Every finding on record at Ararat Convalescent Hospital

Based on interview and record review, the facility failed to identify, assess, and investigate a potential fall for Resident 1 after the resident reported pain and stated she had fallen on 3/2/2026.Nursing staff did not initiate the facility's fall policy, including completing a post fall assessment, neurological monitoring, incident reporting, reassessment of mobility status. This failure resulted in delayed identification of injuries and placed the resident at risk for further harm, unmanaged pain, and unmet care needs.Findings: During a review of Resident 1's admission Record, the resident was noted to have been admitted on [DATE] and readmitted on [DATE], with diagnoses including multiple right sided rib fractures, pneumonia, and dementia. During a review of Resident 1's History and Physical dated 12/31/2025, the documentation indicated the resident had fluctuating capacity to understand information and make decisions. During a review of the Minimum Data Set (MDS) dated [DATE], the assessment indicated the resident had moderate cognitive impairment, used a wheelchair and walker for ambulation, and required supervision and moderate assistance with activities of daily living including eating, toileting, and dressing. During a review of the Morse Fall Risk assessment dated [DATE], the resident was identified as high risk for falls with a score of 80, with documentation of a history of falls and a tendency to overestimate functional abilities. During a review of the facility's investigation summary dated 3/5/2026, the resident was documented as having reported to multiple staff, including a CNA and therapy staff, that she had experienced a fall. Later that evening, at approximately 11:00 PM, the resident reported pain while being assisted to the bathroom using a front wheel walker. During a review of a CT scan dated 3/3/2026, the results indicated probable acute, nondisplaced fractures of the right 5th and 10th ribs. During a review of progress notes titled IDT Notes dated 3/6/2026, an interdisciplinary team meeting was documented with the social services director, a registered nurse, and a family member present. CT scan results from the acute hospital reflected probable acute nondisplaced right rib fractures. The family member reported that the hospital physician stated it would be unlikely for the resident to sustain multiple rib fractures without a traumatic fall. During a review of progress notes titled Health Status Note dated 3/3/2026, the resident stated she had fallen when asked about her pain. During an interview on 3/12/2026 at 10:20 AM, the Director of Nursing (DON) stated that during the initial assessment, RN 1 reported the resident complained of pain and stated she had fallen that morning. The DON stated no fall incident report was completed because the fall was unwitnessed and the CNA had not observed it. During an interview on 3/12/2026 at 10:30 AM, RN 1 stated that on the morning of 3/2/2026, CNA 2 reported the resident pointed to her right lower back and hip area indicating pain during morning care. RN 1 stated she and the LVN supervisor assessed the resident, who again indicated pain by pointing to her hip. RN 1 stated the resident told the LVN supervisor she had fallen; however, RN 1 stated she did not believe a fall occurred because no bruising was visible. RN 1 confirmed the resident was high fall risk and typically waited at the bedside for assistance. During an interview on 3/12/2026 at 1:37 PM, the DON stated the resident was already on fall precautions due to her high fall risk status. The DON reported the facility did not implement the fall policy because staff believed no fall had occurred based on the absence of visible bruising. The DON acknowledged the facility should have conducted a thorough assessment and investigated the potential fall. As a result, required interventions-including 72 hour neurological checks, reassessment of mobility status, and an interdisciplinary review-were not completed. The DON acknowledged this failure could have resulted in delayed identification and treatment of injuries and pain. During a review of the facility's policy titled Fall Risk Assessment, revised March 1, 2015, the policy indicated the facility will ensure the resident's environment is free of accident hazards and that residents receive adequate supervision to prevent accidents. The policy stated a fall may be witnessed or reported by the resident or any observer. During a review of the facility's policy titled Fall Management Program, revised February 29, 2024, the policy indicated the fall program aims to prevent falls through assessment, interventions, education, and ongoing evaluation. The policy required post fall assessments and investigations within 24 hours, review and revision of the care plan as needed, and an interdisciplinary falls committee meeting within 72 hours to complete a root cause analysis. During a review of the facility's policy titled Response to Falls, dated March 31, 2025, the policy indicated staff must respond promptly and appropriately to resident falls. Required post fall actions included assessment, investigation, neurological flow sheet completion for unwitnessed falls, documentation of notifications, and completion of an incident report. The interdisciplinary falls committee was required to review each fall and modify the plan of care as indicated.

Based on observation and interview and record review the facility failed to implement the policy and procedure on food storage, in accordance with professional standards for food service safety by failing to label a used by date for the following food items: -ground meat in a plastic container -three pieces of Armenian pizza -five croissants in a clear plastic bag -five glasses of milk This deficient practice had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food and negatively affect the health of the residents who consumed it. Findings: During an initial kitchen tour and interview with the Dietary Supervisor (DS) on 9/30/2025 at 9:05 AM the following were observed without a label with a used by date. In the freezer: -In the freezer ground meat in a plastic container. -three pieces of Armenian pizza. -five croissants in a clear plastic bag. In the refrigerator: -five glasses of milk. During a concurrent interview on 9/30/2025 at 9:05 AM DS stated, the ground meat are normally added to residents' food, the pizza and croissants are left- overs and the glasses of milk, she was not sure when was it prepared DS stated., the food items should have a used by date label to ensure it was still fresh for consumption, because it potentially could be old and contaminated that could get residents sick when consumed. During an interview on 10/1/2025 at 10:38 AM, the Director of Nursing (DON) stated that, per facility policy, food in the kitchen should be labeled with a use by date. The DON explained having the used by date ensures food freshness, helps kitchen staff know when to discard expired items, and prevents serving unsafe food to residents. The DON stated that failure to follow the policy could lead to food contamination and the growth of microorganisms, potentially causing foodborne illnesses that may negatively impact residents' health and quality of life. During a review of the facility's policy and procedure (P&P) titled, Food Storage, revised 11/20/2025 indicated, a) label and date all food items, b) label and date storage products when received as well as the used by date. During a review of the Food Code 2022, indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Indicated READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. READY-TO-EAT TIME/ TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES.

Based on observation, interview, and record review, the facility failed to follow the facility's policies and procedures (P&P) titled Resident Rights, dated 5/1/2023, by failing to promote privacy and dignity for two of three sampled Residents (Resident 12 and 21) by: 1.Certified Nurse Assistant (CNA 1 and 2) standing over Resident 1 while assisting with feeding Resident 21. 2.CNA 4 did not draw the privacy curtain (a curtain that tracks around the resident's bed to create a private space) fully around Resident 12's bed grooming and shaving Resident 12. These deficient practices violated Resident 21 and Resident 12's resident rights to maintain and enhance their self-esteem and self-worth and the right to be treated with dignity and respect. Findings: 1.During a review of Resident 21's, admission Record (AR), dated 10/16/2025, indicated Resident 21 was admitted to the facility on [DATE], with diagnoses that included dementia (the loss of cognitive functioning — thinking, remembering, and reasoning), heart disease (a range of conditions that affect the heart) and chronic kidney disease (a long-term condition where the kidneys do not work as well as they should). During a review of Resident 21's History and Physical Examination (H&P), dated 1/26/2025, indicated Resident 21 does not have the capacity to understand and make decisions. A review of Resident 21's Minimum Data Set (MDS, a resident assessment tool) dated 10/6/2025, indicated Resident 21 required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, dependent (helper does all the effort) with toileting, bathing, personal hygiene, and dressing. During a concurrent observation and interview on 9/30/2025 at 12:30 PM with CNA 1 and CNA 2 in Resident 21's room, Resident 21 was observed while in bed during mealtime looking up at both CNA 1 and CNA 2. CNA 1 and CNA 2 were observed standing while feeding Resident 21. CNA 1 stated she was assisting CNA 2 to help feed Resident 21. CNA 1 stated, she should have sat down at Resident 21's eye level, because standing over Resident 21 while assisting with feeding violated resident rights to be treated with dignity and respect. CNA 2 stated, she forgot she was supposed to sit eyelevel with Resident 21 during feeding. During an interview on 10/1/2025 at 10:38 AM with Director of Nurses (DON), DON stated, it was not appropriate to assist and feed any resident while standing over the resident. DON stated, CNA 1 and CNA 2 standing over Resident 21 while assisting with feeding violated Resident 21's rights to be treated with dignity and respect. 2. During a review of Resident 12's admission Records (AR), the facility admitted Resident 12 on 2/2/2024 and readmitted Resident 12 on 1/1/2025 with diagnoses that included nontraumatic acute subdural hemorrhage (bleeding in the brain), unspecified dementia (a progressive state of decline in mental abilities), unspecified severity, agitation, and generalized muscle weakness. During a review of Resident 12's H&P, dated 1/7/2025, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognitive (a resident's thought process) skills for daily decision making was severely impaired that required substantial assistance (helper does more than half the effort) for ADLs such as toileting and dressing his lower body and required moderate assistance (helper does less than half the effort) while providing bathing and providing personal hygiene. During an observation on 10/1/2025 at 9:00 AM, in Resident 12's room, CNA 4 was observed next to Resident 12's bed preparing to groom and shave Resident 12. The privacy curtain was drawn from the right side of Resident 12's bed to the foot of the bed that was in front of the open doorway, but the curtain was not drawn all the way to the left side of the bed, which exposed Resident 12 to other residents in the room. During an interview on 10/1/2025 at 10:12 AM with CNA 4, CNA 4 stated that she did not close Resident 12's curtain fully around Resident 12's bed while providing ADL cares. CNA 4 stated, she only closed the curtain on the left side of the bed to the foot of the bed, which was in front of the open doorway. CNA 4 stated, she thought she had closed the curtain more than halfway around the bed when performing Resident 12's ADL cares, but I did not. During the same interview on 10/1/2025 at 10:12 AM with CNA 4, CNA stated it was important to provide residents with privacy during any ADL care such as adult brief care, changing clothing, oral care, grooming, cleaning their face, or shaving. During an interview on 11/19/2025 at 4:00PM with the Director of Nursing (DON), the DON stated the privacy curtain should be drawn all the way around the bed covering the left and right side of the bed while providing ADL cares or any procedures. The DON stated that closing the privacy curtain was to provide the residents with dignity as to not expose the resident to other residents, visitors, or other staff members. During a review of the facility's P&P titled, Privacy and Dignity, dated 7/1/2016, indicated; a) the facility [NAME] promote resident care in a manner that maintains or enhances dignity and respect, and b) staff shall assist resident in maintaining self-esteem and self-worth. During a review of the facility's P&P titled, Resident Rights – Quality of Life, dated 1/1/2017, the P&P indicated that the facility staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care and during treatment procedures. During a review of the facility's P&P titled, Resident Rights, dated 5/1/2023, the P&P indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.

Based on interview and record review, the facility failed to implement its policy and procedures (P&P) titled Informed Consent (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sample residents (Resident 23) by not ensuring an Informed Consent was complete prior to administration of treatment of Mirtazapine (antidepressant, medication to treat depression). This deficient practice violated Resident 23 rights and her Representative Party (RP) to be informed of the risks and benefits of the proposed treatment and offered alternative treatments for Resident 23's antidepressant treatment. Findings: During a review of Resident 23's admission Records (AR), the facility admitted Resident 23 on 9/2/2024 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and unspecified mood [affective] disorder (mental health conditions that primary affect a resident's mood or emotional state). During a review of Resident 23's Minimal Data Set (MDS, resident assessment tool), dated 09/24/2025, the MDS indicated Resident 23's cognition (a person's thought process) was severely impaired. The MDS indicated Resident 23 was receiving an antidepressant. During a review of Resident 23's Order Summary, with an order date of 8/6/2025, the order indicated Resident 23 received Mirtazapine oral tablet 15 milligrams (mg, unit of mass) 1 tablet at bedtime for depression manifested by less than 25% of oral intake. During a review of Resident 23's care plan, dated 8/7/2025, the care plan indicated Resident 23 was receiving Mirtazapine related to depression as manifested by decrease oral intake as evidence by weight loss of 13 pounds (lb, unit of mass) in 6 months. The care plan's interventions included educating Resident 23 and her RP about the risks, benefits, side effects, and expression of sadness due to the medication. During a concurrent interview and record review on 11/18/2025 at 2:30 PM, with Registered Nurse (RN) 1, Resident 23's medical records were reviewed. RN 1 stated, there was no documented evidence of an Informed Consent for Resident 23's use of Mirtazapine that indicated the education was provided to Resident 23 and her RP about the risks, benefits, side effects. During the same interview on 11/18/2025 at 2:33 PM with RN 1, RN 1 stated, all medications that alter a resident's mental behavior and thought process, such as antidepressants, require an Inform Consent form and the resident or the RP must sign it. RN 1 stated that an Informed Consent was used to inform the resident and/or RP about the risks and benefits of the medication or treatment by the primary care physician and the resident and/or RP must consent to the treatment. During an interview on 11/18/2025 at 3PM with the Director of Nursing (DON), the DON stated that the facility's practice for providing antidepressant, or antianxiety medication was to complete an Informed Consent explaining the risks and benefits of the treatment to the resident or the RP. The DON stated, there needed to be an Informed Consent form with two (2) licensed nurses signatures as witnesses if the RP cannot come to the facility within 24-48 hours. The DON stated that there was no documented evidence of any informed consent for Resident 23's Mirtazapine treatment. During a review of the facility's P&P titled Informed Consent, dated 04/01/2024, the P&P indicated the facility will respect the residents right to make an informed decision prior to certain treatments and procedures such as psychotherapeutic medications. The P&P indicated the Attending Physician or Licensed Healthcare will obtain the informed consent and inform the resident or the RP the nature of the proposed treatment, the risks and benefits of the treatment, any alternatives to the proposed treatment, and the resident's or the RPs right to decline consent. The P&P indicated the facility staff will verify that the informed consent was obtained by the Attending Physician or Licensed Healthcare Practitioner, signed by the resident or the RP prior to the administration of the medical therapy or procedure, and documented and placed in the resident's medical care.

Based on observation, interview, and record review, the facility failed to implement a person-centered comprehensive care plan to address the resident's medical and physical needs for one of three sampled residents (Resident 9), who's cognitive skills were severely impaired, and was a high risk for fall, by not ensuring Resident 9's bed alarm (used to alert caregivers and staff when a person at risk of falls is getting out of bed) was properly working. This deficient practice had the potential to not alert the staff when Resident 9 attempted to get out of bed which could lead to a fall incident and/or injury. Findings: During a review of Resident 9's admission Record indicated the resident was admitted originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia (a decline in mental abilities that makes daily life difficult, affecting memory, thinking, and behavior), muscle weakness, abnormalities of gait and mobility and need for assistance with personal care. During a review of Resident 9's History and Physical Examination (HPE), dated 10/17/2025, indicated Resident 9 does not have the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool), dated 8/19/2025, indicated Resident 9's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 9 required partial/moderate assistance (helper does less than half the effort) with eating and personal hygiene, substantial/maximal assistance (helper does more than half the effort) with bathing and dressing and dependent (helper does all the effort) with toileting. During a review of Resident 9's facility document titled MORSE FALL - Senior Living dated 8/19/2025, the document indicated Resident 9's score was 75 which indicates high risk for falling. During a review of Resident 9's care plan (CP) for over mattress sensor pad for bed alarm when resident in bed to prevent fall/injury, dated 8/22/2025, the CP intervention included assure that device sensor pad (bed alarm) is working properly. During a review of Resident 9's facility document titled Order Summary Report (OSR) dated 9/29/2025, the document indicated to apply sensor pad alarm in bed (bed alarm) for fall prevention related to trying to get out of bed unassisted. During a concurrent observation and interview, on 9/30/2025, at 2:59 PM, with Licensed Vocational Nurse (LVN) 1, in Resident 9's room, Resident 9 was in bed, the bed alarm was in place but the on light indicator was off and did not alarm when LVN 1 attempted to trigger the alarm by removing the bed alarm from under Resident 9. LVN 1 stated the bed alarm was not functioning properly and was not checked by LVN 1. LVN 1 stated the bed alarm was used to alert staff when a resident was trying to get out of bed unassisted to prevent fall and/or injury. LVN 1 stated, since the bed alarm was not working, it could have potentially led to Resident 9 falling and/or injure herself. During an interview on 10/1/2025 at 11 AM with the Director of Nurses (DON), the DON stated, the facility did not implement a care plan for Resident 9 by not ensuring her bed alarm was functioning properly. DON stated, Resident 9 was assessed as a high risk for fall resident and a nonfunctioning bed alarm was not acceptable since it could potentially result in a fall and/or injury due to Resident 9 attempting to get out of bed unassisted. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, revised on 2/29/2024, indicated; a) the facility strives to prevent resident falls through meaningful assessment and interventions, b) nursing staff will develop a plan of care specific to the residents' needs with interventions to reduce the risk of falls. During a review of the facility's policy and procedure (P&P) titled, Care Planning, revised on 1/1/2017, indicated; a)comprehensive care plan will be developed for each residents, and will include measurable objectives to meet residents medical, nursing, mental and psychosocial needs, b) comprehensive care plan will describe services that are to be furnished to attain and maintain the resident's highest practicable physical, mental and psychosocial well-being, and c)the Resident has the right to receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure the facility provided necessary care and services to one of one sampled resident (Resident 22) in accordance with the facility's policy and procedure titled Care of Catheter. Resident 22's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was coiled and kinked obstructing the urine flow to the drainage bag. This failure had the potential for the urine to backflow to the bladder and bladder distention ( due to over accumulation of urine in the bladder) and result in catheter-associated urinary tract infection (CAUTI- an infection of the urinary system that occurs when bacteria enter through a indwelling catheter) and bladder collapse affecting the health and safety of Resident 22. Findings: During a review of Resident 22's admission Record, the admission Record indicated the facility admitted the resident on 8/5/2025, with the diagnoses including but not limited to bladder cancer, liver cancer, bile duct cancer, prostate cancer, dementia (a progressive state of decline in mental abilities), chronic kidney disease, hydronephrosis (swelling of one or both kidneys), diabetes type 2 (DM, disorder characterized by blood sugar control and poor wound healing), and dysphagia (difficulty swallowing). During a review of Resident 22's Minimum Data Set (MDS, a resident assessment tool), dated 8/9/2025, the MDS indicated the resident was partially/moderately dependent on self-care activities such as toileting hygiene, personal hygiene, dressing, and shower/bathing self. During a review of Resident 22's History and Physical (H&P), dated 8/26/2025, indicated Resident 22 does not have the capacity to understand and make decisions. During a review of Resident 6's physician orders, dated 10/2025, the physician's orders indicated the resident needed an indwelling catheter due to urinary obstruction (a blockage in the urinary tract that prevents urine from draining) and cancer. During a review of Resident 22's Care Plan for indwelling catheter related to prostate cancer, bladder cancer and chronic failure, the Care Plan indicated the nursing interventions included to secure placement of tubing with anchor and catheter care. During a review of Resident 22's Treatment Administration Record (TAR), dated for the month of September 2025, the TAR indicated Resident 22's indwelling catheter was documented to be in the correct place and proper securement on 9/30/2025 for every shift. During an observation on 9/30/2025 at 9:11 AM, Resident 22's indwelling catheter tube was coiled and kinked on the right upper thigh securement device. During an interview on 9/30/2025 at 10:00 AM with the Registered Nurse (RN) 1, RN 1 stated that the indwelling catheter tubing was coiled and kinked. RN 1 stated that the kinking and coiling of the indwelling catheter could lead to urine backflow, which might increase the risk of infection or potentially cause bladder rupture. During a concurrent interview and record review on 11/19/2025 at 3:30 PM with the Director of Nursing (DON), a photo of Resident 22's coiled and kinked indwelling catheter was reviewed. The DON stated that Resident 22's indwelling catheter tubing should not be kinked or coiled. During a concurrent interview and record review on 11/19/2025 at 3:45 PM with the DON, the facility's P&P titled, Care of Catheter, revised 9/1/2014, was reviewed. The P&P indicated, The catheter and collection tubing should be free of obstruction and kinking. The DON stated the coiling and kinking in the indwelling catheter can cause backflow of urine which can cause an infection or sepsis (a life-threatening blood infection).

Based on observation, interview, and record review, the facility failed to prevent an unplanned weight loss of 15.09% in six months for one of one sampled resident (Resident 7). The facility failed to: 1.Ensure staff identified Resident 7's decrease in oral intake (amount of food and water consumed), reassess and monitor interventions for weight loss when Resident 7 had a weight loss of 16 pounds in six months. 2. Ensure staff provided Resident 7 with a nutritional supplement twice a day as per physician's order from 8/6/2025 - 10/3/2025. These failures resulted in Resident 7's severe weight loss of 6 pounds (lbs.-unit of weight) in three months and placed Resident 7 at risk for malnutrition (lack of proper nutrition, caused by not eating enough), and dehydration (dangerous loss of body fluid). Findings: During review of Resident 7's admission Record, the admission Record indicated the facility admitted the resident on 6/25/2025, with the diagnoses including but not limited to failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), dementia (a progressive state of decline in mental abilities), depression, anemia (a condition where the body does not have enough healthy red blood cells), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 7's History and Physical (H&P), dated 6/26/2025, the H&P indicated Resident 7 does not have the capacity to understand and make decisions. During review of Resident 7's Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 9/29/2024, the MDS indicated Resident 7 is severely impaired in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. The MDS indicated Resident 7 requires supervision or touching assistance when eating (verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity). The MDS also indicated there was no or unknown weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. During a review of Resident 7's Weight and Vitals Summary, dated 6/26/2025, the summary indicated Resident 7's admission weight was 106 lbs. During a review of Resident 7's Weight and Vitals Summary, dated 6/26/2025, the summary indicated Resident 7's weight on 11/4/2025 was 90 lbs. During a review of Resident 7's physician orders, dated 7/9/2025, Resident 7's diet was changed to a no added salt diet, minced and moisture texture, and thin consistency. During a review of Resident 7's care plan, dated 7/8/2025, the care plan indicated Resident 7 refuses food and should have food intake monitored and documented daily. During a review of Resident 7's Nutritional Assessment, dated 9/29/2025, the assessment indicated Registered Dietician (RD) documented Resident 7 had lost ten lbs. since 6/26/2025. During a review of Resident 7's Change of Condition Evaluation (COC), dated 10/2/2025, the COC indicated Resident 7 had lost nine lbs. over the past three months. During a review of Resident 7's physician orders, dated 10/3/2025, the physician orders indicated Resident 7 was ordered sugar free ice cream, twice a day between meals for a nutritional supplement. During a review of Resident 7's Interdisciplinary Care Conference (IDT) notes, dated 10/3/2025, IDT notes indicated Resident 7 had a significant weight loss of nine lbs. since 7/2/2025. During a review of Resident 7's RD Nutritional Assessment (RD notes) notes, dated 10/3/2025, the RD notes indicated the RD documented Resident 7 had ten lbs., 9.4% weight loss since 6/26/2025. RD documented that Resident 7 consumes 76-100% of the estimated food needs. RD also documented Resident 7's oral intake was 25-100% and at times less than 25%. During a review of Resident 7's RD notes, dated 10/6/2025, the RD notes indicated the RD documented Resident 7 had nine lbs., 8.7% weight loss since 7/2/2025. RD documented significant wt. [weight] loss. Resident refusing magic cup. Prefers ice cream. RD also documented Resident 7's oral intake was 25-100% and at times less than 25%. During a review of Resident 7's Weekly Variance Meeting documents, dated 10/29/2025, the Weekly Variance Meeting documents indicated Resident 7 had lost two lbs. from 10/16/2025 to 10/23/2025 and no new orders were recommended. Resident 7's weight will continue to be monitored for one more week. During a review of Resident 7's Weight Variance Report, dated 11/2025, the report indicated Resident 7's weights were: 1.June 2025: 106 lbs. 2.July 2025: 103 lbs. 3.August 2025: 97 lbs. 4.September 2025: 96 lbs. 5.October 2025: 94 lbs. (-8.7 % weight loss since 7/2/2025) 6.November 2025: 90 lbs. During a review of Resident 7's Change of Condition (COC) notes, dated 7/3/2025, the COC indicated that Resident 7 experienced a three lbs. weight loss over the past week (106 lbs. - 103 lbs.) The notes did not indicate there were new physician orders, and the RD was not notified. During a review of Resident 7's COC notes, dated 7/7/2025, the COC indicated that Resident 7's condition was not referred to the RD. During a review of Resident 7's COC notes, dated 7/24/2025, the COC indicated that Resident 7 experienced weight loss, had no new physician orders, and the RD was not notified. During a review of Resident 7's COC notes, dated 8/6/2025, the COC indicated that Resident 7 experienced weight loss, had no new physician orders, and the RD was not notified. During a review of Resident 7's COC notes, dated 10/2/2025, the COC indicated that Resident 7 experienced weight loss, had no new physician orders, and the RD was not notified. During a review of Resident 7's RD notes, dated 7/6/2025 to 10/3/2025, the RD notes did not indicate that Resident 7 was seen as a follow-up in response to the change of condition for weight loss. During a review of Resident 7's Weight and Vitals Summary, dated 11/04/2025, the summary indicated Resident's weight was 90 lbs. During a concurrent observation and interview on 11/18/2025 at 12:00 PM with Certified Nurse Assistant (CNA) 1 in the resident dining room, CNA 1 stated, Resident 7 ate less than 25% of her lunch. During an interview on 11/18/2025 at 4:00 PM with the Dietary Supervisor (DS), the DS stated that she is a picky eater. During an interview with on 11/19/2025 at 1:45 PM with the Registered Dietician (RD), RD stated Resident 7 was ordered ice cream as a nutritional supplement. During an interview on 11/19/2025 at 3:15 PM with the DON, the DON stated Resident 7 has a significant weight loss and stated ice cream nourishment may not be helping her gain weight. During an interview on 11/19/2025 at 1:45 PM with the RD, the RD stated that the failure to thrive diagnosis was the contributing factor to Resident 7's weight loss. RD stated Resident 7 has had a major weight loss of 16 lbs. and we have not been able to do much for her weight loss issue. During a concurrent interview and record review on 11/19/2025 at 2:00 PM with the RD, Resident 7's Weekly Variance Report, dated November 2025, was reviewed. The RD stated, Resident 7's weight in June 2025 was 106 lbs., and 90 lbs. in November 2025. The RD also stated based on the weights documented on the Weekly Variance Report, Resident 7 had a 6.25% weight loss in the last three months and a 15.09% weight loss in the last six months. During a review of the facility's policy and procedures (P&P) titled, Nutrition & Weight Variance Committee, revised 12/1/2025 indicated, the DON or designee must be monitored by the Interdisciplinary Team (IDT) committee months for 5% weight change in one week, 7% weight change in three months and 10% weight change in six months. During a review of the facility's policy and procedures (P&P) titled, Assessment and Management of Resident Weights, revised 12/1/2025 it indicated, If the physician does not implement the dietician's recommendations they will document the rationale for non-implementation in the medical record and residents with significant Weight change will be weighed at least weekly and discussed at the resident at risk or other clinical meeting to determine possible causes of weight gain or loss including goals of care.

Based on observation, interview, and record review, the facility failed to ensure that three (3) Certified Nurse Assistants (CNAs) demonstrated sufficient competency and skills to accurately document the food intake of one of four sample residents (Resident 7) by evaluating their how the CNAs documented meal intakes of the residents in accordance to the facility's policy and procedures (P&P) titled, Documentation - Nursing, dated 1/1/2016 and the Guidelines for Percentage of Meal Intake. This deficient practice resulted in the inaccurate meal percentage documentation for Resident 7 and may result in the resident not receiving interventions for weight loss. Cross Reference F692 Findings: During a review of Resident 7's admission Record (AR), the facility admitted Resident 7 on 6/25/2025 with diagnoses that included protein-calorie malnutrition, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can use weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 7's history and physical (H&P), dated 6/26/2025, the HP indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, resident assessment tool), dated 9/29/2025, the MDS indicated Resident 7's cognition (a person's thought process) was severely impaired. The MDS indicated that Resident 7 needed supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) when eating. During a review of Resident 7's care plan, revised on 6/26/2025, the care plan indicated Resident 7 was at risk for nutritional problems related to adult failure to thrive. The care plan's interventions included monitoring and recording Resident 7's intake every meal. During a review of Resident 7's care plan, revised date 8/5/2025, the care plan indicated Resident 7 was at risk for weight loss and dehydration related to a diagnosis of protein-calorie malnutrition. The care plan's intervention included encouraging a dietary intake of at least 70% daily and monitoring Resident 7's dietary intake by percentage at each meal daily. During a review of Resident 7's care plan, created dated 10/2/2025, the care plan indicated Resident 7 had an unintended weight loss of 9 pounds (lb, unit of mass) in three (3) months. The care plan's interventions indicated to monitor meal percentages every meal as indicated: R - refusal, P - poor 50%, F - fair 50-74%, F - good as > 75% for poor appetite. During a concurrent observation and interview on 11/18/2025 at 12 PM with CNA 5, in the dining room, Resident 7 was observed sitting in her wheelchair eating dinner. CNA 5 stated, Resident 7 ate less than 25% of her lunch. During a concurrent interview and record review on 11/19/205 at 10:25 AM with CNA 6, Resident 7's Nutrition Amount Eaten, document dated from 11/1/2025 to 11/18/2025 was reviewed. CNA 6 stated, she collected Resident 7's lunch tray on 11/18/2025 and indicated Resident 7 ate about 50% of her tray. CNA 6 stated, she was not aware CNA 5 had observed and stated Resident 7 ate less than 25% of her lunch tray on 11/18/2025. CNA 6 stated, she was not aware why there was a document discrepancy when Resident 7 was observed only eating 25% of her lunch tray. CNA 6 stated, it was important to document accurate meal percentage because inaccurate documentation can create a discrepancy in the weight for the resident causing extra weight loss for the resident. During an interview on 11/19/2025 at 10:45 AM with CNA 5, CNA 5 stated, he measured the percentages of the breakfast and lunch/dinner trays differently. CNA 5 stated that he measured the oatmeal as 25%, egg as 25%, toast as 25%, milk as 15%, and juice as 10% of the breakfast tray. CNA 5 stated that the lunch and dinner tray were measured differently. CNA 5 stated, the plate measured 50-75% of the meal and the two (2) smaller plates measured about 25%. During an interview on 11/19/2025 at 11:00 AM with CNA 2, CNA 2 stated, all nursing staff were responsible for measuring and documenting the percentage of a resident's meal. CNA 2 stated that on the breakfast tray, the oatmeal was 25%, egg was 25%, and toast with cheese or marmalade was 25%, and milk and juice accounted for the last 25% of the meal. CNA 2 stated, the lunch and dinner tray were measured differently; the whole plate was 50%, soup was 25%, and dessert was 25% with juice. During an interview and record review on 11/19/2025 at 2:40 PM with the Registered Dietitian (RD), the Guidelines for Percentage of Meal Intake was reviewed. The RD stated, the facility used a standard guideline for measuring the percentage of meal intake. The RD stated, the guideline for the breakfast tray included: coffee as 0%, cereal as 20%, juice as 10%, milk as 15%, egg or breakfast entree as 40%, and toast as 15%. The RD stated, the guideline for the lunch and dinner tray included bread and butter as 5%, milk as 15%, soup or salad as 10%, coffee as 10%, dessert as 10%, meat as 30%, vegetables as 10% and starch/grains as 20%. During a concurrent interview and record review on 11/19/2025 at 3:15 PM with the Director of Nursing (DON), the Inservice Training Report dated 6/15/2025 was reviewed. The DON stated, there was an Inservice training about meal and tray training for the CNAs on 6/15/2025 using the Guidelines for Percentage of Meal Intake document, the document did not indicate an evaluation was performed to verify compliance of the CNAS with the training of documentation of meal intake. The DON stated, I assume the staff would know how to calculate the percentages. The DON stated that inaccurate meal tray percentage calculations may lead to inaccurate weight loss may lead to dehydration, malnutrition, and result in a transfer to the hospital for further evaluation. During a review of the facility's Guidelines for Percentage of Meal Intake document, dated 12/16/2014, the document indicated the objective was for the nursing personnel will learn how to observe and record the food consumptions of each resident meal using the guidelines. The document indicated that for breakfast: egg or breakfast entree was 40%, toast was 15%, cereal was 20%, juice was 10%, milk was 15%, and coffee was 0%. The document indicated that for lunch and dinner: meat was 30%, starch was 20%, vegetable was 10%, soup or salad was 10%, milk was 15%, dessert was 10%, bread and butter was 5%, and coffee was 0%. During a review of the facility's job description titled Certified Nurse Assistant, dated 12/31/2014, the job description indicated that the CNAs will record all entries in an informative and description manner. During a review of the facility's P&P titled Documentation - Nursing, dated 1/1/2016, the P&P indicated that nursing documentation will be conscience, clear, pertinent, and accurate. The P&P indicated the CNA will document the care provided on the facility's method of documentation.

Based on interview and record review, the facility failed to accurately documentation for one of three residents (Resident 36)'s urine characteristics were in the Medical Administration Record (MAR) for October 2025 in accordance with the facility's policy and procedures (P&P) titled Documentation - Nursing, dated 01/01/2016. This deficient practice had the potential to result in inaccurate documentation in Resident 36's urine characteristics which may lead to a missed change of condition in Resident 36. Findings: During a review of Resident 36's admission Record (AR), the facility admitted Resident 36 on 2/4/2022 and readmitted Resident 36 on 6/1/2025 with diagnoses that included atrial fibrillation (AF, irregular and rapid heartbeat) and benign prostatic hyperplasia (BPH, non-cancerous enlargement of the prostate gland) with lower urinary tract symptoms. During a review of Resident 36's Order Summary, dated 6/10/2025, the order indicated Resident 36 received Eliquis (blood thinner) tablet 5 milligrams (mg, unit of mass) 1 tablet by mouth for chronic atrial fibrillation. During a review of Resident 36's Order Summary, dated 6/10/2025, the order indicated to monitor for discolored urine, black tarry stools, sudden severe headache, nausea & vomiting, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, and nose bleeds every shift related to anticoagulant medication use. During a review of Resident 36's care plan, revised 6/10/2025, the care plan indicated Resident 36 had a history of transurethral resection of the prostate (TURP, removal of excess prostate tissue to improve urinary problems) related to BPH. The care plan's interventions included to observe the Resident 36's urine color. During a review of Resident 36's history and physical (H&P), dated 6/11/2025, the HP indicated Resident 36 does have the capacity to understand and make decisions. During a review of Resident 36's Minimum Data Set (MDS, resident's assessment tool), dated 10/29/2025, the MDS indicated Resident 36's cognition (a person's thought process) was intact. The MDS indicated Resident 36 required substantial assistance (helper does more than half the effort) when performing toileting hygiene. During a concurrent interview and record review on 11/19/2025 at 11:43 AM with Registered Nurse (RN)2, Resident 36's Medication Administration Record (MAR) for October 2025 was reviewed. RN 2 stated, it was documented in the MAR that Resident 36 did not experience any discolored urine, black tarry stool, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, or nose bleeding in October 2025. During the same concurrent interview and record review on 11/19/2025 at 11:50 with RN 2, Resident 36's Change in Condition (CoC) evaluation, dated 10/24/2025, was reviewed. RN 2 stated, the Certified Nurse Assistant (CNA) 5 notified her of Resident 36's blood urine noted in the urinal bottle (a simple portable container to collect urine). RN 2 stated, she did not document the discolored urine in the MAR because she created a CoC. During an interview on 11/19/2025 at 5:00 PM with the Director of Nursing (DON), the DON stated that it was important to accurately document Resident 36's urine characteristics because of his history of BPH and anticoagulant use to ensure the resident is properly monitored for any change of condition. The DON stated that inaccurate documentation created an inaccurate assessment of the resident and may lead to missed CoC of the resident. During a review of the facility's P&P titled Documentation - Nursing, dated 01/01/2016, the P&P indicated the nursing documentation will be concise, clear, pertinent, and accurate.

Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled 'Infection Prevention and Control Program, dated 12/1/2021 for three of three sampled residents (Resident 13, 23, and 35) by failing to ensure: 1.Ensure Resident 13's nasal cannula (NS, a flexible tube with two prongs that rest in the nostril to develop supplement oxygen) was changed weekly and did not have a label or a date the last time it was changed. 2.Ensure the Housekeeper 1 performed adequate hand hygiene when going in and out of Resident 23 room while performing environmental cleaning and when bringing dirty laundry to the laundry room. 3.Ensure the Infection Preventionist (IP) 1 performed adequate hand hygiene when entering and exiting Resident 35's room. These deficient practices had the potential to result in Resident 13's NC to harbor pathogens (bacteria and viruses that causes disease) and spread diseases that could result in infections to the residents, visitors and staffs and result in the spread of infection among all facility staff, residents, and visitors. Findings: During a review of Resident 13's admission Record (AR) indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), heart failure (the heart muscle cannot pump enough blood to meet the body's needs). During a review of Resident 13's History and Physical Examination (H&P), dated 3/4/2025, indicated Resident 13 does not have the capacity to understand and make decisions. During a review of Minimum Data Set (MDS, a resident assessment tool), dated 10/20/2025, indicated Resident 13's cognitive skills (ability to make daily decisions) was severely impaired. that required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating, substantial/maximal assistance (helper does more than half the effort) with personal hygiene. During a review of Resident 13's facility document titled Order Summary Report (OSR), dated 9/12/2025, the document indicated Resident 13 was to receive oxygen at 2 to 3 liters per minute (the amount of oxygen, measured in liters, that is delivered each minute) via NC continuously for shortness of breath. During a concurrent observation and interview on 10/1/2025 at 9:17 AM with Licensed Vocational Nurse (LVN) 2 in Resident 13's room, Resident 13's was observed receiving oxygen via NC without a label or date of the last time it was changed. LVN 2 stated, Resident 13 uses the oxygen continuously and the NC was not labeled with date the last time it was changed to identify if the NC was new or old and changed weekly as per facility's policy. LVN 2 stated, if the NC was old or not changed weekly, it had the potential to harbor virus and/or bacteria that could cause infection or sickness to Resident 13. During an interview on 10/1/2025 at 11 AM with the Director of Nurses (DON), DON stated the NC of the residents should have a label of the date the last time it was changed to identify if the NC was new or old, and to ensure it gets changed weekly as per policy. DON stated, the NC of Resident 13 did not have a date of the last time it was changed, there was no way to identify if the NC was new or old. DON stated, an old NC tubing had the potential to harbor bacteria and viruses, that can cause infection to Resident 13 and negatively affect her quality of life. 2. During a review of Resident 23's AR, the facility admitted Resident 23 on 9/2/2024 with diagnoses that included Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23's cognition (a person's thought process) was severely impaired. During an observation on 10/1/2025 at 10:08 AM, inside of Resident 23's room and in the hallway outside of Resident 23's room, Housekeeper 1 was observed entering Resident 23's room without performing hand hygiene to provide environmental cleaning. Housekeeper 1 was further observed exiting Resident 23's room with a bag of dirty linens without wearing gloves, and walked through the hallway, open the door to the laundry room, and dropped off the bag of dirty linens in the laundry room and did not perform hand hygiene. Housekeeper 1 did not perform hand hygiene after exiting the laundry room and proceeded to enter Resident 23's without performing hand hygiene to continue environmental cleaning. During the same observation on 10/1/2025 at 10:25 AM, inside Resident 23's room and in the hallway outside of Resident 23's room, Housekeeper 1 was observed exiting Resident 23's room and proceeded to go to the facility's staff lounge to continue environmental cleaning without performing hand hygiene. During an interview on 10/1/2025 at 10:36 AM with Housekeeper 1, Housekeeper 1 stated she entered Resident 23's room to mop the floor and to clean the surfaces of the tables. Housekeeper 1 stated, after she cleaned Resident 23's room she went to the staff lounge to continue cleaning and mopping. Housekeeper 1 stated, she did not use hand sanitizer or washed hands before entering and after exiting the resident's room for infection control and to prevent the bacteria from going to the resident. 3.During a review of Resident 35's AR, the facility admitted Resident 35 on 2/10/2020 and readmitted Resident 35 on 8/18/2022 with diagnoses that included hemiplegia (total paralysis of the arm, leg, trunk on the same side of the body) and hemiparesis (weakness of one side of the body) following a cerebral infarction (stroke, loss of blood flow to a part of the brain) affecting the left non-dominant side, dementia (a progressive state of decline in mental abilities), and protein-calorie malnutrition (insufficient protein in diet). During a review of Resident 35's H&P, dated 9/2/2026, the H&P indicated Resident 35 did not have the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognition was severely impaired. The MDS indicated Resident 35 was dependent (helper does all the effort) with performing activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily), repositioning herself in bed, and transferring from bed to chair. The MDS indicated Resident 35 was always incontinent of bladder and bowel. During an observation on 10/1/2025 at 9:35 AM, in front of Resident 35's room, IP 1 was observed entering Resident 35's room without using hand sanitizer to help pass breakfast trays and to answer call lights (a button or a soft touch pad used to communicate the need of assistance to the nursing staff). During an interview on 10/1/2025 at 9:39 AM with IP 1, IP 1 stated that facility's staff were supposed to use hand sanitizer before entering and after exiting the resident's room. IP 1 stated that good hand hygiene was important to prevent bacteria growing and prevent the spread of bacteria so no one gets sick. IP 1 stated, she did not use hand sanitizer in Resident 35's room because she went into the room to answer the call light and did not touch the resident. IP 1 stated, if the staff member does not touch anything, I think it is okay to not wash hands or use hand sanitizer. During an interview on 11/19/2025 at 4:05 PM with the DON, the DON stated, hand hygiene was an important part of providing proper infection control. The DON stated, if good hand hygiene was not practiced, it may lead to a break infection control and all staff members, visitors, and residents were at risk for infection. The DON stated, all staff should practice good hand hygiene and use hand sanitizer when entering or exiting the resident's room, especially when touching the resident or the resident's environment. During the same interview on 11/19/2025 at 4:10 PM with the DON, the DON stated that all housekeepers needed to practice good hand hygiene and use hand sanitizer before entering and after exiting the rooms because the housekeepers were touching the resident's environment by wiping down tables, mopping, the floor, moving the beds, and picking up trash. During a review of the facility's job description titled, Environmental Service Aid (Housekeeping), dated 3/1/2007, the job description indicated part of the housekeeping's duties and responsibilities included to ensure that established infection control and universal precautions practices are maintained when performing housekeeping procedures. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 12/1/2021, the P&P indicated that the P&P are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The P&P indicated that the facility's infection control policies and procedures apply equally to all facility staff, consultants, contractors, residents, visitors, volunteer workers, and the general public alike. The P&P indicated the facility must establish an infection prevention and control program under which it identities and prevents infection in the facility. During a review of the facility's P&P titled, Hand Hygiene, dated, 2/20/2025, the P&P indicated that the facility considers hand hygiene the primary means to prevent the spread of infections. The P&P indicated that alcohol-based hand hygiene products can and should be used to decontaminate hands immediately upon entering a resident occupied area regardless of glove use and immediately upon exiting a resident occupied area regardless of glove use. During a review of of the facility's P&P titled, Oxygen Administration, revised 5/21/2025, indicated under infection control, all oxygen tubing and cannulas used to deliver oxygen will be changed weekly.

Based on interview and record review, the facility failed to post an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) per shift on 9/1/2025 up to 9/28/2025 in accordance with the facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Posting. This deficient practice of posting inaccurate nurse staffing information mislead information provided to the residents, resident's responsible parties and visitors about the nursing staffing for the residents. Findings: During a review of the facility documents titled Daily Staff Record, (posting of staffing information) dated 9/1/2025 up to 9/28/2025, the document indicated, the number of scheduled licensed staff and CNAs per shift (not specific to actual hours worked by the nursing staff). During a concurrent interview and record review of Daily Staff Record, on 9/30/2025, at 10:35 AM, with Director of Nurses (DON) indicated on 9/1/2025 to 9/28/2025 the number of scheduled licensed staff and CNAs per shift reflected the number of scheduled licensed staff and CNAs per shift and the projected hours scheduled per shift. However, the posting did not reflect the actual hours worked by the nursing staffs. DON stated, the actual hours worked by the nursing staff daily was recorded through payroll and was not posted. During an interview on 10/1/2025 at 10:38 AM, the DON stated, the daily nursing postings are intended to inform the residents, resident's responsible parties and the visitors about the type and hours of nursing care provided in the facility. DON stated these nursing posting must be accurate to prevent misinformation and confusion. A review of the facility's policy and procedure (P&P) titled, Nursing Department - Staffing, Scheduling & Posting. revised 10/24/2022, indicated, the facility will post the total number and the actual hours worked by licensed and licensed nursing staff directly responsible for resident care per shift (RNs, LVNs, and CNAs).

Based on observation, interview, and record review, the facility failed to ensure the resident's bedrooms accommodated no more than four residents for four (4) of 12 rooms (rooms [ROOM NUMBERS] with six beds in the room, and rooms [ROOM NUMBERS] with five beds in the room) in the facility in accordance with the facility's policies and procedures (P&P) titled Resident Rooms and Environment, dated 11/1/2017. This deficient practice had the potential to negatively affect the residents' privacy, safety, and quality of care due to inadequate space for quality nursing and emergency care services. Findings: During a review of the facility's request for an additional room waiver, dated 11/19/2025, the room waiver indicated rooms [ROOM NUMBERS] were designated for five (5) beds per room and indicated rooms [ROOM NUMBERS] were designated for six (6) beds per room. The room waiver indicated there was adequate space for residents to be transferred out via wheelchair, had adequate range of motion, and accessibility. During a review of the Client Accommodation Analysis form, dated 11/19/2025, submitted by the facility on 11/19/2025, the form indicated the following rooms did not meet the federal requirement of no more than four beds per resident room in a multiple-resident room: From 9/30/2025 to 10/1/2025 and from 11/17/2025 to 11/19/2025, the following were observed: 1.room [ROOM NUMBER] has six (6) beds with four (4) beds occupied 2.room [ROOM NUMBER] has six (6) beds with six (6) beds occupied 3.room [ROOM NUMBER] has five (5) beds with five (5) beds occupied 4.room [ROOM NUMBER] has five (5) beds with three (3) beds occupied During the survey, multiple observations from 9/30/2025 to 10/1/2025 and 11/17/2025 to 11/19/2025 were conducted at random times from 7:30 AM to 5:00 PM. The residents in room [ROOM NUMBER], 3, 4, and 5 had enough space for individualized beds, bedside tables, overbed tables (an adjustable table with lockable wheels designed to roll over a bed or a chair and provide a flat and stable surface), and individualized resident care equipment. During an interview on 11/18/2925 at 1:19 PM, the ADM stated, the number of bed occupancy in Rooms 1, 3, 4, and 5 remained the same. During a concurrent observation and interview on 11/18/2025 at 2:00 PM in Resident 35's room with Resident 35, there were six (6) available beds with four (4) occupied beds. Resident 35 stated, she was comfortable in her room, and the nurses were able to perform her cares without any issue. During an interview on 11/18/2025 at 2:10 PM with Certified Nurse Assistant (CNA) 3, CNA 3 stated, she had residents in rooms [ROOM NUMBER]. CNA 3 stated, she had enough space to perform activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) for every resident in those rooms. During a concurrent observation and interview on 11/18/2025 at 2:15 PM in Resident 4's room with Resident 4, there were six (6) available beds with [NAME] (6) occupied beds. Resident 4 stated, she was comfortable and had enough room in her room. Resident 4 stated she had no concerns with the space during nursing care. During an interview on 11/18/2025 at 2:18 PM with CNA 6, CNA 6 stated she had residents in room [ROOM NUMBER] and room [ROOM NUMBER]. CNA 6 stated, she had enough space to provide care for her residents in room [ROOM NUMBER] and 5, and she had no concerns with the space. During a review of the facility's P&P, dated 11/1/2017, the P&P indicated that the facility must ensure that the resident rooms must be equipped with or located near toilet and bathing facilities to accommodate no more than four residents.

Based on observation, interview, and record review, the facility failed to ensure the resident's bedrooms measured at least 80 square feet per resident in four (4) of 12 rooms (Rooms 1, 3, 4, and 5) in the facility in accordance with the facility's policies and procedures (P&P) titled Resident Rooms and Environment, dated 11/1/2017. This deficient practice had the potential to negatively impact the care and services of the facility's staff to provide safe nursing care and privacy to the residents. Findings: During a review of the facility's request for an additional room waiver, dated 11/19/2025, the room waiver indicated rooms [ROOM NUMBERS] were approximately 456 square feet (sq. ft) and rooms [ROOM NUMBERS] were approximately 348 sq. ft. The room waiver indicated that the delivery and quality of care would not be impacted by the room size, and there was enough space for all residents, both for ambulatory (walking) and non-ambulatory residents. The room waiver indicated the residents in Rooms 1, 3, 4, and 5 were content with the size and number of residents within them, and these residents were prepared to voice their satisfaction with their rooms, along with other residents and family members. During a review of the Client Accommodation Analysis form, dated 11/19/2025, submitted by the facility on 11/19/2025, the form indicated there were four (4) rooms that did not measure 9- sq. ft per resident as listed below: Required Sq. ft for room [ROOM NUMBER] and 3 = 480 sq ft. Actual Sq. ft for room [ROOM NUMBER] and 3 = 456 sq. ft Number of Beds in room [ROOM NUMBER] and 3 = 6 beds Number of Residents in room [ROOM NUMBER] = 4 residents Number of Residents in room [ROOM NUMBER] = 6 residents Required Sq. ft for room [ROOM NUMBER] and 5 = 400 sq ft. Actual Sq. ft for room [ROOM NUMBER] and 5 = 228 sq. ft Number of Beds in room [ROOM NUMBER] and 5 = 5 beds Number of Residents in room [ROOM NUMBER] = 5 residents Number of Residents in room [ROOM NUMBER] = 3 residents During the survey, multiple observations from 9/30/2025 to 10/1/2025 and 11/17/2025 to 11/19/2025 were conducted at random times from 7:30 AM to 5:00 PM. The residents in Rooms 1, 3, 4, and 5 were observed to have adequate room for the operation and use of the wheelchairs (a chair fitted with wheels for use as a means of transport by a person who is unable to walk as a result of illness, injury, or disability), walkers (a device that provides additional support to maintain balance or stability while walking) or canes. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents. During an interview on 11/19/2025 at 1:19 PM with the Administrator (ADM), the ADM stated there have been no complaints from the residents, resident's families, and facility staff about the room size of Rooms 1, 3, 4 and 5. During an interview on 11/19/2025 at 2:00 PM with Resident 35, Resident 35 stated that she was comfortable and the nurses were able to provide care without any problems. During an interview on 11/19/2025 at 2:10 PM with Certified Nurse Assistant (CNA) 3, CNA 3 stated that there was enough space to do her job in Rooms 1, 3, 4, and 5, and every resident has enough space in the rooms. During an interview on 11/19/2025 at 2:15 PM with Resident 4, Resident 4 stated, everything was okay, and she had no concerns about the nurses providing care in her room because she had enough room. During an interview on 11/19/2025 at 2:20 PM with Resident 18, Resident 18 stated, the CNAs have enough room to take care of me. Resident 18 stated, the space in her room was enough and she felt comfortable. During an interview on 11/19/2025 with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that she had enough space to provide care to her residents in room [ROOM NUMBER]. During a review of the facility's P&P titled Resident Rooms and Environment, dated 11/1/2017, the P&P indicated resident rooms must measure at least 80 square feet per resident in multiple resident rooms.

Based on interview and record review, the facility failed to report a Coronavirus 2019 (COVID-19, a contagious disease) outbreak (two or more linked cases of the same illness) to the California Department of Public Health (CDPH) in accordance with the facility's policy and procedure titled Communicable Diseases - Outbreak when the facility experienced a COVID-19 outbreak on 8/14/25. This deficient practice resulted in the facility failing to notify CDPH when an outbreak occurred and had the potential for the facility to underreport future outbreaks within the facility. A review of Resident 3's admission record indicated the Resident was originally admitted to the facility on [DATE], with a diagnosis of Poly-osteoarthritis (pain, swelling, and stiffness in the joints), heart disease (Problems with the heart, such as blocked arteries or heart damage) and hypertensive heart disease(Heart problems caused by long-term high blood pressure). A review of Resident 3's History and physical (H&P) dated 2/25/2025, indicated this Resident has the capacity to understand and make decisions. A review of Resident 3's Minimum data set ( MDS- a standardized assessment and screening tool ) dated 8/12/2025, indicated, Resident 3 has moderate cognitive impairment( may remember some things but have trouble with short- term memory, recalling information after a delay, or staying fully oriented to time), and requires partial assistance ( helper does less than half the effort) with showering. Only requiring set-up or clean - up for toileting, oral hygiene and dressing. A review of Resident 3's Change in Condition Evaluation dated 8/15/2025, indicated Resident 3 had a runny nose, voice hoarsening, occasional cough and weakness. The Evaluation Covid antigen test performed on 8/13/2025 indicated a positive COVID-19 result. A review of Resident 4's admission record indicated the Resident was admitted on [DATE], with a diagnosis of a fracture to the shaft of the right femur (a break in the long, straight part of the thigh bone on the right side). A review of Resident 4's History and physical (H&P) dated 11/1/2024, indicated the Resident does not have the capacity to understand and make decisions. A review of Resident 4's Minimum data set ( MDS- a standardized assessment and screening tool) indicated the Resident has severe memory impairment ( may not be able to remember or repeat words, recall information, or answer orientation questions) but only requires set up or clean up assistance meaning helper sets up or cleans up and Resident can complete activity by self-such as oral care and eating. A review of Resident 4's Change in Condition Evaluation dated 8/16/2025, indicated Resident 4 had a runny nose. Resident 4 was tested for COVID-19 on 8/16/25 and a positive result. A review of Resident 5's admission record indicated the Resident was admitted to the facility on [DATE], with a diagnosis of congestive heart failure ( the heart isn't pumping blood as well as it should, so fluid can build up in the body). A review of Resident 5's Minimum data set (MDS- a standardized assessment and screening tool) dated 5/4/2025, indicated the Resident had the ability to answer simple questions and participate in conversation, but will often need help with more complex decisions, problem - solving or remembering instructions. Resident 5 requires substantial assistance meaning a helper does more than half the effort when getting dressed or toileting. A review of Resident 5's Progress notes dated 8/15/2025, indicated Resident 5 was tested for COVID- 19 on 8/15/2025 and had a positive test result. During a review of the facility provided document titled, Covid - 19 Contact information form for long -Term Care Facilities Resident, dated 8/13/2025, the Form indicated a total of three residents were positive for Covid - 19. The Form indicated the following:Resident 3 was confirmed COVID -19 positive on 8/13/2025Resident 4 was confirmed COVID-19 positive on : 8/16/2025Resident 5 was confirmed COVID-19 positive on: 8/15/2025 During an interview on 9/11/2025 at 11:15 AM with infection preventionist nurse (IP) 1, IP 1 stated since Residents 1, 4, and 5 were symptomatic and were positive for COVID-19, the facility should have reported the positive COVID- 19 residents to the California Department of Public Health. During an interview on 9/11/2025 at 12:35 with the Administrator (ADM) , the ADM stated the facility had a COVID-19 outbreak and stated that CDPH should have been notified regarding the COVID-19 outbreak. During a concurrent interview and record review on 9/11/2025 at 12:35 with the ADM, the ADM, the undated facility's policy and procedure (P&P) titled, Communicable diseases - outbreak was reviewed. The P&P indicated, the administrator will be responsible for reporting to the Department of Public Health and local public health officer a single case of a communicable disease requiring immediate reporting and epidemiology investigation. The Administrator stated not reporting to CDPH since she thought the facility's IP had reported the COVID-19 positive residents to CDPH. During an interview on 9/11/2025 at 12:45PM with Infection Preventionist (IP) 1, IP 1 stated not notifying CDPH because IP 1 thought IP 2 had notified CDPH regarding Resident 1,4, and 5's positive COVID-19 status. During an interview on 9/11/2025 at 12:50PM with the Director of Nursing ( DON) , the DON stated that the Department of Public health and the Public Health Nurse had been notified. Stating the Covid Outbreak consisted of three people. No document could be provided by DON indicating the Department of Public Health had been notified. During an interview on 9/11/2025 at 1:30PM with IP 2, IP 2 not reporting the COVID-19 outbreak to the California Department of Public Health. IP 2 stated not knowing that the facility had to report the COVID-19 cases to CDPH, and by not reporting the COVID-19 cases there would be a lack of outbreak support. During a review of the facility's undated policy and procedure ( P&P) titled, Communicable Diseases - Outbreak,, the P&P indicated the purpose of Policy was to ensure that outbreaks of communicable disease are identified, handled, and reported as required. The P&P indicated outbreaks of communicable diseases within the Facility was promptly identified an appropriated treated and reported. The P&P indicated that the Administrator was responsible for reporting to the Department of Public Health, which included facility outbreak of COVID-19. The P&P indicated outbreak definition was one or more facility acquired COVID-19 case in a resident and/or three or more suspect, probable or confirmed COVID-19 cases. The Policy indicated reporting outbreaks related to a communicable disease, the facility must report the communicable disease data to CDPH.

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1 immediately notify a licensed nurse and not move a resident after a fall on 8/19/2025 prior to a licensed nurse' assessment, in accordance with the facility's policy and procedure (P&P) titled, Response to Falls, for one out of three sampled residents (Resident 1) reviewed for falls. CNA 1 lifted Resident 1 from the floor and moved the resident back to bed. CNA 1 did not notify Licensed Vocational Nurse (LVN) 1 until after 20 minutes. These deficient practices had the potential for Resident 1 to suffer further discomfort and complications from the unwitnessed fall. On 8/19/2025, LVN 1 found Resident 1 shivering and shaking in pain after the fall with a swollen and discolored left foot. The result of an X-ray (imaging technology that creates images of people's body, including the bones, and is often used in diagnosis fractures), dated 8/19/2025, indicated that the resident had a left foot fracture. During a review of Resident 1's admission Record indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), muscle weakness, dementia (a progressive state of decline in mental abilities), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 1's care plans indicated that Resident 1 is at risk for pain, muscle weakness or fractures [due to] Vitamin D deficiency, initiated on 8/27/2022, and revised on 9/26/2023. Interventions in the care plan included for gentle handling during care to avoid accidental fractures and minimize bone pain. During a review of Resident 1's care plan initiated on 8/27/2022, revised on 9/26/2023 indicated that Resident 1 is at risk for falls and had balance problem while walking. The care plan included interventions to have a floor mat on the side of Resident 1's bed, initiated on 3/19/2 025. During a review of Resident 1's History and Physical (H&P), dated 11/29/2024, indicated that the resident does not have the capacity to understand and make decisions. The H&P indicated that the resident has a history of hip fracture. During a review of Resident 1's Morse Fall assessment (an assessment to determine a resident's fall risk factors), dated 5/20/2025, the Fall assessment indicated that Resident 1 was assessed as a high risk for falls. The Fall Note indicated that Resident 1 had a history of falls. The Falls assessment also indicated that Resident 1 overestimates or forgets limits of her ability to walk safely. The Falls assessment did not indicate additional interventions to be added or revised to the resident's care plan as a result of this Fall assessment. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 8/19/2025, indicated the resident has severely impaired cognition (the ability to process thoughts). The MDS indicated that Resident 1 has impaired range of motion on one side of her body. The MDS indicated that Resident 1 required maximal assistance (helper does more than half the effort) on activities such as moving in bed from left to right, changing positions from sitting to lying, sitting to standing, and transferring to and from a bed to a chair. The MDS also indicated that Resident 1 is dependent (helper does all the effort) on activities such as toileting, lower body dressing, transferring to a toilet, and transferring to a tub or shower. The MDS also indicated that Resident 1 was not able to walk 10 feet at the time of assessment. During a review of Resident 1's care plans indicated that Resident 1 is at risk for pathological fractures [due to] aging process and osteoporosis, initiated on 3/4/2023, revised on 9/26/2023. Interventions included for gentle handling of resident to prevent injury/fractures, initiated on 3/4/2023. During a review of Resident 1's care plans indicated the resident is at risk for spontaneous fractures, initiated on 7/21/2023. The care plan indicated a goal to decrease potential of fall and resulting to fractures. The care plan also included interventions initiated on 7/21/2023 to handle resident gently while assisting with [Activities of Daily Living] and transfers. The care plan also indicated interventions for staff to handle gently when moving resident. During a review of Resident 1's Change in Condition (CIC), dated 8/19/2025, timed at 9:11 PM, authored by LVN 1, the CIC indicated that Resident 1 sustained a fall on 8/19/2025. The CIC indicated that the CNA (CNA 1) reported noticing discoloration on the resident's foot. The CIC indicated when LVN 1 assessed Resident 1, she found Resident 1 on the bed and that the top of Resident 1's left foot was swollen [with] bluish discoloration. The CIC indicated that LVN 1 asked the CNA whether he had noticed the discoloration earlier in the shift. The CNA responded that he saw the discoloration 20 minutes earlier, just before informing LVN 1. The CIC further indicated that the CNA found the resident on the floor mat and picked [the resident] up and put [the resident] back in bed. The CIC indicated that Resident 1 had a moderate to severe level of pain. The CIC further indicated that the physician was notified on 8/19/2025 at 9:19 PM with an order for an Xray. During a review of Resident 1's physician's order, dated 8/19/2025, timed at 9:41 PM and authored by LVN 1, included an order for STAT (immediately or right now) X-ray (imaging technology that creates images of people's body, including the bones, and is often used in diagnosis fractures) of the left foot due to pain. During a review of Resident 1's Pain Assessment note, dated 8/19/2025, timed at 10:28 PM, and signed by LVN 1, the note indicated Resident 1 exhibited indicators of pain such as non-verbal sounds, vocal complaints of pain, facial expressions of pain, and protective body movements or postures such as bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement. The Note indicated that Resident 1 received Ibuprofen (a pain medication) 600 mg (milligrams, a unit of measuring weight). During a review of Resident 1's Medication Administration Record (MAR) for the month of August 2025, the MAR included a physician order dated 8/19/2025, timed at 10:13 PM, to administer Ibuprofen Oral Tablet 600 mg give 1 tablet by mouth every 12 hours as needed for moderate pain. The MAR also indicated that on 8/19/2025 at 10:37 PM, Resident 1 was given the medication for a pain level of seven (7) out of ten (10). The MAR also indicated that on 8/19/2025 at 1:04 PM, Resident 1 was given the medication for a pain level of four (4) out of ten (10). During a review of Resident 1's Radiology Report, dated 8/19/2025, timed at 11:40 PM, the Report indicated that Resident 1 had an Acute nondisplaced distal fourth metatarsal neck fracture. Possible additionally distal fifth metatarsal neck fracture. During a review of Resident 1's care plans indicated that Resident 1 had an actual unwitnessed fall [on] 8/19/2025, initiated on 8/20/2025. The care plan indicated for Resident 1 to wear a foot cast (a protective, rigid device, typically made of fiberglass or plaster, that immobilizes a broken bone to hold it in place) on left foot for a left foot fracture for a duration of four (4) weeks. During a review of Resident 1's Progress Notes included an IDT (Interdisciplinary Team) Notes entry, dated 8/20/2025, timed at 6:41 PM. The IDT Note indicated that the social worker and RN 3 discussed Resident 1's unwitnessed fall with the resident's family member, Family Member (FM) 1. The IDT Note indicated that Resident 1's x-ray result confirmed that the resident suffered a left foot fracture . The IDT Note also indicated that FM 1 did not want Resident 1 to be transferred to the acute hospital. The IDT Note further indicated that FM 1 agreed to the interventions of Podiatry (field of medicine that specializes in the treatment of the feet) consultation, pain management measures, the use of a bed alarm (a device placed over a resident's bed that emits a sound to notify staff that the resident is attempting to leave the bed), and Physical and Occupational Therapy. During a review of Resident 1's orders included an order, dated 8/21/2025, for foot cast on left foot for left 4th metatarsal neck fracture every shift for 4 weeks. During a review of Resident 1's Podiatry (the treatment of the feet and their ailments) Note, dated 8/21/2025, the Podiatry Note indicated information about Resident 1's fall on 8/19/2025. The Podiatry Note indicated Resident 1 had severe pain after the fall with painful, swollen, edema, ecchymosis to the dorsal aspect of the left foot. The Podiatry Note indicated Resident 1's range of motion (ROM) was limited due to severe pain on any movement. The Podiatry Note further indicated that Resident 1 had a fracture of the fourth metatarsal (long bone next to the little toe of the foot) of the left foot. The Podiatry Note indicated Resident 1's left foot and left leg were placed in a cast for a duration of four weeks. The Podiatry Note indicated for Resident 1 to have only a bed bath for four weeks and to monitor the left foot toes for discoloration, bruising, erythema, edema and inform the physician. During an observation on 9/4/2025 at 9:28 AM, Resident 1 w as observed lying in bed. Resident 1 was observed wearing a cast over the left foot. Resident 1 was observed comfortable and without any signs or symptoms of pain. An attempt to interview Resident 1 was conducted, but Resident 1 did not respond or acknowledge the presence of the survey team. During an interview on 9/4/2025 at 10:05 AM with CNA 2, CNA 2 stated Resident 1 cannot stand up without assistance from facility staff. CNA 2 stated if a resident is observed on the floor, the resident must not be moved, and the licensed nurse must be informed immediately. During a phone interview on 9/4/2025 at 10:16 AM with CNA 1, CNA 1 stated that on 8/19/2025, between 8:30 PM to 9 PM, he was walking by the facility hallway, outside Resident 1's room when he saw that Resident 1 was not in bed. CNA 1 stated he saw Resident 1's feet were on the floor. CNA 1 stated when he went inside Resident 1's room, he found Resident 1 lying on the floor, face up. CNA 1 stated Resident 1 did not complain of pain nor exhibited signs of pain while on the floor. CNA 1 stated Resident 1 verbally asked for help. CNA 1 then stated that he lifted the resident up from the floor by wrapping his arms around the resident's body, under the armpits, then lifted the resident and carried the resident to the bed. CNA 1 added he did not ask for help because the other nursing staff were busy. CNA 1 stated he didn't need the charge nurse to move the resident back to bed because the resident was not not heavy. During the same phone interview on 9/4/2025 at 10:16 AM with CNA 1, CNA 1 stated it was only when Resident 1 was in bed, the resident complained of pain. CNA 1 further clarified that Resident 1 did not express that the resident experienced pain while on the floor, nor did CNA 1 observe the presence of pain from Resident 1 while the resident was on the floor. During a follow-up phone interview on 9/4/2025 at 11:31 AM with CNA 1, CNA 1 re-stated that Resident 1 complained of pain only after he had put the resident back in bed. CNA 1 also stated he only noticed the bruising when Resident 1 was in bed. CNA 1 added after placing Resident 1 in bed, upon observing the bruising in the left foot, and Resident 1's complaint of pain, he became busy and was not able to inform the nurse immediately. During a phone interview on 9/4/2025 at 11:48 AM with LVN 1, LVN 1 stated that on 8/19/2025, between 9:10 PM to 9:20 PM, CNA 1 approached her at the Nursing Station to report discoloration on Resident 1's foot. LVN 1 stated that upon entering the resident's room, LVN 1 observed Resident 1 lying in bed with a swollen, bluish left foot and the resident was shivering and shaking in pain. When LVN 1 asked CNA 1 about the discoloration, LVN 1 stated that CNA 1 had noticed it approximately 20 minutes earlier. LVN 1 further stated that after further questioning, CNA 1 disclosed that he had found Resident 1 on the floor and had returned her to bed without notifying LVN 1 at the time. During the same phone interview on 9/4/2025 at 11:48 AM with LVN 1, LVN 1 stated CNA 1 should have informed the licensed nurses on 8/19/2025 immediately that Resident 1 was on the floor. LVN 1 added the licensed nurses must assess Resident 1 before she was moved because any injury sustained by the resident could get worse if she was moved. LVN 1 stated CNA 1 did not provide a reason why he did not notify the licensed nurses upon finding Resident 1 lying on the floor on 8/19/2025, immediately. During a phone interview on 9/4/2025 at 12:43 PM with Registered Nurse (RN) 1, RN 1 stated on the evening of 8/19/2025, CNA 1 reported to LVN 1 that Resident 1's left foot had a bruise. RN 1 stated upon her arrival inside Resident 1's room, Resident 1 was already in bed. RN 1 stated she assessed Resident 1's left foot and found that it was swollen and seemed like there was fracture. RN 1 stated Resident 1 also complained of pain when the left foot was touched. During an interview on 9/4/2025 at 2:47 PM with RN 2, RN 2 stated when a CNA finds a resident on the floor, the CNA should inform the licensed nurse immediately. RN 2 stated it is important for a licensed nurse to assess any resident who is found on the floor prior to being moved. RN 2 stated moving a resident prior to a licensed nurse' assessment could potentially cause a fracture and the situation could get worse. RN 2 stated that a licensed nurse should also be present when the resident is moved from the floor to the bed, because it is part of the assessment to identify if the resident has pain in any part of the body, including the feet and legs. During a concurrent interview and record review on 9/4/2025 at 4:43 PM with the Director of Nursing (DON), Resident 1's medical records were reviewed, including the CIC, dated 8/19/2025 authored by LVN 1. The DON stated the CIC indicated that Resident 1 was found to have discoloration on the left foot. The DON stated the CIC also indicated CNA 1 assigned to Resident 1, failed to inform LVN 1, immediately that Resident 1 was found on the floor beside the resident's bed. Furthermore, the DON added the CIC indicated CNA 1 had returned Resident 1 back to bed without notifying LVN 1. During the same interview on 9/4/2025 at 4:43 PM with the DON, the DON stated CNA 1 should have informed the licensed nurses on 8/19/2025, as soon as CNA 1 found Resident 1 lying on the floor. The DON stated prior to moving Resident 1, the licensed nurse should have assessed the resident to look for the presence of pain, bruising or redness, skin breakdown, bleeding, bumps, which could be signs of fracture. The DON added that if the resident presents with signs of fracture, the resident should not be moved and 9-1-1 (an emergency hotline to reach police, fire, and ambulance services) should be called to transfer the resident to an acute hospital. The DON stated inappropriately moving a resident who has fallen, with or without the presence of a fracture, could cause further injury. The DON further added that if a fracture was present before Resident 1 was moved, the act of CNA 1 moving Resident 1 from the floor to the bed could have lead to a more serious injury or fracture and other complications. During a concurrent interview and records review on 9/4/2025 at 4:43 PM with the DON, the facility's job description for a Certified Nursing Assistant, revised 12/31/2004, was reviewed. The DON stated the job description indicated that the CNA's must report all changes in condition or accidents to the licensed nurses as soon as possible. During a concurrent interview and records review on 9/4/2025 at 4:43 PM with the DON, the facility's policy and procedures (P&P) titled, Response to Falls, revised 3/1/2015, was reviewed. The DON stated the P&P indicated to not move the resident when a fall is suspected until after the resident has been assessed by the nurse. During a review of the facility's job description for a Certified Nursing Assistant, revised 12/31/2004, the job description indicated that it is the responsibility of the CNA to report all changes in the resident's condition or any accidents observed as soon as possible to the nurse supervisor/charge nurse. During a review of the facility's policy and procedures titled, Response to Falls, revised 3/1/2015, the P&P indicated the following:1. Residents experiencing a fall will be promptly assessed and treated for injuries.2. Upon witnessing a fall or finding a resident in a position indicating a fall, stay with the resident and send another staff member to notify a licensed nurse if the first responder is not licensed personnel. 3. Do not move the resident initially until after an assessment has been completed.4. If the Licensed Nurse suspects a fractured hip, back or other injury, the Licensed Nurse will make the resident comfortable until emergency medical services arrives.

During an observation, interview and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) was free from the use of physical restraints (a manual method or device that limits a person's ability to move freely), in accordance with the facility ' s policy and procedure titled Restraints by failing to: 1. Identify a situation that constitutes abuse when Certified Nurse Assistant [CNA] 1 had knowledge that Resident 1 was tied to the wheelchair with a white sheet, on 11/9/24, during the 3 PM to 11 PM shift, as evidenced by a videoclip . CNA 1 did not untie (remove) the white sheet from Resident 1 and did not report the observation to the licensed vocational nurse (LVN 1) immediately. 2. Protect Resident 1 from potential harm that could result in an injury by not responding immediately to protect Resident 1 when CNA 1 witnessed Resident 1 tied up with a white sheet to the wheelchair on 11/9/24. Instead, CNA 1 recorded a video of Resident 1 while tied up with a white sheet to the wheelchair, inside another resident ' s [Resident 2] room. 3. Report all alleged violations of abuse immediately to the abuse coordinator [Administrator] and other State Agencies immediately or within two hours when CNA 1 had knowledge of Resident 1 being restrained with a white sheet on 11/9/2024. CNA 1 did not inform the abuse coordinator [Administrator] of witnessing Resident 1 tied up to the wheelchair on 11/9/2024. These failures resulted in Resident 1 experiencing abuse and had the potential to result in serious injury that included strangulation [occurs when something compresses the neck tightly enough to restrict airflow], accidental asphyxiation [compression of the chest wall] to Resident 1, who was cognitively impaired [difficulties with thinking, learning, remembering, and making decisions] and unable to verbalize needs. On 11/13/2024 at 9:30 AM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance [not following rules] with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility ' s failure to ensure Resident 1 was free from restraints. The surveyor notified the Administrator and the Director of Nursing (DON) of the IJ situation on 11/13/2024 at 9:30 AM, due to the facility ' s failure to protect Resident 1 and identify a situation that constitutes abuse when CNA 1 witnessed the improper use of physical Restraints against Resident 1. On 11/15/2024 at 1:53 PM, while onsite and after the surveyor verified/confirmed the facility ' s full implementation of the IJ Removal Plan (a detailed plan to address the IJ findings) through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the Administrator. The acceptable IJ Removal Plan included the following information: 1. Starting 11/1/4/2024, staff including but not limited to license nurses, certified nursing assistants, office staff, kitchen staff, and housekeeping staff will have in-service education regarding elder abuse, reporting abuse and the use of physical restraints, conducted by the Director of Staff Development [DSD], DON and /or Administrator. The in-services are based on facility Policies and Procedures titled Restraints, Abuse Prevention and Prohibition Program, and Definitions. By 11/18/2024, 50 out of 61 facility employees will have received in-service education regarding elder abuse, reporting abuse and the use of physical restraints. 2. A posttest was created to verify staff competency on abuse and use of restraints. The post test will be given to all staff to determine understanding of in-service. Staff will be given repeat in-service on areas found to be lacking in knowledge until 100% score is received. 3. Starting 11/12/2024, charge nurses were assigned to complete Abuse Rounds on a minimum once per shift to ensure there are no signs or symptoms of abuse or restraints. Rounds will continue once per shift for a minimum of three months. 4. If a suspected abuse or improper restraint is identified charge nurse will immediately notify the Administrator and DON. 5. On 11/15/2024 at 2:30 PM, the facility ' s Social Services Consultant will provide staff in-service regarding abuse. 6. All charge nurses will be in-serviced on use of SOC 341 [a form used to report suspected abuse or neglect of dependent adults and elders] starting 11/14/2024 7. By 11/19/2024, the Administrator will review facility ' s current Abuse Prevention Plan with DSD to develop a new yearly in-service schedule with increased abuse training. New employee Orientation abuse and neglect training will be reviewed and updated as needed during the facility ' s Quality Assurance and Performance Improvement (QAPI) [is a data driven and proactive approach to quality improvement] on 11/19/2024. Findings: During a review of Resident 1 ' s Admission Record, [AR] the AR indicated the facility admitted the resident on 12/20/2018 and readmitted on [DATE], with a primary diagnosis of dementia (loss of ability to think, remember and reason), anxiety disorder [an emotion characterized by feeling of worried thoughts and tension) and history of falling. During a review of Resident 1 ' s care plan revised on 1/3/2024, the care plan indicated Resident 1 was a Wandering/Elopement [leaving without permission] Risk as evidenced by attempts to leave the facility unattended, wanders aimlessly, and had impaired safety awareness. The care plan interventions included to allow Resident 1 to wander in safe surroundings within the facility, and to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The care plan interventions further indicated to monitor Resident 1 ' s whereabouts with visual checks at least every two hours for safety. During a review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/11/2024, the MDS indicated the resident had severely impaired cognition (thought process). The MDS indicated Resident 1 exhibited wandering behavior daily. During a review of Resident 1 ' s Multidisciplinary Care Conference (ID- Interdisciplinary Team) dated 9/6/2024, the IDT indicated the resident was confused and disoriented with a history of dementia and to keep resident safe and comfortable by offering a physical and social environment that provides activities appropriate for the resident ' s cognitive functioning and interests. The care plan interventions further indicated to reassure the resident that she was safe in the facility, loved and wanted. During a review of Resident 1 ' s Wandering Risk Assessment (a tool to identify residents who are at risk of wandering dated 9/11/2024, the Assessment indicated Resident 1 was disoriented and does not understand surroundings. The Assessment indicated Resident 1 was a known wanderer with a history of wandering. During a concurrent observation and interview with Resident 1 on 11/13/2024 at 9:57 AM, at the facility ' s Dining Room, Resident 1 was observed walking steadily. Resident 1 stated she did not recall anything and could not remember being tied with a white sheet to the wheelchair. During a telephone interview with CNA 1 on 11/13/2024 at 10:29 AM, CNA 1 stated on 11/9/2024, at around dinner time (8 PM), during the 3 PM to 11 PM shift, CNA 1 found Resident 1 inside another resident ' s [Resident 2] room and witnessed Resident 1 tied up with a white sheet to the wheelchair which was tied at the back with a knot. CNA 1 further stated that she recorded a videoclip of the incident [Resident 1 while tied up to the wheelchair]. CNA 1 stated Resident 1 appeared scared at the time. CNA 1 stated that on 11/9/2024, CNA 1 had called the Administrator on the phone from the facility ' s parking lot after witnessing Resident 1 tied up to the wheelchair. CNA 1 stated when she returned from the parking lot, CNA 1 stated someone had removed the sheet from Resident 1. CNA 1 stated, she did not inform the Administrator about what she had witnessed, Resident 1 tied up with a white sheet to the wheelchair. CNA1 stated she did not notify the Charge Nurse or any of the facility staff on duty that evening [11/9/2024] about witnessing Resident 1 tied up with a white sheet to the wheelchair. CNA 1 stated it was not until the following Monday, on 11/11/2024, when she informed the Administrator, in person, that she witnessed Resident 1 tied up with a white sheet to the wheelchair on 11/9/2024. CNA 1 stated that she informed the Administrator of taking a videoclip while Resident 1 was tied up. On 11/13/2024, at 10:58 AM, during a review of the videoclip shared via instant messaging [iMessage - a communication technique that facilitates text-based communication to include multimedia content such as photos, videos, and audio recording] by CNA 1, the videoclip showed Resident 1 sitting on a wheelchair inside a room, in front of the television, with a white sheet around the resident with a knot tied to the back of the wheelchair. The recorder [CNA1] continued going around Resident 1 showing a full 360-degree angle [a view in every direction] of Resident 1 tied down with a white sheet while sitting on the wheelchair. The part of the videoclip recording at 00:28 [timecode] mark, showed an individual (unknown) pushing Resident 1 ' s hands away from the resident ' s chest showing full view of the white sheet tied across the resident ' s chest. During another telephone interview on 11/13/2024 at 11:15 AM with CNA 1, CNA 1 stated the time she witnessed Resident 1 with a white sheet tied to the back of the wheelchair on 11/9/2024, was around 8 PM. CNA 1 stated she saw Resident 1 inside another resident ' s [Resident 2] room sitting on a wheelchair with a white sheet wrapped around Residents 1 ' s abdomen/chest area tied in a knot at the back of the wheelchair. CNA 1 stated she recorded a video of Resident 1 tied up, as proof to show the Administrator of the alleged abuse. CNA 1 stated after recording a video of Resident 1 she did not report it to the charge nurses or LVN 1 or any facility staff in the facility because CNA 1 was afraid, they [other facility staff] would untie Resident 1 and deny ever tying her. During the same interview, on 11/13/2024 at 11:15 AM, CNA 1 stated she stepped out of the facility to go to the facility ' s parking lot to call the Administrator on 11/9/2024, because she knew to report any type of abuse she witnessed to the facility's Administrator. CNA 1 stated she spoke to the Administrator over the phone and informed the Administrator that he had to come to the facility right away, to see with his own eyes what was happening to Resident 1. CNA 1 further stated she did not tell the Administrator what she observed, and told the Administrator, It was an urgent matter concerning Resident 1 and that he had to come in person to the facility to witness with his own eyes. CNA 1 stated the Administrator informed her [CNA 1], that he would talk to CNA 1 on Monday [11/11/2024]. CNA 1 stated after ending the phone conversation, CNA 1 sent another text message to the Administrator asking him to come to the facility because it was something very important and wanted the Administrator to see with his own eyes. CNA 1 stated the Administrator did not respond to her text message. CNA 1 stated that when she went back inside the facility to check on Resident 1, CNA 1 observed Resident 1 was back in her room lying in bed. CNA 1 stated she did not know who from the facility had untied and returned Resident 1 back to her room. During an interview with the DON on 11/13/2024 at 11:30 AM, the DON stated she was not aware of Resident 1 being tied to the wheelchair until 11/11/2024. The DON stated the Administrator had called her on 11/9/2024 and informed her that there was a CNA incident [the phone call that the Administrator received from CNA 1] that happened at the facility, and that the Administrator and the DON would follow up the following Monday, on 11/11/2024. The DON stated, on 11/11/2024, the Administrator and the DON met with CNA 1 to discuss what CNA 1 wanted to discuss on 11/9/2024. The DON stated CNA 1 informed both the Administrator and the DON about witnessing Resident 1 tied up to the wheelchair on 11/9/2024 and briefly shared the videoclip of Resident 1 during that evening. The DON stated when CNA 1 was asked why she had not reported the abuse incident earlier, on 11/9/2024, CNA 1 stated that she preferred to report Resident 1 ' s incident [abuse] in person. The DON stated there was a delay of three days when CNA 1 decided to report witnessing Resident 1 tied up to the wheelchair on 11/11/2024. During an interview with the Administrator on 11/13/2024, at 11:45 AM, the Administrator stated he received a text message from CNA 1 on 11/9/2024 at around 5 PM informing him that CNA 1 had proof of something very important. The Administrator stated that at 6:22 PM, CNA 1 texted him again stating this was not about CNA 1 but about a resident [did not indicate a specific resident ' s name]. Administrator stated he called CNA1 back at around 6:24 PM and asked about her concerns in the text message. The Administrator stated that CNA1 informed him, there was no emergency, and the issue was not urgent and stated CNA 1 would discuss the situation to the Administrator that following Monday, 11/11/2024. The Administrator stated he called the DON to inform her of the CNA 1 ' s phone call and that they would talk to CNA 1 on Monday [11/11/24]. During the same interview with the Administrator on 11/13/2024 at 11:45 AM, the Administrator stated on 11/11/2024 at 3:13 PM, CNA 1 came to his office and showed the DON and himself, the videoclip of the incident [being tied up to the wheelchair] involving Resident 1. The Administrator stated he informed CNA 1 that the videoclip CNA 1 showed was abuse and should have been reported by CNA 1 immediately to the proper authorities [abuse coordinator and other State Agencies] as soon as it was witnessed in accordance with the facility ' s policy and procedure [P&P]. During a concurrent interview on 11/13/2024 at 2:15 PM with the Administrator, the Administrator stated he had started an investigation on 11/11/2024 regarding Resident 1 ' s abuse incident on 11/9/2024, that was reported to the Administrator on 11/11/2024 by CNA 1. The Administrator stated he had place CNA 1 on suspension (temporarily removed from their job duties, usually while an investigation is underway) on 11/11/2024, but had not suspended CNA 2 who was the assigned CNA for Resident 1 during the 3 PM to 11 PM shift, on 11/9/2024 (4 days after the abuse incident). The Administrator stated that he did not suspend CNA 2 right away because CNA 2 was not scheduled to work until Thursday, 11/14/2024. During an interview with LVN 1 on 11/14/2024 at 1:15 PM, LVN 1 stated she was working on a Saturday, dated 11/9/2024, during the 3 PM to 11 PM shift, as a Charge Nurse. LVN 1 stated no one had come forward to report seeing any resident in a sheet restraint. LVN 1 stated, the Administrator called her at the facility on 11/9/2024 and gave her instructions to make rounds to ensure the safety of the residents. LVN 1 stated, she had asked CNA 1 if there were any issues she wanted to discuss or report on 11/9/2024, but CNA1 stated it was not an emergency and refused to discuss the matter with LVN 1. During a review of the facility ' s P&P titled Restraints revised on 11/1/2017, the P&P indicated residents shall be provided an environment that is restraint- free, unless a restraint is necessary to treat a medical symptom in which case the least restrictive measures shall be used. During a review of the facility ' s P&P titled Abuse Prevention and Prohibition Program revised on 10/24/2022, the P&P indicated each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion. Anyone who suspects that an abuse has been committed against a resident must immediately report this information to the Administrator and to the Director of Nursing Services. The P&P indicated it is the Administrator ' s responsibility to ensure the proper authorities and individuals are notified immediately or within two hours.

Based on observation, interview, and record review, the facility failed to ensure to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 removed her personal protective equipment (PPE, specialized equipment such as gown, gloves, and mask that minimize exposure to hazards that may cause illness) before leaving a designated isolation room. 2. Ensure CNA 2 used proper hand hygiene in between Resident 8 and Resident 3 ' s room. 3. Ensure Kitchen Assistant [KA] wore gloves when handling and preparing food/drink in the kitchen. 4. Family Visitor (FM) 2 observed walking into the facility and resident hallway without wearing a surgical mask. 5. Ensure Certified Nursing Assistant (CNA) 6 performed hand hygiene when touching Resident 24 ' s wheelchair and food tray for lunch. 6. Ensure CNA 7 donned personal protective equipment (PPE) when entering a contact isolation (used for patients with disease caused by microorganisms [bacteria and viruses] that are spread through direct and indirect contact) room and performed hand hygiene when touching Resident 2 ' s food tray and resident food cart. 7. Ensure Activities Staff (AS) performed hand hygiene when touching Resident 6 ' s walker and chairs in the dining/activity room. 8. Housekeeping (HK) 1 did not change gloves when sweeping and mopping the floor, touching Resident 16 ' s bed control remote, cleaning and disinfecting Resident 16 ' s floor mat, and touching Resident 16 ' s bedside table in Resident 16 ' s room. Resident 16 was under Contact Precautions (a set of steps to prevent the spread of infectious diseases through direct or indirect contact with a patient or their environment). 9. Certified Nursing Assistant (CNA) 4 did not wear a gown when picking up Resident 7 ' s food tray, who was having gastrointestinal (GI, the body system that takes in food and liquids and break them down into substances that the body can use for energy, growth, and repair) symptoms. Then, CNA 4 went to Resident 19 ' s bed and picked up Resident 19 ' s food tray. Resident 19 did not have GI symptoms. 10. Family Member (FM) 1 did not follow the facility ' s Contact Precautions when visiting Resident 14, who was having GI symptoms. 11. The facility did not report the GI outbreak timely. These deficient practices had the potential to result in the infection spread throughout the facility. In additon, this failure resulted in a Gastrointestinal Illness (GI) outbreak that affected 15 residents and 7 staff members who experienced symptoms such as nausea, vomiting, and diarrhea since 10/28/2024. Findings: 1. During a review of the facility's entrance on 11/14/2024 at 11:00 AM, a total of 4 signages were observed. The signages indicated the following: -Please use mask and use hand sanitizer during flu season October 2024- March 2025 -Attention All Visitors we are currently experiencing an outbreak; please put a mask on prior to entering the facility; speak with an LVN or RN Prior to entering any patient room for further infection control precautions; these precautions are for your safety ass well as the safety of your love ones; thank you. - Stop (Picture of Stop sign) - All Visitors; due to a stomach bug outbreak PLEASE WEAR A MASK AND WASH HANDS AT ALL TIMES During a concurrent observation and interview in the kitchen on 11/14/2024 at 11:04 AM, KA was observed pouring juice from a pitcher to individual cups, and then covering the cups with saran wrap. KA was observed not wearing gloves. KA stated she did not realize she was not wearing gloves. During an interview with the Dietary Supervisor (DS) on 11/14/2024 at 11:06 AM, DS stated kitchen staff were instructed by Public Health to use disposable gloves when preparing and handling food for the patients affected by the outbreak. DS stated kitchen staff was informed that only disposable plates and utensils were to be used for the residents. DS stated kitchen staff should practice safety in wearing gloves when handling ready to eat foods and should wash their hands frequently at the end of the task. During an observation in the facility hallway on 11/14/2024 at 12:01 PM, FM 2 was observed walking to the dining room without wearing a mask. Multiple facility staff did not stop FM 2 as she walked from the facility entrance to dining/activity room. During a review of Resident 24's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 24 was admitted to the facility on [DATE], with diagnoses that included atherosclerosis of aorta (also known as coronary artery disease, condition characterized by the buildup of plaque, consisting of fat, cholesterol, calcium, other subastances on the inner walls of the aorta), bilateral primary osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down) of knee, and Type 2 Diabetes Mellitus (a disorder characterized by difficulty in blood sugar control and poo wound healing). During a review of Resident 24's History and Physical dated 2/6/2024 indicated Resident 24 had the capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/9/2024, indicated the resident was cognitively (mentally) intact. The MDS indicated resident required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with sit to stand position, chair/bed-to-chair transfer, and walking more than 10 feet. During a concurrent observation and interview on 11/14/2024 at 12:04 PM, CNA 6 was observed wheeling Resident 24 from the dining room to Resident 24 ' s room. CNA 6 was observed touching resident ' s wheelchair and food tray cover to assist resident for lunch. CNA 6 did not wash hands with soap and water, CNA 6 did not assist Resident 24 to wash resident ' s hands with soap and water. CNA 6 stated she used hand sanitizer for herself and walked out of the room. During an interview on 11/14/2024 at 12:45 PM, CNA 6 stated she used hand sanitizer for hand hygiene and did not help Resident 24 wash her hands prior to eating lunch. CNA 6 stated it was important to wash hands with soap and water during the gastrointestinal outbreak, to prevent infection. CNA 6 stated hand sanitizer was used for hand hygiene if she was really busy. During a review of Resident 2's Face Sheet indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease stage 3, type 2 Diabetes Mellitus, and anemia (condition that develops when blood produces a lower-than normal amount of healthy red blood cells). During a review of Resident 2's History and Physical dated 5/20/2024 indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/26/2024, indicated the resident had severely impaired cognition. The MDS indicated resident was dependent with sit to stand position, chair/bed-to-chair transfer, and walking more than 10 feet. During a review of Resident 2's Order Summary Report, the physician prescribed an order on 11/5/2024 for Contact isolation precaution every shift for colonized clostridium difficile (C-Diff, very contagious bacterial infection that causes symptoms such as frequent watery diarrhea, abnormal cramping, nausea) for 60 days. During an observation on 11/14/2024 at 12:30 PM, CNA 7 was observed bringing food tray into Resident (PPE)2 ' s room who was under contact isolation. CNA 7 did not don personal protective equipment prior to entering resident ' s room. CNA 7 was observed removing the cover of Resident 2 ' s food tray which had resident ' s lunch in disposable plates and utensils. CNA 7 observed exiting Resident 2 ' s room and proceeded to touch food cart to get another resident ' s tray for lunch. CNA 7 did not perform hand hygiene during entire observation. During an observation on 11/14/2024 at 12:58 PM, prior to entering Resident 2 ' s room was signage that indicated Contact Isolation, MUST PHYSICALLY WASH HANDS. During an interview on 11/14/2024 at 1:12 PM, CNA 7 stated was from registry and was not aware of the gastrointestinal outbreak. CNA 7 stated when he arrived at facility this morning he was given his assignment and was not told about hand washing or instructed about the facility ' s outbreak. During an interview on 11/14/2024 at 1:40 PM, the infection prevention nurse (IPN) stated it was important to wash hands with soap and water during GI outbreak for infection control. IPN stated staff should wash their hands with soap and water and wear PPE if they are going into a contact isolation room. During a review of Resident 6's Face Sheet indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included atherosclerotic heart disease of native coronary artery (coronary artery disease), paroxysmal atrial fibrillation (a fast, irregular heartbeat that lasts a few hours or days), and type 2 Diabetes Mellitus. During a review of Resident 2's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/26/2024, indicated the resident was cognitively intact. The MDS indicated resident required partial/moderate assistance with sit to stand position and chair/bed-to-chair transfer. During a concurrent observation and interview on 11/14/2024 at 12:37 PM, AS was observed carrying Resident 6 ' s walker from the dining room and into Resident 6 ' s room. AS left resident ' s room and proceeded to touch chairs in the resident dining/activity room. AS did not perform hand hygiene during this entire observation. AS stated she brought the walker to resident ' s room and forgot to wash her hands. AS stated she should wash her hands every time she is in contact with resident belongings. AS stated the importance of hand washing is for infection control. During a review of Public Health's Gastrointestinal Outbreak Notification Letter dated 10/31/2024, the letter indicated the following recommendation to enforce strict hand washing procedures for all residents and staff, especially washing hands with warm water and soap before meals and after visiting the toilet. During a review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Program, dated 10/24/2022 indicated the facility establishes and maintains an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with Federal and State requirements. 46779 2. During a review of Resident 16's Admission Record indicated the facility originally admitted Resident 16 on 10/2/2023 and readmitted on [DATE] with diagnoses that included mood disorder (a mental health condition that primarily affects your emotional state) and urinary tract infection (an infection in any part of your urinary system [the body system eliminate waste from the body]). During a review of Resident 16's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/24/2024, indicated Resident 16 had severely impaired cognitive (ability to think and reason) skills for daily decision making. During an observation on 11/1/2024 at 1:26 PM, in Resident 16's room, HK 1 was holding a dry dust mop and sweeping the floor with both her gloved hands. Then, HK 1 held Resident 16's bed control remote, which was hung on the bed rail, and pressed the remote with her gloved left hand to elevate the bed to clean the floor underneath the bed. After sweeping the floor underneath the bed, HK 1 pressed the remote to lower the bed to low position, then, she hung the remote on the bed rail. HK 1 continue to sweep the rest of the floor in the room. During an observation on 11/1/2024 at 1:31 PM, in Resident 16's room, HK 1 was holding a wet mop to mop the floor without changing her gloves that she used to sweep the floor with the dry dust mop. HK 1 held Resident 16's bed control remote and pressed the remote with her gloved left hand to elevate the bed to mop the floor underneath the bed. After mopping the floor underneath the bed, HK 1 pressed the remote to lower the bed to low position, then, she hung the remote on the bed rail. HK 1 continue to mop the rest of the floor in the room and the floor in Resident 16's restroom. During an observation on 11/1/2024 at 1:35 PM, in Resident 16's room, HK 1 pulled the floor mat which was next to Resident 16's bed to the other side of the room, then, she cleaned and disinfected the floor mat with both her gloved hands, but she had not changed the gloves since she swept the floor. During an observation on 11/1/2024 at 1:36 PM, in Resident 16's room, HK 1 put the floor mat next to Resident 16's bed after cleaning and disinfecting it with both gloved hands, then, she pushed Resident 16's bedside table next to Resident 16's bed with her right gloved hand without changing gloves. Next, HK 1 removed the gloves and the gown, and threw in the trash bin inside the room, then, she exited the room. During an interview on 11/1/2024 at 1:37 PM, with HK 1, HK 1 stated she did not change gloves in between the tasks of sweeping and mopping the floor, touching the bed control remote, cleaning and disinfecting the floor mat, and touching the bedside table. HK 1 stated she only clean and disinfect the bed control remote and beside table at the beginning of cleaning the room, but she did not clean and disinfect the bed control remote and the bedside table after she sweeping and mopping the floor, and cleaning and disinfecting the floor mat. During an interview on 11/1/2024 at 06:30 PM, with the Director of Nursing (DON), the DON stated the gloves were dirty during the process of sweeping and mopping the floor and cleaning and disinfecting the floor mat. The DON stated HK should change gloves before touching the clean items and disinfect the bed control remote and bedside table before exiting. 3. During a review of Resident 7's Admission Record indicated the facility originally admitted Resident 7 on 7/24/2023 and readmitted on [DATE] with diagnoses that included dementia (A group of thinking and social symptoms that interferes with daily functioning) and heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body). During a review of Resident 7's MDS, dated [DATE], indicated Resident 7 had severely impaired memory and cognition. The MDS indicated Resident 7 required setup or clean-up assistance with eating and oral hygiene, partial/moderate assistance with toileting hygiene, personal hygiene, and chair/bed-to-chair transfer, and substantial/maximal assistance with shower/bathe self. During a review of Resident 19's Admission Record indicated the facility originally admitted Resident 7 on 3/8/2021 and readmitted on [DATE] with diagnoses that included dementia (A group of thinking and social symptoms that interferes with daily functioning) and hyperlipidemia (a condition where there are high levels of fat in the blood). During a review of Resident 19's MDS, dated [DATE], indicated Resident 19 had moderately impaired memory and cognition. During an observation on 11/1/2024 at 5:32 PM, the Contact Precautions (a set of steps to prevent the spread of infectious diseases through direct or indirect contact with a patient or their environment) signage was posted by the door of Resident 7's room, indicating everyone must put on gloves and gown before room entry for Resident 7. Resident 7 was sitting at her bedside table with her completed dinner tray on the table in the room. Certified Nursing assistant (CNA) 4 put on a pair of new gloves and went into Resident 7's room without putting on a gown, then, she picked up Resident 7's dinner tray and put the tray on the food delivery cart. CNA 4 sanitized her hands with the alcohol sanitizer, then, she went in Resident 19's room and pick up Resident 19's dinner tray from the bedside table and put it to the food delivery cart. During an interview on 11/1/2024 at 5:34 PM, with CNA 4, CNA 4 stated she knew that Resident 7 was on contact isolation, and she should put on a gown when providing care Resident 7. CNA 4 stated she did not put on a gown when picking up Resident 7's tray because she did not realize that her other parts of body and clothing could contract bacteria and virus and pass the infection to other residents. During an interview on 11/1/2024 at 6:31 PM, with the DON, the DON stated contact precautions must be followed when providing care to the infected resident, including wearing personal protective equipment (PPE). 4. During a review of Resident 14 's Admission Record indicated the facility admitted Resident 14 on 2/9/2024 with diagnoses that included dementia and hyperlipidemia. During a review of Resident 14's MDS, dated [DATE], indicated Resident 14 had moderately impaired memory and cognition. The MDS indicated Resident 14 was independent with eating, personal hygiene, and chair/bed-to-chair transfer, and required partial/moderate assistance with shower/bathe self. During an observation on 11/1/2024 at 5:38 PM, the Contact Precautions signage was posted by the door of Resident 14's room, indicating everyone must put on gloves and gown before room entry for Resident 14. In Resident 14's room, Resident's family member (FM) 1 was wearing a pair of gloves and a mask, but she was not wearing a gown. FM 1 was touching and arranging Resident 14's bed linens that were on Resident 14's bed. During an interview on 11/1/2024 at 5:40 PM, with FM 1, FM 1 stated when she came in the facility to visit Resident 14, no staff stopped her and told her to put on a gown before she entered Resident 14's room. FM 1 stated she did not pay attention to the Contact Precautions signage posted by the door of Resident 14's room. FM 1 stated she did not know the facility was having an outbreak and Resident 14 was infected in this outbreak. During a concurrent observation and interview on 11/1/2024 at 5:45 PM, with the Administrator (ADM), a signage was posted on the wall above the visitor's sign-in table, indicated due to a stomach bug outbreak, all visitors need to wear a mask and wash hands at all times. FM 1 was visiting Resident 14 without wearing a gown. The ADM stated the signage, that only informing the visitors to wear a mask and wash hands, did not provide the proper protection guidance for the visitors. ADM stated a proper signage for the visitor would be posted to be compliance with the contact precautions during the outbreak. The ADM stated when the visitor, who was visiting the infected resident, must follow the contact precautions to put on gloves and a gown before entering the room. The ADM stated the staff should inform and educate the visitors the importance of putting on proper PPEs to protect themselves and the residents in the facility. 5. During a record review of the Facsimile Transmittal Sheet, dated 10/31/2024, indicated the facility reported the gastrointestinal (GI, the body system that takes in food and liquids and break them down into substances that the body can use for energy, growth, and repair) outbreak in the facility on 10/31/2024 at 2:25 PM. During an interview on 11/1/2024 at 4:25 PM, with the DON, the DON stated two residents exhibited the GI symptoms, such as nausea, vomiting and diarrhea on 10/28/2024 nighttime, but she thought the two symptomatic resident were isolated cases when she came in to work on 10/29/2024. The DON stated two more residents reported similar GI symptoms on 10/29/2024 nighttime. The DON stated when she returned to work on 10/30/2024 morning and was informed about two more symptomatic residents, she started to link these four residents together and suspected a GI outbreak. The DON stated she reported to Los Angeles County Department of Public Health (LAC DPH) and spoke to a doctor from LAC DPH on 10/30/2024. The DON stated the LAC DPH doctor suspected Norovirus (a group of viruses that causes severe vomiting and diarrhea. It's a very common illness and it's very contagious) might be the cause of the outbreak and provided her with the guidance. During a concurrent interview and record review on 11/1/2024 at 4:27 PM, with the DON, Norovirus (Viral Gastroenteritis) Control Measures for Skilled Nursing Facilities, dated 12/1/2006, was reviewed. The DON stated according to the guidance, the facility should notify LAC Public Health and LAC Health facilities. The DON stated she did not report to LAC Health Facilities on 10/30/2024 because the phone number that listed on the guidance for LAC Health Facilities was not a working number. During a concurrent interview and record review on 11/4/2024 at 12:20 PM, with the ADM, the facility's Policy and Procedure (P&P) titled, Unusual Occurrence Reporting, dated 10/1/2017, was reviewed. The ADM stated they had the LAC Health Facilities phone number in the nursing station and the DON should have reported the outbreak to the LAC Health Facilities on 10/30/2024. The ADM stated he did not know the cases were reportable cases to LAC Health Facilities until the Public Health Nurse informed him to report to LAC Health Facilities on 10/31/2024, then, he faxed the report to LAC Health Facilities on 10/31/2024. The ADM stated according to the facility's P&P, the facility should report the unusual occurrences to the appropriate agency within 24 hours, but the reporting of the outbreak to the LAC Health Facilities was delayed this time. During a review of the facility's P&P titled, Norovirus (Viral Gastroenteritis) Control Measures for Skilled Nursing Facilities, dated 12/1/2006, indicated notify LAC Public Health at . and LAC Health Facilities at . The P&P indicated the facility should increase frequency of routine ward cleaning and give special attention to frequently touched objects. The P&P also indicated Educate staff, residents and visitors about methods of transmission. Wear Gloves, gown, and surgical or procedural mask when in contact with a symptomatic resident. Remove protective equipment and wash hands after contact with an ill resident and before contact with an unaffected resident. During a review of the facility's P&P titled, Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, dated 2/15/2017, indicated the facility ensure that the visitors comply with hand hygiene and Contact Precautions. During a review of the facility's P&P titled, Unusual Occurrence Reporting, dated 10/1/2017, indicated Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. During a review of the facility's P&P titled, Personal Protective Equipment, dated 4/28/2020, indicated staff wear gloves whenever there is touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin, and gloves are used only once and are discarded into the appropriate located in the room in which the procedure is being performed. During a review of the facility's P&P titled, Reportable Diseases, dated 12/1/2021, indicated the facility to ensure the timely reporting of disease as required to the appropriate officials. During a review of the facility's P&P titled, Visitation-Infection Control, dated 10/10/2022, indicated the facility will post a notice to visitors related to limitations or restrictions on visitation at each entrance. The P&P indicated visitors must follow instruction regarding Facility infection control practices and visitation restrictions, which includes donning and doffing of PPE. During a review of the facility's P&P titled, Resident Isolation-Categories of Transmission-based Precautions, dated 10/24/2022, indicated PPE are required, including gloves and gowns, to care for residents who are placed under Contact Precautions. 50203 6. During a review of Resident 20's Admission Records (Face sheet), the facility admitted Resident 20 on 2/10/2020 and readmitted her on 8/18/2022 with diagnoses of, but not limited to, a broken left leg and hemiplegia (paralysis) of the left side. During a review of Resident 20's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/19/2024, Resident 20 was severely cognitively (mental process involved in knowing, learning, and understanding) impaired. During a review of Resident 20's History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 9/3/2024, Resident 20 does not have the capacity to understand and make decisions. During a review of Resident 6's Admission Records (Face sheet), the facility admitted Resident 6 on 10/11/2024 with diagnoses of, but not limited to, a broken right leg and atherosclerotic heart disease (build-up of fats or cholesterol in the arteries [tublike structures transporting blood from the heart of the rest of the body]). During a review of Resident 6's H&P, dated 10/12/2024, Resident 6 does not have the capacity to understand and make decisions. During a review of Resident 6's MDS, dated [DATE], Resident 6 was cognitively intact. During a review of the Sample Case Log of Resident and Staff with Acute Gastrointestinal Illness, received on 11/1/2024, Resident 6 ' s started to experienced nausea and vomiting on 10/29/2024. During an observation on 11/1/2024 at 1PM, a Contact Precaution isolation sign (isolation sign posted by an isolation room that required staff and visitors to wear a gown and gloves) was posted by Resident Room (RR) 1 with Resident 6 ' s bed number written on it. Certified Nurse Assistant (CNA) 1 was observed inside the room wearing personal protective equipment (PPE, specialized equipment such as gown, gloves, and mask that minimize exposure to hazards that may cause illness) and seated next to Resident 20 ' s bed. During an observation on 11/1/2024 at 1:10PM, CNA 1 walked out of RR 1 wearing her PPE and holding a food tray. CNA 1 walked down the hallway to the kitchen and dropped off the food tray. During an interview on 11/1/2024 at 1:14PM with CNA 1, CNA 1 stated, she was helping Resident 20 with her lunch but wore her PPE just in case Resident 6 needed help. CNA 1 stated, she should have removed her PPE before leaving the room for infection control and to not spread germs. 7. During a review of Resident 8's Face sheet, the facility admitted Resident 8 on 12/01/2022 and readmitted Resident 8 on 7/19/2024 with diagnoses of, but not limited to, atherosclerotic heart disease and urinary tract infection (UTI, an infection in the bladder/urinary tract). During a review of Resident 8's H&P, dated 7/20/2024, Resident 8 does not have the capacity to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], Resident 8 was severely cognitively impaired. During a review of the Sampled Case Log of Resident ad Staff with Acute Gastrointestinal Illness, received on 11/1/2024, Resident 8 started to experience nausea and vomiting on 10/30/2024. During a review of Resident 3's Face sheet, the facility admitted Resident 3 on 8/13/2021 with diagnoses of, but not limited to, hemiplegia of the left side and dementia (loss of cognitive function that interferes with a person ' s daily life and activities). During a review of Resident 3's H&P, dated 9/3/2024, Resident does not have the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], Resident 3 was severely cognitively impaired. During an observation on 11/1/2024 at 1PM, a Contact Precaution isolation sign was posted by RR 2 with Resident 8 ' s bed number written on it. During an observation on 11/1/2024 at 1:27PM, CNA 2 was in RR 2 talking with Resident 8. CNA 2 walked out of RR 2 and walked into RR 3 to talk to Resident 3 without using the hand sanitizer. During an interview on 11/1/2024 at 1:30PM with CNA 2, CNA 2 stated, he did not use the alcohol-based hand rub before entering or leaving a resident room. CNA 2 stated, he should have used alcohol-based hand rub or wash his hands before any contact with the resident, changing resident ' s undergarments, assisting with feeding the resident, and going in between two residents. During an interview on 11/1/2024 at 3:55PM with the Infection Preventionist (IP), the IP stated, the staff members should wash their hands or use alcohol-based hand rub before and after caring for the residents. The IP stated, it was important to stop the spread of virus or infection to other residents and staff members. During an interview on 11/1/2024 at 6:30PM with the Director of Nursing (DON), the DON stated, CNA 1 should have not worn the PPE in the hallway. The DON stated, CNA 1 ' s PPE could have spread the virus or the bacteria to other residents, visitors, or staff members in the hallway. The DON stated, it was important for staff members to wash their hands with soap and water or use alcohol-based hand rub in between resident cares to stop the spread of infection. During a review of the facility policies and procedures (P&P) titled Personal Protective Equipment, dated 4/28/2024, indicated if the gown was used, it should be used once and thrown away in the same room it was used in. During a review of the facility ' s P&P titled Resident Isolation - Categories of Transmission-Based Precautions, dated 10/28/2022, indicated the gown should be removed and hand hygiene should be performed before leaving the resident ' s environment. During a review of the facility ' s P&P titled Hand Hygiene, dated 6/1/2017, indicated that the facility staff followed the hand hygiene procedures to help prevent the spread of infection to other staff, residents, and visitors. The P&P indicated that facility staff, visitors, and volunteers must perform hand hygiene procedures such using alcohol-based hand hygiene products immediately upon entering or exiting a resident occupied area.

Based on observation, interview and record review, the facility failed to accommodate the needs of one of three sampled residents (Resident 1) with history of fall and a high risk for fall, in accordance with the facility ' s policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach. This deficient practice had the potential for Resident 1 not to receive assistance especially during a fall or not receive immediate care with Activities of Daily Living (ADL) if unable to reach the call light. Findings: During a review of Resident 1's Admission Record, indicated the facility originally admitted Resident 1 on 10/2/2023 and readmitted on [DATE] with diagnoses that included osteoporosis (a disease that causes bones to become weak and more likely to break), generalized muscle weakness, and history of falling. During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/2/2024, indicated Resident 1 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guarding assistance as resident completes activity) with toileting, personal hygiene, sit to stand, and required partial/moderate assistance (helper does less than half the effort) with bathing and dressing. A review of Resident 1 ' s care plan (CP) for requiring assistance with transfer/ambulation due to poor balance potential for falls/injury, revised 1/6/2024, the CP indicated intervention included call light within easy reach and answered promptly. A review of Resident 1 ' s care plan (CP) dated on 8/3/2024, revised 8/6/2024 indicated Residnet 1 had an actual, unwitnessed fall. The CP intervention included call lights to be within easy reach. A review of Resident 1 ' s facility document titled Fall Risk Assessment, dated 4/4 2024, 7/3/2024, 10/2/2024, the document indicated Resident 1 was a high risk for fall. During a concurrent observation and interview on 11/7/2024at 9:06 AM with certified nurse assistant (CNA) 1 in Resident 1 ' s room, Resident 1 in bed with head of bed elevated, call light chord was wedged between Resident 1 ' s mattress and headboard above Resident 1 ' s head, the call light button was about 2 inches from the ground. CNA 1 stated, the call light should not be there, Resident 1 cannot reach it. CNA 1 stated, Resident 1 can use the call light for assistance, and she is a fall risk so it should be within reach at all times. During an interview on 11/7/2024at 9:15 AM with Social Service Director (SSD), SSD stated, Resident 1 can use the call light when she needs assistance, so it needs to be within reach, otherwise she may try to get up and result in fall that could hurt herself. During an interview on 11/7/2024 at 9:45 AM with Registered Nurse (RN) 1, RN 1 stated, Resident 1 was able to use call light for assistance, so it needs to be within reach to accommodate her needs. RN 1 stated, Resident 1 needs assistance getting up, so her call light is important to prevent fall and injury. During an interview on 11/7/2024 at 9:45 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 uses the call light if she needs assistance to the bathroom. During an interview on 11/7/2024 at 10:40 AM with Occupational Therapist (OT), OT stated, Resident 1 requires assistance to go to the restroom, she cannot do it by herself, she uses the call light for assistance. During an interview on 11/7/2024 at 11:25 AM with Director of Nurses (DON), DON stated, Resident 1 always need the call light to be within reach for assistance and to accommodate her needs with ADLS, because Resident 1 was at high risk for fall and injury. A review the facility ' s policy and procedure (P&P) titled, Resident Rights - Accommodation of Needs, dated 8/1/2024, the P&P indicated; a) the facility provides an environment and services that meet residents ' individual needs, b) the facility ' s environment is designed to assist the resident in achieving independent functioning and maintaining the residents ' dignity and wellbeing, and c) Residents ' individual needs and preferences are accommodated to the extent possible. A review the facility ' s policy and procedure (P&P) titled, Communication - Call System, dated 10/24/2022, the P&P indicated; a) facility to provide a mechanism for residents to promptly communicate with nursing staff, b) the facility will provide a call system to enable residents to alert the nursing staff from their beds, and c) call cords will be placed within the resident ' s reach in the residents room.

Based on interview and record review, the facility failed to meet professional standards of practice for one of three sampled residents (Resident 1), who sustained an unknown injury, when Resident 1 was found with swelling on the left cheek from an unknown cause. The facility failed to conduct neurological assessments (series of tests that evaluate a patient's nervous system function) and develop a care plan. As a result of these deficient practices, Resident 1 had the potential to suffer further deterioration of health. Findings: A review of Resident 1 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy (a change in how the brain works due to an underlying condition), Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and muscle weakness. A review of Resident 1 ' s History and Physical (H&P), dated 9/19/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (a federally mandated resident assessment tool), dated 9/22/2024, indicated the resident has severe cognitive impairment. A review of Resident 1 ' s Incident Note, dated 10/6/2024, timed at 9:32 PM, signed by the Director of Staffing Development (DSD), indicated Resident 1 was observed with light blue colored swelling on left cheek that was noted with 2 small red spots on it. The notes added Resident 1 had light discoloration on lower lip. A review of the facility ' s investigation conclusion, dated 10/10/2024, signed by Administrator (ADM), indicated when Resident 1 was interviewed regarding the cause of the swelling, Resident 1 responded that she fell outside. A review of resident ' s entire medical chart did not indicate documented evidence that NA was conducted to assess Resident 1 in response to Resident 1 ' s left cheek injury. A review of Resident 1 ' s entire care plans did not indicate documented evidence that a care plan was developed in response to Resident 1 ' s left cheek injury that would have included goals and interventions for facility staff to follow to address the resident ' s left cheek injury. During an interview on 10/17/2024 at 10:42 AM with Licensed Vocational Nurse (LVN), LVN stated when a resident sustains an injury of unknown cause that involves the head or face, NA must be conducted. During an interview on 10/17/2024 at 1:08 PM with Registered Nurse (RN), RN stated when a resident sustains a new injury such as Resident 1 ' s left cheek swelling, a care plan must be developed. RN stated when an injury that involved the head or face is observed, the resident must undergo NA by the nurses and the assessments logged into the Neurological Flow Sheet. During a concurrent interview and record review on 10/17/2024 at 1:12 PM with RN, Resident 1 ' s entire medical records were reviewed. RN stated there is no evidence in Resident 1 ' s chart that a care plan was developed to address Resident 1 ' s left cheek swelling. RN stated there is also no evidence that NA were conducted in response to Resident 1 ' s left cheek swelling. RN stated NA is more extensive than regular monitoring conducted by nurses because NA involves more tests. During an interview on 10/17/2024 at 1:32 PM with DSD, DSD stated NA should be conducted when head injuries are suspected, such as in the case for Resident 1. DSD stated if NA is not conducted, the resident ' s health could deteriorate because the resident would not be adequately monitored for serious injuries like a bleed in the brain or vision problems. DSD further stated care plans should be initiated for any injuries because care plans serve as a plan for staff to follow. DSD stated failure to not develop a care plan can lead to staff to not provide adequate care to the resident. A review of the facility ' s P&P titled, Care Planning, revised 10/24/2022, indicated care plans serve to help the resident move toward resident-specific goals that address the resident ' s medical, nursing, mental, and psychosocial needs. The P&P also indicated the care plan will describe services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. The P&P also indicated changes may be made to the care plan on an ongoing basis for the duration of the resident ' s stay. A review of the facility ' s policy and procedure (P&P) titled, Neurological Assessment, revised 8/1/2014, indicated nursing staff will perform NA following a fall or other accident/injury involving head trauma. The P&P also indicated nursing staff will perform NA following an unwitnessed fall. The P&P indicated NA consists of tests that include determining the resident ' s level of consciousness and pupillary activity (refers to the size of a part of the eye called the pupil and how it changes in response to different stimuli). The P&P further stated early signs of neurological compromise includes changes in the resident ' s level of consciousness and pupillary activity. A review of the facility ' s P&P titled, Response to Falls, revised 3/1/2015, indicated the licensed staff will complete the NA using the Neurological Flow Sheet for any un-witnessed fall with known head injury for 72 hours following the fall.

Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS, a federal mandated resident assessment tool) was accurate for one of two sampled residents (Resident 20): These deficient practices had the potential to result in Resident 20 not receiving appropriate treatment and/or services. Findings: 1. A review of Resident 20 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was admitted to the facility on [DATE] with diagnoses that included Depression, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) with acute (sudden ) exacerbation and chronic congestive heart failure (a condition where the heart has difficulty pumping blood thought out the body). A review of Resident 20 ' s History and Physical assessment dated [DATE], indicated Resident 20 did not have the capacity to understand and make decisions. A review of Resident 20 ' s MDS section I, titled Active Diagnosis dated 7/22/2024 did not indicate Resident 20 ' s active diagnosis of depression (a serious mood disorder that can affect how a person feels, thinks, and behaves). During a concurrent interview and record on 10/14/24 at 8:08PM, with the Director of Nursing (DON), Resident 4 ' s MDS, dated [DATE] was reviewed. The DON stated when conducting MDS assessments, a full assessment of the resident was conducted which included direct observation of the resident, interviewing of the resident, and observing the overall status of the resident which included their medical history. The DON stated accurate completion of a resident ' s MDS was important to provide a clear picture of the overall wellbeing and care of the resident The DON stated when the MDS was inaccurately completed, Resident 20 ' s plan of care would not match the care Resident 20 required. A review of facility policy and procedure titled Admission Assessment-nursing manual dated August 30,2019, indicated Licensed nursing staff will complete an admission assessment for residents upon admission to the facility, using the resident assessment instrument (RAI) specified by the Centers for Medicare and Medicaid Services (CMS) as well as coordinate the assessment with the recommendations provided by the preadmission screening resident review.