while before her soiled diaper was changed. Review of Resident 8's Facesheet indicated Resident 8 was admitted to the facility on [DATE] with diagnoses that included legal blindness, anxiety disorder and major depressive disorder (a persistent feeling of sadness). Review of Resident 8's MDS dated [DATE] under Section C, indicated a score of 14, meaning Resident 8 was cognitively intact. The MDS Section GG titled, Functional Abilities, indicated that Resident 8 was dependent on toileting and needed the assistance of 2 or more helpers in performance of her toileting needs. MDS section H indicated Resident 8 was always incontinent in urination and was frequently incontinent in her bowel movements. c. During a concurrent observation and interview on 4/30/25, at 2:00 p.m., Resident 48 was lying in bed and stated he was very upset, resident stated he had been waiting for an hour to have his diaper changed because he had a bowel movement, and stated it was not acceptable that the average wait for the staff to attend to his needs were an average of 40 to 50 minutes. Stated the staff would answer, you are not my patient' and then turn off the call light. Also stated there were times the staff said they would come back to attend to his needs but would never come back. Review of Resident 48's Facesheet indicated, Resident 48 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (a persistent feeling of sadness). During a review of Resident 48's MDS dated [DATE] under Section C, it indicated a score of 14, meaning Resident 48 was cognitively intact. The MDS Section GG titled, Functional Abilities indicated a need for ADL (activities for daily living) support with at least one person providing physical assistance. The MDS also indicated that Resident 48 was occasionally incontinent with urine and bowel movement. d. During an initial tour on 4/28/25 at 9:55 a.m. Resident 88 was sitting in bed. Resident 88 expressed concerns regarding the call light. Resident 88 stated his call lights were not answered on time and some of his needs were not met on a timely basis. Review of Resident 88's Facesheet indicated, Resident 88 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (kidneys can no longer function on their own) and dependence on dialysis (kidneys have failed to filter waste from the blood, and dialysis is required to perform these functions). During a review of Resident 88's MDS dated [DATE] under Section C, it indicated a score of 15, meaning Resident 88 was cognitively intact. The MDS Section GG titled, Functional Abilities, indicated that Resident 88 needed moderate to maximal physical assistance from a helper in performance of his ADLs. e. During a concurrent observation and interview on 4/28/25 at 1:25 p.m., Resident 113 was lying in bed with a bedside commode by her bedside, the resident stated her call lights were not always answered on time. Stated the staff did not place her in the bedside commode in time and she would have accidents in her diaper. Review of Resident 113's Facesheet indicated Resident 113 was admitted to the facility on [DATE] with diagnoses that included weakness and fall. During a review of Resident113's MDS, dated [DATE] under Section C, indicated a score of 15, meaning Resident 113 was cognitively intact. The MDS Section GG titled, Functional Abilities indicated, Resident 113 needed substantial to maximal assistance from a helper in toileting/hygiene. f. During a concurrent observation and interview on 4/28/25 at 1051a.m., Resident 370 was lying in bed, and the resident stated his call lights were always not answered on time. Stated his needs were sometimes not met. Review of Resident 370's Facesheet indicated Resident 370 was admitted to the facility on [DATE] with diagnoses that included weakness and need assistance with personal care. Review of Resident 370's MDS dated [DATE] under Section C, indicated a score of 15, meaning Resident 370 was cognitively intact. The MDS Section GG titled, Functional Abilities indicated that Resident 370 needed the partial to moderate physical assistance of a helper in performance of his ADLs. During an interview on 4/30/25 at 9:21a.m., with the Director of Staff Development (DSD), DSD stated, residents call lights should be answered within 2 to 3 minutes. Also stated she conducted an in-service to the staff regarding answering the residents' call lights, but stated she did not have documentation of staff compliance in answering call lights after her staff in-service (an in-service training is education given to the staff to improve performance by equipping them with new knowledge, skills, and abilities to better perform their jobs). During an interview on 4/30/25 at 2:32 p.m., with the Assistant Director of Nursing (ADON), ADON stated the residents' call lights should be answered promptly and the risks of not answering the call lights promptly were the possibility of the residents' falling and skin problems due to incontinence. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised March 2021, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs . If the resident's request is something you can fulfill, complete the task within 5 minutes if possible .

Based on observation, interview, and record review, for one of three sampled residents (Resident 45), the facility failed to developed and implement adequate person-centered interventions to prevent Resident 45 with dementia from wandering into the rooms of other residents. Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptom and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). This failure cause Resident 45 falls, injuries, and had the potential to cause residents increased confusion and emotional distress. Findings: During a review of Resident 45's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 3/17/25, indicated Resident 45's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 45's score was 05 meaning poor cognition. MDS indicated Resident 45 is Chinese and preferred language is Mandarin. MDS indicated Resident 45 had no potential indicators of psychosis, no hallucination, no delusions. MDS indicated Resident 45 had fall with injury with admission to facility. Resident 45's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 45's care plan, titled, Behavioral Symptoms, initiated 4/14/23, care plan indicated Resident 45 had physical and verbal behavioral symptoms manifested by wandering episodes, Resident 45 tends to wander around facility. Further review of care plan, titled, Going into other residents rooms initiated 5/21/24 indicated problem included Resident 45 going into other resident's room, verbally aggressive when asked to leave. Care plan goal indicated Resident 45 will be free of avoidable complication, interventions included monitor closely, provide redirection as needed. During an observation on 4/28/25 at 10:52 a.m. Resident 45 wandered in hallways with a front wheeled walker looking into other residents rooms. During a review of Resident 45's clinical notes, dated 1/18/25, the clinical notes indicated, at 6:20 a.m. Resident 45 was seen on the floor in the hallway. Last seen ambulating from station 1 to station 2 and going from room to room. Upon assessment Resident 45 sustained a bump on the right side of forehead. Resident 45 was transferred to hospital. Further review of Resident 45's clinical notes, dated 1/2/25, the clinical notes indicated Resident 45 had an unwitnessed fall. During an interview on 4/29/25 at 11:43 a.m. with Director of Nursing (DON), DON stated Resident 45 wander in hallways. DON stated that on 1/18/25, Resident 45 had a fall in the hallway was found sitting on the floor with bump on the right side of her forehead. DON stated Resident 45 was sent to the hospital for evaluation and came back with closed fracture of the temporal bone (skull fracture). During an interview on 4/30/25 at 8:33 a.m. with Certified Nursing Assistant (CNA1), CNA1 stated Resident 45 wandered around the facility goes into other residents rooms . CNA1 stated Resident 45 was very confused, wanders into other residents rooms, switch off the light in the room and get agitated when redirected. During an interview on 4/30/25 at 8:37 a.m. with CNA 2 , CNA 2 stated Resident 45 roams around the facility. CNA 2 stated CNA2 checked on Resident 45 as she was at risk for falls and sometimes found her in another resident's room. CNA 2 stated Resident 45 liked to check light and switch it off. During a concurrent observation and interview on 4/30/25 at 8:55 a.m. with staff Interpreter (IT), Resident 45 sat up in bed in her room, walker by bedside. Resident 45 with hand gesture instructed both surveyor and IT to leave her room. During an interview on 4/30/25 at 12:07 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 45 wanders around the facility, into other residents rooms and turn off the light. LVN 1 stated Resident 45 continued to wanders into other resident rooms despite redirection. During an interview on 4/30/25 at 12:11 p.m. with Resident 25, Resident 25 stated Resident 45 wanders into his room, switch off light in the room and take ensure supplement that did not belong to her. Resident 25 stated he was not comfortable with Resident 45 coming into his room. During a review of Resident 25's MDS, dated [DATE], indicated Resident 25's BIMS score was 15 meaning intact cognition. During an interview on 5/1/25 at 8:20 a.m. with Resident 66, Resident 66 stated Resident 45 wanders into her room, cuts all our lights off. Resident 66 stated Resident 45 had an habit of taking things, she has taken my roommates clothes, she has taken my clementines before but staff was able to take it from her, feels like invasion of privacy. Resident 66 said she pressed the call light when Resident 45 wandered inside her room. During a review of Resident 66's MDS, dated [DATE], indicated Resident 66's BIMS score was 15 meaning intact cognition. During an interview on 5/1/25 at 8:45 a.m. with CNA 3, CNA 3 stated Resident 45 get agitated when redirected from other residents room. CNA 3 stated Resident 45 was redirected from male residents room to prevent her from getting hurt. During a review of Resident 1's physician order sheet, dated 2/28/24, physician order indicated to monitor Resident 45's behavior of going into other residents room, taking other patient's food/clothes, pulling curtains in other patients room, closing doors , turning off lights, removing other patient's food tray, taking belongings from other residents and monitor Resident 45 every hour episodes of going into other residents rooms for safety. During an interview on 5/1/25 at 12:16 p.m. with Social Services Director (SSD) , SSD stated Resident 45 wandered around the facility. SSD stated facility had discussed Resident 45's transfer to appropriate facility because of Resident 45 dementia status. SSD stated Resident 45's responsible party did not want Resident 45 transferred from facility. During an interview on 5/1/25 at 12:26 p.m. with Director of Nursing (DON), DON stated Resident 45 needed one-on-one monitoring or memory care placement. DON stated facility had discussed with Resident 45' daughter need for placement in a small building. DON stated Resident 45 continued to wander in the hallways and into other residents rooms despite interventions. During a review of Resident 45's Interdisciplinary team noted (IDT), dated 2/26/24, the IDT indicated, Plan of action would be to move Resident 45 to a facility that can better manage her behaviors. SSD will make list of closeby places that accept memory care residents. Discussed how Resident 45 requires a higher level of care due to her constant behaviors towards other residents and staff like hitting, spitting, rummaging in personal items. (An interdisciplinary team is a group of professional from different fields who collaborate to achive a common goal often focusing on patient care).

Based on observations, interviews, and record reviews, the facility did not ensure the standardized recipes for the regular diet were followed as printed, in accordance with menu guidance and facility policy. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the nutritional status of the facility residents. The facility census was 114. Cross reference F801 and F803 Findings: During a review of the facility's Lunch Menu titled Daily Spreadsheet- Wednesday Day 25, Week 4 Day 4, indicated Main Regular Diet NAS (4-5 grams): 3 oz. Tomato Braised Pot Roast, 1/2 cup Lyonnaise potatoes, 1/2 Steamed spinach, 1 Bread or roll, 1 cup of choice of beverage, 1 slice of 7-up Cake . During a concurrent kitchen observation, interview and record review on 4/29/25 at 2:38 PM with the evening [NAME] (CK) 2 and Dietary Services Manager (DSM), a large metal pot was found in the walk-in refrigerator with foil on it labeled Pot roast 4-29-25 Use by 5-1-25. CK 2 stated the morning [NAME] made the pot roast and placed it in the refrigerator an hour ago. A review of the Cool Down Log sheet dated April 2025 indicated that the morning [NAME] did not log the cool down start time for when it was placed in the refrigerator. The surveyor's thermometer was placed in the roast meat and it read 141.6 degrees Fahrenheit (F). The DSM and evening [NAME] acknowledged the initial temperature was missing from the log sheet and the temperature on the Surveyor's thermometer. The DSM stated the pot roast needed to be recooked in the oven to ensure it reached the final cooking temperature and to restart the cool down process. The evening [NAME] confirmed there weren't any vegetables like carrots and celery in the pot roast juice for the pot roast in the metal pan. The DSM stated the recipe should have been followed. During a review of the facility's recipe titled Tomato braised Pot Roast- 3 oz., dated 3/14/25, the recipe indicated .1. Season meat with salt .and pepper.Brown at 450 degrees Fahrenheit (F) for about 30 minutes. 2. Add water . tomato puree and bay leaf to browned meat; cover and cook slowly until tender (3-4 hours) . 3. Add carrots, celery, and onion during the last hour of cooking. CCP: At completion of cooking internal temperature should register 145 degrees F for 4 minutes.4. Serve 3 oz. meat with 2 oz. sauce per portion . The Steamed Spinach recipe was requested but not provided. During a concurrent observation and interview on 4/30/25 at 12:57 PM with the Registered Dietitian (RD) and Dietary Services Manager (DSM) of a test tray of the regular diet and pureed diet lunch meals, the RD and DSM each stated they typically do not do test tray evaluations at the facility. After the RD and DSM tasted the Regular diet lunch entrée roast beef and vegetable side, spinach, they both acknowledged the food items tasted bland, and had no flavor. The RD also stated the Regular diet roast beef entrée was also dried out and tasted overcooked. The RD and the DSM stated the brown gravy parts of the roast beef helped improve the flavor. After the RD, DSM, and Surveyor tasted the spinach from the Regular diet, the RD stated, It's like the spinach had no seasoning at all. The DSM stated the regular spinach could have used more seasoning. The RD then stated she expected the Cooks to follow the recipes because they've already been tested and approved. During a review of the facility's policy and procedure (P&P) titled Section 5 Meal Service, dated 2018, the P&P indicated .Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner . During a review of the facility's P&P titled Food Preparation, dated 2018, the P&P indicated .Food shall be prepared by methods that conserve nutritive value, flavor, and appearance.1. The facility will use approved recipes, standardized to meet the resident census.2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide.

Based on observation, interview, and record review the facility staff did not follow their infection control prevention policy and standards of practice during med pass for (two of twenty-five residents,) Resident 50 and Resident 86, when: 1. The facility staff did not clean and sanitize the medication cart in between resident's care, (Resident 50 and Resident 86), after placing soiled medication cup used by Resident 50, into the medication cart. 2. An uncapped and exposed lancet (a small needle used to poke the skin, [usually on a finger for Residents with diabetes] to get a small drop of blood) was left in med storage room B with no name or identifier. 3. The facility staff did not keep medication pill crusher (used to crush medications during medication administration), on the medication cart, clean and sanitized. The failure to practice universal precaution and infection control during medication administration had the potential to result in infection or spread of infection for Resident 86 and increased exposure for all facility residents and staff in the facility, possibly hospitalization for Residents. Findings: 1. During a record review of Resident 86's Facesheet (FC), the FC indicated Resident 86 is [AGE] years old, was admitted to the facility in 2022. The FC also indicated Resident 86 has diagnosis of Type 2 Diabetes (adult onset diabetes, characterized by high blood sugar and insulin resistance), Atrial fibrillation (irregular, often rapid heart rate), Urinary Tract Infection (when bacteria enter the urinary tract through and up to the bladder), Hypertension (high blood pressure), Chronic Viral Hepatitis B (a serious liver infection caused by Hepatitis B Virus), and Emphysema (chronic lung disease that progressively damages the alveoli [tiny air sacs] in the lungs). During a review of Resident 50's Facesheet (FC), the FC indicated Resident 50 is [AGE] years old, was admitted to the facility in 2025. The FC also indicated Resident 50 has diagnosis of Pneumonia (infection that causes an inflammation of the lung, which may filled with fluid), Type 2 Diabetes, Malignant Neoplasm of Renal Pelvis (Kidney cancer [healthy cells grow and form a tumor]), Acquired Absence of Kidney (a person is missing one or both kidneys due to injury or surgical procedure), Hypertension (high blood pressure), and Orthostatic Hypotension (low blood pressure that happens when standing up from sitting or lying down. During an observation on 4/29/2025 at 9:41 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 took Resident 50's meds into his room, in a small medication cup, LVN 3 gave all the meds due at 0900 med pass, then Resident 50 refused three of his medications, one Colace, two Senakots tabs and one Midodrine tablet. LVN 3 placed these meds on Resident 50's bedside table and after Resident 50 was done taking his other medications, LVN 3 picked up the medications with her hands and then placed the soiled cup on top of the medication cart designated for Resident med administration. LVN 3 took the soiled med cup and placed it in the top drawer of the med cart. LVN 3 then went to Resident 86's room, prepared Resident 86's medications and administered his medications without sanitizing the med cart. LVN 3 took the med cart back to the storage area and sat down at the nurse's station 2. During an interview on 4/29/2025 at 10:15 a.m., with LVN 3, LVN 3 stated she was supposed to have cleaned the med cart after she had placed the soiled med cup on the med cart for cross contamination purposes. LVN 3 stated she took the cup into Resident 50's room and then placed the cup back on the cart without cleaning the medication cart. 2. During an observation and an interview on 4/30/2025 at 11:12 a.m., with Registered Nurse 1 (LN 3), in medication room B, staff left an old, soft texture zipper black organizer bag with sticky, oily substance, with one small glucometer (machine to check blood sugar), test strips (used to collect blood to measure blood sugar level), and an uncapped sharp pointed lancet in one of the medication cabinet. LN 3 stated the bag with the glucometer, test strips, and uncapped lancet was supposed to have been discarded, destructed. And that Supervisors do destruction (get rid of, damage) every week and then sign they completed the task. LN 3 stated the bag containing the lancet sharp should not be left in the med cabinet for safety, someone does not stick themselves and because it does not have no resident identifier. 3. During an observation and an interview on 4/30/2025 at 10:40 a.m., with LN 3, medication pill crusher on medication cart 1B used to crush residents' medications had residue of dirty, sticky, dark brown particles, and white dusty powder in the inside and outside of it. LN 3 stated the pill crusher looks like it has not been cleaned for a while, and that the med cart should be cleaned once a week to prevent infection and cross contamination. During an interview on 4/30/2025 at10:43 a.m., with Licensed Vocational Nurse (LVN 3), LVN 3 stated the pill crusher was used to crush residents' medication on 4/30/2025. During a review of facility's policy and procedures (P&P), titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 2009, the P&P indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendation for disinfection and the OSEA Bloodborne Pathogens Standard . c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1). Non-critical residents care items include bedpans, blood pressure cuffs, crutches and computers . (2). Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location) . d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . (i). Single resident-use items are cleaned/disinfected between uses by a single-resident and disposed of afterwards . During a review of facility's policy and procedure (P&P), titled Administering Medication, dated 2001, the P&P indicated, 22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident 45), Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), was accurate when Resident 45 MDS section E was not coded accurately to reflect Resident 45's wandering behavior. This failure had the potential for residents to not received appropriate care. Findings: During an observation on 4/28/25 at 10:52 a.m. Resident 45 wandered in hallways with a front wheeled walker looking into other residents rooms. During an interview on 4/30/25 at 8:33 a.m. with Certified Nursing Assistant (CNA1), CNA1 stated Resident 45 wandered around the facility goes into other residents rooms . CNA1 stated Resident 45 was very confused, wanders into other residents rooms, switch off the light in the room and get agitated when redirected. During a review of Resident 45's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 3/17/25, indicated MDS section E wandering presence and frequency was coded zero meaning wandering behavior was not exhibited. During a concurrent interview and record review on 4/30/25 at 12:53 p.m. with Social Services Director (SSD), Residents 45's MDS section E behavior, dated 3/17/25 was reviewed. The MDS indicated, Wandering presence and frequency, has the resident wandered coded zero, behavior not exhibited. SSD stated she was responsible for completion of Resident 45's MDS section E. SSD stated Resident 45's MDS section E for wandering was not coded accurately.

Based on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 1) had at least two staff members to assist Resident 1 when Certified Nursing Assistant 1 (CNA 1) performed incontinence care by themselves which resulted in Resident 1 falling from their bed. This failure resulted in Resident 1 falling from their bed sustaining a left arm and left leg fracture. Resident 1 was not suitable for surgery to repair the fractures and had to enter hospice care due to the injuries sustained in the fall. Findings: A review of Resident 1 ' s admission record, dated 2/13/25, indicated Resident 1 was admitted to the facility for dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior), morbid obesity, osteoarthritis (inflammation of bone tissue leading to impaired function and pain) of the knees, and osteoporosis (reduction of bone density leading to increased risk of fracture). The admission record indicated Resident 1 was roomed with Resident 2 and 3. During a record review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 12/17/24, the MDS indicated Resident 1 had functional impairment in both legs, was completely dependent (indicating resident does none of the effort to complete the activity or the assistance of two or more helpers is required to complete the activity) on staff for toileting hygiene and needed maximum assistance (helper lifts or holds trunk or limbs and provides more than half the effort) to roll left and right in bed. The MDS also indicated Resident 1 was not able to stand or walk and needed a wheelchair for locomotion. During a record review of Resident 1 ' s vital signs record titled, Resident Vital Sign Report, dated 2/13/25, the record indicated, on 12/2/24, Resident 1 had a weight of 321 pounds (lbs. unit of weight measurement) A review of Resident 2 ' s admission record, dated 2/13/25, indicated Resident 2 was admitted to the facility for chronic heart failure (condition of reduced heart function), muscle atrophy (loss of muscle tissue) and hypertension (high blood pressure). The admission record indicated Resident 2 was roomed with Resident 1 and 3. During a record review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 had Brief Interview for Mental Status score of 15 (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS indicated Resident 2 had impaired vision (able to see large print, but not regular print in books). A record review of Resident 2 ' s nursing note titled, Nursing Weekly Summary, dated 1/2/25, indicated Resident 2 wear eye glasses .in bed watching television. A review of Resident 3 ' s admission record, dated 2/13/25, indicated Resident 3 was admitted to the facility for rehabilitation after a hip fracture. The admission record indicated Resident 3 was roomed with Resident 1 and 2. During a record review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 had a BIMS score of 15, had adequate vision and hearing. A record review of Resident 3 ' s nursing note titled, Nursing Weekly Summary, dated 1/2/25, indicated Resident 3 had no complaint of visual problem .alert and verbally responsive. During a concurrent observation and interview on 1/21/25, at 3:20 p.m., with Resident 2 and Resident 3, Resident 2 was in bed. Resident 3 was in a wheelchair next to their own bed. Resident 2 and 3 stated Resident 1 was in the bed in the middle of the room and both were able to recall Resident 1 ' s fall on 1/3/25. Resident 2 stated it was around 9:00 a.m. and CNA 1 had come in to change Resident 1 ' s brief. Resident 2 saw CNA 1 leave the room to find help but CNA 1 returned alone, unable to get help. CNA 1 then started to clean Resident 1. CNA 1 rolled Resident 1 on their side and then Resident 1 fell off the bed. Both Resident 2 and 3 stated CNA 1 should have waited because they knew Resident 1 was unable to safely hold onto the bed rail. Both Resident 2 and 3 stated they had observed Resident 1 needing two or more people to assist during care. Resident 3 stated they saw Resident 1 on the floor between Resident 1 and Resident 3 ' s bed. Resident 3 stated Resident 1 was assessed by staff before being transported out to the hospital. During a phone interview on 2/14/25, at 12:08 p.m., with CNA 1, CNA 1 stated on 1/3/25 at around 9:00 a.m., he was in Resident 1 ' s room to change Resident 1 ' s brief. CNA 1 had not worked with Resident 1 before but knew Resident 1 needed at least two staff for assistance. CNA 1 did not get report from the previous shift or the charge nurse about the level of assistance Resident 1 required. CNA 1 looked down two nearby hallways to find help but could not find anyone. CNA 1 then started to perform incontinence care for Resident 1. Resident 1 was in bed, and CNA 1 rolled Resident 1 on their left side. CNA 1 instructed Resident 1 to hold themselves up using the bed rail, and it seemed like Resident 1 was able to comply. CNA 1 looked away to grab a cleaning wipe at the end of the bed and saw Resident 1 sliding off the bed. CNA 1 attempted to hold on to Resident 1 but was unable to prevent them from falling to the ground. CNA 1 then went out to get help. LVN 1 came in to assess Resident 1, and Resident 1 was transported to a hospital. During a record review of Resident 1 ' s change in condition note titled, Clinical Note Entry Change in Condition, dated 1/3/25, by Licensed Vocational Nurse 1 (LVN 1), the note indicated writer was notified by CNA that resident had witnessed fall. Writer noticed resident lying on the floor with her front belly side on the floor at 9:15 a.m .CNA stated he was cleaning (sic) up the resident around her back, had resident holding on to railing turned towards left side, resident legs slide down and fell on her legs first and the body. During an interview on 2/14/25, at 12:49 p.m., with LVN 1, LVN 1 stated on 1/3/25, they were the charge nurse for Resident 1 on that day. While LVN 1 was performing a medication pass, CNA 1 came up to report a fall. LVN 1 entered Resident 1 ' s room and found Resident 1 on the floor on their chest. LVN 1 stated for activities of daily living (ADL, life activities such as eating, hygiene, toileting and ambulation) care such as turning and repositioning, Resident 1 needed two staff to assist to prevent falls and injury. LVN 1 stated Resident 1 was over 300 lbs., had poor upper body strength and did not have enough strength or coordination to hold herself on her side. LVN 1 stated CNA 1 did not ask about how much assistance Resident 1 needed before starting care. During a concurrent interview and record review on 2/14/25, at 1:30 p.m., with Director of Staff Development (DSD), CNA 1 ' s in-service record titled, Facility Class Attendance Record, dated 1/3/25, was reviewed. The DSD stated CNA 1 completed a one on one in-service with the DSD after Resident 1 ' s fall. The DSD stated they had reinforced expectations to have two staff or more assist any residents which appeared heavier than 200 lbs. The DSD stated Resident 1 ' s weight indicated they required two staff to assist during care. During a concurrent interview and record review on 2/14/25, at 2:45 p.m., with the Assistant Director of Nursing (ADON), Resident 1 ' s fall assessment titled, Fall Risk Assessment, dated 12/31/24, was reviewed. The ADON stated the assessment indicated Resident 1 had a fall assessment score of 10 which indicated Resident 1 was at high risk for falls. The ADON stated Resident 1 required two staff for all ADL care because of her weight. The ADON stated at the beginning of the shift, nurses were expected to inform CNAs the ADL needs for each resident and CNAs were expected to endorse resident needs to the next shift. During a record review of Resident 1 ' s assessment of bowel and bladder function titled, Bowel and Bladder Assessment, dated 12/31/24, the assessment indicated Resident 1 was always incontinent of bowel and urine .no motivation to participate .2 or more person assist with transfer/ambulation. During a record review of Resident 1 ' s hospital history and physical assessment note titled, [Facility] Hospital Medicine History & Physical, dated 1/3/25, the note indicated on 1/3/25, Resident 1 accidentally rolled out of bed and onto the floor .found to have L humeral fx (left upper arm fracture) and L femoral neck fx (left leg fracture at the top thigh bone). During a record review of Resident 1 ' s hospital record titled, Specialty Palliative Care: Follow up Consult, dated 1/15/25, the record indicated per orthopedic surgery consult, no benefit from surgical management .plan for discharge to board and care with hospice. During a review of facility policy and procedure (P&P) titled, Falls - Clinical Protocol, dated 4/2013, the P&P indicated, nurse shall assess and document/report .musculoskeletal function .neurological status .staff will document risk factors for falling in the resident ' s record and discuss resident ' s fall risk .staff and physician will monitor and document individual ' s response to interventions intended to reduce falling.

Based on observation, interview and record review, the facility failed to protect one of one sampled resident (Resident 1) from physical abuse. Resident 1 stated she was physically assaulted by Certified Nursing Assistant (CNA) 1 in the shower. Resident 1 was physically harmed which was demonstrated by bruising below her eyes. Findings: Medical Record review on 6/24/13 showed that Resident 1 was being treated for [REDACTED]. She would move her hands and arms about, touching or hitting staff during care. On 6/24/13 at 12:35 p.m., Resident 1 was observed in her bed, clean hands and fingernails cut short. Below the left eye the skin was yellowish / and slightly green in color. The skin below the right eye was pinkish/red in color. Resident 1's eyes responded by looking toward voices and motion in the room. An interview was attempted but, she stated she did not want to talk and moved her hand, in a go away motion. In an interview on 6/24/13 beginning at 12:30 p.m., the Director of Nursing (DON), stated that she was asked by Registered Nurse (RN) 1 to assess Resident 1 for discoloration under both eyes. The DON stated Resident 1 reported that a small skinny pregnant CNA punched her in the shower. Resident 1 did not complain of pain. The DON stated her assessment showed the skin below the left eye was pinkish / purplish. The skin below the right eye was a pinkish / reddish color. The DON stated that the facility had only one CNA (CNA 1) that matched the description and she had been assigned to Resident 1 on 5/25/13, the day of the incident. CNA 1 had been suspended from work since the day of the incident pending investigation. The DON described Resident 1 as having the ability to recognize people and recall incidents. During an interview on 6/24/13 at 1 p.m., RN 1 stated CNA 1 asked her to look at Resident 1's face but did not say what needed to be assessed and RN 1 did not ask. RN 1 went to the room at approximately 2:30 p.m., after caring for another resident and saw the skin under the left eye was purplish and under the right eye it was pinkish. She did not do a full assessment as Resident 1 was agitated and told her to get out. RN 1 stated, during the 5:30 - 600 p.m. rounds, Resident 1 was screaming and told her "someone punched me on my face," in the shower that morning. Resident 1 described her as small, skinny and pregnant. Resident 1 stated, "I cannot see," referring to her left eye. RN 1 recounted interview with CNA 1 stating that CNA 1 became frustrated with Resident 1 due to continuous calling out and name calling. CNA 1 also reported to RN1 that Resident 1 had hit her in the stomach on that same day. Review of RN 1's, Account of Incident, dated 5/25/13 at 2:30 p.m., showed Resident 1 had a purplish skin discoloration under the left eye and a pinkish / reddish discoloration under the right eye. There was no swelling or tenderness noted and Resident 1 did not complain of pain. Resident 1 claimed a small, skinny, pregnant CNA hit her eye when giving her a shower in the afternoon. The notes stated Resident 1 was alert, oriented and emotionally stable. There was no anxiety, depression or crying noted. During an interview, 7/15/13 at 11:10 a.m., CNA 1 stated she requested help from co-workers, CNA 2 and CNA 3, to get Resident 1 into a shower chair as she had soiled herself. Resident 1 was transferred to the shower chair without problem and CNA 1 took Resident 1 to the shower alone. She stated while in the room she had noticed a little bit of redness in an "L" shape on one of Resident 1's eyes. CNA 1 was unsure which one it was. She thought Resident 1 had scratched herself and did not point it out to CNA 2 or CNA 3. CNA 1 stated Resident 1 did not want to wipe her own face in the shower so CNA 1 did it for her. CNA 1 stated she was "scared" when she first saw the "L" on the eye because Resident 1 had a history of [REDACTED]. CNA 1 waited to report the redness because she wanted to get the shower done first because the resident was soiled. CNA 1 stated she requested RN 1 to assess Resident 1 twice between 2 p.m. and 3:30 p.m. CNA 1 stated Resident 1's hands were always moving, she cursed, tapped you to stop care and scratched. CNA 1 stated she did not document that Resident 1 had tapped her stomach that morning or about the eye before she left for the day. When asked how she responded to Resident 1 touching her stomach, CNA1 stated she told her, "Don't do that, please. I'm pregnant." When asked how being hit in the stomach made her feel, CNA 1 corrected that she was not hit, but tapped. CNA 1 stated she did not feel anything, she was not angry, just worried because she was pregnant. When asked if she had stated to the Charge Nurse (RN 1) that Resident 1 made her mad and she wanted to hit her, CNA 1 stated "it was a busy day; residents always want and need something, sometimes you say things you wouldn't do." In separate interviews, CNA 2, on 6/24/13 at 1:35 p.m., and CNA 3, on 7/17/15/13 at 12:05 p.m., both stated they had been asked by CNA 1 to assist getting Resident 1 into a shower chair and they had not observed any redness on Resident 1's face. After Resident 1 was in the shower chair, they left and CNA 1 took her for a shower. CNA 2 stated that Resident 1 had a history of [REDACTED]." Review of the social service note, on 6/24/13, dated for 5/28/13 at 1 p.m., showed Resident 1 stated, "Someone pushed me in the shower. I am okay." Review of the Alameda Police Department report, #13-2936, dated 6/3/13; Resident 1 was able to identify CNA 1 from a photo lineup as the person who hit her in the shower. Review of CNA1's employee file on 6/24/13 showed that CNA1 had no prior history of hitting residents and had attended inservices on 12/26/13 "Your Legal Duty - Mandated Reporting of Abuse", and on 10/31-11/1/12- "Verbal Abuse- Yell at Residents" and "Residents Rights". Review of the Abuse Prevention Program policy, dated 1/13 stated, "the company has zero tolerance for any type of abuse" and it is the expectation... that any and all reports ...injuries of an unknown source shall be promptly investigated by the facility management."

Based on observation, interview and record review, the facility failed to follow physician's orders to remove the Foley catheter for one of one sampled residents (1). Resident 1 had a Foley catheter in place to assist pressure ulcers in healing. AFoley Catheter drains urine from the bladder into a bag to keep the pressure ulcers dry. Resident 1 had a surgical repair of the pressure ulcers which meant they were no longer an open wound and the catheter was to be removed. The facility failed to remove the catheter and the resident had 3 episodes of urinary tract infections . Findings: Record review on 1/30/13 showed that Resident 1 was originally admitted to the facility on [DATE] with a Foley Catheter in place to help keep her open pressure sores dry. Resident 1 had a stage III to stage IV pressure sore on the lower back part of her Right hip bone. Stage III means that loss of the full thickness of the skin exposing the underlying tissues. Stage IV means loss of the full thickness of skin and tissue with exposed bone. On 9/10/12 Resident I was sent to hospital to undergo a repair of the stage III/IV pressure sore. The pressure areas were closed so there was no exposed tissue. Resident 1 returned to the facility on [DATE], with the [DIAGNOSES REDACTED]. Her past medical history included urinary tract infection, and septic shock. The physician noted that she had a right ischia surgical site wound, sutures, and was quadriparetic (paralyzed). According to the physician orders dated 10/10/12 the Resident was to have a " Foley catheter ....for wound healing." The orders indicated that the Foley was to be discontinued once the sutures were removed adn the Foley was to be changed every 10 weeks, catheter care to be given every shift and the drainage bag to be changed once a month. The facility treatment record for 12/12 revealed that the redness to the right and left buttocks which was treated with soap and water and dermaseptin ointment, was healed on 12/18/12. Once all the wounds were healed there was no need for a Foley Catheter to remain in place. A review of the October and November treatment showed that the order to change the Foley every 10 week, the bag every month and catheter care given every shift had not been entered. Instead there was a treatment order that read: Change Foley "PRN (as needed) occulsion or dislodgement". The order to change the Foley bag was "PRN". There was no documentation showing that the Foley catheter or the drainage bag was changed in either October or November 2012 A review of the resident's lab tests dated 11/8/12 showed the resident had a urinary tract infection with [MEDICAL CONDITION]/[MEDICATION NAME] resistant bacteria (MRSA) and was treated with [MEDICATION NAME] 100 mg twice a day for five days. On 12/14/12 the resident's lab test results dated 12/14/12 revealed that she had another urinary tract infection which was treated with [MEDICATION NAME] 100 mg. once a day for 5 days. On 1/7/13 the resident again developed a urinary tract infection according to the lab test dated 1/11/13 and was treated with Keflex 500 mg four times a day for 10 days. The physician's order for Foley catheter was discontinued on 1/15/13. In a telephone interview with the Director of Nurses (DON) on 2/4/12 at 10:30 a.m. she stated that she spoke with " one of the nurses " who told her that the physician (Dr. 1) told her he wanted the Foley to stay in to protect the healed pressure ulcer but that the nurse did not write it down anywhere. " Dr. 1 stated in a telephone interview on 2/8/13 at 2:12 p.m. that he told the nurses to discontinue the Foley after the wound was healed, but the nurse called him back and said that ' the family didn't want it out.' He reiterated that he did not want the resident to have the Foley catheter after the wound was healed. On 3/5/13 at 2:05 p.m. during an interview the Assistant Director of Nurses (ADON) stated she ws the nurse who spoke with the the physician but could not remember the date. She remembered the family attended a care conference and they wanted the Foley removed because they believed it contributed to the resident's urinary tract infections. She did not write the order but gave it to a nursing supervisor who she thinks wrote it. She did say she did not want to remove the Foley because she was concerned about keeping the surgical flap dry. The resident was very heavy and it was hard for the nurses to keep her clean and dry. She stated that she called the physician because of the family's request.