Every finding on record at Arrowhead Healthcare Center, LLC

Based on observation, interview, and record review, the facility failed to ensure safe infection control practices and sanitary environment were followed when: 1.physician's orders were not followed for Resident 53 and Resident 21, when the residents' oxygen nasal cannula tubing (device used to deliver oxygen into the nose via a tube) and humidifier (bottle filled with distilled water that attaches to an oxygen concentrator or tank to add moisture to the oxygen) were found unlabeled and undated2.Three Hoyer lift (a mechanical lift) slings (strong, fabric harnesses that securely hold a person with limited mobility while a mechanical lift moves them) were observed hanging from the exterior bars outside the laundry room windows.3.The facility failed to ensure staff adhered to required infection prevention and control practices, including appropriate PPE use during high-contact care for Resident 37 on Enhanced Barrier Precautions (EBP-an infection control guideline that requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading infectious diseases) placing Residents 37 at risk for potential transmission of infection.4.Two manual blood pressure cuffs (a tool used to measure blood pressure without electronics) were found visibly soiled with a white substance and lint in two of seven sampled Enhanced Barrier Precautions (EBP- an infection control guideline that requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading infectious diseases) carts (mobile supply carts stocked with EPP- personal protective equipment such as gowns, gloves, and goggles.) located outside resident rooms.5. A staff member did not perform hand hygiene after removing gloves upon exiting a resident room on enhanced barrier precautions (EBP - an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of multidrug resistant organisms [MDRO - bacteria that have become resistant to certain antibiotics]).These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to 54 medically compromised residents and staff in the facility.Findings: 1.A. During a review of Resident 53's admission Record (contains medical and demographic information), the admission Record indicated Resident 53 was admitted to the facility on [DATE], with diagnoses which included Acute Respiratory Failure with hypoxia (the lungs cannot properly transfer oxygen into the blood, leading to dangerously low blood oxygen levels), Dependence on Supplemental Oxygen (the lungs or heart cannot get enough oxygen into the bloodstream from normal room air to keep the body functioning properly), and Cerebral Infarction (when a part of the brain dies because it is not getting enough blood and oxygen). During a review of Resident 53's Physician Order dated March 6, 2026, the Physician Order indicated, Oxygen @ 4 L/Min (Liter/Minute – unit of measurement) via nasal cannula or face mask continuously for SOB (Shortness of Breath). Monitor q (every) shift if oxygen is delivered at 3 L/min or above. Humidifier must be applied. During a review of Resident 53's Physician Order dated March 6, 2026, the Physician Order indicated, Change nasal cannula or face mask and tubing q week on Sunday. Date nasal cannula or face mask and tubing when changed. Every night shift every Sunday. If oxygen is delivered at 3 L/min or above, humidifier must be changed weekly with nasal cannula or face mask. During an observation on April 6, 2026, at 10:57 AM, in Resident 53's room, Resident 53 was observed on oxygen 4 L/Min via nasal cannula tubing, and a humidifier was attached to an oxygen concentrator (device that provides supplemental oxygen). The nasal cannula tubing and humidifier were unlabeled and undated. During a concurrent observation and interview on April 6, 2026, at 11:13 AM, with Infection Preventionist (IP) in Resident 53's room, the IP inspected Resident 53's nasal cannula tubing and humidifier. The IP verified the nasal cannula tubing and humidifier were not labeled or dated. The IP stated both should have been labeled and dated to prevent infections. During a concurrent interview and record review on April 7, 2026, at 9:50 AM, with the Director of Nursing (DON), Resident 53's Physician Order dated March 06, 2026, indicated, Change nasal cannula or face mask and tubing q week on Sunday. Date nasal cannula or face mask and tubing when changed. Every night shift every Sunday. If oxygen is delivered at 3 L/min or above, humidifier must be changed weekly with nasal cannula or face mask. The DON stated the physician order was not followed. She further stated it is important to change the oxygen nasal cannulas and humidifier to prevent infections. B. During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD – a progressive, long-term lung disease that makes it hard to breathe), Nonrheumatic Aortic Valve Stenosis (the main valve controlling blood flow out of the heart becomes stiff, thick, and narrow, making it hard for blood to flow to the rest of the body), and Dependence on Supplemental Oxygen (the lungs or heart cannot get enough oxygen into the bloodstream from normal room air to keep the body functioning properly). During a review of Resident 21's Physician Order dated March 18, 2026, the Physician Order indicated, Oxygen @ 4 L/Min via nasal cannula or face mask continuously for COPD. Monitor q shift. If oxygen is delivered at 3 L/min or above, humidifier must be applied. During a review of Resident 21's Physician Order dated March 22, 2026, the Physician Order indicated, Change nasal cannula or face mask and tubing q week on Sunday. Date nasal cannula or face mask and tubing when changed. Every night shift every Sunday. If oxygen is delivered at 3 L/min or above, humidifier must be changed weekly with nasal cannula or face mask. During an observation on April 6, 2026, at 11:02 AM, in Resident 21's room, Resident 21 was observed on oxygen 4 L/Min via nasal cannula tubing, and a humidifier was attached to an oxygen concentrator. The nasal cannula tubing and humidifier were unlabeled and undated. During a concurrent observation and interview on April 6, 2026, at 11:17 AM, with Infection Preventionist (IP) in Resident 21's room, the IP verified the nasal cannula tubing and humidifier were not labeled or dated. The IP stated both should have been labeled and dated to prevent infections. During a concurrent interview and record review on April 7, 2026, at 9:56 AM, with DON, the Physician Order dated March 22, 2026, were reviewed. The physician order indicated, Change nasal cannula or face mask and tubing q week on Sunday. Date nasal cannula or face mask and tubing when changed. Every night shift every Sunday. If oxygen is delivered at 3 L/min or above, humidifier must be changed weekly with nasal cannula or face mask. The DON stated the physician order was not followed for this resident either. She further stated it should have been followed to help prevent infections. 2. During an observation and interview on April 6, 2026, at 8:23 AM, with Administrator, outside Administration building next to the laundry building, two Hoyer lift (a mechanical lift) slings (strong, fabric harnesses that securely hold a person with limited mobility while a mechanical lift moves them) were observed hanging from the bars on the laundry room window. The Administrator stated the sling should not be outside and should be laundered inside the laundry room because it an infection control and contamination concern. During an observation and interview on April 7, 2026, at 3:01 PM, with Housekeeping Supervisor (HS), outside laundry building, one Hoyer lift slings were observed hanging from the bar on the laundry room window. HS stated the sling should not be outside and there is a new employee that needs to be educated on the correct process to laundry slings. HS further states slings should be wiped down then hang in laundry room to dry. During an observation and interview on April 8, 2026, at 7:47 AM, with HS, at unit 1 linen closet, there was a Hoyer lift sling stored in clean linen closet. HS states once slings are laundered, they are stored in clean linen closet on units 1 and 2. During an interview and record review on April 8, 2026, at 3:50 PM, with the Administrator, the facility's P&P titled, Laundry, undated, was reviewed. The P&P indicated, . All linen will be handled in a manner to prevent contamination.1f.Linen should be stored in covered, clean storage carts or areas. The Administrator confirmed the P&P was not followed and stated that adherence is important due to the increased risk for infection within the resident population. 3. During a review of Resident 37 's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE], with the diagnoses which included, gastrostomy Status(G tube-surgically placed tube that provides direct access to the stomach for nutrition, fluids, and medications.), Acute Myocardial Infarction ( MI-heart attack), Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 37's care plan titled, Resident requires Enchased barrier precautions due to Gastrostomy tube. History of ESBL (bacteria that is resistant to a wide range of antibiotics), MRSA(bacteria that is resistant to a wide range of antibiotics) dated February 13, 2026, the care plan indicated, PPE to be used for enhanced barrier precautions: 1. Gloves 2. Gown, when in direct contact with resident during care.Gloves and gown prior to the 6 moments of high-contact care activities (enhanced precautions (e.g., gloves and gowns) are specifically recommended to prevent MDRO; dressing, bathing or showering, transferring, providing hygiene, toileting). During an observation on April 8, 2026, at 6:22 AM, inside Resident 37's room, observed Resident 37's feeding tube discounted and draining on floor. Licensed Vocational Nurse 3 (LVN 3) and Certified Nursing Assistant 2 (CNA 2) responded to the situation. CNA 2 was observed cleaning the feeding solution from the floor and assisting LVN 3 with resident care, removing soiled towels and linens. LVN 3 was then observed flushing Resident 37's G-tube, assessing the site, and reconnecting the enteral feeding tube. Resident 37 was on EBP requiring the use of personal protective equipment (PPE), including a gown. LVN 3 and CNA 2 failed to wear the required gown during high-contact resident care. During an observation on April 8, 2026, at 6:31 AM, inside Resident 37's room, Resident 37's was observed again with the feeding tube disconnected, and feeding solution leaking. Registered Nurse Supervisor 2 (RNS 2) and CNA 3 responded and performed high-contact care activities, including removing and cleaning the feeding solution and providing G-tube care. RNS 2 was observed reconnecting the feeding tube. RNS 2 and CNA 3 failed to wear the required gown during high-contact resident care for Resident 37, who was on EBP. During an interview and observation on April 8, 2026, at 6:42 AM with LVN 3, outside Resident 37's room, observed signage posted outside the door indicating enhanced barrier precautions for resident 37. LVN 3 stated she should have been wearing a gown when she was providing care to Resident 37 due to G tube and increased risk for infection. During an interview on April 8, 2026, at 6:55 AM with Infection Preventionist (IP), outside resident 37's room. IP stated staff are expected to wear gloves, gowns and masks for residents on EBP when performing high contact care. She states the staff didn't follow the EBP guidelines. During an interview with the Administrator on April 9, 2026, at 12:32 PM, in the Administrator office, the Administrator stated the facility does not have a policy and procedure (P&P) on enhanced barrier precautions. The Administrator further stated the facility follows the CDC enhanced barrier precautions guidelines and the CDC guidelines signage is placed outside Resident's on enhanced barrier precaution rooms. The Administrator stated the staff did not follow the CDC guidelines line. 4. During an observation and interview on April 6, 2025, at 10:09 AM, with Certified Nursing Assistant 1 (CNA 1), in the hallway of unit 2, two manual blood pressure cuffs were found visibly soiled with white substance and lint inside top drawer of two EBP carts. CNA 1 acknowledged the blood pressure cuffs were dirty with white substances and lint. CNA 1 stated the facility's expectation is that resident care equipment must be cleaned after each use. During an observation and interview on April 6, 2025, at 10:15 AM, with Infection Preventionist (IP), in hallway of unit 2, the IP verified that two manual blood pressure cuffs were visibly soiled with white substance and lint and were stored inside the top drawers of two EBP carts. IP stated the facility's Policy and Procedure (P&P) require cleaning resident care equipment immediately after each resident use. The IP further stated EBP carts are used for residents at high risk of acquiring or spreading infectious diseases, and dirty equipment increases the infection risk for these and other residents. During a concurrent interview and record review on April 7, 2026, at 10:23 AM, with the Director of Nursing (DON), the facility's P&P titled, Cleaning & Disinfecting Blood Pressure Machine and Blood Pressure Cuff, undated, was reviewed. The P&P indicated, .It is our policy that the sphygmomanometer, used to measure blood pressure of residents, must be cleaned in between each resident's use.1. The blood pressure cuff and gauge will be cleaned after each use with a disinfectant wipe. Remove any visible soil first and then wipe with disinfectant wipe. The DON confirmed the P&P was not followed and stated that adherence is critical due to the increased infection risk within the resident population. 5. During an observation on April 6, 2026, at 10:25 AM, room [ROOM NUMBER] had a sign outside the doorway which indicated Enhanced Barrier Precautions.Everyone must: clean their hands, including before entering and when leaving the room. Housekeeper 1 (HK 1) was mopping the floor in the room and removed her disposable gloves and did not perform hand hygiene (hand washing or use of alcohol based hand sanitizer) after removing her gloves or upon exiting room [ROOM NUMBER]. Housekeeper 1 then continued mopping the hallway outside room [ROOM NUMBER]. During a concurrent observation and interview on April 6, 2026, at 10:29 AM, HK 1 was still mopping the hallway and had not yet performed hand hygiene after removing her disposable gloves or upon exiting room [ROOM NUMBER], when she agreed to be interviewed. HK 1 stated she removed her gloves and gown when leaving room [ROOM NUMBER] (on enhanced barrier precautions) but didn't perform hand hygiene because she was not done mopping so she continued to mop in the hallway. During an interview on April 6, 2026, at 10:36 AM, with the Director of Nursing (DON), the DON stated hand hygiene was supposed to be done every time before and after removing Personal Protective Equipment (PPE). The DON further stated hand hygiene was supposed to be done upon exiting a room on enhanced barrier precautions. The DON stated hand hygiene was important to prevent the spread of infection from one person to another person. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene Program, undated, the P&P indicated, Rationale for hand hygiene: Prevent transmission of infectious agents.indications for performing hand hygiene: -before and after glove use.

Based on observation, interview, and record review, the facility failed to ensure five of five rooms (each with four resident beds per room) had the minimum required square footage for each resident. This failure had had the potential for increased risk of accidents and injuries to occur within the room as a result of limited space for wheelchair and Hoyer lift access (a mechanical device that helps move people with limited mobility), limited space to accommodate resident care activities, increased risk for falls, and a potential delay in the evacuation of residents during an emergency.Findings: During a review of the facility document titled, [name of facility] Census (a document which indicates the total number of residents within the facility and their room number) dated April 6, 2026, the document indicated there was a total of five rooms within the facility each with four beds and the ability to house 4 residents The rooms were: 102, 105, 106, 107 and 112.During a concurrent observation and interview on April 9, 2026, at 8:45 AM, with the Maintenance Supervisor (MS) and the Director of Nursing (DON), the MS measured Rooms 102, 105, 106, 107, and 112. All measurements were verified by both the MS, the DON and the surveyor using the facility's measuring tape and the following measurements were obtained:room [ROOM NUMBER]: Length (L) 185 (inches) x width (W) 237 = 43845 square inches (sq in) total room area. Within the room, there was one moveable wardrobe cabinet which measured 23 x 40 = 920 and one unmovable wardrobe cabinet which measured 39 x 19 = 741.room [ROOM NUMBER]: Length 178.5 x width 238 = 42483 sq in total room area. Within the room, there was one un-moveable wardrobe cabinet which measured 42 x 18 = 756 and a moveable wardrobe cabinet which measured 36 x 19 = 684.room [ROOM NUMBER]: Length 184 x width 238 = 43792 sq in total room area. Within the room, there was one moveable wardrobe cabinet which measured 36 x 19 = 684.room [ROOM NUMBER]: Length 178 x 244 = 43432 sq in total room area. Within the room there was one moveable wardrobe cabinet which measured 33 x 18 = 594 and another moveable wardrobe cabinet which measured 33 x 19 = 627.room [ROOM NUMBER]: Length 184 x 239 = 43976 sq in total room area. Within the room, there was one moveable wardrobe cabinet which measured 23.5 x 40 = 940 and another moveable wardrobe cabinet which measured 39 x 24.5 = 955.5.During an interview on April 9, 2026, at 2:30 PM, with the Administrator (ADMIN), and the Assistant Director of Nursing (ADON), the ADMIN and ADON were shown the measured room sizes of rooms 102, 105, 106, 107, and 112. The measurements of the rooms were discussed and the following sq ft per resident were calculated:room [ROOM NUMBER]: Length (L) 185 (inches) x width (W) 237 = 43845 square inches (sq in) total room area. 43845 sq in divided by 144 (to convert to square feet) = 304.47 square feet (sq ft) total room area. Divided by 4 (number of residents in the room) = 76.11 sq ft per resident. However, within the room there was one moveable wardrobe cabinet which measured 23 x 40 = 920 and one unmovable wardrobe cabinet which measured 39 x 19 = 741. After subtracting the moveable wardrobe space (since it is not considered useable room space) the total sq ft per resident was decreased to 73.23 sq ft.room [ROOM NUMBER]: Length 178.5 x width 238 = 42483 sq in total room area. 42483 sq in divided by 144 (to convert to sq ft) = 295.02 sq ft total room area. Divided by 4 (number of residents in the room) = 73.75 sq ft per resident. However, within the room there was one un-moveable wardrobe cabinet which measured 42 x 18 = 756 and a moveable wardrobe cabinet which measured 36 x 19 = 684. After subtracting the moveable wardrobe space, the total sq ft per resident was decreased to 71.25 sq ft.room [ROOM NUMBER]: Length 184 x width 238 = 43792 sq in total room area. 43792 sq in divided by 144 (to convert to sq ft) = 304.11 sq ft total room area. Divided by 4 (number of residents in the room) = 76.02 sq ft per resident. However, within the room there was one moveable wardrobe cabinet which measured 36 x 19 = 684. After subtracting the moveable wardrobe space, the total sq ft per resident was decreased to 74.84 sq ft.room [ROOM NUMBER]: Length 178 x 244 = 43432 sq in total room area. 43432 sq in divided by 144 (to convert to sq ft) = 301.61 sq ft total room area. Divided by 4 (number of residents in the room) = 75.40 sq ft per resident. However, within the room there was two moveable wardrobe cabinets. One measured 33 x 18 = 594 and the other measured 33 x 19 = 627. After subtracting the moveable wardrobe space, the total sq ft per resident was decreased to 73.28 sq ft.room [ROOM NUMBER]: Length 184 x 239 = 43976 sq in total room area. 43976 sq in divided by 144 (to convert to sq ft) = 305.38 sq ft total room area. Divided by 4 (number of residents in the room) = 76.34 sq ft per resident. However, within the room there was one moveable wardrobe cabinet which measured 23.5 x 40 = 940 and another moveable wardrobe cabinet which measured 39 x 24.5 = 955.5. After subtracting the moveable wardrobe space, the total sq ft per resident was decreased to 73.05 sq ft per resident.The Administrator (ADMIN) stated she agreed on the calculations and that based on the measurements of rooms 102, 105, 106, 107, and 112; all five of the rooms were less than the required 80 sq ft per resident.During an interview on April 9, 2026, at 11:20 AM, with the ADMIN, the ADMIN was asked for a list of residents who resided in Rooms 102, 105, 106, 107, and 112, and of those, which required the use of a wheelchair, walker, Hoyer lift, and/or Geri chair (a large, padded chair that's designed to help people with limited mobility sit and stand comfortably).During a review of the facility's document titled, List of 5 rooms who Have 4 Residents, undated, the document indicated of the five rooms (Rooms 102, 105, 106, 107, and 112) four residents required use of Hoyer lift, nine residents had wheelchairs, five residents had Geri chairs, and two residents required walkers.The facility did not have a policy and procedure regarding minimum required room square footage required per resident

Based on observation, interview, and record review, the facility failed to ensure dignity was maintained for one of 18 sampled residents (Resident 4) when Resident 4's urinary collection bag (bag which collect and hold urine) was found not covered with a dignity bag (a drainage bag holder used to cover and hold the catheter drainage/collection bag, so it is not visible). This failure resulted in Resident 4's urine being visible to residents, staff, and visitors, which compromised his privacy and diminished his dignity, self-worth, and sense of respect.Findings: During a review of Resident 4's admission Record, (contains demographic and medical information), indicated Resident 4 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (the final, permanent stage of chronic kidney disease where kidney function falls below 15% of normal), dependence on renal dialysis (a person's kidneys have failed [typically <15% function] and can no longer filter waste or manage fluids, making regular, life-sustaining dialysis treatments necessary to stay alive), obstructive uropathy (a blockage in the urinary system that prevents urine from flowing freely, causing it to back up into the kidneys) and reflux uropathy (a condition in which the kidneys become damaged or scarred due to the backward flow of urine from the bladder into the kidneys). During a concurrent observation and interview on April 6, 2026, at 11:26 AM in Resident 4's room, Resident 4 was observed resting in bed and had a suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen to drain urine). The urinary collection bag connected to the suprapubic catheter, was observed to contain urine, was not labeled with a date and was not concealed within a dignity bag, making it visible to anyone entering or passing by the room. Resident 4 stated the facility did not offer or provide him a cover (dignity bag) for his catheter drainage bag. During a concurrent observation and interview on April 6, 2026, at 11:35 AM, with the Infection Preventionist (IP) at Resident 4's room, IP acknowledged the urinary collection bag was not labeled with a date and the bag was not concealed within a dignity bag, resulting in its visibility to anyone entering or passing by the room. IP stated dignity bags are currently unavailable within the facility and reported that a request to reorder dignity bags had been made a while ago.During an interview on April 7, 2026, at 9:31 AM, with the Assistant Director of Nursing (ADON), the ADON stated all urinary collection bags should be covered with a dignity bag. The ADON further stated dignity bags were used for maintaining residents' privacy and dignity.During a concurrent interview and record review on April 9, 2026, at 10:37 AM with the Administrator (Admin) and the ADON, the facility's Policy and Procedure (P&P) titled, Foley Catheter, undated, was reviewed. The P&P stated . 3. Maintenance of foley catheter . g. Urinary drainage is kept inside a urinary drainage bag holder. The Admin stated all urinary collection bags should be covered with a dignity bag at all times to maintain resident's privacy and dignity. The Admin acknowledged the P&P was not followed when Resident 4's urinary collection bag was not concealed within a dignity bag, making it visible to anyone entering or passing by the room.

Based on interview, and record review, the facility failed to ensure nursing staff followed a physician's order for hypoglycemia (low blood sugar) management for one of one sampled residents (Resident 43) reviewed for insulin (medication used to help lower blood sugar levels), when on multiple occasions, staff did not document a required repeat blood sugar check after the Resident 43's initial blood sugar was below 70 milligrams per deciliter (mg/dl).This failure resulted in Resident 43 to not receive care and monitoring of blood sugar levels as ordered by the physician and for Resident 43 to experience hypoglycemia without staff knowledge or intervention.Findings: During a review of Resident 43's admission Record (contains medical and demographic information), the admission Record, indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (condition in which the body can't regulate blood sugar levels adequately, leading to high blood sugar levels), hemiplegia and hemiparesis (weakness and paralysis), and history of cerebral infarction (a specific type of stroke, referring to dead brain tissue caused by prolonged lack of blood flow).During an interview on April 6, 2026, at 10:09 AM, with Resident 43, Resident 43 stated her blood sugar levels had been low lately.During a review of Resident 43's care plan (an individualized plan for the medical care of a resident), titled, [Name of Resident 43] has diabetes mellitus.at risk for hypo/hyperglycemic episodes [episodes of low and high blood sugar levels].interventions.diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness.Monitor blood sugar as ordered and provide insulin as ordered per sliding scale.During a review of Resident 43's physician's orders, dated June 1, 2024, indicated, Humalog solution [type of insulin] 100 unit/ml [units per milliliter - unit of measure].inject as per sliding scale: if 0-70 = 0 units give 4 oz [ounces] of juice Recheck BS [blood sugar] x 15 minutes. If results are below 60 notify MD or sent to ER [emergency room].During a review of Resident 43's Medication Administration Record (MAR - document used to record medications, treatments, and assessments), dated March 1, 2026, through March 31, 2026, the MAR indicated the following:1.On Sunday, March 1, 2026, at 6:30 AM, Resident 43's blood sugar was documented as 68 mg/dl. There was no documentation regarding a repeat blood sugar level.2.On Thursday, March 19, 2026, at 6:30 AM, Resident 43's blood sugar was documented as 67 mg/dl. There was no documentation regarding a repeat blood sugar level.3.On Wednesday, March 25, 2026, at 6:30 AM, Resident 43's blood sugar was documented as 69 mg/dl. There was no documentation regarding a repeat blood sugar level.During a concurrent interview and record review on April 9, 2026, at 10:05 AM, with the Director of Nursing (DON), Resident 43's MAR dated March 1, 2026, through March 31, 2026, was reviewed. The DON stated per the physician's orders, if Resident 43's blood sugar level was below 70 mg/dl, staff were supposed to give the resident four (4) ounces of juice (to attempt to raise the blood sugar), then recheck the blood sugar after 15 minutes and if it was below 60 mg/dl, staff were supposed to notify the physician and send the resident to the emergency room (ER). The DON acknowledged Resident 43's blood sugar levels were 68 mg/dl on March 1, 2026, at 6:30 AM, 67 mg/dl on March 19, 2026, at 6:30 AM, and 69 mg/dl on March 25, 2026, at 6:30 am. The DON further stated staff were supposed to recheck the residents blood sugar level after administering juice and the follow up blood sugar levels should have been documented as a progress note. The DON then reviewed Resident 43, progress notes, and the rest of the clinical record and stated she was unable to find documented evidence anywhere in the clinical record that Resident 43's blood sugar was rechecked on March 1, March 19, and March 25, of 2026 when the Resident 43's blood sugar was initially below 70 mg/dl.During a concurrent interview and record review on April 9, 2026, at 10:05 AM, with the Assistant Director of Nursing (ADON), Resident 43's clinical record was reviewed. The ADON stated she also was unable to find documented evidence that staff rechecked Resident 43's blood sugar level on on March 1, March 19, and March 25, of 2026 when Resident 43's blood sugar was initially below 70 mg/dl.During an interview on April 9, 2026, at 10:12 AM, with the ADON, the ADON stated it was important to ensure Resident 43's blood sugar levels were rechecked and documented as ordered by the physician to ensure the juice that was given to the resident effectively raised the blood sugar level as expected and to ensure the facility informs the physician if it did not (raise the blood sugar level).During a review of the facility's policy and procedure (P&P) titled, Resident Assessment and Care Planning, dated January 2026, the P&P indicated, .2. The facility will develop and implement a comprehensive person-centered care plan consistent with resident rights and aimed to provide services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 6) reviewed for pressure ulcers (injury to skin and underlying tissues that develops as a result of prolonged pressure, shear, or friction) had a low air loss mattress (LAL mattress - a specialized mattress which is air filled and is designed to help prevent and treat pressure ulcers) programmed to the correct weight as ordered by the physician. This failure resulted in the low air loss mattress to not have the most therapeutic effect for the prevention and treatment of pressure ulcers and for Resident 6 to have increased risk for the development of new pressure ulcers and a delay in wound healingFindings: During a review of Resident 6's admission Record (contains medical and demographic information), the admission Record, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (a condition where the heart is unable to pump blood effectively enough to meet the body's needs), type 2 diabetes mellitus (a condition which causes high blood sugar levels), age related osteoporosis (an age-related condition characterized by decreased bone density and structural deterioration, making bones fragile and more likely to fracture), muscle wasting and atrophy (loss of muscle mass and strength), and major depressive disorder (a mood disorder characterized by persistent depressed mood leading to significant functional impairment).During an observation on April 9, 2026, at 9:16 AM in Resident 6's room, Resident 6 was lying in bed turned to her left side while on a low air loss mattress. The low air loss mattress was programmed to 350 lbs.During a concurrent observation and interview on April 9, 2026, at 9:20 AM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the purpose of a low air loss mattress was to prevent pressure ulcers from forming and to ensure existing pressure ulcers did not worsen. LVN 1 further stated low air loss mattresses were supposed to be set per physician's orders. LVN 1 then observed resident 6 in bed and acknowledged Resident 6's low air loss mattress was programmed to 350 pounds and set to firm. LVN 1 then reviewed Resident 6's physician's orders and stated Resident 6's low air loss mattress was incorrectly set and should have been set to 70-80 pounds per the physicians orders but the mattress was instead set to 350 lbs. LVN 1 stated she did not know why the low air loss mattress was set to the incorrect weight.During an interview on April 9, 2026, at 10:18 AM, with the Director of Nursing (DON), the DON stated low air loss mattresses were supposed to be programmed for the correct weight as indicated in the physician's order and if it was not, it defeated the purpose of trying to reduce pressure and prevent pressure ulcers from developing or worsening.During a review of Resident 6's physicians orders, dated April 1, 2026, indicated, may use low air loss mattress at air pressure range of 70-80 lbs. [pounds] monitor mattress air pressure q shift [every shift]. If pressure is out of range, adjust bed and document variance and actions taken in progress note.During a review of Resident 6's Care Plan Report, a document which includes all of Resident 6's care plans (an individualized plan for the medical care of a resident), titled, Has new onset stage 2 pressure injury, risk for infection, worsening impairment, uncontrolled pain, dated March 27, 2026, the care plan indicated, Low air loss (LAL) mattress.provide tx [treatment] as ordered.During a review of the facility's policy and procedure (P&P) titled, Air Mattress, dated January 21, 2026, the P&P indicated, Purpose: To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure. Policy: It is the policy of this facility to utilize air mattress therapy under the direction of a physician's order or when the resident's clinical condition warrants pressure reducing devices.During a review of the facility's P&P titled, Pressure Injury Prevention and Management, dated January 21, 2026, the P&P indicated, Purpose: To provide a system of evaluation, assessment and monitoring of residents for prevention and/or management of pressure injuries.2. An assessment of care needs for pressure injury prevention and/or management will be made with emphasis on, but not limited to, prevention, pressure reducing devices.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for one of 18 sampled Residents (Resident 4) when: 1.Urinary collection bag was not changed every Sunday and PRN (as needed) according to physician's orders. 2. Suprapubic catheter (a tube inserted into the bladder through a small abdominal incision, rather than the urethra, to drain urine) was not flushed with 60 cc (cubic centimeter: a unit of measurement) normal saline (a solution used for flushing suprapubic catheter) according to physician's orders This failure resulted in Resident 4's urinary drainage bag not being flushed and changed for several months, placing Resident 4 at risk for developing an urinary tract infections and causing discomfort and decline in Resident 4's health and well being.Findings:1.During a review of Resident 4's admission Record (contains demographic and medical information), indicated Resident 4 was readmitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (the final, permanent stage of chronic kidney disease where kidney function falls below 15% of normal), dependence on renal dialysis (a person's kidneys have failed [typically <15% function] and can no longer filter waste or manage fluids, making regular, life-sustaining dialysis treatments necessary to stay alive), and obstructive uropathy (a blockage in the urinary system that prevents urine from flowing freely, causing it to back up into the kidneys) and reflux uropathy (a condition in which the kidneys become damaged or scarred due to the backward flow of urine from the bladder into the kidneys). During an observation on April 6, 2026, at 11:26 AM, in Resident 4's room, Resident 4 was observed resting in bed with a urinary collection bag positioned on the mattress between his legs. The urinary collection bag contained cloudy, concentrated urine, with significant sedimentation visible in the tubing and was emitting a foul odor. The urinary collection bag was not labeled with a date and was not properly positioned to allow for adequate drainage to prevent urine backflow into the Resident 4's bladder.During a concurrent observation and interview on April 6, 2026, at 11:35 AM, with the Infection Preventionist (IP) in Resident 4's room, the IP acknowledged the urinary collection bag was found laying on the mattress between the residents' legs. IP acknowledged the urinary bag contained cloudy, concentrated urine with significant sedimentation visible in the tubing and emanating a foul odor. IP acknowledged the urinary collection bag showed signs of long-term use, lacked any labeling indicating recent replacement and was not properly positioned to allow for adequate drainage to prevent urine backflow into Resident 4's bladder. IP was unable to state when the bag was changed and stated that for optimal urine drainage, the urinary collection bag should be properly secured to the bed's frame and kept below the level of the bladder. During a record review of Resident 4's Physician Orders dated January 4, 2026, the order stated, Suprapubic Catheter, change catheter bag Q [every] week on Sunday and PRN (as needed) if leakage, blockage or if soiled. During a record review of Resident 4's Treatment Administration Record (TAR) for January, February, March and April 2026 it was revealed there is no documentation indicating that the drainage bag had been changed since the order was received on January 4, 2026. During an interview with the Admin, on April 9, 2026, at 10:37 AM, the Admin confirmed there is no documentation indicating the urinary collection bag was changed since the order was received on January 4, 2026. The Admin explained that most likely staff were not aware of a weekly order for drainage bag change. The Admin acknowledged the physician orders to change catheter bag every week on Sunday and as needed if leakage, blockage or if soiled were not follow. During a concurrent interview and record review on April 9, 2026, at 10:37 AM with Admin and Assistant Director of Nursing (ADON), the facility's Policy and Procedure (P&P) titled, Close Drainage System Urinary Drainage Bags, revised January 21, 2026, was reviewed. The P&P stated, Purpose: To allow a system for the collection of urine from in [NAME] Foley catheters with infection control practices to prevent cross contamination. Policy: It is the policy of this facility that drainage system for indwelling foley catheters are maintained as closed system to the extent possible. Urinary drainage bags are changed only when the catheter is changed or if it becomes cloudy, leaks or has an odor . F. Position drainage back below the level of the bladder and ensure it does not touch the floor. Admin and ADON acknowledge the P&P was not followed. 2. During an observation on April 6, 2026, at 11:26 AM in Resident 4's room, Resident 4 was observed resting in bed with a urinary collection bag positioned on the mattress between his legs. The urine collection bag contained cloudy, concentrated urine, with significant sedimentation visible in the tubing and was emitting a foul odor. The urinary collection bag was not labeled with a date and was not properly positioned to allow for adequate drainage to prevent urine backflow into Resident 4's bladder.During a concurrent observation and interview on April 6, 2026, at 11:35 AM, with the Infection Preventionist (IP) in Resident 4's room, the IP acknowledged the urinary collection bag was found laying on the mattress between Resident 4's legs. The IP acknowledged the urinary bag contained cloudy, concentrated urine with significant sedimentation visible in the tubing and emanating a foul odor. The IP acknowledged the urinary bag showed signs of long-term use, lacked any labeling indicating recent replacement and was not properly positioned to allow for adequate drainage to prevent urine backflow into Resident 4's bladder. The IP was unable to state how often and when the last time the suprapubic catheter was flushed.During a record review of Resident 4's Physician Orders dated January 4, 2026, the order stated, Suprapubic Catheter, irrigate PRN with 60 cc (cc - unit of measurement for fluids) normal saline to prevent blockage.During a concurrent interview and record review with the Administrator (Admin) and Assisted Director of Nurses (ADON) on April 9, 2026 at 10:37 AM, a review of Resident 4's Treatment Administration Record (TAR) for January, February, March and April 2026 was conducted. Resident 4's TAR revealed there was no documentation indicating the suprapubic catheter had been flushed since the order was received on January 4, 2026. The Admin and the ADON stated the expectations are that staff follow physicians' orders as written stating the physician orders to flush the suprapubic catheter PRN with 60 cc normal saline were not followed.During a concurrent interview and record review on April 9, 2026, at 10:37 AM with the Admin and the ADON, the facility's Policy and Procedure (P&P) titled, Close Drainage System Urinary Drainage Bags, revised January 21, 2026, was reviewed. The P&P stated Purpose: To allow a system for the collection of urine from in [NAME] Foley catheters with infection control practices to prevent cross contamination. Policy: It is the policy of this facility that drainage system for indwelling foley catheters are maintained as closed system to the extent possible. Urinary drainage bags are changed only when the catheter is changed or if it becomes cloudy, leaks or has an odor . F. Position drainage back below the level of the bladder and ensure it does not touch the floor. The Admin and ADON acknowledged the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure nursing staff were competent in the monitoring of a dialysis access sites for one of one sampled resident (Resident 31) when multiple nursing staff were documenting Resident 31 had bruit (a whooshing or humming sound heard through a stethoscope placed over a fistula [surgically created connection between and artery and a vein], and thrill (a vibration or buzzing sensation felt under the skin when you lightly place your fingertips over a fistula. A normal continuous thrill indicates a functioning, patent fistula, confirming adequate blood flow) despite Resident 31 not having a fistula and instead had a Central Venous Catheter (CVC- a long, flexible tube inserted into a large vein which provides direct access to central circulation.) In addition, no nursing staff contacted the doctor for clarification of Resident 31's physician's order. This failure resulted in inaccurate documentation and demonstrated nursing staff confusion regarding monitoring of bruit and thrill on a fistula versus monitoring of complications with a central venous catheter. This poses a risk for missed, incorrect, or misleading clinical information regarding Resident 31's vascular access device.Findings: During a review of Resident 31's admission Record (contains medical and demographic information), the admission Record, indicated Resident 31 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (kidney failure), dependence on renal dialysis (a condition in which the kidneys cannot adequately filter waste or balance fluids, requiring the patient to rely on lifelong dialysis treatments [a medical treatment that filters waste, toxins, and excess fluid from the blood]), and legal blindness.During a concurrent observation and interview on April 7, 2026, at 9:51 AM, with Resident 31, Resident 31 stated he received dialysis three times a week. Resident 31 further stated his dialysis access site was a central venous catheter on his right chest as he pointed to his chest. A central venous catheter was observed with a dressing over the insertion site of the chest.During a review of Resident 31's physician's orders, dated March 24, 2026, indicated Resident 31 was to receive hemodialysis three times a week every Monday, Wednesday, and Friday.During a review of Resident 31's physician's orders, dated March 16, 2026, indicated, .Monitor shunt on right upper chest for Bruit q [every] shift and notify MD [medical doctor] if none is felt. Additionally, a physician's order dated March 16, 2026, indicated, .Monitor shunt on right upper chest for thrill q shift and notify MD if none is felt.During a review of Resident 31's Medication Administration Record (MAR - a document used to record the administration of medications, treatments, and assessments), dated March and April of 2026, the following was identified:1.For the physician's order monitor shunt on right upper chest for bruit q shift and notify MD if none is felt. the task was documented as completed on 70 different shifts amongst a total of six (6) different licensed nurses (which included Registered Nurse Supervisor [RNS] and Licensed Vocational Nurse 1 [LVN 1]).2.For the physician's order monitor shunt on right upper chest for thrill q shift and notify MD if none is felt. the task was documented as completed on 70 different shifts amongst a total of seven (7) different licensed nurses.During a concurrent interview and record review on April 8, 2026, at 2:08 PM, with the Director of Nursing (DON), the DON stated checking for bruit and thrill could only be done on a shunt/fistula and could not be done on a central venous catheter. The DON further stated the order to check bruit and thrill was inappropriate since the resident only had a central venous catheter. The DON then reviewed Resident 31's clinical record and stated the physician's order to check bruit and thrill was never clarified and no licensed nurse questioned the appropriateness of the order.During a concurrent interview and record review on April 8, 2026, at 2:15 PM, with the Assistant Director of Nursing (ADON), the ADON stated nursing staff input the physician's order to check bruit and thrill on a central venous catheter but they only check bruit and thrill on a fistula/shunt. Resident 31's MAR dated March and April 2026, were reviewed. The ADON acknowledged there were numerous nurses who were consistently documenting that they had successfully checked Resident 31 for bruit and thrill despite having a central venous catheter. The ADON further stated staff would need to be in-serviced (trained) regarding dialysis assessment of bruit and thrill. During an interview on April 9, 2026, at 11:20 AM, with RNS, RNS acknowledged he documented in Resident 31's MAR as successfully checking for bruit and thrill despite Resident 31 only having a central venous catheter. RNS stated you can't check bruit and thrill on a central venous catheter.During an interview on April 9, 2026, at 11:25 AM, with LVN 1, LVN 1 acknowledged she documented in Resident 31's MAR for multiple days in March and April 2026 for checking resident 31 for bruit and thrill. LVN 1 further stated she checked for bruit by listening with a stethoscope to one of Resident 31's arms and checked for thrill by palpating (feeling) the arm where a shunt/fistula would usually be located. LVN 1 further stated she didn't realize the resident didn't have a shunt/fistula and thought she heard bruit and thrill even though the resident had a central venous catheter only. LVN 1 stated staff could benefit from re-education about assessing bruit and thrill.During a review of the facility's policy and procedure (P&P) titled, Competency of Nursing Staff, dated May 2019, the P&P indicated, .Licensed nurses and nursing assistants employed (or contracted) by the facility will.b. Demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.4. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: .f. basic nursing skills.l. identification of changes in condition.During a review of the facility's P&P titled, Documentation, dated January 21, 2026, the P&P indicated, Purpose: To provide guidelines to ensure documentation is completed which meets facility standards and regulations.c. Resident specific special needs will be assessed and findings documented. Special needs include, but is not limited to, the following: .vi. Dialysis.

Based on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents (Resident 5) Metformin (a medication used for the treatment of high blood sugar) was administered as prescribed by the physician when the medication was administered without food. This failure had the potential for Resident 5 to have adverse side effects including gastrointestinal intolerance (the body's inability to properly digest or break down certain foods or substances, leading to uncomfortable digestive symptoms) and hypoglycemia (occurs when the blood sugar level drops below 70).Findings: During a review of Resident 5's admission Record (list of diagnoses and demographic information), the admission Record indicated, Resident 5 was admitted to the facility on [DATE], with the diagnoses which included Type 2 Diabetes Mellitus (a chronic condition where the body cannot effectively use insulin or produce enough of it, leading to high blood sugar levels) and Gastrostomy (a surgical procedure that creates an opening in the stomach wall through the abdomen to insert a feeding tube [G-tube]).During a medication administration observation on April 8, 2026, at 5:43 AM, Licensed Vocational Nurse 2 (LVN 2)was observed checking Resident 5's blood sugar level, it was 83. LVN 2 then removed one 500 mg (milligram - unit of weight in the metric system) tablet of Metformin from the medication bubble pack, placed it in a plastic cup, crushed the tablet, and delivered the medication via the resident's G-tube (GT - gastric tube - small tube surgically inserted through the abdomen directly into the stomach used for administration of nutrition, fluids, and medications), followed by a 30 ml (milliliter - unit of volume in the metric system) water flush. After completing the procedure, LVN 2 capped the G-tube and left the resident's room without providing Resident 5 with any food as prescribed by the physician.During an interview and record review with LVN 2 on April 8, 2026, at 5:55 AM, LVN 2 was prompted to read the yellow label on the Metformin bubble pack. LVN 2 read the instruction on the pharmacy-issued yellow label, which stated, Take this medication with a meal. LVN2 was prompted to read the pharmacy-issued white label on the bubble pack, which included the resident's name, medication name, dose, route, frequency and physician's instruction. LVN2 read aloud the instruction, .give with food. LVN 2 was asked what time breakfast will be served. LVN2 stated that breakfast will be served at around 7 AM. LVN 2 acknowledged she administered the Metformin to Resident 5 without food and not following physician's order.During a record review on April 8, 2026, at 6:03 AM, Resident 5's physicians orders were reviewed. The physician order dated March 17, 2023, stated Metformin HCL tablet 500 milligram give one tablet via G tube every morning and at bedtime related to type 2 diabetes mellitus with unspecified complication take with food or via by mouth. During a further review of Resident 5's physician orders, the physician order dated October 16, 2025, stated CCHO [Controlled carbohydrate Fortified diet], Soft and Bite sized texture, Regular consistency, With regular bread and may deviate from dietary restriction during special occasions.During an interview with the Assistant Director of Nursing (ADON) On April 8, 2026, at 7:48 AM, the ADON confirmed the physician's orders were not followed. The ADON stated Metformin should have been administered with food.During a concurrent interview and record review with the Administrator (Admin) on April 9, 2026, at 11:50 AM, the facility's Policy and Procedure (P&P) titled, Procedure: Administration of Doses, revised March 2026, was reviewed. The P&P stated, 1. Right resident - Each resident shall be appropriately identified prior to the administration of any medication by name and armband and or photograph. If applicable, vital signs or tests shall be done prior to the administration of a dose (ex. Pulse with digitalis preparations, periodic blood pressures with antihypertensive, and urine or blood sugar with insulin, ordered) by nurse before administering medication, 2. Right drug - compare physicians order with prescribed medication to ensure the correct medication is being administered, 3. Right dose - ensure prescription labeled dose is consistent with the prescriber's order, 4. Right route - follow the orders administration instructions. Adequate fluid will be offered with oral medications, 5. Right time - administer the medication at the appropriate time as ordered by the prescriber. The Admin acknowledged the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure the call light (a device that allows patients to communicate with nursing staff when they need assistance) was within residents' reach for two of six sampled residents (Resident 5 and 9) when: 1.For Resident 5, the call light was located on the floor on resident's right side of the bed and unreachable by the resident. 2.For Resident 9, the call light was wrapped around the feeding pump located on a pole away from resident's reach. This failure had the potential to placed Resident 5 and 9 at risk for their safety and well being.Findings: 1.During a review of Resident 5's admission Record ( a document that gives a summary of resident information), the admission Record indicated, Resident 5 was admitted to the facility on [DATE], with the diagnoses which included Hemiplegia (a form of paralysis that causes severe or complete loss of movement on one side of the body) and Hemiparesis (weakness on one side of the body, affecting the arm, leg, and sometimes the face) following unspecified cerebrovascular disease (the group of conditions that interfere with blood flow to your brain, such as strokes) affecting left non dominant side.During an observation on April 8, 2026, at 5:43 AM, Resident 5 was laying in bed, awake. The call light was located on the floor on resident's right side of the bed and unreachable by the resident.During an observation and interview with Licensed Vocational Nurse 2 (LVN 2) on April 8, 2026, at 5:45 AM, LVN2 acknowledged the call light was on the floor and unreachable to resident. LVN2 stated the call light must have been fallen to the floor when I gave her the medication. LVN2 further stated the call light must be within resident's reach at all times.During an interview conducted with Resident 5 on April 8, 2026, at 5:52 AM, Resident 5 reported that she was unable to access the call light. She further indicated that, in the event she required assistance, she would likely need to yell for help, as the call light was not within her reach.During concurrent interview and record review on April 8, 2026, at 10:31 AM with the Administrator (Admin) and with the Assistant Director of Nursing (ADON), the facility policy and procedure (P&P) titled Answering the Call Light, revised October 2010 was reviewed. The P&P indicated, Purpose - The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines . 4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. The ADON stated the call light should be within resident's reach at all times. The Admin acknowledged the P&P was no followed when Resident 5's call light was located on the floor on resident's right side of the bed and unreachable by the resident.2.During a review of Resident 9's admission Record (list of diagnoses and demographic information), the admission Record indicated Resident 9 was admitted to the facility on [DATE], with the diagnoses which included Paraplegia (the partial or complete paralysis of the lower half of the body, typically affecting both legs and sometimes the lower torso), acute and chronic respiratory failure (a life-threatening condition where there's not enough oxygen or too much carbon dioxide in your body), contracture of muscles (the permanent or long-lasting tightening, shortening, and hardening of muscles, tendons, or skin, which leads to rigid joints and a severe loss of movement) and dementia (a lasting decline in mental abilities, including memory, thinking, and reasoning, that is severe enough to interfere with daily life).During an observation on April 6, 2026, at 11:05 AM, Resident 9 was in laying in bed asleep, facing the wall and covered with blankets. The call light was wrapped around the feeding pump located on a pole away from residents' reach.During an observation and interview with Certified Nursing Assistant 1 (CNA 1) on April 6, 2026, at 11:08 AM, CNA1 acknowledged the call light was wrapped around the feeding pump located on a pole away from residents' reach. CNA1 states the call light should have been within resident's reach so she could call for assistance when needed. During an observation and Interview with MDS Coordinator (MDSC) on April 6, 2026, at 11:12 AM, The MDSC acknowledged the call light was wrapped around the feeding pump located on a pole away from residents' reach. The MDSC stated the call light should have not be hanging on the pole and should have been clipped on the bed linens within resident's reach. During concurrent interview and record review on April 8, 2026, at 10:31 AM with the Admin and with ADON, the facility policy and procedure (P&P) titled, Answering the Call Light, revised October 2010, was reviewed. The P&P indicated, Purpose - The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines . 4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. The ADON acknowledged the P&P was followed and stated the call light should be within resident's reach at all times. The Admin acknowledged the P&P was not followed when Resident 9's call light was wrapped around the feeding pump located on a pole away from residents' reach.

Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was available onsite at least eight (8) hours a day, seven (7) days a week for 58 Residents from March 1, 2025, through April 10, 2025, when the facility did not have RN onsite for 3 days. This failure had a potential to negatively affect Residents overall health and safety by not having RN oversight and assessment in a universe of 58 residents. Findings: During an observation on April 10, 2025, there was no RN on duity. During an interview on April 10, 2025, at 10:47 AM, with the Administrator (Admin 1) The Admin 1 indicated that there is no RN available today as the Director of Nursing (DON 1) is absent due to Covid. She elaborated that the DON 1 is the only full-time RN on staff. Additionally, she mentioned that there is a part-time RN (RN 1) who is scheduled to work only on Mondays and Fridays from 8:00 am to 5:00 pm. The current census stands at 58 residents. She further stated according to the policy, the facility requires one RN for eight hours each day. During a concurrent interview and record review on April 10, 2025, at 11:07 AM, with the admin 1, the timecards for DON 1 and RN 1, covering March and April 2025, were examined. Admin 1 confirmed that there were no registered nurses present on Wednesday, March 19, 2025, Thursday, March 27, 2025, and Thursday, April 10, 2025. It was stated that the RN hour requirements are governed by CDPH policy, and according to the policy, the absence of an RN on those days resulted in a failure to meet the necessary requirements. A review of the facility policy and procedure (P&P) titled, Staffing , dated December 2019, indicated, To ensure adequate staffing is provided to meet the needs of the current resident population and to comply with regulations. The facility will have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considers the number, acuity and diagnosis of the resident population in accordance with the facility assessment .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections, in a universe of 55 residents (Residents 1 to 55), when: 1. The facility did not conduct an annual review of its infection control program's policies and procedures (P&P) and update their program, as necessary. This failure had the potential to cause the facility to be out-of-date with current best practices and overlook potential gaps in their procedures. 2. Laundry staff (LS 1) did not follow the manufacturer's guidelines for the disinfectant used to disinfect laundry carts and dirty laundry barrels. Housekeeping staff (HS 1) did not follow the manufacturer's guidelines for the disinfectant used to disinfect resident rooms. This failure had the potential to cause the development and transmission of communicable diseases (an illness or infection that can spread from one person to another, or from a surface to a person) and infections to residents. 3. Housekeeping staff (HS 1) did not follow Enhanced Standard Precautions (ESP- a set of guidelines for preventing the transmission of Multidrug-Resistant Organisms (MDROs) in skilled nursing facilities) to prevent the spread of infection when HS 1 failed to don (to put on) a gown when cleaning and disinfecting an ESP room (ESP designated rooms require staff to don gloves and a gown when cleaning and disinfecting the environment). This failure had the potential to cause the transmission of MDROs to HS 1's clothing and then accidental transmission to other residents. Findings: 1. A review of the facility's policy and procedure (P&P) titled Infection Prevention and Control Program, dated revised June 2021, was conducted. The P&P indicated it had been reviewed and revised in June 2021. During an interview with the Administrator (Admin) on December 18, 2024, at 12:16 PM, the Admin stated the Infection Control Policies should be reviewed and updated as often as necessary but at least once per year. The Admin verified the Infection Control Policies the facility provided were reviewed and revised in June 2021. A review of the facility's P&P titled, Facility Policies and Procedures - Annual Reviews, dated revised April 2007, indicated, Policy Statement: Our facility reviews its operational policies and procedures and resident care policies as needed and at least annually. 2a. During a laundry services observation and interview on December 19, 2024, from 9:38 AM, to 10:30 AM, with a Laundry Staff (LS 1), Housekeeping Supervisor (H/Sup), and an Infection Preventionist (IP), LS 1 described the laundry process and stated the Certified Nursing Assistants (CNAs) brought the dirty laundry carts out of the facility and transferred the dirty laundry to the yellow barrels, LS 1 pointed to a row of yellow barrels lined up against an outside brick wall. LS 1 stated the yellow barrels were cleaned every weekend and more often if necessary. LS 1 explained how she would clean the yellow barrels by bringing them over to the outside hose, put a couple of drops of a multi-use cleaner in the barrel, spray water into the barrel, use a brush to clean the barrel and then rinse the barrel out with the hose. LS 1 stated she had been instructed to use a disinfectant on the yellow barrels, but she liked the multi-use cleaner better. In a continued observation and interview with LS 1, H/Sup and an IP, LS 1 demonstrated how she removed clean laundry from the dryer and placed it into a wire laundry basket on wheels, LS 1 stated she cleaned the clean laundry baskets with the disinfectant, by spraying the clean laundry basket with the disinfectant and then immediately wiping it off with a cloth. LS 1 stated she did not leave the basket's surface wet for any period of time. The IP stated the dirty laundry yellow barrels and clean laundry baskets were to be cleaned with the disinfectant and needed to stay wet with the disinfectant for 10 minutes, in order to kill or reduce bacteria and viruses. 2b. During a facility cleaning and disinfection observation and interview on December 19, 2024, from 9:49 AM, to 10:30 AM, with the H/Sup, a Housekeeping Staff (HS 1) and the IP, the H/Sup stated the disinfectant was used to clean the facility, such as, floors, rails, resident rooms, bathrooms, and floors. The H/Sup approached a resident's room which had the following postings at the rooms entrance: Notice of Room Deep Cleaning and Enhanced Standard Precautions (ESP) in effect. HS 1 was actively cleaning the room and was not wearing a gown, a form of Personal Protective Equipment (PPE). HS 1 explained a deep clean meant the room was cleaned top to bottom, the walls, all surfaces in the room, the bathroom and the floor was last. HS 1 stated she used the disinfectant for all the surfaces except the floor. HS 1 stated the surfaces needed to stay wet for 10 minutes except the walls and the floor. HS 1 stated she used a multi-use cleaner on the floor not the disinfectant. The IP stated she provided teaching on facility disinfection to the H/Sup who then instructed the housecleaning and laundry staff the proper way to disinfect. The IP stated for rooms under deep cleaning the staff needed to keep the walls wet with the disinfectant for 10 minutes and the disinfectant was supposed to be used on the room's floor and the floor was to be kept wet for 10 minutes, in order to kill or reduce bacteria and viruses. A review of the facility's multi-use cleaner titled, [Name of the disinfectant], undated, indicated, .cleans and deodorizes in one application. There was no documented evidence to show [Name of the disinfectant] disinfected surfaces. A review of the facility's disinfectant titled, [Name of the disinfectant], undated, indicated, . is a one step neutral disinfectant that is effective against a broad spectrum of bacteria, is virucidal [having the ability to destroy or inactivate viruses] . and inhibits the growth of mold and mildew . when used as directed. to disinfect inanimate [not alive], hard nonporous [does not allow air or liquid to pass through it] surfaces . Apply solution with a mop, cloth, sponge, hand pump trigger sprayer, or low-pressure coarse sprayer so as to wet all surfaces thoroughly. Allow to remain wet for 10 minutes, then remove excess liquid. A review of the facility's P&P titled, Housekeeping - Cleaning Resident Rooms and Equipment, undated, indicated, PURPOSE: To maintain a clean and sanitary environment for residents. POLICY: Resident rooms and equipment shall be maintained in a clean and sanitary condition by appropriately trained and assigned staff. Cleaning products shall be reviewed by the Infection Preventionist and the housekeeping supervisor. The Infection Control Committee shall approve any change in housekeeping supplies. D. Environmental Rounds: 1. Safety Committee members including but not limited to the Infection Preventionist and housekeeping supervisor shall monitor the cleanliness of the facility and infection control practices on a regular basis to assure compliance with cleanliness and sanitation standards. 3. During a facility cleaning and disinfection observation and interview on December 19, 2024, from 9:49 AM, to 10:30 AM, with the H/Sup, HS 1 and the IP, the H/Sup approached a resident's room which had the following postings at the rooms entrance: Notice of Room Deep Cleaning and Enhanced Standard Precautions (ESP) in effect. HS 1 was actively cleaning the room and was not wearing a gown, a form of Personal Protective Equipment (PPE). HS 1 explained a deep clean meant the room was cleaned top to bottom, the walls, all surfaces in the room, the bathroom and the floor was last. HS 1 confirmed she was not wearing a gown and should be. She stated, I forgot. The H/Sup verified HS 1 was not wearing a gown and should be when cleaning an ESP room. The IP stated HS 1 was required to wear a gown when cleaning ESP designated rooms. A review of the facility's Enhanced Standard Precautions (ESP) posting, undated, indicated, For these six groups of care activities, use hand hygiene, gloves, and gowns, for residents who are on Enhanced Standard Precautions. cleaning and disinfecting the environment. A review of the facility's P&P for Personal Protective Equipment (PPE), undated, indicated, PPE is provided to our employees at no cost to them. Training in the use of appropriate PPE for specific tasks or procedures is provided by our Infection Preventionist and Director of Staff Development. The types of PPE available to our employees include Surgical masks, Gloves, Gowns, . PPE is located throughout the facility including nursing station(s), central supply, carts located directly outside a resident's room who is in need of Transmission Based Precautions [a set of infection control measures used for residents who may be infected with certain infectious agents]. All employees have immediate access to PPE. The Infection Preventionist will ensure that PPE is available for 'at will' use by the facility staff.

Based on observation, interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for four of nineteen sampled residents (Residents 25, 27, 32, and 56) when: 1) Resident 25's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 25 had only minimal hearing loss, and did not have a hearing aid. 2) Resident 27's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 27 was not considered Pre-Admission Screening and Resident Review (PASRR) level 2 by the state. 3) Resident 32's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 32 received insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). 4) Resident 56's RAI-MDS assessment dated [DATE], incorrectly indicated Resident 56 had an indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine). These failures had the potential to result in unmet care needs for the residents (Residents 25, 27, 32, and 56) and for the residents' clinical records to inaccurately reflect their health status. Findings: 1) During a review of Resident 25's Face Sheet dated December 19,2024, the 'Face Sheet indicated, Diagnosis information, Schizophrenia, and bipolar disorder. During an interview on December 16, 2024, at 10:41 AM with Resident 25, Resident 25 stated, I do not have a hearing aid, but I would like one. Communication was facilitated with a writing board as she was only able to hear some of the words spoken. During a review of Resident 25's Audiology consult note dated February 6,2024, the Audiology Consult note indicated, hearing aids will be ready on February 21, 2024. During an interview and concurrent record review on December 19,2024 at 2:15 PM with the Social Services Director (SSD), Resident 25's Psychosocial Discharge Planning eval [evaluation] dated November 11,2024, indicated, 4b. Other information provided: Resident has hearing aids and refuses to wear them. The SSD, stated, She refuses the wear the hearing aids, I have them in my office storage for her. During a review of Resident 25's MDS dated [DATE], the MDS indicated, Section B0200 Hearing, coded 1. Minimal difficulty, and Section B0300 Hearing aid, coded 0. No During a concurrent interview and record review on December 19,2024 at 1:50 PM with MDS nurse, Resident 25's Quarterly MDS dated . November 19,2024 was reviewed. The Quarterly MDS indicated, Section B0200 Hearing coded, 1.) Minimal difficulty and B0300 hearing aids coded, 0.) No. The MDS nurse stated, I will update the MDS, I don't feel like minimal is correct for her, it been getting worse. I will do corrections on her MDS documentation it should be coded correctly. She also has hearing aids and I answered No, which is also wrong. 2) During a review of Resident 27's Face Sheet dated, December 19,2024, the Face Sheet indicated, Diagnosis Information, Schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania) and bipolar (a mental illness that causes extreme mood swings, or shifts from mania to depression) type. During a review of Residents 27's Preadmission Screening and Resident Review (PASRR) dated, September 13,2022, the PASSAR indicated, Your Level 1 screening was conducted at [facility name], followed by a Level 2 Evaluation on July 25,2022, by [social worker name]. The results of this Level 2 evaluation are provided in the PASRR Determination Report attached to this letter. Facility Staff will receive a copy of this Determination Report, will discuss the results with you in a timely manner, and will incorporate the recommendations into your care plan. During a review of Resident 27's Minimum Data Set (MDS), dated [DATE], the MDS indicated, A1500, Preadmission Screening and resident review (PASRR), Is the resident currently considered by the state level 2 PASRR process to have serious mental illness and/or intellectual disability or related conditions? Data entered, 0 No. During a concurrent interview and record review with the MDS Nurse, on December 17,2024 at 5:16 PM the Resident Assessment Instrument 3.0 User manual (RAI Manual) dated October 2024, was reviewed. The RAI Manual indicated, A1500: Preadmission Screening and Resident Review (PASRR) . Steps for Assessment 2. Review the Level I PASRR form to determine whether a Level II PASRR was required. 3. Review the PASRR report provided by the State if Level II screening was required. Coding Instructions o Code 0, no: and skip to A1550, Conditions Related to ID/DD Status, if any of the following apply: - PASRR Level I screening did not result in a referral for Level II screening, or - Level II screening determined that the resident does not have a serious Mental Illness and/or Intellectual disability (ID- is a neurodevelopmental condition that can affect a person's mental health) /Developmental Disabilities (DD-A group of conditions that can be caused by physical, learning, language, or behavioral impairments.) or related conditions. Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. The MDS nurse stated, If the resident ever had a level 2 PASSR we would have to document, 1. yes, I made a mistake. 40171 3) During a review of Resident 32's Admission Record (contains medical and demographic information), the Admission Record, indicated Resident 32 was admitted to the facility on [DATE], with diagnoses which included epilepsy (seizure disorder), schizophrenia (a serious mental health condition that affects how people think, feel and behave), and alcohol abuse. During a review of Resident 32's RAI-MDS, dated [DATE], the RAI-MDS indicated in section N- Medications, that Resident 32 received insulin. During a review of Resident 32's Medication Administration Record (MAR - a document used by staff to record medications administered to the resident), dated September 2024, the MAR indicated Resident 32 did not receive insulin at any time for the month. During a concurrent interview and record review on December 19, 2024, at 4:03 PM, with the Minimum Data Set Nurse (MDSN), Resident 32's RAI-MDS assessment, dated September 20, 2024, was reviewed. The MDSN stated the RAI-MDS assessment indicated Resident 32 had received insulin. The MDSN then reviewed Resident 32's clinical record and stated the resident did not receive insulin and the RAI-MDS assessment dated [DATE], was incorrect. The MDSN further stated she was the one who completed the RAI-MDS assessment, and it was done in error. During a review of the MDS 2.0 Manual titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.11, dated October 2023, section 1.3 Completion of the RAI, indicated, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status .(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts .In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) . 4) During a review of Resident 56's Admission Record, (contains medical and demographic information), the Admission Record, indicated Resident 56 was admitted to the facility on [DATE], with diagnoses which included benign prostatic hyperplasia (a noncancerous condition that causes the prostate gland to enlarge), obstructive and reflux uropathy (a condition in which the flow of urine is blocked), and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). During a concurrent observation and interview on December 16, 2024, at 3:52 PM, Resident 56 did not have an indwelling urinary catheter. Resident 56 stated he had not had an indwelling catheter for a few months and that it had been removed. During a review of Resident 56's RAI-MDS, dated [DATE], the RAI-MDS indicated in section H - Bladder and Bowel, that Resident 56 had an indwelling catheter. During a concurrent interview and record review on December 19, 2024, at 4:07 PM, with the Minimum Data Set Nurse (MDSN), Resident 56's RAI-MDS assessment, dated November 19, 2024, was reviewed. The MDSN stated the RAI-MDS assessment indicated Resident 56 had an indwelling catheter. The MDSN then reviewed Resident 56's clinical record and stated the catheter had been discontinued in August 2024 and the RAI-MDS assessment dated [DATE], was incorrect. The MDSN further stated she was the one who completed the RAI-MDS assessment, and it was done in error. During an interview on December 19, 2024, at 4:12 PM, with the MDSN, the MDSN stated the facility did not have a policy and procedure (P&P) regarding completion of the RAI-MDS assessments and the facility used the current RAI-MDS assessment manual as the facility's P&P. During an interview on December 19, 2024, at 4:13 PM, with the DON, the DON stated it was important that the RAI-MDS assessments were coded correctly to ensure the facility documented a complete and accurate assessment of the resident. During a review of the MDS 2.0 Manual titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1, dated October 2024, section 1.3 Completion of the RAI, indicated, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20(b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status .(3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts .In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: a. Walk in refrigerator and freezer temperatures were not being monitored daily. b. A kitchen staff was observed working in the kitchen without a hair net. c. Shelves in the walk-in refrigerator had black residue on them where food was stored. These failures had the potential for bacteria to growth and cause foodborne illness in a highly susceptible population of 49 residents who received food and beverages from the kitchen. Findings: a. During a concurrent observation and interview on December 16, 2024, at 9:20 AM, in the kitchen with the Dietary Supervisor (DS), the walk-in refrigerator was observed not to contain a thermometer to monitor the temperatures inside, the logs identifying temperatures were being checked daily could also not be identified. The DS stated, those items need to be available, or we would not have record of if the temperature is safe. The DS further stated, they could not find the logs for the freezer either and these logs should be readily available if they are doing the checks every day. During a review of facility policy and procedure (P&P) titled, Cold Storage Temperature Monitoring and Record Keeping dated, 2023, the P&P indicated, 1. Food and Nutrition staff will check the inside temperature of refrigerators and freezers. 2. Food & Nutrition Service staff will record and initial the temperatures on the health care menus direct, LLC's Cold Storage temperature Log at the beginning of the AM and PM shifts. 3. If the temperatures are not within standards, Food and nutrition Services staff will notify the Food and nutrition services director. During a record review of the Federal FDA 2017 Food Code 3-501.16, the Federal FDA 2017 Food Code 3-501.16 indicated, Time/Temperature Control for Safety Food, Hot and Cold Holding. Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 5 degree C to 57 degree C (41-degree F to 135-degree F) too long. Up to a point, the rate of growth increases with an increase in temperature within this zone. Beyond the upper limit of the optimal temperature range for a particular organism, the rate of growth decreases. Operations requiring heating or cooling of food should be performed as rapidly as possible to avoid the possibility of bacterial growth. b. During a concurrent observation and interview on December 17,2024, at 2:40 PM, in the Kitchen with the DS, the DS was observed working next to the kitchen stove containing food, with no hair net on and exposed hair. The DS stated, I should be wearing a hair net, I forgot I wasn't wearing one. During a record review of the Federal FDA 2017 Food Code 2-402.11 the Federal FDA 2017 Food Code 2-402.11 indicated, Hair Restraints 2-402.11 Effectiveness, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE SERVICE and SINGLE-USE ARTICLES. During an interview on December 19, 2024, at 3:53 PM, with the Infection Preventionist (IP- healthcare professionals who work to prevent and contain the spread of infectious diseases in healthcare settings), the IP stated, Working without hair nets is a concern for infection control related to food and drink contamination. c. During a concurrent observation and interview on December 17,2024 at 2:45 PM in the Kitchen with the DS, the walk-in refrigerator was observed, the top rack of the walk-in containing food items and drinks, was dirty with a black residue along the length of the shelves. The DS stated, Yes its dirty, we need to clean it. During a record review of the Federal FDA 2017 Food Code 4-601.11 the Federal FDA 2017 Food Code 4-601.11 indicated, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. During an interview on December 19,2024 at 3:53 PM with IP, the IP stated, Residents consume the food in the kitchen, it is not okay to have dirty storage shelving it needs to be as clean as possible.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of pests, when a cockroach was observed on the wall behind the steam table (a type of food-holding equipment designed to keep hot foods at a safe holding temperature). This failure had the potential to cause contamination of food and beverage for 49 residents who receive food and beverage from the kitchen, potentially leading to a resident infection. Findings: During a concurrent observation and interview on December 16, 2024, at 8:48 AM, in the Kitchen, with the Dietary Supervisor (DS), a cockroach was observed on the wall behind the steam table in the kitchen. DS stated, There shouldn't be any bugs or cockroaches in the kitchen. During a concurrent interview and record review on December 19, 2024, at 3:34 PM, with Dietary Supervisor, the State Operations Manual S483.90(i)(4) was reviewed. The State Operations Manual S483.90(i)(4) indicated, Maintain an effective pest control program so that the facility is free of pests and rodents. Dietary Supervisor stated, we are out of compliance with this because of the cockroach. During an interview on December 19, 2024, at 3:53 PM, with the Infection Preventionist (IP-healthcare professionals who work to prevent and contain the spread of infectious diseases in healthcare settings), the IP stated, Cockroaches are a concern for infection control as they can spread disease. During a review of facility's policy and procedure (P&P) titled, Pest Control (undated), the P&P indicated, If pests are seen in the kitchen, the food services manager or appropriate staff shall be informed, describing where the pest was seen and when. Appropriate action will be taken to eliminate any reported pest situation in the department . 2. If a pest situation is reported, the contractor come sin to spray at appointed times. The contractor will document the visit along with actions taken. During a review of Service Inspection report dated December 12, 2024, the Service Inspection Report indicated, Service description: Pest control maintenance No other comments or explanation of the visit could be obtained.

Based on interview, and record review, the facility failed to provide evidence staff discussed with one of nineteen sampled residents (Resident 32) whether the resident had an existing advance directive (a legal document that explains how an individual wants medical decisions to be made if the individual is incapable of making their own decisions) and was educated on his rights to establish a new advance directive if desired. This failure had the potential for Resident 32 to receive end of life care not in accordance with his wishes and for life sustaining measures to be rendered against what the resident wanted. Findings: During a concurrent interview, and record review, on December 19, 2024, at 11:00 AM, with the Director of Nursing (DON), the DON was asked to provide evidence regarding if Resident 32 had an advance directive in place. The DON provided a copy of Resident 32'sPhysician Orders for Life-Sustaining Treatment (POLST) (written medical orders that addresses a limited number of critical medical decisions) signed by the resident on January 10, 2020. During a record review of Resident 32's POLST signed by Resident 32 on January 10, 2020, the POLST indicated in section D - Information and Signatures regarding Advance Directives (section regarding facility discussion with resident or resident representative, regarding advance directives), was unanswered and left blank. Section D did not indicate whether or not Resident 32 had an advance directive in place which was available and reviewed by facility, did not have an advance directive available, or had no advance directive at all. During a concurrent interview, and record review, on December 19, 2024, at 11:15 AM, with Registered Nurse Supervisor 1 (RNS 1), Resident 32's POLST, signed by the resident on January 10, 2020, was reviewed. RNS 1 acknowledged the POLST section D regarding advance directives was left blank. RNS 1 stated all residents were supposed to have an Advance Directive Acknowledgement form (a form which acknowledges a resident was educated about their right to formulate an advance directive, and includes specifics regarding their wishes for medical care). RNS 1 then reviewed Resident 32's clinical record and stated he was unable to find evidence that an Advance Directive Acknowledgement form was completed for Resident 32. RNS 1 further stated it was the responsibility of the social worker to complete the advance directive acknowledgement form and POLST form with residents or resident representatives. During a concurrent interview, and record review, on December 19, 2024, at 11:32 AM, with the Social Services Director (SSD), the SSD stated all residents were supposed to either have a POLST form, or an Advance Directive Acknowledgement form completed. Resident 32's POLST, signed by the resident on January 10, 2020, was reviewed. The SSD confirmed section D of the POLST regarding advance directives was left blank and stated it was supposed to have been completed but it was not. Resident 32's clinical record was then reviewed. The SSD stated Resident 32's clinical record did not have an advance directive acknowledement form and she was unable to find any other documented evidence to indicate advance directives were discussed with Resident 32. During a review of the facility's policy and procedure (P&P) titled, Social Service Department - Advance Directives, (undated), the P&P indicated, The facility will ensure that a resident's choice concerning the development of advance directives relative to his/her refusal of medical surgical treatment are followed in accordance with the facility's advance directive policy and procedure and current state law .Prior to, or upon admission, the Admission Coordinator or Social Services staff member will provide Resident's or their surrogate decision maker with written information concerning the residents right under state law to accept or refuse medical or surgical treatment and the resident's right to prepare an advance directive .The Resident or Surrogate Decision Maker will be asked to complete an Advance Directive Acknowledgment indicating that the facility has provided information about the right to accept/refuse medical treatments, the rights to formulate an advance directive, the right that an advance directive is not required and that the facility will honor the advance directive as permitted by law .

Based on interview, and record review, the facility failed to provide two of three sampled residents (Residents 17 and 28) with beneficiary liability protection notifications (A notification letter which explain resident rights regarding financial liability and the right to appeal) when: 1) Resident 17 was not provided with estimated costs on the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN - informs the resident about potential non-coverage and the option to continue services with the resident accepting financial liability for those services). 2) Resident 28 was not provided with estimated costs on SNF ABN and the Notice of Medicare Non-Coverage (NOMNC -informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization) was not provided to the resident at least two days before the end of a Medicare covered Part A stay. This failure had the potential for Residents 17 and 28 to be uninformed regarding their specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal. Findings: 1) During a review of Resident 17's Admission Record (contains medical and demographic information), the Admission Record, indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus, schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors), and dysphagia (difficulty swallowing). During a review of the document titled, Beneficiary Notice - Residents discharged Within the last Six Months (a list of residents who were discharged from Medicare covered Part A stay with benefit days remaining in the past 6 months), undated, the document indicated Resident 17 was discharged from Medicare Part A services on June 7, 2024. The document also indicated the resident remained in the facility. During a review of Resident 17's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), dated May 30, 2024, the form indicated, Beginning on 6/8 [June 8, 2024], you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs .Care: Skilled Services .Estimated Cost: NA [not applicable] During a concurrent interview and record review on December 19, 2024, at 8:09 AM, with the Business Office Manager (BOM), Resident 17's SNF ABN form dated May 30, 2024 was reviewed. The BOM stated she oversaw the beneficiary notices at the facility. The BOM acknowledged Resident 17's SNF ABN form indicated NA where Estimated Cost was indicated. The BOM stated the total cost of the daily room rate was supposed to be indicated on the form instead of NA. The BOM further stated the current daily room rate was three hundred twenty five dollars (325.00 $). 2) During a review of Resident 28's Admission Record (contains medical and demographic information), the Admission Record, indicated Resident 28 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a chronic disease that occurs when the body is unable to regulate blood sugar levels), benign neoplasm of cerebral meninges (a noncancerous tumor that originates in the meninges, the membranes that cover the brain), and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). During a review of the document titled, Beneficiary Notice - Residents discharged Within the last Six Months undated, the document indicated Resident 28 was discharged from Medicare Part A services on July 2, 2024. The document also indicated the resident remained in the facility. During a review of Resident 28's Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), dated July 1, 2024, the form indicated, Beginning on 7/3/24 [July 3, 2024], you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs .Care: Skilled Services PT/OT [physical therapy/Occupational therapy] .Estimated Cost: NA [not applicable] During a concurrent interview and record review on December 19, 2024, at 8:09 AM, with the Business Office Manager (BOM), Resident 28's SNF ABN form dated May 30, 2024, was reviewed. The BOM acknowledged Resident 28's SNF ABN form indicated NA where Estimated Cost was indicated. The BOM stated the total cost of the daily room rate was supposed to be indicated on the form instead of NA. The BOM further stated the current daily room rate was three hundred twenty-five dollars (325.00 $). During a review of Resident 28's Notice of Medicare Non-Coverage (NOMNC) form, dated July 1, 2024, the form indicated, The effective date coverage of your current skilled nursing services will end 7/2/24 [July 2, 2024] (one day prior to when the form was signed by the resident). During a concurrent interview and record review on December 19, 2024, at 8:02 AM, with the BOM, Resident 28's NOMNC form dated July 1, 2024, was reviewed. The BOM stated the NOMNC form was supposed to be provided to Resident 28 three days or more in advance, but it was not. The BOM further stated she did not know why the NOMNC form was not provided timely to Resident 28 and there was another business office manager at the time the form was provided to the resident. During a review of the facility's policy and procedure (P&P) titled, Medicare Termination Notification, dated November 2017, the P&P indicated, .2. When a resident is covered on Medicare Part A: and covered services are terminated where the beneficiary has remaining SNF [skilled nursing facility] days available and continues to reside in the facility: a. Notify the resident/resident representative no later than 2 days prior to the last day of coverage in writing by providing them with the Medicare Provider Non-Coverage (Generic Notice) .b. provide the beneficiary and/or resident representative with the SNF ABN .

Based on interview, and record review, the facility failed to ensure a resident representative was notified of transfer in writing for one of 20 sampled residents (Resident 17). This failure had the potential to cause confusion about the transfer process and possibly leave the resident and the resident representative unable to make an informed decision about the transfer. Findings: During a review of Resident 17's Face sheet (a document containing demographic information) dated December 19,2024, the Face sheet indicated, Resident 17 has a diagnosis of schizophrenia (a chronic mental illness that affects how a person thinks, feels, and behaves) and metabolic encephalopathy (a brain dysfunction that occurs when a chemical imbalance in the blood affects the brain). The face sheet also indicated who the resident representative, emergency contact, and guardian is (Resident Representative 1). During an interview on December 17, 2024, at 8:18 AM, with resident representative (RR 1), RR 1 stated, Last month [Resident 17] was sent to the hospital for vomiting dark liquid, I was told they would transfer [Resident 17] and hold the bed, by phone call. During a concurrent interview and record review with the Minimum Data Set Nurse (MDSN-a nurse responsible for collecting and submitting assessment data for nursing home patients) on December 19,2024, at 10:45 AM, the [facility name] Healthcare notice of proposed transfer/discharge notice dated, 11/26/2024 was reviewed. The [facility name] Healthcare notice of proposed transfer/discharge notice indicated, 1. Resident name [Resident 17] b. Resident representative [Resident Representative 1] c. Verbally communicated on: 11/26/24 . d. Verbally Communicated to: [Resident Representative 1] . 2. Transfer/ Discharge was necessary due to: 1. The transfer/ discharge is necessary for your welfare and your needs cannot be met in the facility, the MDSN stated, the transfer document indicates we notified the resident representative via phone. During a concurrent interview and record review on December 19,2024 at 10:50 AM with Social Services Director (SSD-a hospital resource that help people in need with a variety of needs, including medical appointments, cost assistance, and psychosocial support), the State Operations Manual S483.15(c)(3) was reviewed. The State Operations Manual S483.15(c)(3) indicated, Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. SSD stated, We did not provide this in writing to the resident representative.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 51) reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) received care and services for skin breakdown as was specified in the resident's care plan (an individualized plan for the medical care of a resident) and physician's orders when: -Resident 51's low air loss mattress (a mattress that uses air to help prevent and treat pressure wounds, and to regulate temperature and moisture levels) was not set to the correct pressure as specified by physician orders. -Resident 51 did not have on heel protectors [device that provides cushioning, support, and pressure relief to the heel] while in bed. -Resident 51's Electronic Medical Record (EHR) included a nursing weekly summary (weekly progress note created by licensed staff) which inaccurately specified Resident 51's skin was intact. These failures had the potential for Resident 51's to experience worsening pressure ulcers, for the delay in the identification and subsequent treatment of new pressure ulcers, and the clinical record to inaccurately reflect Resident 51's altered skin integrity. Findings: During a review of Resident 51's medical record, the Admission Record (contains medical and demographic information), indicated Resident 51 was initially admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a chronic metabolic disease that occurs when the body can't control its blood sugar levels), pressure ulcer of sacral region (low back/upper buttocks area stage 2 [a shallow open sore]), and pressure-induced deep tissue damage of right heel (Deep Tissue Injury [DTI] - a form of pressure-induced damage to underlying tissues, including muscles, bones, and subcutaneous layers [a layer of connective tissue that lies immediately below the skin and contains fat, larger blood vessels, and nerves]). During a concurrent observation and interview on December 17, 2024, at 3:50 PM, in Resident 51's room, with Certified Nursing Assistant 5 (CNA 5), Resident 51 was in bed and was not wearing heel protectors. In addition, Resident 51's low air loss mattress was set to a setting of 80 millimeters of mercury (mmHg). CNA 5 observed Resident 51 in bed and confirmed the resident was not wearing heel protectors and his low air loss mattress was set to 80 mmHg. Prior to leaving the room, CNA 5 did not attempt to put on Resident 51's heel protectors and did not ask the resident if he wanted them on. During a concurrent observation and interview on December 17, 2024, at 3:55 PM, in Resident 51's room, with the Director of Nursing (DON), Resident 51 was observed in bed. The DON stated Resident 51 was supposed to have on heel protectors while in bed and acknowledged Resident 51 did not have on heel protectors. The DON then observed the low air loss mattress and acknowledged it was set to 80 mm/hg. During a concurrent interview and record review on December 17, 2024, at 4:20 PM, with the DON, Resident 51's physician's orders were reviewed. An order dated November 13, 2024, indicated, May use low air loss mattress at air pressure range of 155 to 165 [mm/Hg]. Monitor mattress air pressure q [every] shift. If pressure is out of range, adjust bed and document variance and actions taken in progress note. Every shift. The DON stated Resident 51's low air loss mattress was supposed to be set between 155-165 mm/Hg but it was not because it was only at 80 mm/Hg. Upon Further review of Resident 51's physician's orders, an order dated November 13, 2024, indicated, Resident may have bilateral heel protectors while in bed. Monitor placement every shift for DTI. During a review of Resident 51's care plan (untitled), dated November 13, 2024, the care plan indicated, [name of Resident 51] was readmitted from acute hospital with DTI to right heel. Interventions for the care plan included, Apply heel protectors daily while in bed .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations .Pressure reducing mattress . During a concurrent interview and record review on December 17, 2024, at 4:15 PM, with the DON, Resident 51's weekly nursing assessment titled, NW-Weekly Summary, dated December 12, 2024, was reviewed. The Assessment indicated in section G (section for Skin/Wound), No evidence of impaired skin integrity at this time. The DON stated the weekly nursing summary was incorrect and the nurse who completed the weekly assessment did not identify Resident 51 had a deep tissue injury to the heel and therefore the documentation was not accurate. During an interview on December 19, 2024, at 3:21 PM, with the DON, the DON stated the purpose of a low air loss mattress was to help prevent skin breakdown for residents who cannot or will not reposition themselves in bed. The DON further stated the purpose of heel protectors were to help prevent skin breakdown to the heels. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment and Care Planning, revised May 2019, the P&P indicated, .2. The facility will develop and implement a comprehensive person-centered care plan consistent with resident rights and aimed to provide services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .Weekly Assessments: A. Weekly resident assessments are completed by a licensed staff nurse to ensure effectiveness of the current plan of care and to document residents' progress towards individualized goals, as well as early detection of changes in condition and identification of new/altered resident needs. B. Components of a weekly assessment should include, when appropriate, the following: 1) Skin integrity assessment - 100% head to toe body check .b. Check findings against current treatment orders and weekly pressure injury report. Check that identified sites are correctly described and located. Correct errors .

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 37) reviewed for accidents had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) next to her bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident). This failure had the potential for Resident 37 to sustain a serious injury during a fall in which the severity of the injury may have been lessened if the fall mat had been in place. Findings: During a review of Resident 37's Admission Record (contains medical and demographic information), the Admission Record, indicated Resident 37 was admitted on [DATE], with diagnoses which included dementia (a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life), legal blindness, psychotic disorder (a severe mental disorder that causes abnormal thinking and perceptions), and impulse disorder (a mental health condition that makes it difficult to control impulses or urges, which can lead to harmful behaviors). During an interview on December 16, 2024, at 12:01 PM, with Resident 37's representative (RR 37), RR 37 stated she was informed by facility staff, that Resident 37 had experienced a fall from bed some months ago (could not remember exactly what month). During an observation on December 17, 2024, at 2:18 PM, in Resident 37's room, Resident 37 was lying in bed and did not have a fall mat noted next to or near her bed. Resident 37 was nonverbal and did not respond to questioning. During a concurrent observation and interview on December 17, 2024, at 2:41 PM, with Licensed Vocational Nurse 1 (LVN 1), in Resident 37's room, Resident 37 was lying in bed and did not have a fall mat next to or near her bed. LVN 1 stated she did not know why Resident 37 did not have a fall mat next to her bed. During a review of Resident 37's Fall/Risk Evaluation (an assessment of fall risk), dated November 8, 2024, the fall risk evaluation indicated Resident 37 was at High Risk for falls. During a review of Resident 37's nursing progress notes, a note dated June 10, 2024, indicated, .LVN noted [resident] lying on floor next to bed. No injuries noted. Resident assisted back to bed . During further review of Resident 37's nursing progress notes, a note dated July 5, 2024, indicated, Staff went to assist resident .as CNA (Certified Nursing Assistant) arrived resident was sitting on floor in room . During an interview on December 17, 2024, at 3:10 PM, with the Director of Nursing (DON), the DON stated Resident 37's care plan for risk for falls included the facility designated interventions to help prevent falls and/or lessen the extent of injuries sustained by a fall. During a review of Resident 37's care plan (an individualized plan for the medical care of a resident), dated February 26, 2021, the care plan indicated, [name of Resident 37] is at risk for falls r/t [related to] confusion, gait [walking]/balance problems, deconditioning, poor safety awareness/judgement .incontinence, vision/hearing problems . Interventions listed for the care plan indicated, .Floor mat to assist resident with secured footing when getting out of bed. During a concurrent observation and interview on December 17, 2024, at 3:16 PM, with the DON, while in Resident 37's room, the DON observed Resident 37 in bed and acknowledged there was no fall mat next to or near the resident's bed. The DON further stated Resident 37 was supposed to have a fall mat by her bed and she was unsure of why there was not one. During a follow up interview on December 19, 2024, at 3:21 PM, with the DON, the DON stated the purpose of a fall mat was to minimize injury if an actual fall occurred. During a review of the facility's policy and procedure (P&P) titled, Prevention of Falls, Revised April 2024, the P&P indicated, It is the policy of this facility to assess residents for falls and to use appropriate measures to prevent falls .Every effort is utilized to prevent falls . During a review of the facility's P&P titled, Resident Assessment and Care Planning, revised May 2019, the P&P indicated, .the facility will develop and implement a comprehensive person-centered care plan consistent with resident rights and aimed to provide services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to ensure five of five rooms (each occupied by four residents per room) had the minimum required square footage for each resident. This failure had had the potential for increased risk of accidents and injuries to occur within the room as a result of limited space for wheelchair and Hoyer lift access (a mechanical device that helps move people with limited mobility), limited space to accommodate resident care activities, increased risk for falls, and a potential delay in the evacuation of residents during an emergency. Findings: During an observation on December 16, 2024, at 9:59 AM, in room [ROOM NUMBER], there were four residents observed to occupy the room. During a review of the facility document titled, [name of facility] Census (a document which indicates the total number of residents within the facility and their room number) dated December 15, 2024, the document indicated there was a total of five rooms within the facility each of which were shared by four residents. The rooms were: 102, 105, 106, 107 and 112. During a concurrent observation and interview on December 19, 2024, at 8:45 AM, with the Maintenance Supervisor (MS), the MS measured Rooms 102, 105, 106, 107, and 112. All measurements were verified by both the MS and the surveyor using the facility's measuring tape and the following measurements were obtained: room [ROOM NUMBER]: Length (L) 185 (inches) x width (W) 237 = 43845 square inches (sq in) total room area. Within the room, there was one moveable wardrobe cabinet which measured 23 x 40 = 920 and one unmovable wardrobe cabinet which measured 39 x 19 = 741. room [ROOM NUMBER]: Length 184 x width 239 = 42542 sq in total room area. Within the room, there was one un-moveable wardrobe cabinet which measured 42 x 18 = 756 and a moveable wardrobe cabinet which measured 36 x 19 = 684. room [ROOM NUMBER]: Length 184 x width 240 = 44160 sq in total room area. Within the room, there was one moveable wardrobe cabinet which measured 36 x 19 = 684. room [ROOM NUMBER]: Length 177 x width 243 = 43011 sq in total room area. Within the room there was two moveable wardrobe cabinets which measured 33 x 18 = 594. room [ROOM NUMBER]: Length 184 x width 240 = 44160 sq in total room area. Within the room, there was one moveable wardrobe cabinet which measured 23 x 40 = 920 and another moveable wardrobe cabinet which measured 40 x 21.5 = 860. During an interview on December 19, 2024, at 10:40 AM, with the Administrator (ADMIN), and the MS, the ADMIN was shown the measured room sizes of rooms 102, 105, 106, 107, and 112. The measurements of the rooms were discussed and the following sq ft per resident were calculated: room [ROOM NUMBER]: Length (L) 185 (inches) x width (W) 237 = 43845 square inches (sq in) total room area. 43845 sq in divided by 144 (to convert to square feet) = 304.47 square feet (sq ft) total room area. Divided by 4 (number of residents in the room) = 76.11 sq ft per resident. However, within the room there was one moveable wardrobe cabinet which measured 23 x 40 = 920 and one unmovable wardrobe cabinet which measured 39 x 19 = 741. After subtracting the moveable wardrobe space (since it is not considered useable room space) the total sq ft per resident was decreased to 72.6 sq ft. room [ROOM NUMBER]: Length 184 x width 239 = 42542 sq in total room area. 42542 sq in divided by 144 (to convert to sq ft) = 295.43 sq ft total room area. Divided by 4 (number of residents in the room) = 73.85 sq ft per resident. However, within the room there was one un-moveable wardrobe cabinet which measured 42 x 18 = 756 and a moveable wardrobe cabinet which measured 36 x 19 = 684. After subtracting the moveable wardrobe space, the total sq ft per resident was decreased to 71.35 sq ft. room [ROOM NUMBER]: Length 184 x width 240 = 44160 sq in total room area. 44160 sq in divided by 144 (to convert to sq ft) = 306.66 sq ft total room area. Divided by 4 (number of residents in the room) = 76.66 sq ft per resident. However, within the room there was one moveable wardrobe cabinet which measured 36 x 19 = 684. After subtracting the moveable wardrobe space, the total sq ft per resident was decreased to 75.4 sq ft. room [ROOM NUMBER]: Length 177 x width 243 = 43011 sq in total room area. 43011 sq in divided by 144 (to convert to sq ft) = 298.68 sq ft total room area. Divided by 4 (number of residents in the room) = 74.67 sq ft per resident. However, within the room there was two moveable wardrobe cabinets which measured 33 x 18 = 1188. After subtracting the moveable wardrobe space, the total sq ft per resident was decreased to 72.6 sq ft. room [ROOM NUMBER]: Length 184 x width 240 = 44160 sq in total room area. 44160 sq in divided by 144 (to convert to sq ft) = 306.66 sq ft total room area. Divided by 4 (number of residents in the room) = 76.66 sq ft per resident. However, within the room there was one moveable wardrobe cabinet which measured 23 x 40 = 920 and another moveable wardrobe cabinet which measured 40 x 21.5 = 860. After subtracting the moveable wardrobe space, the total sq ft per resident was decreased to 73.57 sq ft per resident. The ADMIN stated she agreed that based on the measurements of rooms 102, 105, 106, 107, and 112; all five of the rooms were less than the required 80 sq ft per resident. The ADMIN further stated possible negative outcomes included falls and accidents if the rooms were too small. During an interview on December 19, 2024, at 2:40 PM, with the ADMIN, the ADMIN was asked for a list of residents who resided in Rooms 102, 105, 106, 107, and 112, and of those, which required the use of a wheelchair, Hoyer lift, and/or Geri chair (a large, padded chair that's designed to help people with limited mobility sit and stand comfortably). During a review of the facility's document titled, List of Residents with Wheelchair/Hoyer's, undated, the document indicated of the five rooms which housed 20 total residents (Rooms 102, 105, 106, 107, and 112) 10 residents required use of Hoyer lift, nine residents had wheelchairs, and seven residents had Geri chairs. During an interview on December 19, 2024, at 12:07 PM, with the Administrator (ADMIN), the ADMIN stated the facility did not have a policy and procedure (P&P) regarding the minimum required square footage of resident's rooms.

Based on observation, interview and record review, the facility failed to ensure the emergency cart was immediately ready for use for 52 residents in a medical emergency. This failure had the potential to result in harm by delaying licensed nurses in administering oxygen and the ability to suction a resident during cardio-pulmonary resuscitation (CPR). Findings: During an observation on (MONTH) 3, (YEAR) at 12:26 PM in front of the nursing station near the counter, the emergency cart was not immediately ready for use. The emergency cart did not have the suction pump (a machine for sucking mucus from the nose or mouth) attached to the suction canister (a container). The suction canister laid on top of the emergency cart in three pieces and the suction tubing (this tubing attaches to the canister) was not connected and ready for use. Three expired suction catheters size 14 French (French - a numerical size for medical equipment) dated (MONTH) (YEAR) were found in the third drawer of the emergency cart. The oxygen tank did not have the regulator gauge (sets the amount of oxygen to be administered) and oxygen tubing affixed to the tank to be ready for use. During an interview on (MONTH) 3, (YEAR) at 12:30 PM with a Licensed Vocational Nurse (LVN 1), LVN 1 stated the oxygen tank and suction were not assembled, not ready for use, and did not know why three expired suction catheters were on the emergency cart. During an interview on (MONTH) 3, (YEAR) at 1:08 PM with the Director of Nursing (DON), the DON stated the emergency cart should be complete and ready for an emergency with the suction being ready and assembled and the oxygen tank with the gauge there to use it. The DON further stated everything should be assembled before an emergency. During an interview on (MONTH) 4, (YEAR) at 11:00 AM with a Licensed Vocational Nurse (LVN 2), LVN 2 stated she was not given any training on how to assemble the emergency cart during orientation. LVN 2 further stated LVN 3 had to assemble the cart before using it during a code (code - an emergency in which a resident was found unresponsive, with no pulse and not breathing requiring cardio-pulmonary resuscitation (CPR)) a month ago. During an interview on (MONTH) 4, (YEAR) at 11:20 AM with a Licensed Vocational Nurse (LVN 3) who stated being involved in a code a month ago, LVN 3 stated having had to assemble the suction and oxygen equipment prior to responding to the code which delayed LVN 3's ability to respond to the resident needs. During a record review of a facility document titled, Crash Cart Checklist, undated, indicated by check marks the suction machine was setup with the canister and tubing, plugged in and the suction machine worked on (MONTH) 3, (YEAR) and (MONTH) 3, (YEAR). The checklist did not match the actual state of readiness of the emergency cart for the date based on interviews with licensed nursing staff (LVN 1, LVN 2 and LVN 3). During a concurrent interview with the DON on (MONTH) 3, (YEAR) at 1:08 PM, the DON confirmed the checklist showed the contents of the emergency cart were to be assembled and ready for use but they were not and the employees would be counseled. During a record review of a facility document titled, Licensed Nurse Clinical Skills Checklist - Annual, undated did not indicate cardio-pulmonary resuscitation (CPR) skills validation or competency with the emergency cart equipment. A review of the facility's policy and procedure titled, Emergency cart supplies and equipment indicated It is the policy of (name of facility) maintains sufficient emergency medical supplies and equipment to meet the needs of residents at all times. Procedure: B. At a minimum, the facility will maintain emergency medical supplies and equipment at the nurses' station, including but not limited to: Oxygen tank (should be readily assembled for use) .Suction machine (should be readily assembled for use). On (MONTH) 3, (YEAR) at 3:05 PM, after observation, interview and record review, an Immediate Jeopardy (IJ- a situation that had the potential to harm the health and safety of the residents) was called in the presence of the Administrator and Director of Nursing. The corrective action plan provided by the facility included: A. The facility began the immediate correction on (MONTH) 3, (YEAR) by the DON and Director of Staff Development (DSD) conducting in-services on: crash cart contents, checking for expired equipment, policy and procedure on checking the crash cart completion daily and the process of assembling the suction and oxygen. B. The DON restocked the crash cart on (MONTH) 3, (YEAR) with up to date supplies and assembled the connection tubing for suction and oxygen. C. The DON initiated a skills competency for the licensed nurses for proper setup and assembly of emergency equipment. D. All licensed nurses who are not in attendance will receive training and skills competency before resuming work on the floor. E. The crash cart will be located outside the nursing station for ready access. During an interview on (MONTH) 4, (YEAR) at 10:45 AM with the DON, the DON stated I have not have not done a competency/skills check with the emergency cart during annual skills day. During observations, interviews and record reviews from (MONTH) 3, (YEAR) to (MONTH) 4, (YEAR) the DON: A. Provided on (MONTH) 3, (YEAR) at 5:00 PM copies of the in-service sign-in sheets, and lesson plan for the emergency cart supplies and equipment. B. Showed on (MONTH) 4, (YEAR) at 9:40 AM the emergency cart was assembled and ready for use. C. Provided on (MONTH) 3, (YEAR) at 5:00 PM copies of the emergency cart competency evaluation and performance satisfactory completion which included: assembling the oxygen, suction catheter assembly, use of the back board, use of the rebreather mask, use of the Ambu-bag (a bag with a mask used to administer air into the lungs), connecting the [MEDICATION NAME] (specific name of a type of suction catheter) to the suction machine, disinfection of used equipment, resupplying the emergency cart, disposal of used supplies and completing the supply checklist daily. D. Verbally stated on (MONTH) 3, (YEAR) at 5:00 PM all nurses have received the in-service minus one LVN who will be in-serviced on (MONTH) 4, (YEAR) when the nurse returns to work. Interviews with licensed nursing staff on (MONTH) 4, (YEAR) from 9:40 AM to 11:20 AM demonstrated their understanding of the in-service training. E. Showed on (MONTH) 4, (YEAR) at 9:40 AM the emergency cart was located at the nursing station. The corrective action plan was reviewed and accepted on (MONTH) 4, (YEAR) at 11:45 AM in the presence of the Administrator and Director of Nurses. The IJ was lifted on (MONTH) 4, (YEAR) at 11:45 AM in the presence of the Administrator and Director of Nurses in the DON office.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent 1 of 2 sampled residents (Resident A) elopement as evidenced by not implementing the every 15 minute observation checks as per the facility policy and procedure for residents who are at risk for elopement. This failure contributed to the resident eloping from the facility and placing him at risk for serious harm. Finding: On November 15, 2016 at 2:00 PM, an unannounced visit to the facility was made to investigate Resident A's elopement from the facility. During an interview with the Assistant Director of Nursing (ADON) on November 15, 2016 at 2:15 PM, she stated, they did not know how he (Resident A) exited. She said the Licensed Vocational Nurse (LVN 1) said she locked the doors at 5:00 PM, but stated that the resident (Resident A) was gone prior to that. Resident A was not found when the dinner trays were passed at 5:00 PM. A review of Resident A's clinical record showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident A's History and Physical dated November 14, 2016, showed the resident has fluctuating capacity to understand and make decisions, but can make immediate needs known. A review of the Nurse's Notes for Resident A, dated October 13, 2016 at 18:45 (6:45 PM), documented Resident A stated, Can't I just walk to my mom's from here, she lives right here, resident continued to repeat my mother is dead and stated, I live in her house. I have to go see her house now. A review of the Nurse's Notes for Resident A, dated November 11, 2016 at 7:11 PM, reflected at 5 PM the charge nurse went to lock the doors and check on all residents with Q (every) 15 (minutes) checks. The nurse found out that the resident was not in his room. Staff then spread out to look for the resident and could not find the resident. During an interview with the Director of Nursing (DON) on November 15, 2016 at 3:10 PM, when asked why Resident A was placed on Q 15 minute (every 15 minutes) observation checks beginning November 2, 2016, she stated, we had the LVNs complete an elopement risk assessment on all of the residents. She said we started the Q 15 minute checks for the ones deemed at risk. During an interview with Certified Nurse Assistant (CNA 3), on November 15, 2016 at 4:25 PM, who worked the afternoon shift on November 11, 2016, CNA 3 stated, I did see him when we were passing out waters at 3:45 PM, he (Resident A) was in his room. During an interview with Certified Nurse Assistant (CNA 4), on November 15, 2016 at 4:30 PM, who worked the afternoon shift on November 11, 2016, CNA 4 stated, dinner trays were already out and were being passed. I personally did not see him . he was the type of person to be on heightened alert, he had not tried to leave prior, but would stand at the doors watching during the change of shifts. During an interview with the Certified Nurse Assistant (CNA 5), on November 16, 2016 at 11:00 AM, who worked the afternoon shift on November 11, 2016, CNA 5 stated, Resident A's dinner time was 5:15 PM, and it was noticed then that he was not in his room. CNA 5 further stated, Resident A is always in the hallway and she did not see him that afternoon. During an interview with LVN 2, on November 17, 2016 at 11:30 AM, who worked the afternoon shift on November 11, 2016, LVN 2 stated, . I had not seen him that day .normally he follows someone asking to leave at least every other day . he also carried around an envelope that had an address, and said his mom was passed away and wanted to go there. A review of Resident A's Elopement Risk Assessment dated October 31, 2016 at 8:08 PM (18 days after Resident A's admission), indicated the resident was an elopement risk. A review of Resident A's Wandering Care Plan (not dated and not signed) indicated the following approaches: Place resident in area where constant observation is possible. Do not allow resident to leave facility. Place resident on Q 15 minute observation. In an interview with LVN 1 on April 12, 2017 at 1:35 PM, she stated that it was the CNA's responsibility to do the Q 15 minute checks and it is the LVN's responsibility to make sure the CNA does them. A review of the Resident Q 15 Minute Observation Record for Resident A, showed the 15 minute observation checks were done by the staff of Resident A's presence in the facility beginning November 9, 2016 at 6:30 AM and ending November 10, 2016 at 6:15 AM, and November 10, 2016 beginning at 6:30 AM ending November 11, 2016 at 3:40 PM. There was no documentation to show the 15 minute check observations were done after 3:40 PM on November 11, 2016. In an interview with ADON on April 12, 2017 at 1:35 PM, she stated she did not know why the Q 15 minute checks were not done. She stated it was the CNA's responsibility to do the Q 15 minute checks. A review of a facility policy and procedure titled, Admission Elopement Risk Policy and Procedure, undated, showed the following: Procedure: The steps the facility will take to identify residents at risk for elopement on admission will include: An Elopement Risk Observation report will be completed upon admission by admitting nurse. Residents will be put on a Q (every) 15-minute watch for the first 72 hours of placement in the facility per MD (physician)/PSYCH (Psychiatrist) order. This will be documented on the Q 15-minute observation form and signed off at the end of shift by the charge nurse . During an interview with the ADON on February 24, 2017, she stated that the resident has not been found.

Based on observation, interview, and record review, the facility failed to provide timely care and services in accordance with facility policy and procedure for two (2) of 13 sampled residents (Resident 9 and 12) when: 1. For Resident 12, the charge nurse failed to notify the physician, endorse to the next shift, and document the fall incident. Resident 12 was diagnosed with [REDACTED]. 2. For Resident 9, the charge nurse failed to notify the physician and the DON when the resident reported that her right knee was bumped in to by another resident's wheelchair. There was no documented evidence to show that an incident report or investigation was completed. Resident 9 was diagnosed with [REDACTED]. Findings: 1. During an interview with Licensed Vocational Nurse (LVN 3) on March 9, 2017 at 3:20 PM, she stated that last January 24, 2017 at 7:51 PM, she went to Resident 12's room to give her medications. Resident 12 was sitting at the edge of her bed. LVN 3 went to put on gloves and noticed Resident 12 began to slip from her bed. LVN 3 said she assisted her (Resident 12) in going down to the floor and she then alerted the closest Certified Nurse Assistant (CNA 7) and they both assisted Resident 12 back to bed. During another interview with LVN 3 on March 9, 2017 at 3:30 PM, she stated she made assessments and Resident 12 did not had any pain or injury. She further stated that the next shift was notified but no documentation was shown to indicate the assessment or notification to the Director of Nursing (DON) or the next shift was notified at the time of the incident. She confirmed that lowering Resident 12 to the floor is considered an assisted fall and must be reported immediately to the Director of Nursing (DON). During a phone interview with Licensed Vocational Nurse (LVN 1, incoming shift 11:00 PM to 7:00 AM charge nurse on January 24, 2017) on March 10, 2017 at 10:15 AM, she stated that she was not aware of the incident and no endorsement was made. A review of the departmental (nurses notes) notes, dated January 30, 2017 and January 31, 2017, indicated the following: a. A late entry of the fall incident for January 24, 2017, was entered on departmental notes on January 30, 2017. b. Resident 12 was transferred to an acute care hospital on January 31, 2017 at 5:30 PM, due to the swelling of her left upper leg. A review of acute hospital's physician notes dated January 31, 2017, indicated that 1. The patient has suffered a mechanical fall in which there was no loss of consciousness, resulting in a left hip intertrochanteric fracture ([MEDICAL CONDITION] part of the thigh bone) with dislocation. A review of another facility's departmental notes revealed that .Resident is post surgery for [REDACTED]. A review of the facility's Rehab Post Fall Screening, signed by the physical therapist on November 21, 2016, indicated that patient was found by CNA on the bathroom floor with no injury noted. A fall risk assessments for Resident 12 were completed on September 29, 2016 and November 18, 2016. A review of the clinical record of Resident 12 indicated that she was admitted to the facility on [DATE], which included the diagnosis (identification of an illness) of aged related [MEDICAL CONDITION] (thinning or weakening of the bones). The facility policy and procedure titled, Falls - Clinical Protocol, not dated, indicated that Assessment and Recognition . 5. The staff will evaluate and document falls that occur while the individual is in the facility. A review of a facility policy and procedure titled, Dealing with a Fall, not dated, indicated that Any fall needs to be investigated immediately (lowering a resident to the ground is considered a fall). You must do the fall risk assessment and post fall assessment. Slide the completed incident report under the DON office door. A review of the facility's Charge Nurse - RN/LVN (Registered Nurse/Licensed Vocational Nurse) specific job function of a charge nurse includes . Gives thorough report to oncoming charge nurse and details changes in conditions, incidents, new orders etc. 2. A review of Resident 9's clinical record indicated Resident 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation of Resident 9 on March 9, 2017 at 1:30 PM, Resident 9 was observed lying in bed with a leg immobilizer (an apparatus to prevent movement) on her right leg and a wound dressing over the right knee. Resident 9 was alert and oriented to place and person, answered questions appropriately, and was able to make needs known. During an interview with Resident 9 on March 9, 2017 at 1: 35 PM, when asked what happened to her leg, she stated that someone bumped her knee with their wheelchair. During an interview with Resident 9's family member on March 9, 2017 at 7:30 PM, she stated that no one informed her of the incident that happened on February 11, 2017, when Resident 9 was bumped on the right knee by someone else's wheelchair. The family member stated that when she visited her mom on February 19, 2017, she found the resident in bed with two (2) CNAs trying to help her up to a wheelchair. Her right knee was swollen and she was complaining of pain. The family member stated that the last time she saw her mother was about two weeks ago she was able to stand with assist to a wheelchair. According to the family member, one of the CNA told her, I don't want to lie to you; but your mom was hurt on the right knee when it got bumped. A review of the nurse's note dated February 11, 2017 at 7:14 AM, by Licensed Vocational Nurse (LVN 1), indicated that the resident was complaining of right knee pain. Upon further assessment the resident stated that she was hit by someone else's wheelchair. Swelling was present. During an interview with a Licensed Vocational Nurse (LVN 1), on February 14, 2017 at 10:30 AM, LVN 1 stated that she was the LVN on duty on February 11, 2017 at 7:14 AM, when the resident complained of pain in her right knee. LVN 1 said the resident stated that someone else's wheelchair bumped her on the right knee. The incident was unwitnessed. The resident complained of pain, and the right knee had more swelling than usual when she did the assessment. The resident was medicated for pain and she was placed in bed. LVN 1 stated that she did not initiate an incident report and further stated, Now I know that I should have initiated one. An interview was conducted with the Assistant Director of Nursing (ADON) on March 10, 2017 at 10:50 AM. The ADON stated that there was no investigation or incident report done because the resident kept changing her story and giving conflicting stories. I did not know or I am not aware that we called and notified anybody when the incident happened. A review of the physician's orders [REDACTED]. Result of x- ray reading on February 15, 2017 taken by {name of Laboratory facility} on February 15, 2017 indicated, Right knee 2V (two views) there is a prosthetic right femoral in proper alignment . There is no fracture or acute dislocation. There were no nurse's notes to review from February 15, 2017 at 6:18 PM through February 19, 2017. On February 20 2017 at 2:36 PM, the nurse's note indicated, Resident was having right knee pain 10/10 (pain level indicating severe pain). Resident's right knee was swollen and warm to touch. MD (Medical Doctor) notified. MD advised to send her out. Called AMR (Transport ambulance) and they transferred her to {name of hospital}. A review of the acute hospital's Emergency Department (ED) notes dated February 20, 2017 at 12:05 PM, indicated, Chief complaint: right leg swelling, pain to touch and movement. Per EMS (Emergency Medical Services) patient's knee was bumped by another wheelchair at the facility. A review of the ED physician's note dated February 21, 2017, indicated, x-ray of the right knee showed, [MEDICAL CONDITION] diaphysis of the femur with angulation at the fracture site, displacement and override of the fracture fragments as well ([MEDICAL CONDITION] that occur just above the knee joint). Surgery was advised but the resident's daughter declined at that time. A consult interview was conducted with the Radiologist (a medical doctor that specializes in diagnosing and treating diseases and injuries using medical imaging techniques) at {name of laboratory facility} on March 14, 2017 at 12:15 PM, who stated that it is possible that the fracture could have been blocked by the right knee prosthesis (artificial body part) on the first x-ray, that's why the fracture was not seen on the x-ray taken on February 15, 2017, and there was no follow up x-ray done for comparison. A review of the nurse's notes for Resident 9, dated February 22 to February 27, 2017, showed the resident continued having pain and was medicated with routine [MEDICATION NAME](an extended release form of [MEDICATION NAME], a narcotic used for pain) 15 mg (milligrams-medication to relieve pain), and Tylenol 650 mg, added as a new medication for pain. Resident was dependent with transfer. An interview was conducted with a Restorative Nursing Assistant (RNA 1) on March 14, 2017 at 3:15 PM. RNA 1 stated, Before February 11, 2017 the resident was not complaining of pain during RNA, but starting on the 11th of February 2017, she was complaining of pain in her right leg so I did not perform exercises on the lower extremities. I only perform exercises on the upper part of the body. Resident was taken to {name of Ortho. clinic} accompanied by a staff member on February 28, 2017 for appointment. A review of physician's progress notes dated February 28, 2017, indicated, Long spiral fracture extending along the distal diaphysis (the shaft of a long bone) to the prosthesis. Surgery was recommended STAT (as soon as possible) ORIF (An open reduction internal fixation- refers to a surgical procedure to fix a severe bone fracture) was performed at {name of hospital} on February 28, 2017. An interview was conducted with the facility Administrator in the presence of the Director of Nursing (DON) on March 10, 2017 at 4:30 PM. The Administrator stated that the incident of fracture did not occur in the facility, that's why there was no investigation done and there was no incident report generated. The Administrator further stated that the fracture could have happened in the ambulance or at the hospital. The DON stated that there was no assessment done upon return to the facility from {name of hospital} because the resident came back to the facility in less than 24 hours. A review of the facility's policy and procedure titled, Unexplained Injuries- Investigation, dated January 1, 2012 indicated, Purpose: to protect the health and safety of our residents by ensuring that all unexplained injuries are promptly and thoroughly investigated and addressed. Procedure: 1. If a resident is observed with unexplained injuries, the Charge Nurse on duty will complete AN-08-Form A-Incident & Accident Report Form and record such information into the resident's medical record. ll. Documentation must include information relevant to risk factors and conditions that causes or predisposes someone to similar signs and symptoms (e.g. receiving anticoagulants, having [MEDICAL CONDITION], having movement disorder .). lll. The nursing staff will discuss the situation with the Attending Physician or Medical Director to consider whether medical conditions or other risk factors could account for the findings. An IJ was called on March 14, 2017 at 3:28 PM, and verbally notified in the presence of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Quality Assurance. The corrective action plan was received on March 14, 2017 at 5:10 PM. After review and deliberation, the corrective action plan lacked specific details as to it's implementation and was discussed and returned to the administrator in the presence of the QAC, DON and administrator-in-training (AIT) on March 14, 2017 at 5:50 PM. An amended corrective action plan was received and accepted on March 15, 2017 at 8:26 AM, with the following information. a. All identified incidents will have an incident report completed by the licensed nurse at the time of the event. At the time of the incident report, a post fall assessment and fall risk assessment must be completed by the licensed nurse. Included in the incident report is a check off list to guide the licensed nurses through the process. All assessments such as pain, skin and any part of associate injuries must be done with accurate documentation. b. The resident will be placed on Q shift (every shift) monitoring by the licensed nurse for a minimum of 72 hours. This will be monitored by the medical records daily Monday thru Friday using the change of condition audit with results forwarded to the DON for review and follow up. c. Body checks will be done daily with irregularities reported to the Licensed Nurse. Certified Nurse Assistant (CNA) conduct personal care to their assigned residents throughout their shift and are required to notify their charge nurse of any change in resident's condition daily. d. Weekly assessments (summaries) by licensed nurses include full body assessment and are completed on a daily basis per the medical records calendar. Medical records will audit for the completion of the weekly assessment Monday through Friday. e. In the event of a serious injury, fall with fracture, fracture with unknown cause would be considered as unusual occurrence. The Director of Nursing and administrator must be notified immediately. The IJ was removed on March 15, 2017 at 12:33 PM, in the presence of the Administrator, Director of Nursing, Assistant Director of Nursing, and Quality Assurance Coordinator.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident A) was free from sexual abuse when a Certified Nurse Assistant (CNA 1) was observed to inappropriately touch Resident A's penis and comment that he was, Hung like a horse. Findings: On September 28, 2016, a review of Resident A's clinical record was conducted. A review of the Admission Face Sheet reflected Resident A as a [AGE] year old male. Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Annual Assessment Form, dated July 31, 2016, indicated Resident A did not have the capacity to understand and make decisions. During an interview with a Licensed Vocational Nurse (LVN 1) on September 28, 2016 at 2:15 PM, she stated that on September 22, 2016, it was reported to her that the facility Psychologist overheard a conversation between two Certified Nurse Assistants (CNA 2 and CNA 5) on the 3-11 shift who stated that CNA 1 was being sexually inappropriate with Resident A and that CNA 1 had made a statement, He (Resident A) is hung like a horse. LVN 1 stated CNA 1 was suspended pending investigation of alleged abuse against Resident A per the facility policy. During an interview and concurrent record review with LVN 1 on September 28, 2016 at 2:30 PM, she reviewed the personnel file for CNA 1 and was not able to find documentation to show the abuse training as being completed in 2015, and was not able to find a completed criminal back ground check prior to CNA 1 being hired. During an Interview with CNA 2 on September 28, 2016 at 3:30 PM, when asked about the event that happened to Resident A, CNA 2 stated, I think it was on a Tuesday or Wednesday a few weeks ago on the 3-11 shift. I was walking down the hall when CNA 1 opened the door of the resident's (Resident A) room screaming for another aide to come down and help her. When I went over towards that room CNA 3 was coming out of the room shaking her head. I asked her what is wrong and she said, its ok. I then looked into the room and saw CNA 4 holding Resident A's hands and CNA 1 said, He (Resident A) is hung like a horse. CNA 2 stated, I was scared to report overhearing the statement by CNA 1 and so I did not say anything. She said I should have reported it to the Charge Nurse, Director of Nursing or Administrator. During an Interview with CNA 5 on September 28, 2016 at 3:45 PM, when asked about the event that happened to Resident A, she stated, I think it was on a Sunday a few weeks ago on the 3-11 shift. CNA 5 said I was in the resident's room taking care of the resident assigned to me when I heard CNA 1 laughing and saying to CNA 4 He (Resident A) is hung like a horse and she started to stroke his penis. I yelled, Stop, I was shocked. CNA 5 said, I did not report it right away because I was afraid of CNA 4 and the other aide, she might retaliate against me. On September 29, 2016 at 3:25 PM, Resident A was observed located next to the bed in his room. Resident A was sitting in his wheel chair, leaning over a lap buddy (a safety device that hooks into the arms of wheel chair across residents lap to prevent him/her from standing unassisted), with his eyes closed. The Licensed Vocational Nurse (LVN 1) called his name and Resident A was observed to open his eyes and sit up straight in the wheel chair. The surveyor asked Resident A, are you ok? He did not respond. The surveyor then asked Resident A if there was anything he needed, he again did not respond. During an Interview with CNA 4 on September 30, 2016 at 4:30 PM, when asked have you ever been assigned to take care of Resident A, she stated, Yes, he is very quiet and he does not say much. CNA 4 said, he is not too difficult to take care of, but it helps if someone holds his hands because it keeps him from walking around the room as we are changing him (changing the adult brief). When asked about the event that happened to Resident A, CNA 4 stated, I was on vacation from August 23, 2016, to August 31, 2016, I returned to work on September 1, 2016, a Tuesday. She stated, I just do not remember holding his (Resident A) hands. CNA 4 said I never heard CNA 1 say anything derogatory towards Resident A. She stated that when she was helping change Resident A she usually stands in front of the resident and holds his hands. During an interview with the Assistant Administrator (AA) on September 30, 2016 at 4:45 PM, she stated that CNA 1 was terminated due to the result of the facility investigation of abuse. When asked about the staff abuse training not being completed in 2015, she stated, she was not aware that the training had not been completed for 2015. She said that she was not aware that the back ground check for CNA 1 had not been done. During a phone interview with the Psychologist on October 28, 2016 at 3:00 PM, she stated that she was informed of the incident that happened to Resident A, by CNA 5. She said CNA 5 was upset that CNA 1 was stroking Resident A's large penis. CNA 5 told her that she was afraid to report it due to CNA 1 having a large family of gang members. CNA 5 also told her that she was afraid of retaliation by CNA 1. The Psychologist stated she immediately reported the event to the Director of Staff Development (DSD) but did not remember the date. On November 2, 2016, the personnel file for CNA 2 was reviewed and indicated the last abuse training was provided and competed on June 30, 2016. There was no evidence to show a criminal back ground check for CNA 2 had been completed prior to hire. During an interview with the DSD on November 2, 2016 11:00 AM, she stated the Abuse training is completed once a year and during orientation for new employees. The DSD stated, The background checks are completed when hired and annually thereafter. During an interview with the DSD on November 2, 2016 at 11:40 AM, she reviewed the personnel file for CNA 2 and was able to find documentation for completion of abuse training as being completed in 2016. She was not able to find a completed criminal back ground for CNA 2 prior to being hired. On November 2, 2016, the personnel file for CNA 5 was reviewed and indicated the last abuse training was provided and competed on September 2, 2014, however there was no evidence to show a criminal back ground check for CNA 5 had been completed prior to hire. During an interview with the Director of Staff Development (DSD) on November 2, 2016 at 11:40 AM, the personnel file for CNA 5 was reviewed. The DSD confirmed there was no documentation for completion of abuse training in 2015, and no completed criminal back ground check prior to CNA 5 being hired in 2001. A review of the facility policy and procedures entitled, Reporting Abuse, undated, indicated, Procedure I. Mandatory Reporters: i. Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and California Abuse and dependent Adult Civil Protection Act to report known or suspected incidents of abuse of elder or dependent adults. Section VI. Notice to facility staff, Facility staff members will annually, receive a notice of their obligations to comply with the law and the facilities policy and procedures. CNA 1 and CNA 3 have signed documented training for mandated reporting requirements in their employee file. CNA 2 and CNA 5 have no currently signed documented evidence of training for mandated reporting requirements in their employee file. A review of the facility policy and procedures entitled, Patient Abuse and Prevention, indicated, I. Screening: Prior to hiring of an employee, facility shall ensure provisions covering employment screening for potential history of abuse, neglect or mistreatment of [REDACTED]. Section (S), If the suspected perpetrator is a staff member, immediately place the staff member under administrative leave for three days or more .

Based on interview and record review, the facility failed to ensure adequate supervision for one of (3) three sampled residents (Resident A). The facility did not provide adequate supervision to ensure that Resident A did not elope from the facility. This failure resulted in Resident A eloping from the facility and not being located for (4) four days, and when Resident A was found she was unable to walk and was admitted to a General Acute Care Hospital (GACH). Findings: During a phone interview with the Assistant Administrator (AA) on April 12, 2016 at 5:00 PM, to investigate an entity reported incident of a resident elopement, she stated on April 11, 2016 at 8:30 PM, a License Vocational Nurse (LVN 1) was taking nourishments and medications to Resident A's room and discovered Resident A was missing. The facility staff searched for Resident A inside and outside the facility but were unsuccessful. The AA stated local law enforcement was contacted and a missing person's report was made, and the physician and conservator were notified. During a follow up phone interview with the AA on April 14, 2016 at 2:24 PM, she stated Resident A still had not been located and her whereabouts were unknown, a total of three (3) days after elopement. The AA stated Resident A was admitted to the facility for treatment of [REDACTED]. Resident A had a soft cast (flexible fiberglass casting material that is molded to the patient's injured limb), cam boot (brace in the form of boot) and walker. The cam boot and walker were left behind when Resident A eloped from the facility. During a review of the clinical record for Resident A, the facesheet (demographics) indicated Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The facesheet indicated Resident A was under conservatorship (when a judge appoints a responsible person or organization to care for another adult who cannot care for himself or herself). Under the section titled,History and Physical, the physician documented Resident A did not have the capacity to understand and make decisions due to psychosis. A review of the pre-admission hospital case manager notes dated January 19, 2016 through February 24, 2016, which were provided to the facility prior to Resident A's admission, reflected the hospital case manager had attempted to place Resident A back at the facility where she had resided since February 18, 2015. The hospital case manager attempted to place Resident A at other psychiatric facilities without success. The hospital case manager note dated February 24, 2016, indicated after the facility agreed to accept Resident A, She (the facility staff accepting Resident A for admission) requested that interfacility form stated the patient (Resident A) does not have a 1:1 sitter. A review of the physician's history and physical for Resident A dated January 19, 2016, written while she was in the general acute care hospital prior to admission to the facility, documented, The patient will have a sitter at all times. During an unannounced visit to the facility on [DATE] at 4:45 PM, an interview with the AA was conducted, the AA stated she was not aware that Resident A was an elopement risk at the time of admission and an elopement risk assessment was not done. The AA stated from the day of admission, Resident A had informed staff she wanted to leave the facility, and would tell the staff she knew what she had to do to leave the facility, such as jump in front of a car. The AA stated Resident A had a previous elopement attempt on March 30, 2016. The AA stated after Resident A's elopement attempt on March 30, 2016, Resident A was placed on a one to one observation (increased level of observation and supervision in which included a continuous one-to-one monitoring). Resident A was on one-to-one observation from March 30, 2016 through April 11, 2016 at 10:13 AM, (a total of 11 days). The AA stated Resident A's one-to-one observation was discontinued on April 11, 2016, and the routine every (2) two hour rounding (staff check on the status and location of residents) was implemented. The AA stated there was no elopement risk assessment done after Resident A's elopement attempt on March 30, 2016, and could not explain the reason an elopement risk assessment was not done. During an interview with a License Vocational Nurse (LVN 2) on April 14, 2016 at 6:51 PM, LVN 2 stated she was Resident A's nurse on March 30, 2016, when Resident A attempted to elope from the facility. LVN 2 stated on March 30, 2016, Resident A stated she did not want to be at the facility and was inquiring about how to leave the facility. LVN 2 stated, Resident A was found at the front gate attempting to elope from the facility and was brought back inside by the facility staff. LVN 2 stated after the elopement attempt, Resident A became aggressive and attempted to swallow a zipper head (the part of a zipper used to pull it up or down). Resident A was then placed on a one-to-one observation. LVN 2 was unable to verbalize the facility's protocol for continued observations of a resident after a one-to-one observation was discontinued. During an interview with the AA on April 14, 2016 at 7:41 PM, the AA stated there was no policy and procedure in place for staff to follow for a one-to-one observation which included: a. What criteria was to be used to place a resident on a one-to-one observation. b. What criteria was used to discontinue a one-to-one observation. c. What would be the next level of observation after a resident was removed from one-to one-observation. During an interview with the Director of Nurses (DON) on April 15, 2016 at 9:38 AM, she stated an Interdisciplinary Team meeting (involves clinical department heads) was not done, nor was an elopement risk assessment completed after Resident A's elopement attempt on March 30, 2016. The DON stated she did not know why an IDT meeting or the elopement risk assessment were not done, I should have followed up. During an interview with the DON on April 15, 2016 at 1:23 PM, the DON stated Resident A was found around the corner from the facility at approximately 11:30 AM on April 15, 2016 (a total of 4 days from elopement). The DON stated Resident A was sitting on the sidewalk against a building, was delusional (having false ideas or beliefs that are caused by mental illness) and Resident A stated she could not walk. The DON stated 9-1-1 was called and Resident A was transported to the nearest hospital for medical treatment. The facility policy and procedure titled Wandering Residents dated August 2006, indicated .1. All residents who are at risk for harm because of wandering (elopement) will be assessed by the interdisciplinary care planning team. The facility policy and procedure titled, Change in a Resident's Condition or Status, dated April 2007, indicated .2. A significant change of condition is a decline in the resident's status .requires interdisciplinary review . An Immediate Jeopardy (IJ) was called on April 14, 2016, at 7:48 PM, in the presence of the facility's Assistant Administrator due to the facility's failure to have a system in place to identify and protect the residents at risk for elopement. On April 15, 2015 at 2:12 PM, the Administrator, Director of Nursing, and Assistant Administrator presented a corrective action plan to the surveyor. The corrective action plan consisted of the following elements: 1. New temporary policy and procedure's were created for Admission Elopement Risk and One-to-One Observation. 2. All staff present were immediately in-serviced on the new policy and procedures and inservices will be continued for all scheduled staff until 100% compliance. The new policy and procedure titled, Admission Elopement Risk, included the following: An Elopement Risk Observation will be completed upon admission. Residents will be put on a Q (every) 15 minute watch for the first 7 days of placement in facility per MD/PSYCH order. At the end of the 7 days the MD/PSYCH will be called and the report of the Q 15-minute watch will be relayed for further re-evaluation. MRD (Medical Records Director) will call previous placement, family, and/or conservator within the first 72 hours to see if there have been any previous attempts of elopement. The new policy and procedure titled, One-on-One Observation, included the following: an order for [REDACTED]. The order for 1:1 will be for 72 hours, within the 72 hours one of the following: MD, Psychiatrist, PA (Physician Assistant)/NP (Nurse Practioner) will come to the facility to assess the need for the 1:1. An attempted elopement will trigger the Procedure to start immediately. 3. The temporary policy and procedures are going to be presented at the quarterly Quality Assurance and Performance Improvement (QAPI) on April 19, 2016, for official approval and amendment to the facility's current policy and procedures. On April 15, 2016 at 4:43 PM, after interviews, record review, and approval of the corrective action plan, the surveyor met with the Administrator, Director of Nursing, Assistant Administrator, Assistant Director of Nursing, MDS (Minimum Data Set) Nurse, Dietetic Service Supervisor, and the Activities Director and informed them the Immediate Jeopardy was lifted.