Every finding on record at Beachside Post Acute

Based on interview and record review, the facility failed to ensure a care plan was created for one of six sampled residents (Resident 1), who had a closed reduction and alignment (the broken or dislocated bone put back into its proper place by a hand, without surgery) after a dislocation of the right hip prosthesis (an artificial, man-made replacement part used to substitute a worn-out or damaged hip joint). This deficient practice resulted in no plan care for Resident 1's condition and had the potential for Resident 1's care needs to be unmet and/or unidentified which could delay the delivery of her care and services.Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis including dislocation of internal right hip prosthesis and a history of falls. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/2/2026, the MDS indicated Resident 1 was able to make consistent and reasonable decisions and required a one person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Clinical Records (Care Plan section), the Care Plan section indicated there was no Care Plan created for Resident 1, who had a closed reduction and alignment after a dislocation of the right hip prosthesis. During an interview on 8/12/2026 at 2:02 p.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 was admitted to the facility because she needed rehabilitation therapy, pain management and assistance with her care after a closed reduction and alignment of a dislocated right hip prosthesis. During a concurrent record review on 8/12/20206 at 2:02 p.m.,, LVN 1 confirmed Resident 1 did not have a specific plan of care for a dislocated hip and stated a plan of care should have been formulated for Resident 1, to reflect specific measures and/or interventions such hip precautions during ADLs and to identify signs worsening of conditions. During an interview on 8/14/2026 at 12:14 p.m., the Director of Staff Development (DSD) stated although the nursing staff were in serviced regarding hip precautions and care assistance of residents with hip surgery, it was important for a plan of care to be formulated, implemented, and documented to ensure communication amongst the nursing staff, uniformity of care and precautions necessary for the safety of Resident.During an interview on 8/14/2026 at 12:45 p.m., the Minimum Data Set Nurse (MDSN) stated she should have ensured Resident 1's comprehensive care plan was created to include a specific plan of care for a dislocated hip. The MDSN stated the residents' care plan serves as a guide and/or reference for the nursing staff to ensure residents' care needs, safety precautions, and worsening conditions were addressed and escalation of their care was processed in a timely manner. During a review of the facility's Policy and Procedure (P/P) titled, Care Plans, Comprehensive Person-Centered revised 3/2026, the P/P indicated the facility shall provide a comprehensive person-centered care plan for each resident, to meet their physical, mental, psychological and functional needs, promote their well-being and to ensure: a. the goals and interventions are derived from a thorough comprehensive assessment of the residents' condition b. measurable objectives and time frames c. accurate description of the care and services that are to be furnished, and which professional services are responsible for each element of care, d. reflection of the residents' current condition, required standard of practice to address their problem areas and relevant clinical decision making; and e. continuity of the residents' assessments with the care plan revised as information and/or as the residents' condition change.

Based on observation, interview, and record review, the facility failed to ensure the kitchen dishwasher temperature gauge was functioning properly. This failure had the potential to expose residents to dishes washed at unsafe temperatures, which could promote bacterial growth and increase the risk of foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins )Findings:During a concurrent observation and interview on 12/16/2025 at 9:03 a.m. in the kitchen with Dietary Aide (DA 1), a low-temperature dishwasher was observed being used to wash dishes. DA 1 stated the wash temperature gauge displayed 120 degrees Fahrenheit ( F- unit of temperature). However, a photo taken of the gauge at that time showed the temperature reading was 95 F. During an interview on 12/17/2025 at 1:16 p.m. in the kitchen with Dietary Aide (DA 2), DA 2 ran a dishwasher cycle and stated the temperature gauge displayed 110 F. DA 2 further stated that the temperature gauge had not been working since 12/15/2025. During an interview on 12/19/2025 at 11:25 a.m. with Dietary Aide (DA 1), DA 1 stated that the dishwasher temperature gauge had been broken since 12/15/2025. DA 1 admitted she was nervous and provided an inaccurate temperature reading during the previous observation on 12/17/2025. DA 1 further stated that the temperature gauge needs to be functional to ensure proper sanitization and prevent infection. During an interview on 12/19/2025 at 11:32 a.m. with the Dietary Supervisor (DS), the DS stated she contacted maintenance to have the water temperature checked because the dishwasher temperature gauge was broken and the wash cycle readings were above 130 F. The DS confirmed the temperature gauge was broken and stated the facility was waiting for replacement parts to arrive. During an interview on 12/19/2025 at 11:40 a.m. with the Director of Nursing (DON), the DON stated the dishwasher temperature gauge needs to be functional to ensure the correct temperatures were reached to kill germs or microbes (microorganisms are tiny living organisms found in air, water, soil, and the human body). The DON emphasized that proper heat was necessary to sanitize dishes and prevent infection. During a review of Dish Machine Temperature Log dated 12/2025, the Dish Machine Temperature Log indicated instructions for wash temperatures must be at least 120 degrees Fahrenheit. and to run the machine until temperature is at 120 degrees to 140 degrees using infrared gun. During a review of facility's policy and procedure titled Sanitation, revised 11/2022, the P&P indicated, .Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: b. Low-Temperature Dishwasher (Chemical Sanitization): (1) Wash temperature (120 F) . During a review of the facility's P&P, titled, Maintenance Service, date revised 12/2009, the P&P indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe. During a review of the facility's P&P, titled, Dietary Aide (Feeding Assistant), date revised 10/2020, the P&P indicated, Ensure that the department is maintained in a clean and safe manner by assuring that necessary equipment and supplies are maintained.Report all hazardous conditions/equipment to your supervisor immediately. During a review of the facility's P&P, titled Certified Dietary Manager, date revised 10/2020, the P&P indicated, Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly.

Based on observation, interview, and record review, the facility failed to monitor range of motion (ROM-the full movement potential of a joint) for four of nine sampled residents (Residents 58, 15, 38, and 52) who had or were at risk for limited ROM and mobility. The facility failed to:1.Ensure Resident 58 received two quarterly Joint Mobility Screens (JMS-a brief assessment of ROM in both arms and legs) in 5/2025 and 8/2025.2.Ensure Resident 15 received a quarterly JMS in 7/ 2025.3.Ensure Resident 38 received a quarterly JMS in 7/2025.4.Ensure Resident 52 received a quarterly JMS in 5/2025.These failures had the potential for Residents 58, 15, 38, and 52 to develop further ROM limitations in the arms and legs due to the lack of monitoring.1. During a review of Resident 58's admission Record (AR), the AR indicated Resident 58 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side, Type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) with other specified complication. During a review of Resident 58's History and Physical Examination (H&P) dated 11/29/2025, the H&P indicated Resident 58 could make needs known but could not make medical decisions. During a review of Resident 58's Minimum Data Set (MDS, resident assessment tool) dated 11/5/2025, the MDS indicated Resident 58 had severe cognitive impairments (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 58 required partial assistance with eating, oral hygiene, upper body dressing, sit to lying and required substantial assistance with bathing, lower body dressing, sit to stand, and chair to bed transfers. The MDS indicated Resident 58 required supervision assistance with walking 50 feet. The MDS indicated Resident 58 had functional limitations in ROM on both sides of the upper extremity (UE, shoulder, elbow, wrist, hand) and did not have any functional impairments in ROM in the lower extremities ([NAME], hip, knee, ankle, foot). During a review of Resident 58's Care Plan (CP) revised on 11/20/2025, the CP indicated Resident 58 needed a Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) ambulation (walk) program and was at risk for decline in ambulation, at risk for falls, and demonstrated impaired safety judgement for functional mobility. The CP goal indicated Resident 58 will maintain/prevent decline in ambulation status through next review. The CP intervention included to monitor resident's response and tolerance to treatment and RNA to do ambulating using front-wheeled walker (type of mobility aid with wide base of support and two wheels in the front) three times a week as tolerated. During a review of Resident 58's JMS dated 11/4/2025, the JMS indicated Resident 58 had full range of motion in both UE and full range of motion in both [NAME]. There were no other JMS noted in 2025 in Resident 58's medical records. During an observation and interview on 12/18/2025 at 12:05 p.m., Resident 58 was sitting in a wheelchair in the hallway and using both legs to self-propel and move around the hallway. Resident 58 was able to move the left arm, and the right arm was relaxed to the right side. Resident 58 stated he could not move the right arm, and he used the left arm to eat. During a concurrent interview and record review on 12/18/2025 at 1:46 p.m. with the Director of Rehabilitation (DOR), Resident 58's JMS were reviewed. DOR stated there was a JMS completed on 11/4/2025 and stated there were no other JMS completed for Resident 58 in 2025. DOR stated the facility revised their policy to increase JMS on an annual basis to a quarterly basis starting in April 2025. DOR stated Resident 58 should have had two quarterly JMS completed in May 2025 and August 2025, but the JMS were not completed. DOR stated if therapy staff miss a quarterly JMS, there was a potential for staff to miss any ROM declines and provide therapy interventions as needed to restore any ROM declines. During an interview on 12/18/2025 at 3:24 p.m., the Director of Nursing (DON) stated it was important for the facility to monitor resident's ROM so that staff could catch any declines in ROM and mobility and provide any therapy intervention to maintain the resident's mobility and minimize contractures (loss of motion of a joint). During a review of the facility's policies and procedures (P&P) revised May 2025, titled Rehab Screening and Joint Mobility Assessments, the P&P indicated joint mobility assessments should be completed quarterly, annually, and as needed to identify residents with functional changes and/or changes in ROM. 2. During a review of Resident 15's admission Record (AR), the AR indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to stiffness of right hip, stiffness of right knee, stiffness of left hip, stiffness of left knee, contracture (loss of motion of a joint) left elbow, contracture right knee, contracture left knee, contracture right shoulder, contracture left shoulder, contracture right elbow, contracture right hand, contracture left hand, and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 15's History and Physical Examination (H&P) dated 6/2/2025, the H&P indicated Resident 15 did not have the capacity to understand and make decisions. During a review of Resident 15's Minimum Data Set (MDS, resident assessment tool) dated 11/5/2025, the MDS indicated Resident 15 was severely impaired in cognitive skills (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) for daily decision making. The MDS indicated Resident 15 required dependent assistance from staff for oral hygiene, bathing, dressing, rolling, and bed to chair transfers. The MDS indicated Resident 15 had functional limitations in ROM for both sides of the upper extremities (BUE, shoulder, elbow, wrist/hand) and both sides of the lower extremities (BLE, hip, knee, ankle/foot). During a review of Resident 15's Care Plan (CP) initiated on 11/25/2025 for RNA Therapy, the CP indicated Resident 15 needed a therapeutic exercise/ROM Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) program and was at risk for decline in ROM, risk for decreased muscle strength, decreased functional use of extremity, and risk for deformity and contracture (loss of motion in a joint) formation. The CP goal indicated Resident 15 will maintain/prevent decline in ROM through next review. The CP interventions included to monitor resident's response and tolerance to treatment, RNA to do passive range of motion (PROM, movement at a given joint with full assistance from another person) to BLE daily five times per week as tolerated, and RNA to do PROM to BUE daily five times per week or as tolerated. During a review of Resident 15's quarterly JMS dated 10/7/2025, the JMS indicated severe loss in ROM in both hand/fingers, both wrists, both elbows, and both shoulders. The JMS indicated severe loss in ROM in both hips, both knees, and both ankles. The JMS indicated a recommendation for skilled physical therapy and occupational therapy evaluation. During an observation and interview on 12/17/2025 at 10:21 a.m., Resident 15 was lying in bed and did not speak. Resident 15 was observed wearing an elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) on both elbows, the right wrist was bent forward and both hands/fingers were bent and had a blue carrot hand splint inside both hands. Resident 15's right index finger was bent backwards. Resident 15's knees were straight and there was a soft boot on both ankles/feet. During a concurrent interview and record review on 12/18/2025 at 1:46 p.m. with the Director of Rehabilitation (DOR), Resident 15's JMS were reviewed. DOR stated there was a quarterly JMS completed on 11/21/2025 and stated there were no other quarterly JMS completed for Resident 15. DOR stated the facility revised their policy to increase JMS on an annual basis to a quarterly basis starting in April 2025. DOR stated Resident 15 should have had a quarterly JMS completed in July 2025, but the JMS was not completed. DOR stated if therapy staff miss a quarterly JMS, there was a potential for staff to miss any ROM declines and provide therapy interventions as needed to restore any ROM declines. During an interview on 12/18/2025 at 3:24 p.m., the Director of Nursing (DON) stated it was important for the facility to monitor resident's ROM so that staff could catch any declines in ROM and mobility and provide any therapy intervention to maintain the resident's mobility and minimize contractures. During a review of the facility's policies and procedures (P&P) revised May 2025, titled Rehab Screening and Joint Mobility Assessments, the P&P indicated joint mobility assessments should be completed quarterly, annually, and as needed to identify residents with functional changes and/or changes in ROM. 3. During a review of Resident 38's admission Record (AR), the AR indicated Resident 38 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to metabolic encephalopathy (any damage or disease that affects the brain), contracture (loss of motion in a joint) left knee, acute respiratory failure with hypoxia (low oxygen level in tissues). During a review of Resident 38's History and Physical Examination (H&P) dated 11/10/2025, the H&P indicated Resident 38 did not have the capacity to understand and make decisions. During a review of Resident 38's Minimum Data Set (MDS, resident assessment tool) dated 9/23/2025, the MDS indicated Resident 38 was severely impaired in cognitive skills (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) for daily decision making. The MDS indicated Resident 38 required dependent assistance from staff for oral hygiene, bathing, dressing, rolling, and bed to chair transfers. The MDS indicated Resident 38 had functional limitations in ROM for both sides of the upper extremities (BUE, shoulder, elbow, wrist/hands) and both sides of the lower extremities (BLE, hip, knee, ankle/foot). During a review of Resident 38's Care Plan (CP) initiated on 10/29/2025, the CP indicated Resident 38 needed a Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) splinting (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) program and was at risk for decline in ROM, risk for decreased muscle strength, decreased functional use of extremity, and risk for deformity and contracture formation. The CP goal indicated Resident 38 will maintain/improve functional joint alignment and maintain/prevent decline in functional use of extremity through next review. The CP interventions included monitor resident's response and tolerance to treatment, RNA to do apply LUE hand roll (device to keep fingers open) five times a week for six hours, elbow extension splint to both elbows five days a week for six hours, left knee splint five times a week for six hours, right wrist hand finger orthosis five times a week for six hours or as tolerated. During a review of Resident 38's quarterly JMS dated 10/2/2025, the JMS indicated severe loss in ROM in both hand/fingers, both wrists, both elbows, and both shoulders. The JMS indicated moderate loss of ROM in both hips and both ankles and severe loss of ROM in both knees. The JMS indicated a recommendation for RNA program. During an observation and interview on 12/17/2025 at 10:10 a.m., Resident 38 was lying in bed and did not speak. Resident 38 was observed wearing an elbow splint on both elbows, a right wrist hand orthosis, a left handroll, a left knee splint, and green soft boot on both ankles/feet. Resident 38's both elbows were bent and both knees were bent. During a concurrent interview and record review on 12/18/2025 at 1:46 p.m. with the Director of Rehabilitation (DOR), Resident 38's JMS were reviewed. DOR stated there was a quarterly JMS completed on 10/2/2025 and stated there were no other quarterly JMS completed for Resident 38. DOR stated the facility revised their policy to increase JMS on an annual basis to a quarterly basis starting in April 2025. DOR stated Resident 38 should have had a quarterly JMS completed in July 2025, but the JMS was not completed. DOR stated if therapy staff miss a quarterly JMS, there was a potential for staff to miss any ROM declines and provide therapy interventions as needed to restore any ROM declines. During an interview on 12/18/2025 at 3:24 p.m., the Director of Nursing (DON) stated it was important for the facility to monitor resident's ROM so that staff could catch any declines in ROM and mobility and provide any therapy intervention to maintain the resident's mobility and minimize contractures. During a review of the facility's policies and procedures (P&P) revised May 2025, titled Rehab Screening and Joint Mobility Assessments, the P&P indicated joint mobility assessments should be completed quarterly, annually, and as needed to identify residents with functional changes and/or changes in ROM. 4. During a review of Resident 52's admission Record (AR), the AR indicated Resident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting dominant right side, contracture (loss of motion in a joint) right elbow, and contracture right hand. During a review of Resident 52's History and Physical Examination (H&P) dated 11/1/2025, the H&P indicated Resident 38 did not have the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set (MDS, resident assessment tool) dated 11/20/2025, the MDS indicated Resident 52 was severely impaired in cognitive skills (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) for daily decision making. The MDS indicated Resident 52 required dependent assistance from staff for oral hygiene, bathing, dressing, rolling, and bed to chair transfers. The MDS indicated Resident 52 had functional limitations in ROM for both sides of the upper extremities (UE, shoulder, elbow, wrist/hand) and both sides of the lower extremities ([NAME], hip, knee, ankle/foot). During a review of Resident 52's Care Plan (CP) initiated on 10/10/2025, the CP indicated Resident 52 needed a therapeutic exercise/ROM Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) and was at risk for decline in ROM, risk for decreased muscle strength, decreased functional use of extremity, and risk for deformity and contracture formation. The CP goal indicated Resident 52 will maintain/prevent decline in ROM and will show prevention or reduced risk of deformity or contracture progression or formation through next review. The CP interventions included to monitor resident's response and tolerance to treatment, RNA to do active assistive range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) to left [NAME] five times a week, RNA to do passive range of motion (PROM, movement at a given joint with full assistance from another person) to right [NAME] daily five times a week, and RNA to do PROM to right UE daily five times a week as tolerated. During a review of Resident 52's quarterly JMS dated 2/28/2025, the JMS indicated moderate ROM loss in the right hand/fingers, severe loss in ROM in right wrist, right elbow, and right shoulder. The JMS indicated Resident 52 had full ROM in the left hand/fingers, left wrist, left elbow, and left shoulder. The JMS indicated full ROM in both hips, both knees, and both ankles. The JMS indicated a recommendation for an RNA program and skilled occupational therapy evaluation. During a review of Resident 52's quarterly JMS dated 10/16/2025, the JMS indicated full ROM in the right hand/fingers and moderate loss in ROM in right wrist, right elbow, and right shoulder. The JMS indicated Resident 52 had full ROM in the left hand/fingers, left wrist, left elbow, and left shoulder. The JMS indicated full ROM in both hips, both knees, and both ankles. The JMS indicated a recommendation for an RNA program for BLEs and was on skilled occupational therapy services. During an observation and interview on 12/17/2025 at 11:06 a.m., Resident 52 was lying in bed and did not speak. Resident 52 was observed wearing a right elbow and right wrist/hand splint. Resident 52's left elbow was bent about halfway, wrist was straight, and the fingers relaxed. During a concurrent interview and record review on 12/18/2025 at 1:46 p.m. with the Director of Rehabilitation (DOR), Resident 52's JMS were reviewed. DOR stated there was a quarterly JMS completed on 2/28/2025 and stated there was another quarterly JMS completed on 10/16/2025. DOR stated the facility revised their policy to increase JMS on an annual basis to a quarterly basis starting in April 2025. DOR stated Resident 52 should have had a quarterly JMS completed in May 2025, but the JMS was not completed. DOR stated if therapy staff miss a quarterly JMS, there was a potential for staff to miss any ROM declines and provide therapy interventions as needed to restore any ROM declines. During an interview on 12/18/2025 at 3:24 p.m., the Director of Nursing (DON) stated it was important for the facility to monitor resident's ROM so that staff could catch any declines in ROM and mobility and provide any therapy intervention to maintain the resident's mobility and minimize contractures. During a review of the facility's policies and procedures (P&P) revised May 2025, titled Rehab Screening and Joint Mobility Assessments, the P&P indicated joint mobility assessments should be completed quarterly, annually, and as needed to identify residents with functional changes and/or changes in ROM.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 113) was assessed, and that the physician was notified when Resident 113 experienced a significant change of condition (COC- a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff) of low blood pressure. This failure resulted in Resident 113's low blood pressure going unnoticed by licensed staff, placing the resident at risk for adverse outcomes.Findings:During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of but not limited to hypertension (HTN-high blood pressure), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 113's Care Plan, titled Hypertension, revised 11/19/2025, the Care Plan indicated Resident 113 was at risk for fluctuating blood pressure. The Care plan indicated to monitor, document, and report side effects such as orthostatic hypotension.( a sudden drop in blood pressure when standing up from sitting or lying down, causing dizziness, lightheadedness, or fainting). During a review of Resident 113's Minimum Data Set (MDS-a resident assessment tool), dated 11/28/2025, the MDS indicated Resident 113 had the ability to express ideas and wants. The MDS indicated Resident 113 usually understands verbal content. The MDS indicated Resident 113 was dependent on nursing staff for eating, oral hygiene, toileting, showering dressing, and transferring. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 2), Resident 113's blood pressure reading dated 11/26/2025, 11/27/2025 and 11/28/2025 were reviewed. Resident 113's blood pressure readings indicated on: 11/26/2025 at 4:20 p.m. the blood pressure was 90 / 62 millimeters per mercury (mmHg-unit of measurement) 11/26/2025 at 4:43 p.m., blood pressure was 90 / 62 mmHg11/27/2025 1:34 a.m. blood pressure was 94 / 62 mmHg11/27/2025 3:48 a.m. blood pressure was 100 / 66 mmHg11/27/2025 8:22 a.m. blood pressure was 108 / 64 mmHg11/27/2025 8:45 a.m. blood pressure was 108 / 64 mmHg11/27/2025 1:04 p.m. blood pressure was 104 / 66 mmHg11/27/2025 4:27 p.m. blood pressure was 99 / 72 mmHg11/27/2025 6:18 p.m. blood pressure was 100 / 70 mmHg11/28/2025 2:48 a.m. blood pressure was 100 / 70 mmHgLVN 2 stated licensed nursing staff should immediately notify Resident 113's physician if systolic blood pressure was below 110, or diastolic blood pressure was below 90. LVN 2 stated the licensed nurses should document an SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition for low blood pressure. LVN 2 stated there was no documentation to indicate Resident 113's physician was notified and no documentation to indicate Resident 113 had a change of condition. LVN 2 stated licensed staff should notify physician to know the plan of care for Resident 113. LVN 2 stated low blood pressure can cause sleepiness, compromise breathing, or cause the residents to faint. During a concurrent interview and record review conducted on 12/19/2025 at 9:14 a.m. with Registered Nurse Supervisor (RNS 2), RNS 2 stated that there was no documentation of an SBAR or a change of condition for Resident 113's low blood pressure, and the physician was not notified. RNS 2 stated low blood pressure constitutes a change of condition and without intervention, the resident could experience symptoms such as dizziness and lethargy, and the blood pressure could continue to decrease. During an interview on 12/19/2025 at 11:44 a.m. with the Director of Nursing (DON), the DON stated that on 11/26/2025 the resident's blood pressure should have been reassessed, and the physician should have been notified. The DON stated the SBAR tool was used to assess and monitor any change of condition and to communicate with physicians for medication adjustments or discontinuations as needed. During a review of the facility's policy and procedures (P&P), titled Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 18) by not addressing Resident 18's toenail fungus (a fungal infection below the surface of the nail) in the care plan.This deficient practice had the potential to negatively impact the delivery of necessary care and services for Resident 18.Findings:During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs) and osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage). During a review of Resident 18's Minimum Data Set (MDS- a resident assessment tool) dated 11/6/2025, the MDS indicated Resident 18's cognition (ability to think, learn, and remember) was severely impaired and Resident 18 required maximum (helper does more than half the effort) assistance with toileting and showering. During a review of Resident 18's Podiatrist (foot doctor) Note dated 10/23/2025, the Podiatrist Note indicated Resident 18 had onychomycosis (a fungal infection of the nail unit) and onychodystrophy (deformity of the toenails). During an observation on 12/16/2025 at 12:56 p.m., in Resident 18's room, Resident 18 was noted to have yellow, crusty, and thick toenails of all 10 toes. During a concurrent interview and record review on 12/18/2025 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated she was familiar with Resident 18 but was not aware of the resident's toenail fungus. LVN 4 stated there was no care plan addressing the condition and stated that a care plan should be in place for Resident 18's toenail fungus to ensure follow-up on interventions and monitor their effectiveness. During a concurrent interview and record review on 12/19/2025 at 8:06 a.m. with Registered Nurse Supervisor (RNS) 2, RNS 2 reviewed Resident 18's Podiatrist Notes and confirmed the resident had onychomycosis. RNS 2 stated there should be a care plan in place for this condition. RNS 2 stated a care plan was important so staff can monitor and assess Resident 18 for improvement or worsening of the toenail fungus. During an interview on 12/19/2025 at 8:55 a.m. with the Director of Nursing (DON), the DON stated care plans address problems with goals, interventions, and monitoring for improvement. The DON stated there should be a care plan in place for Resident 18's toenail fungus so staff could assess and monitor for improvement or worsening of the Resident 18's toenail fungus. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated 12/2026, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

Based on observation, interview, and record review, the facility failed to initiate a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) process for one of four sampled residents (Resident 106), when Resident 106 reported pain in his left shoulder.This failure had the potential for Resident 106's pain to remain uncontrolled, affecting comfort and quality of life.Findings:During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was admitted to the facility on [DATE] with the diagnosis including encephalopathy (damage or disease that affects the brain), anemia (a condition where the body does not have enough healthy red blood cells) and dementia (a progressive state of decline in mental abilities).During a review of Resident 106's History & Physical (H&P) dated 8/22/2025, the H&P indicated Resident 106 was alert and oriented.During a review of Resident 106's Minimum Data Set (MDS-resident assessment tool) dated 11/26/2025. The MDS indicated Resident 106 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS also indicated Resident 106 needed setup or clean up assistance (helper sets up or cleans up resident completes activity) with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 106's Order Summary Report dated 12/19/2025. The Order Summary Report indicated Resident 106 was started on diclofenac sodium ( used for temporary relief of arthritis [joint inflammation causing pain, swelling, and stiffness] pain in specific joints like hands, wrists, elbows, feet, ankles, and knees ) external gel 1% apply to neck, left upper shoulder and right upper shoulder apply two times a day for pain management started date 12/11/2025.During a concurrent observation and interview on 12/16/2025 at 12:09 p.m. with Resident 106 in the dining room. Resident 106 was observed rubbing his left shoulder. Resident 106 stated his shoulder was hurting bad and the cream they were putting on wasn't working. Resident 106 stated he needed something stronger. During a concurrent interview and record review on 12/17/2025 at 2:49 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 106's Order Summary Report dated 12/19/2025 was reviewed. LVN 2 stated Resident 106 was started on diclofenac sodium 1% external gel (a topical medication applied to the skin) to the neck, left upper shoulder, and right upper shoulder, to be applied twice daily for pain management beginning on 12/11/2025. LVN 2 stated a change of condition (COC) should be initiated when a resident was experiencing pain and a new medication was started to ensure the medication was effective and the resident was tolerating it. LVN 2 stated there was no COC documented and stated one should have been completed on 12/11/2025 when diclofenac was started. LVN 2 stated that without a COC, licensed nurses could not adequately monitor the effectiveness of the medication, placing Resident 106 at risk for unmanaged pain. During an interview on 12/19/2025 at 9:05 a.m. with the Director of Nursing (DON), the DON stated she was aware that Resident 106 was started on diclofenac on 12/11/2025 for pain management and confirmed that no change of condition (COC) was completed. The DON stated that a COC should have been initiated when Resident 106 was experiencing pain to ensure the resident was tolerating the medication and that it was effective in managing pain. The DON further stated that without this process, Resident 106's comfort level was at risk of being compromised. During a review of Resident 106's care plan titled At Risk for Alteration in Comfort, the care plan indicated Resident 106 was receiving Diclofenac Gel 1% as ordered. The care plan interventions indicated to monitor and document the probable cause of each pain episode and remove or limit contributing factors where possible. During a review of the facility's Policy and Procedure (P&P) titled Change in a Resident's Condition or Status, dated 2001. The P&P indicated our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Unless otherwise instructed by the resident, a nurse will notify the resident's representative. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.

Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents 84 and 113) were free from significant medication errors. The facility failed to:1.Ensure Resident 84's lidocaine patch (a medication used for localized pain relief) was removed at the scheduled time.This failure had the potential to expose Resident 84 to prolonged medication absorption and increase the risk of adverse reactions, which could lead to a decline in the resident's ability to perform activities of daily living.2.Ensure Resident 113 did not receive medication for heart failure when the resident's systolic blood pressure was less than 110 millimeters per mercury (mmHg-unit of pressure), as required by the physician's order to hold the medication if systolic blood pressure was below 110 mmHg.This failure had the potential to cause Resident 113 to experience adverse effects such as weakness, dizziness, fainting, lightheadedness, blurred vision, nausea, and difficulty concentrating. Findings: During a review of Resident 84's admission Record (Face Sheet), the admission Record indicated the facility admitted Resident 84 on 12/13/2024 and was readmitted on [DATE] with diagnoses including cellulitis (a skin infection that causes swelling and redness) of left upper limb, pain in left wrist, pain in right leg, and intervertebral disc degeneration (breakdown of the cushions between the bones of the spine) lumbar (lower back) region with lower extremity (legs, from the hip to the foot) pain only. During a review of Resident 84's History and Physical (H&P) dated 12/14/2024, the H&P indicated Resident 84 had the capacity to understand and make decisions. During a review of Resident 84's Minimum Data Set (MDS – a resident assessment tool) dated 9/16/2025, the MDS indicated Resident 84 had severe problems with thinking and memory. The MDS indicated Resident 84 was independent with eating, needed setup or clean up assistance with oral hygiene, maximal assistance (helper does more than half of the effort to complete the activity) with toileting, showering, and lower body dressing, supervision or touching assistance (helper provides verbal cues and or touching steadying and or contact guard assistance as resident completes activity) with upper body dressing, and dependent assistance (helper does all of the effort to complete the activity) with putting on or taking off footwear. During a review of Resident 84's physician order dated 7/1/2025, the physician order indicated, Lidocaine External Patch 5% (Lidocaine) Apply to L (Left) and R (Right) knee topically one time a day for pain management Apply 1 patch to right knee and 1 patch to left knee and remover per schedule. During an observation on 12/18/2025 at 8:06 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 84's room, Resident 84 had lidocaine patches on both right and left knee dated 12/17/2025. LVN 1 removed the old lidocaine patches and applied new lidocaine patches. During a concurrent interview and record review on 12/18/2025 at 9:46 a.m. with LVN 1, Resident 84's medication administration record (MAR) for 12/2025 was reviewed. The MAR indicated, on 12/17/2025 at 9:00 p.m. the lidocaine patch was removed. LVN 1 stated Resident 84's lidocaine patch was removed on 12/17/2025 at 9:00 p.m. LVN 1 stated the nurse documented the removal of the patches but did not remove the patches. LVN 1 stated the afternoon nurse should have removed the patches, if the lidocaine patches were applied for extended periods, the patches would lose effectiveness, and the resident will not have pain relief due to increased tolerance to the medication. During an interview on 12/18/2025 at 3:00 p.m. with LVN 3 for lidocaine patches, LVN 3 stated she should not have clicked the MAR to document the removal before removing the patches. LVN 3 stated the importance of removing lidocaine patches at the scheduled time per physician's order was to ensure the resident does not obtain skin irritation or breakdown and the resident does not develop tolerance to the medication and experience prolonged side effects. During an interview on 12/18/2025 at 3:15 p.m. with the Director of Nursing (DON) for lidocaine patches, The DON stated lidocaine patches should be removed by the afternoon shift. The DON stated it is important to remove the lidocaine patches to protect the skin from irritation and breakdown and to ensure the lidocaine patches would have the same effect to the resident when the patches were reapplied. The DON stated if the lidocaine patches were left on the resident for extended periods there would be potential for skin irritation or breakdown, and the resident would build tolerance to the medication and the resident would not have pain relief to perform daily activities. During a review of the facility's policy and procedures (P&P) titled Administering Medications dated 2001, the P&P indicated .4. Medication are administered in accordance with prescriber orders, including any required time frame. 2. During a review of Resident 113's admission Record, the admission Record indicated Resident 113 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of but not limited to hypertension (HTN-high blood pressure), heart failure (heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 113's Order Summary Report, the Order Summary Report indicated on 11/15/2025 Resident 113 had an order for spironolactone (medication used to treat heart failure and blood pressure related conditions) 25 milligram (mg- metric unit of measurement) give one tablet by mouth in the morning for heart failure, hold if the systolic blood pressure is less than 110 mmHg. During a review of Resident 113's Care Plan, titled Hypertension, dated revised 11/19/2025, the Care Plan indicated Resident 113 was at risk for fluctuating blood pressure. The Care plan indicated to monitor, document, and report side effects such as orthostatic hypotension (a sudden drop in blood pressure when standing up from sitting or lying down, causing dizziness, lightheadedness, blurred vision, or fainting) . During a review of Resident 113's Care Plan, dated 11/25/2025, the Care Plan indicated, Resident 113 is on diuretic (water pill) therapy spironolactone medication related to heart failure. The Care Plan indicated Resident 113 was at risk for hypotension (low blood pressure) . The Care Plan indicated to monitor, document, report as needed adverse reactions to diuretic therapy including dizziness, postural hypotension, fatigue, and increased risk for fall. During a review of Resident 113's Minimum Data Set (MDS-a resident assessment tool), dated 11/28/2025, the MDS indicated Resident 113 had the ability to express ideas and wants. The MDS indicated Resident 113 usually understands verbal content. The MDS indicated Resident 113 was dependent on nursing staff for eating, oral hygiene, toileting, showering, dressing, and transferring. During a record review with Licensed Vocational Nurse (LVN 2), Resident 113's blood pressure readings dated 11/26/2025, 11/27/2025 and 11/28/2025 were reviewed. Resident 113's blood pressure reading indicated on: 11/21/2025 at 10:08 a.m. blood pressure was 105/67 mmHg 11/27/2025 8:45 a.m. blood pressure was 108 /64 mmHg During a concurrent interview and record review on 12/19/2025 at 9:14 a.m. with Registered Nurse Supervisor (RNS 2), Resident 113's Medication Administration Record (MAR) dated 11/2025 was reviewed. The MAR indicated that on 11/21/2025 and 11/27/2025 at 9:00 a.m., Resident 113 received spironolactone 25 mg by mouth in the morning for heart failure, despite a physician order to hold the medication if systolic blood pressure was less than 110 mmHg. RNS 2 stated spironolactone was administered on those dates and stated, licensed nurse should not give spironolactone because the systolic blood pressure was below 110 mmHg. RNS 2 further stated that administering the medication under these conditions could cause Resident 113 to experience dizziness, nausea, vomiting, headaches, and lethargy. During an interview on 12/19/2025 at 11:44 a.m. with the Director of Nursing (DON), the DON stated on 11/21/2025 and 11/27/2025, Resident 113's blood pressure should have been reassessed and the physician notified. The DON stated medication parameters (specific, measurable instructions that guide the appropriate administration and monitoring of a drug to ensure effectiveness and safety) were in place, so licensed staff know which medications to administer and which to hold. The DON stated that if spironolactone was given when the resident's blood pressure was low, the resident could experience negative effects such as dizziness, lightheadedness, headaches, and fatigue, and the blood pressure could decrease further. During a review of the facility's policy and procedures (P&P), titled Administering Medications, dated 4/2029, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame.The following information is checked/verified for each resident prior to administering medications are allergies to medications and vital signs, if necessary.

Based on observation, interview and record review, the facility failed to ensure the two dryers' gas hoses connected to the gas line were intact and free from leaks.This failure had the potential to increase the risk of fire or carbon monoxide exposure to residents which could result in injury or harm. Findings:a. During a concurrent observation and interview on 12/17/2025 at 10:45 a.m. with Laundry Aid (LA) 1 in the laundry room, the laundry room had a strong pungent distinct odor. LA 1 stated she did not smell any odor that was different from any other chemicals used for laundering. LA 1 stated if a gas leak was suspected, she would stop the dryers, turn off the gas supply and report it to the maintenance supervisor.During an interview on 12/17/2025 at 10:45 a.m. with the Administrator (ADM)in the laundry room, the ADM stated she smelled a slight odor like gas in the laundry room.During an interview on 12/17/2025 at 12:20 p.m. with the ADM, the ADM stated the gas company was contacted and found minimal leaks in three different areas of the hoses connected to the dryers prior to the gas shut off valve connected to the gas line. The ADM stated the laundry room gas line was separate from the kitchen gas line and leaks were not on the main gas line.During an interview on 12/17/2025 at 12:30 p.m. with the ADM, the dryers were not in use until the local gas company cleared the facility to use the dryers.During an interview on 12/19/2025 at 11:45 a.m. with the Maintenance Supervisor (MS), the MS stated the leak was on the hoses connected to the dryers and not the main gas line. The MS stated he turned off the gas supply as there was a gas valve prior to the hoses connected to the dryers. The MS stated since he was not certified nor had the tools to test for gas leaks, he turned off the gas and informed the Administrator.During a concurrent interview and record review on 12/19/2025 at 11:50 a.m. with the ADM, the ADM stated the importance of making sure the dryer hoses were being checked was to ensure dryers remain functional to supply linen and clothes to the residents and to ensure residents, staff, and visitors would not be exposed to odorless gas that may result in injury or harm.During a review of the facility's policy and procedure (P&P) titled Natural Gas Emergencies dated 12/22/2023, the P&P did not indicate procedures to prevent and monitor for potential gas leak in the facility.

Based on interview and record review, the facility failed to implement its abuse prevention policy when they did not report an unusual occurrence of an acute new distal femur fracture (a break in the lower part of the thighbone, near the knee joint) of unknown cause to the State Survey Agency (California Department of Public Health - CDPH) within 24 hours of the occurrence, for one of the three sampled residents (Resident 1). This failure had the potential for resident harm and/or death, due to CDPH ' s inability to promptly investigate the possibility of resident abuse in the facility. This delayed CDPH response to ensure Resident 1 was safe and free from possible abuse and/or mistreatment in the facility and had the potential for other unusual occurrences to go unreported. Findings: During a review of Resident 1 ' s admission Record (the front page of the chart that contains a summary of basic information about the resident), dated 5/19/2025, the admission Record indicated, the facility originally admitted Resident 1 on 2/28/2024, then re-admitted Resident 1 on 5/8/2025, with diagnoses that included age-related osteoporosis (weak and brittle bones due to lack of calcium and vitamin D) without current pathological fracture (broken bone caused by disease), dementia (a progressive state of decline in mental abilities), and contracture of the right knee (the tissues around the joint have become stiff or tight, limiting the knee's ability to move freely). During a review of Resident 1 ' s History and Physical, dated 5/9/2025, the H&P indicated Resident 1 did not have the capacity to understand nor make decisions. During a review of Resident 1 ' s Minimum Data Set, (MDS — a federally mandated resident assessment tool), dated 2/24/2025, the MDS indicated, Resident 1 was dependent on assistance (helper performs all the effort. Resident did none of the effort to complete the activity. Or the assistance of two or more helpers was required for the resident to complete the activity). During a review of Resident 1 ' s Radiology Result Report X-ray (a photograph of the internal composition of a body part) of the right knee, dated 5/4/2025, the report indicated Resident 1 had an acute mildly displaced supracondylar fracture of the distal femur. During a review of Resident 1 ' s Progress Notes, dated 5/6/2025, the documentation indicated the results of Resident 1 ' s X-ray were reported to the facility on 5/4/2025. During a review of the facility ' s fax transmittal document, dated 5/7/2025, the document indicated the facility reported the unusual occurrence regarding Resident 1 to CDPH on 5/7/2025 at 8:51 p.m. During an interview on 5/19/2025 at 3:27 p.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated the results of Resident 1 x-ray should have been reported to CDPH within 24 hours of the facility becoming aware of the results. RNS 1 stated the failure to report unusual occurrences or test results within the required timeframe could have further jeopardized Resident 1 ' s well-being. During a concurrent interview and record review on 5/19/2025 at 3:27 p.m. with the Director of Nursing (DON), the fax transmittal document, dated 5/7/2025, and Resident 1 ' s Radiology Result Report X-ray, dated 5/4/2025, were each reviewed. The DON stated Resident 1 ' s x-ray results should have been reported to CDPH as soon as the facility became aware of the results and no later than 24 hours. The DON stated unusual occurrences should be reported as soon as possible, but not later than 24 hours. The DON stated the results of Resident 1 ' s x-ray were not reported to CDPH until 5/7/2025 but should have been sent on 5/5/2025 instead. During a review of the facility ' s policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation — Reporting and Investigating, revised 3/24/2025, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported: . 5. Immediately is defined as:a. within two hours of an allegation involving abuse or resulting in physical harm/serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in physical harm/serious bodily injury. During a review of the facility ' s policy and procedure titled, Unusual Occurrence Reporting, revised 12/2007, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors: . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations.

Based on observation, interview, and record review the facility failed to ensure kitchen staff including the dietary supervisor assistant (DSA) and dietary aide (DA 1) were competent regarding their food thawing policies. These deficient practices had the potential to result in pathogen (germ) exposure and placed 99 out of 106 total residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps (a type of abdominal pain that feel like contractions and can vary in intensity, nausea (a feeling of sickness or discomfort in the stomach that may come with an urge to vomit), vomiting (stomach pain with urge to expel contents through the mouth) , diarrhea (Loose, watery stools that occur more frequently than usual), and fever (elevated body temperature indicating illness) and can lead to other serious medical complications and hospitalization . Findings: During an observation on 10/30/2024 at 11:02 a.m., there was a box of frozen chicken sitting by the food preparation sink in the kitchen, the chicken appeared to have soft pliable skin and appeared partially thawed. The cardboard box had become wet from the thawing chicken juice. The dietary supervisor assistant (DSA) informed dietary aide (DA 1) that they were no longer going to use the chicken for the next day. The DSA instructed DA 1 to place the chicken back into the main freezer located outside of the kitchen. During an observation on 10/30/2024 at 11:09 a.m., DA 1 placed the partially thawed box of chicken back into the facility's main freezer. During an observation on 10/30/2024 at 11:18 a.m., the DSA instructed staff to remove the partially thawed chicken from the facility's main freezer and place it back into the food preparation sink for thawing. During an observation on 10/30/2024 at 11:27 a.m., the chicken that was thawing in the food preparation sink on 10/30/2024 at 11:02 a.m., for thawing, was now sitting in the food preparation sink again to continue thawing without running water over it. During an observation on 10/30/2024 at 11:30 a.m., the DSA walked over to the food preparation sink and turned the water on to run over the thawing chicken. During an observation on 10/30/2024 at 11:31 a.m., the dietary supervisor (DS) came into the kitchen and stated, I told you people that you can't refreeze chicken. During an interview on 10/30/2024 at 11:33 a.m., the DS stated when the kitchen staff decided they were no longer going to use the chicken for the intended meal they should have placed the partially thawed chicken into the refrigerator to continue thawing (good for 3 days) instead of placing the chicken back into the freezer. During an interview on 11/1/2024 at 1:51 p.m., DA 1 stated thawed items should never be put back in the freezer but she did not want to question her supervisor (DSA)'s orders. During an interview on 11/1/2024 at 1:59 p.m., the DSA stated they were not allowed to put partially thawed items back in the freezer (unknown reason why it was done on 10/30/2024). The DSA stated food could not just sit in the sink to thaw, it had to be under running water. The DSA stated if food was not thawed properly there was the potential outcome of food contamination because bacteria begin to grow on the food. During a review of the facility's policy and procedure (P/P) titled Food Receiving and Storage dated 11/2022, the P/P indicated refrigerated foods were to be labeled, dated and monitored so they are used by their use-by date. Frozen foods were to be maintained at a temperature to keep food frozen solid. During a review of the facility's P/P titled Food Preparation and Service dated 11/2022, the P/P indicated food was not to be thawed at room temperature and food being thawed by water need to be completely submerged in cold running water that is running fast enough to agitate and remove loose ice particles. During A review of the 2022 U.S. Food and Drug Administration food Code, Code # 3-501.11 Frozen Food; 3.501.12 Time/Temp Control for Safety Food, Slacking and 3-501.13 Thawing, Indicated, Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful number and produce toxins. If the food is then refrozen, significant number of bacteria and toxins are preserved.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope [a scientific magnifying device]) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated [something that has been made impure or unfit for use by contact with something harmful] food for 99 out 106 total residents in the facility by not ensuring: a.Cottage cheese in the reach-in refrigerator was not past the use by date. b.The temperature log for the walk-in refrigerator was filled out twice daily c. Food such as raw chicken and frozen waffles were not thawed and then returned to the freezer. d.Proper thawing techniques by not having running water over thawing chicken in the sink. e.The facility ice machine was maintained in a clean and sanitary way. f. There was a cleaning log kept for the upper portion of the ice machine. These deficient practices had the potential to result in pathogen (an organism that can cause illness) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps (a type of abdominal pain that feel like contractions and can vary in intensity, nausea (a feeling of sickness or discomfort in the stomach that may come with an urge to vomit), vomiting (stomach pain with urge to expel contents through the mouth) , diarrhea (Loose, watery stools that occur more frequently than usual), and fever (elevated body temperature indicating illness) and can lead to other serious medical complications and hospitalization . Findings: During an observation on 10/29/2024 at 8:47 a.m., with the dietary supervisor (DS), the reach in refrigerator contained a container labeled cottage cheese and labeled with a use by date of 10/27/2024. During an observation and concurrent interview on 10/29/2024 at 8:52 a.m., with the DS, the facility's main freezer located outside of the kitchen contained frozen Waffles that were thawed for breakfast that morning and then placed back in the refrigerator after not being used. The DS stated it was not facility procedure to put thawed items back into the freezer. During an observation on 10/30/2024 at 11:02 a.m., there was a box of frozen chicken sitting by the food preparation sink in the kitchen, the chicken was partially thawed. The cardboard box had become wet from the thawing chicken juice. The dietary supervisor assistant (DSA) informed dietary aide (DA 1) that they were no longer going to use the chicken for the next day and if DA 1 could place the chicken back into the main freezer located outside of the kitchen. During an observation on 10/30/2024 at 11:09 a.m., DA 1 placed the partially thawed box of chicken back into the facility's main freezer. During an observation on 10/30/2024 at 11:18 a.m., the DSA instructed staff to remove the partially thawed chicken from the facility's main freezer and place it back into the food preparation sink for thawing. During an observation on 10/30/2024 at 11:21 a.m., the temperature log for the walk-in refrigerator was missing the documented temperature for the morning of 10/30/2024. During an observation on 10/30/2024 at 11:27 a.m., the chicken that was thawing in the food preparation sink for thawing was now sitting in the food preparation sink to continue thawing without running water over it. During an observation on 10/30/2024 at 11:30 a.m., the DSA walked over to the food preparation sink and turned the water on to run over the thawing chicken. During an observation on 10/30/2024 at 11:31 a.m., the DS came into the kitchen and stated, I told you people that you can't refreeze chicken. During an interview on 10/30/2024 at 11:33 a.m., the DS stated when the kitchen staff decided they were no longer going to use the chicken for the intended meal they should have placed the partially thawed chicken into the refrigerator to continue thawing (good for 3 days) instead of placing the chicken back into the freezer. During an observation and concurrent interview on 10/31/2024 at 12:10 p.m., the maintenance supervisor (MS) opened the top panel of the ice machine. There was dust around the edges of the ice machine behind the upper panel and covering the inside of the upper portion of the ice machine. A black substance was growing where condensation (water which collects as droplets on a cold surface when humid air is in contact with it) was collecting on the water lines in the upper portion of the ice machine. The MS stated it was a black substance growing in the upper portion of the ice machine and there was a layer of dust in there. The maintenance supervisor stated he cleaned the upper portion of the ice machine every 6 months, but he did not keep record of the cleaning log when he performed the cleaning. During an interview on 11/1/2024 at 1:51 p.m., DA 1 stated all items in the refrigerator past the use by date needed to be thrown out and it was everyone's responsibility to check the dates. DA 1 stated thawed items should never be put back in the freezer but she did not want to question her supervisor (DSA)'s orders. During an interview on 11/1/2024 at 1:59 p.m., the DSA stated she saw the upper portion of the ice machine when the MS opened it on 10/31/2024 and it was dirty, she saw dust and dark colors in there. The DSA stated it was facility policy to clean the upper portion of the ice machine at least every 6 months and there should have been a log to keep track of the cleaning frequency because if there was no record they would not know how frequently the ice machine was being cleaned. The DSA stated there was a potential that cross-contamination for the ice if the upper portion of the ice machine was dirty. The DSA stated it was important to ensure items were not past the use by date to protect the residents from food poisoning. The DSA stated it was important to check the temperature logs for the refrigerator to ensure it was functioning properly and the food would not spoil. The DSA stated they were not allowed to put partially thawed items back in the freezer (unknown reason why it was done on 10/30/2024). The DSA stated food could not just sit in the sink to thaw, it had to be under running water. The DSA stated if food was not thawed properly there was the potential outcome of food contamination because bacteria begin to grow on the food. During an interview on 11/1/2024 at 4:45 p.m., the infection preventionist nurse (IPN) stated if the upper portion of the ice machine was not clean, there was a potential that residents could get sick. The IPN stated if there was no cleaning log for the upper portion of the ice machine, there was no evidence that it had ever been cleaned. During a review of the facility's policy and procedure (P/P) titled Ice Machines and Ice Storage Chests undated, the P/P indicated information regarding the cleaning and care of the ice machine was to be obtained in the owner's manual. During a review of the user's manual for the Ice Machine Installation and User's [NAME] undated, the user's manual indicated the ice machine should be cleaned and sanitized every six months or more frequently as needed. During a review of the facility's P/P titled Food Receiving and Storage dated 11/2022, the P/P indicated refrigerated foods were to be labeled, dated and monitored so they are used by their use-by date. Frozen foods were to be maintained at a temperature to keep food frozen solid. During a review of the facility's P/P titled Food Preparation and Service dated 11/2022, the P/P indicated food was not to be thawed at room temperature and food being thawed by water need to be completely submerged in cold running water that is running fast enough to agitate and remove loose ice particles. During A review of the 2022 U.S. Food and Drug Administration food Code, Code # 3-501.11 Frozen Food; 3.501.12 Time/Temp Control for Safety Food, Slacking and 3-501.13 Thawing, Indicated, Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful number and produce toxins. If the food is then refrozen, significant number of bacteria and toxins are preserved.

45891 Based on observation, interview, and record review, the facility failed to ensure the clinical records were complete and accurately documented by: a. failing to ensure the documentation for one out of six sampled residents (Resident 84) related to Resident 84's intravenous (IV, administered into a vein) access and IV fluids (liquids that are injected into a vein to prevent or treat dehydration [occurs when the body loses more fluids than it takes in]) was accurate. This deficient practice had the potential to reflect inaccurate hydration for Resident 84 b.failing to ensure one of eight sampled residents (Resident 49) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns had complete clinical records for the provision of Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) services. This failure resulted in Resident 49's records being incomplete regarding the provision of RNA in April 2024. Findings: a.During a review of Resident 84's admission record, the admission record indicated Resident 84 was admitted to the facility 8/9/2024 with diagnoses of seizures (a temporary episode of abnormal electrical activity in the brain that causes a sudden change in behavior, movement, or consciousness), acute kidney failure (a sudden loss of kidney function that can be life-threatening if left untreated), and nontraumatic intracerebral hemorrhage (bleeding in the brain). During a review of Resident 84's minimum data set (MDS, a federally mandated resident assessment tool) dated 8/13/2024, the MDS indicated Resident 84 had severe cognitive (ability to make decisions of daily living) impairment. During a review of Resident 84's Situation, Background, Assessment, and Recommendation (SBAR) Communication Form dated 10/28/2024, the SBAR indicated Resident 84 had inadequate hydration with elevated blood urea nitrogen (BUN, a blood test related to kidney function) and creatinine (a blood test related to kidney function). During a review of Resident 84's Physician's orders, the Physician's orders indicated IV fluids and IV site access was ordered on 10/28/2024, the orders read: 1). 1/2 Normal Saline (a solution used to treat cellular dehydration) at 40 milliliters (ml, a unit of measurement of volume) per hour for 500 ml only, for elevated BUN and creatinine every shift for 1 day. 2.) monitor IV access site based on phlebitis scale (measures any signs of irritation at the IV access site). The Physician's orders indicated the 1/2 NS hydration solution to be completed on 10/29/2024 at 8:49 a.m. During a review of Resident 84's Post change of condition (COC)/ SBAR note dated 10/30/2024 at 9:54 p.m., the note indicated Resident 84 was on monitoring for elevated BUN/ creatinine and Resident 84 continued to have 1/2 NS running at 40 ml/ hr. in the left upper arm (LUA) and it was infusing well. The note indicated Resident 84's IV site was intact (in place) and was not swollen or bleeding. There was another COC/SBAR note dated 10/31/2024 at 7:10 a.m., indicating Resident 84 was still on IV fluids for hydration and the IV site in the LUA was intact, this information was struck out (removed from documentation) on 10/31/2024 at 11:24 p.m. due to error in documentation. During a review of Resident 84's Nurse Progress Note dated 10/31/2024 at 11:55 a.m., the progress note indicated it was a late entry note (entered at a later time) for 10/29/2024 at 11:00, the note indicated Resident 84's IV fluids were completed, and the treatment nurse (TXN 1) removed the IV site from the LUA. During an observation on 10/30/2024 at 9:33 a.m., Resident 84 was in bed with no IV fluids infusing at bedside and no IV access. During an observation on 10/31/2024 at 10:20 a.m., Resident 84's body was assessed by licensed vocational nurse (LVN 6), LVN 6 stated Resident 84 did not have IV access and there was only a gauze (a thin, loosely woven fabric) dressing covering the old IV access site. During a concurrent interview and record review on 10/31/2024 at 10:28 a.m., with registered nurse supervisor (RNS 1) of Resident 84's post COC/SBAR notes from 10/20/2024 and 10/31/2024, RN 1 stated Resident 84 completed his IV fluid infusion on 10/29/2024 and his IV access was removed the same day. RNS 1 stated Resident 84's post COC/ SBAR notes from 10/30/2024 and 10/31/2024 documentation was inaccurate because he did not have IV access or IV hydration anymore. RNS 1 stated it was important to have accurate documentation because if he still had IV access it was a risk for infection (IV access only good for 72 hours before needing to change site) and it was important to reflect accurate hydration. RNS 1 stated the inaccurate documentation suggested that the licensed nurses were not doing a complete assessment on Resident 84's body. During an interview on 11/1/2024 at 3:51 p.m., the director of nursing (DON) stated the importance of accurate documentation was to reflect the residents actual care and needs. b.During a review of Resident 49's Admission Record, the Admission Record indicated the facility initially admitted Resident 49 on 12/11/2019 and readmitted the resident on 7/15/2023. The Admission Record indicated Resident 49's diagnoses included dementia (a progressive state of decline in mental abilities), functional quadriplegia (paralysis from the neck down, including the arms and legs), and contractures (stiffening/shortening at any joint that reduces the joint's range of motion) in both shoulders, left elbow, and both hands. During a review of Resident 49's physician orders, dated 7/25/2023, the physician orders indicated for the RNA to perform passive range of motion (PROM) to both legs except the right knee, five times per week as tolerated. A review of Resident 49 physician orders, dated 7/31/2023, indicated for the RNA to perform PROM to both arms, five times per week, to apply both elbow extension splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) for four to six hours, five times per week, and to apply carrot splints (hand splint shaped like a carrot to position the fingers away from the palm for severe hand contractures) to both hands for four to six hours, five times per week. During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49 had no speech, rarely/never expressed ideas and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 49 had ROM impairments in both arms and legs. The MDS also indicated Resident 49 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for dressing, showering, toileting, rolling to both sides in bed, and chair/bed-to-chair transfers. During an observation on 10/31/2024 at 9:42 a.m., in Resident 49's room, Resident 49 was awake while lying in bed with the head-of-bed elevated. Resident 49 was observed with a fully bent right elbow, right wrist bent downward, and both hands were positioned in closed fists. Resident 49's legs were resting straight on the bed. Restorative Nursing Aide 1 (RNA 1) performed PROM to both arms, applied both elbow splints, and applied both carrot splints. RNA 1 then performed PROM to both legs except the right knee. During a review of Resident 49's Restorative Nursing (RNA) flow sheets (record of RNA sessions) from 12/2023 to 11/2024, the RNA flow sheet for 4/2024 was not included in Resident 49's clinical record. During a concurrent interview and record review on 11/1/2024 at 2:47 p.m., with the Director of Rehabilitation (DOR) and the DON, Resident 49's RNA flow sheets were reviewed. The DOR and DON were unable to locate Resident 49's RNA flow sheet for 4/2024. The DON stated the RNAs were supposed to submit the residents' RNA flow sheets to the facility's Director of Medical Records (DMR). The DON stated Resident 49's clinical records were incomplete since the RNA flow sheets were missing for 4/2024. During a review of the facility's undated policy and procedure (P&P) titled, Charting and Documentation, the P&P indicated all services provided to the resident shall be documented in the resident's medical record. The P&P indicated the resident's medical record should be complete and accurate.

Based on observation, interview and record review, the facility failed to implement infection control measures by failing to: A. Ensure Resident 260's visitor was wearing Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and Licensed Vocational Nurse (LVN) 2 and LVN 3 were doffing (removing PPE in a way that avoids self-contamination) PPE properly without self-contamination after caring for Resident 260 who was on Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms). B. Ensure LVN 1, LVN 4, and Certified Nurse Assistant (CNA) 1 were wearing proper PPE during the care of Resident 8 who was on EBP. C. Ensure the duct tape (a water resistant tape that is not waterproof and will eventually break down and allow water to pass) placed on 4 out of 22 sampled resident's (Resident 16, Resident 54, Resident 59, and Resident 84) beds' padded side rails (a raised side fitted to a bed) was not cracked or pealing, revealing the foam (a soft porous material, and the degree of porosity can vary depending on the type of foam) underneath the duct tape to ensure proper disinfection of the side rails. These deficient practices resulted in facility staff not following infection prevention protocols and had the potential to spread infection amongst residents, staff, and visitors. Findings: A. During a review of Resident 260's Admission Record, the Admission Record indicated, Resident 260 was admitted to the facility on [DATE] with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and pressure ulcer/injury (damage to skin and underlying tissue caused by unrelieved pressure) unstageable (full thickness tissue loss but is either covered by extensive dead tissue) of sacral region (the portion of the spine between lower back and tailbone). During a review of Resident 260's History and Physical (H&P), dated 10/28/2024, the H&P indicated, Resident 260 had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/31/2024, the MDS indicated Resident 260 required dependent assistance (Helper does all of the effort) from two or more staff for roll left and right, sit to lying, and lying to sitting on side of bed. During a concurrent observation and interview on 10/29/2024, at 10:21 a.m., with Visitor 1 in Resident 260's room, there was signage that indicated Resident 260 was on EBP. Visitor 1 was not wearing a gown or gloves. Visitor 1 was stroking Resident 260's hair and fixing his blanket with bare hands. Visitor 1 was leaning over the left bed siderail. Visitor 1 stated, she did not know about EBP and did not know she needed to wear PPE. Resident 260 pressed the call light to be re-positioned. LVN 2 and LVN 3 answered the call light and donned PPE, but they did not ask Visitor 1 to wear PPE. Visitor 1 stated, nursing staff saw her not wearing PPE, but they did not say anything to her. During a concurrent observation and interview on 10/29/2024, at 10:24 a.m., with LVN 2 and LVN 3 in Resident 260's room, LVN 2 and LVN 3 were doffing their PPE after providing direct care for Resident 260. LVN 2 and LVN 3 were still wearing their gloves when they untied their gowns. LVN 2 and LVN 3's gloves were touching the back side of their work uniforms near the necks. They took off the gowns then took off the gloves last. LVN 2 stated, she always took off her gloves last. LVN 2 stated, she did not realize that there was signage for how to remove PPE and the gloves should be off before removing other PPE. LVN 2 stated, she should have taken off her gloves first to prevent self- contamination. LVN 3 stated, she also realized they were doffing PPE incorrectly and had contaminated themselves without knowing. LVN 2 and LVN 3 stated, incorrect donning and doffing of PPE would spread infection to the vulnerable residents of the facility. During a review of Resident 260's untitled Care Plan (CP), revised 10/28/2024, the CP Focus indicated, Resident 260 was on EBP. The CP Interventions indicated, Care team to provide teaching and education regarding care. Staff will perform hand hygiene, wear PPE before and after high contact care activities. According to the Centers for Disease Control (CDC a national public health agency), a review of a document titled, How to safetly remove personal protective equipment (CS250672-E), indicated to remove PPE before leaving the resident's room, and to remove gloves first because the outside of the gloves are contaminated. (https://www.cdc.gov) B. During a review of Resident 8's Admission Record, the Admission Record indicated, Resident 8 was initially admitted to the facility on [DATE] and last readmitted on [DATE] with diagnoses including aquired absence of left leg above the knee, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dependence on supplemental oxygen (odorless colorless gas that sustains life), and pressure ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) of sacral region (the portion of the spine between lower back and tailbone). During a review of Resident 8's H&P, dated 10/9/2024, the H&P indicated, Resident 8 had the capacity to understand and make decisions. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 required maximal assistance (Helper does more than half the effort) from one staff for toileting transfer, sit to stand, and moderate assistance (Helper does less than half the effort) from one staff for roll left and right, sit to lying, lying to sitting on side of bed. During an observation on 10/29/2024, at 12:13 p.m., in Resident 8's room, there was signage that indicated Resident 8 was on EBP. Resident 8 was sitting in a wheelchair next to her bed and was complaining that her oxygen tank needed to be replaced. LVN 1 came in to Resident 8's room without wearing PPE . LVN 1 grabbed the handle of Resident 8's wheelchair and pulled out the portable oxygen tank from the back of Resident 8's wheelchair. LVN 1 called Certified Nursing Assistant 1(CNA 1) to bring a new oxygen tank. CNA 1 brought the new oxygen tank and did not donn PPE before entering the room. LVN 1 changed the oxygen tank and adjusted Resident 8's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) without wearing gloves while CNA 1 was helping Resident 8 to adjust her posture. LVN 1 asked LVN 4 who was assigned to Resident 8 to adjust the oxygen flow level. LVN 4 donned gloves, but he did not wear the gown. LVN 4 adjusted Resident 8's oxygen level and re-adjusted Resident 8's nasal cannula. LVN 4's uniform was touching Resident 8's wheelchair while he was providing care. During an interview on 10/29/2024, 12:17 p.m., with LVN 1, LVN 1 stated, they should have worn PPE before providing care for Resident 8 to prevent spreading infection. LVN 1 stated, wearing proper PPE was important to protecting residents and staff from infection. During a review of Resident 8's untitled CP, revised 10/21/2024, the CP Focus indicated, Resident 8 was on EBP due to gastrostomy and open wounds. The CP Interventions indicated, Care team to provide teaching and education regarding care. Staff will perform hand hygiene, wear PPE before and after high contact care activities. During an interview on 11/1/2024, at 10:23 a.m., with the Director of Staff Development (DSD), the DSD stated, he mentioned to staff that glove should be the last PPE to put on and first one to take off after providing care during the in-service. The DSD stated, following proper donning and doffing of PPE could protect residents and staff both. During an interview on 11/1/2024, at 10:49 a.m., with the Infection Preventionist Nurse (IPN), IPN stated, PPE should have worn before caring the resident who was on EBP to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). IPN stated, LVN 4 was wearing gloves, but he did not realize that he had indirect contact with Resident 8. IPN stated, PPE was applicable to the visitors and EBP signage indicated wearing PPE was for everyone. IPN stated, staff should have asked Visitor 1 to wear PPE and provided education. During an interview on 11/1/2024, at 11:12 a.m., with Director of Nursing (DON), the DON stated, the staff should follow EBP guidelines and wear proper PPE when indicated for infection control to protect themselves and vulnerable residents. During a review of the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, revised 8/2022, the P&P indicated, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation: 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing) . 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of [NAME] colonization . 12. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. During a review of the facility's Policy and Procedure (P&P) titled, Personal Protective Equipment, revised 10/2018, the P&P indicated, Policy Interpretation and Implementation . 5. Training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals. 6. Employees who fail to use personal protective equipment when indicated may be disciplined in accordance with personnel policies. 7. Visitors and residents who are asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment at no charge. C. During a review of Resident 16's admission record, the admission record indicated Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of quadriplegia (unable to move all four limbs), dementia (a chronic condition that causes a decline in cognitive abilities, such as thinking, remembering, and reasoning, that interferes with daily life), and osteoporosis (weak bones). During a review of Resident 16's MDS dated [DATE], the MDS indicated Resident 16 had severe cognitive impairment (a condition that makes it very difficult for a person to remember things, learn new things, concentrate, or make decisions). During a review of Resident 16's physician's orders dated 9/22/2024, the Physician order indicated Resident 16 may have padded bilateral grab bars (smaller side rails) as an enabler for positioning and supporting during care. During a review of Resident 54's admission record, the admission record indicated resident 54 was admitted to the facility 4/29/2019 with diagnoses of hemiplegia (can not move one side of the body) affecting the right side and epilepsy (a chronic brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain). During a review of Resident 54's Physician's orders dated 11/2/2023, the physician order indicated Resident 54 may have left side 1/2 padded side rails as enabler for bed mobility and for seizure precaution. During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 54 had severe cognitive impairment. During a review of Resident 59's admission record, the admission record indicated Resident 59 was admitted to the facility on [DATE] with diagnoses of dementia and history of falling. During a review of Resident 59's physician orders dated 5/16/2024, the physician order indicated Resident 59 may have bilateral (both sides) grab bars as enablers for bed mobility. During a review of Resident 59's MDS dated [DATE], the MDS indicated Resident 59 had severe cognitive impairment. During a review of Resident 84's admission record, the admission record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses of seizures, history of falling, and nontraumatic intracerebral hemorrhage (bleeding in the brain). During a review of Resident 84's MDS dated [DATE], the MDS indicated Resident 84 had severe cognitive impairment. During a review of Resident 84's physician's orders dated 10/17/2024, the physicians order indicated Resident 84 may have bilateral padded grab bars up as enablers for turning and repositioning and for seizure precaution. During an observation on 10/29/2024 at 9:40 a.m., Resident 16's bilateral grab bars were wrapped with duct tape, the duct tape was cracked exposing the black foam padding underneath the duct tape. During an observation on 10/29/2024 at 10:05 a.m., Resident 59's bilateral grab bars were covered in duct tape with some sections of duct tape that had pealed off exposing the black foam padding underneath. During an observation on 10/29/2024 at 10:19 a.m., Resident 54's right side 1/2 padded side rail was covered with duct tape that was cracked and pealing exposing the black foam padding underneath. During an observation on 10/29/2024 at 10:35 a.m., Resident 84's bilateral grab bars only had duct tape wrapped around the top of the grab bars and the rest of the black foam padding was exposed. During an interview on 10/29/2024 at 3:21 p.m., the maintenance supervisor (MS) stated they wrapped the grab bars with duct tape to secure the foam padding to the bed rails. The MS stated the purpose of the duct tape was so housekeeping could clean and sanitize the bed rails because they couldn't clean the foam and they couldn't find a cover, so the facility decided to use duct tape. The MS stated the manufacture fo the bed did not recommend for the bed rails to be wrapped in duct tape. The MS stated nursing staff was to alert him when the tape was cracked or pealing so he could fix it because the black foam padding should not be exposed because it could not be sanitized. The MS checked the duct tape on the bed rails for Resident 16, Resident 54, Resident 59, and Resident 84. The MS stated that the duct tape on both siderails of Resident 16's bed was cracked, exposing the black foam. The MS stated that Resident 84's grab bars were not fully covered in duct tape. The MS stated Resident 54's tape on the right-side rail was cracked and pealing and Resident 59's duct tape on the bilateral grab bars was cracked. The MS said the duct tape should not be that way and it needed to be fixed. During an interview on 11/1/2024 at 2:23 p.m., the housekeeping supervisor (HKS) stated they used a brand name disinfectant for all cleaning in the facility including the bed rails with padding and duct tape. The HKS stated if the black foam padding was exposed under the duct tape there was a risk for infection because bacteria (microscopic organisms that can make you sick) can live in the cracks (pores) of the foam. The HKS stated the duct tape was not a hard, nonporous surface. During an interview on 11/1/2024 at 4:45 p.m., the IPN stated there was a potential for bacteria to grown and build up if the duct tape was broken or missing exposing the black foam padding on the bed rails. During a review of the literature for brand name disinfectant used by the facility, undated, the literature indicated the product was to be used as part of a simple and effective cleaning and disinfection program for facilities on hard, non-porous surfaces.

Based on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of five sampled residents (Resident 8). This failure had the potential to prevent Resident 8 from receiving the necessary care and services timely. Findings: During a review of Resident 8's Admission Record, the Admission Record indicated, Resident 8 was initially admitted to the facility on [DATE] and the last readmission was on 9/20/2024 with diagnoses including left leg above knee amputation (surgical removal of the portion of the left leg above the knee joint), muscle weakness, dependence on supplemental oxygen (a colorless, odorless gas element that sustains life), and pressure ulcer/injury (damage to skin and tissue underneath the skin caused by unrelieved pressure) stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) of sacral region (the portion of the spine between lower back and tailbone). During a review of Resident 8's History and Physical (H&P), dated 10/9/2024, the H&P indicated, Resident 8 had the capacity to understand and make decisions. During a review of Resident 8's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/11/2024, the MDS indicated Resident 8 required maximal assistance (Helper does more than half the effort) from one staff for toileting transfer, sit to stand, and moderate assistance (Helper does less than half the effort) from one staff for roll left and right, sit to lying, lying to sitting on side of bed. During a concurrent observation and interview on 10/29/2024, at 12:10 p.m., with Resident 8 in Resident 8's room, Resident 8 was sitting on a wheelchair next to the right-side of the foot of the bed and her nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was connected to a portable oxygen tank that was behind her wheelchair. Resident 8 was hyperventilating (rapid or deep breathing) and seemed very anxious (experiencing worry, unease, or nervousness). Resident 8's call light was clipped on the left side of her bed near the upper siderail, and Resident 8 was unable to reach the call light. Resident 8 stated, she believed her oxygen was almost out because she was barely feeling air coming out from her nasal cannula. Resident 8 stated, she was afraid because she was having shortness of breath (difficulty breathing) and she was not able to reach the call light. Resident 8 stated, she was has been hospitalized multiple times due to breathing issue. Resident 8 stated, she felt helpless not being able to call for help. During an interview on 10/29/2024, at 12:13 p.m., with Licensed Vocational Nurse (LVN) 1 in Resident 8's room, LVN 1 stated, the call light was not placed within reach, and it should have been within reach at all times. LVN 1 stated, Resident 8's oxygen tank indicated 400 pounds per square inch (PSI- the pressure that results when a 1-pound force is applied to a unit area of 1 square inch) which was low pressure and needed to be changed. LVN 1 stated, Resident 8 has had many episodes of difficulty breathing and nursing staff should have placed the call light within reach in case of emergency. During an interview on 11/1/2024, at 10:23 a.m., with the Director of Staff Development (DSD), the DSD stated, the call light should be within reach to accommodate residents' needs in a timely manner. The DSD stated, Resident 8 could have gone into respiratory distress (a person having trouble breathing or not getting enough oxygen) if she was not able to reach call light to alert someone that her oxygen supply is running out. During an interview on 11/1/2024, at 11:12 a.m., with the Director of Nursing (DON), the DON stated call lights should always be accessible and within the resident's reach. The DON stated that if the call light was not within the resident's reach, the resident would be unable to call for assistance to get his or her needs met. During a review of Resident 8's untitled Care Plan (CP), revised 9/3/2024, the CP Focus indicated, Resident 8 was at risk for fall related to impaired balance and poor safety awareness. The CP Interventions indicated, keep call light and bed controls within easy reach. During a review of the facility's policy and procedure (P&) titled, Answering the Call Light, revised 10/2010, the P&P indicated, Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to monitor range of motion ([ROM] full movement potential of a joint [where two bones meet]) in both legs for one of eight sampled residents (Resident 49) with limited range of motion and mobility (ability to move) by failing to perform an annual Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in both arms and both legs) on 4/18/2024 in accordance with the facility's policy titled, Resident Mobility and Range of Motion. This failure had the potential for Resident 49 to develop further ROM limitations in both legs due to the lack of monitoring for potentially 21 months from Resident 49's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) discharge on 7/25/2023 to 4/2025 (next annual JMS). Findings: During a review of Resident 49's Admission Record, the Admission Record indicated the facility initially admitted Resident 49 on 12/11/2019 and readmitted the resident on 7/15/2023. The Admission Record indicated Resident 49's diagnoses included dementia (a progressive state of decline in mental abilities), functional quadriplegia (paralysis from the neck down, including the arms and legs), and contractures (stiffening/shortening at any joint that reduces the joint's range of motion) in both shoulders, left elbow, and both hands. During a review of Resident 49's PT Evaluation and Plan of Treatment, dated 7/19/2023, the PT Evaluation indicated Resident 49's ROM in both hips, knees, and ankles were impaired. The PT Evaluation indicated Resident 49's ROM limitations included right hip flexion (bending the leg at the hip joint toward the body) 0 to 35 degrees (0-35 degrees, normal 0-120 degrees), left hip flexion 10-60 degrees, right knee flexion (bending the knee) 0-10 degrees (normal 0-135 degrees), left knee flexion 10-60 degrees, both ankles dorsiflexion (bending the ankle toward the body) 0-5 degrees (normal 0-20 degrees), both ankles plantarflexion (bending the ankle away from the body) 0-10 degrees (normal 0-45 degrees). The PT Evaluation indicated Resident 49 had rigid (stiff) muscle tone (amount of tension in the muscle) in both legs, including the right knee which was difficult to bend. During a review of Resident 49's PT Discharge Summary, dated 7/28/2023, the PT Discharge Summary indicated the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) provided a 100 percent [%] return demonstration for performing passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises to Resident 49's left leg, right hip, and right ankle. The PT Discharge Summary Recommendations indicated for the RNA to provide PROM to both legs. During a review of Resident 49's physician orders, dated 7/25/2023, the physician orders indicated for the RNA to perform PROM to both legs except the right knee, five times per week as tolerated. During a review of Resident 49's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 1/18/2024, the MDS indicated Resident 49 had no speech, rarely/never expressed ideas and wants, rarely/never understood verbal content, and was severely impaired for daily decision making. The MDS indicated Resident 49 had ROM impairments in both arms and legs. The MDS also indicated Resident 49 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for dressing, showering, toileting, rolling to both sides in bed, and chair/bed-to-chair transfers. During a review of Resident 49's annual JMS, dated 4/18/2024, the JMS indicated Resident 49 had moderate (26-50% ROM loss) ROM limitations in the left elbow and severe (more than 50% ROM loss) ROM limitations in both shoulders, right elbow, and both hands. The JMS was blank (no assessment) for both legs. During a review of Resident 49's MDS, dated [DATE], 7/12/2024, and 10/11/2024, the MDS indicated Resident 49 had ROM limitations in both arms and legs. The MDS also indicated Resident 49 was dependent for dressing, showering, toileting, rolling to both sides in bed, and chair/bed-to-chair transfers. During an interview on 10/30/2024 at 9:36 a.m., with the Director of Rehabilitation (DOR), the DOR stated the JMS was performed upon a resident's (in general) admission, readmission, change of condition, and annually. The DOR stated the JMS were performed to assess a resident's ROM. During a concurrent observation and interview on 10/31/2024 at 9:42 a.m., in Resident 49's room, Resident 49 was awake while lying in bed with the head-of-bed elevated. Resident 49 was observed with a fully bent right elbow, right wrist bent downward, and both hands were positioned in closed fists. Resident 49's legs were resting straight on the bed. Restorative Nursing Aide 1 (RNA 1) provided PROM to both arms and legs except the right knee. RNA 1 stated Resident 49's right knee did not bend. During a concurrent interview and record review on 10/31/2024 at 1:29 p.m., with the Director of Rehabilitation (DOR), Resident 49's PT Evaluation, dated 7/19/2023, and PT Discharge Summary, dated 7/25/2023, were reviewed. The DOR stated the PT Evaluation indicated Resident 49 had spasticity (stiffness) into extension on both legs, making it difficult to bend both legs. The DOR stated the PT Discharge Summary, dated 7/25/2023, included recommendations to perform PROM to the left leg, right hip, and right ankle, five times per week. The DOR stated the recommendation did not include Resident 49's right knee since it remained in extension. The DOR stated the PT did not provide Resident 49 with any intervention since discharge from PT on 7/25/2023. During a concurrent interview and record review on 11/1/2024 at 1:30 p.m., with the MDS Coordinator (MDSC) and the MDS Assistant (MDS 2), Resident 49's MDS, dated [DATE], was reviewed. The MDSC stated Resident 49's MDS indicated Resident 49 had ROM impairments in both arms and legs. The MDSC stated Resident 49's MDS did not indicate the location and severity of Resident 49's ROM impairments. During an interview on 11/1/2024 at 1:32 p.m. with the MDSC and MDS 2, the MDSC stated the facility could not use the MDS (in general) to track a resident's ROM limitations since the MDS indicated the presence of ROM limitations but did not indicate the location and severity. During a concurrent interview and record review on 11/1/2024 at 2:47 p.m., with the DOR and the Director of Nursing (DON), Resident 49's annual JMS, dated 4/18/2024, was reviewed. The DOR stated the JMS (in general) was completed to track any decline in ROM to prevent the development of contractures, pressure injuries (pressure-related damage to skin and/or underlying tissue), and pain. The DOR reviewed Resident 49's annual JMS, dated 4/18/2024, and stated Resident 49's ROM in both legs were not assessed. The DOR stated Resident 49 had an increased potential for decline in ROM since both legs were not assessed since discharge from PT services (on 7/25/2023). During a concurrent interview and record review on 11/1/2024 at 2:57 p.m., with the DOR and the Director of Nursing (DON), Resident 49's annual JMS, dated 4/18/2024, was reviewed. The DON stated it was the facility's policy to perform the JMS annually for each resident. The DOR stated Resident 49's next annual JMS would have been in 4/2025 in accordance with the facility's policy. The DON stated Resident 49 would have gone 21 months (7/25/2023 to 4/2025) without an assessment of both legs, which the DON stated was a long period of time. During a review of the facility's policy and procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated resident with limited ROM and mobility will receives appropriate services, equipment and assistance to maintain or improve mobility. The P&P further indicated the rehabilitation screening will be completed upon admission and yearly.

Based on observation, interview and record review, the facility failed to provide prompt dental services after dentures were lost on 9/10/24 and provide documentation of what they did to ensure resident could still eat and drink adequately while awaiting dental services for one of two sample residents (Resident 30). This deficient practice resulted in Resident 30 not being able to eat the mechanical soft diet without the dentures until replacement was delivered on 10/31/24. During a review of Resident 30's Admission Record, the Admission Record indicated Resident 30 was admitted to the facility under Hospice (that provides medical, emotional, and spiritual support for people who are terminally ill and nearing the end of their life) on 8/2/2024 with diagnoses included dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), palliative care (specialized medical care for people living with a serious illness providing relief from the symptoms and stress of the illness). During a review of Resident 30's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 8/8/2024, the MDS indicated Resident 30 was severely impaired in cognitive skills (thought process) skills for daily decision-making and was dependent (helper does all of the effort to complete activities, the assistance of two or more helpers is required) on self-care abilities such as eating, oral hygiene, toileting, shower/bathing, upper and lower body dressing and mobility functions such as rolling left and right, sitting to lying, lying to sitting, bed to chair transfers and shower transfers. During a review of Resident 30's Order Summary Report, the Order Summary Report indicated there was no dental consult ordered. During a review of Resident 30's Order Summary Report, the Order Summary Report indicated fortified diet (foods that have been enhanced with additional nutrients, such as vitamins, minerals, protein, carbohydrates, or fats), mechanical soft texture (foods that are soft and easy to chew, less chewing than regular foods), regular liquid consistency ordered on 8/15/2024. During a review of Resident 30's Social Services Note dated 9/11/2024, the Social Service Note indicated Resident 30 was referred to a Dentist today 9/11/2024. The social Service note indicated that family was made aware and will follow up as needed. During a review of Resident 30's Dental Progress Notes, dated 9/25/2024, the Dental Progress Notes indicated Resident 30 has full lower dentures (FLD) only and no treatment indicated due to Resident 30's medical condition. During a review of Resident 30's Social Services Note dated 9/30/2024, the Social Service Note indicated Resident 30 was seen the Dental Care agency on 9/25/2024 to continue with treatment plan. Resident did not express having any trouble eating or drinking, or pain or discomfort. Will follow up as needed. Family also made aware of visit. During a review of Resident 30's Interdisciplinary Team (IDT-team members from different departments working together with a common purpose to set goals and make decisions that ensure the resident received the best care) Care Conference Summary dated 10/16/2024, the IDT Care Conference Summary indicated Resident 30's diet remained the same as mechanical soft consistency since 8/15/2024 and resident was last seen by dentist on 9/25/2024 for new dentures. The IDT Care Conference Summary indicated Resident 30 had poor oral intake of 25-50%, there was significant weight loss noted in two months, Dietary team will continue to monitor, and Registered Dietitian as needed. During a review of Resident 30's Dental Progress Notes dated 10/16/2024, the Dental Progress Notes indicated Resident 30 had missing full upper dentures (FUD), new FUD requested by facility. Resident 30 was informed of new FUD, impressions (imprints of your teeth and mouth) taken with Resident 30's consent. During a review of Resident 30's Social Services Note dated 10/16/24, the Social Service Note indicated Resident 30 was seen on 9/25/2024 and on 10/16/2024 for dental services to continue with treatment. Family made aware and was very thankful. During a review of Resident 30's Dental Progress Notes dated 10/24/24, the Dental Progress Notes indicated try in new FUD, recommend repair for lower denture. During an observation and interview on 10/29/2024 at 12:55 p.m., with Certified Nursing Assistant (CNA) 2 in Resident 30's room, CNA 2 stated the dentures at Resident 30's bedside did not fit the resident anymore. CNA 2 stated Resident 30 cannot really talk without her dentures. Resident 30 was observed eating lunch with no dentures. Resident 30 was observed eating potatoes but only ate one small bite and did not want to eat anymore. During a telephone interview on 10/30/2024 at 10:45 a.m., with Resident 30's Responsible Party (RP), the RP stated the facility lost Resident 30's upper dentures. The RP stated the dental consult saw Resident 30 last week to take impressions of her mouth. During a review of Resident 30's Dental Progress Notes dated 10/30/24, the Dental Progress Notes indicated delivered new FUD. During a concurrent interview and record review on 10/31/2024 at 2:00 p.m. with the Social Service Director (SSD), the SSD stated Resident 30's date of lost dentures was on 9/10/2024 and dental services came to see Resident 30 on 9/25/2024. The SSD stated there was an IDT Care Conference meeting on 10/16/2024, Resident 30's lost dentures were discussed during the meeting, but interventions were already in place to replace the lost dentures. There was no discussion about Resident 30's diet consistency even though there was weight loss and no dentures so no ability to chew. The SSD stated the replacement dentures arrived today and will check to see if it fits Resident 30's mouth. During a review of Resident 30's Social Services Note dated 10/31/2024, the Social Service Note indicated that the Social Service Director (SSD) met with Resident 30 to see how she was doing and how her new dentures were fitting. Resident 30 stated that she is doing fine and that they fit okay. Resident 30 did not express any concerns or discomfort. The SSD will follow up as needed. During a concurrent telephone interview and record review on 10/31/2024 at 2:19 p.m. with the Registered Dietitian (RD), the RD stated she did not get informed that Resident 30 did not have her dentures. The RD stated if Resident 30 had a chewing problem, the RD would have downgraded the diet to lower-level diet consistency like a puree diet which did not require chewing. The RD stated if a resident cannot consume the diet consistency, the outcome when a diet was not tolerated by a resident was weight loss. The RD stated that Resident 30 did not verbalize any chewing or swallowing issues during visits the RD made with Resident 30 but since Resident 30 had diagnosis of dementia, what Resident 30 says might not be valid. During an interview on 11/1/2024 at 5:04 p.m. with the Director of Nursing (DON), the DON stated she was aware Resident 30 did not have her dentures. The DON stated Resident 30 did not want to wear dentures during meals. The DON stated she does not know how the dentures got lost when Resident 30 did not want to wear the dentures during meals. The DON stated there was no discussion to change the diet consistency during the time Resident 30 did not have her dentures. The DON stated the replacement dentures arrived yesterday. During a review of the facility's policy and procedure (P/P) titled Availability of Services, Dental, revised August 2017, the P/P indicated oral healthcare and dental services will be provided to each resident dental services are available to all residents requiring routine and emergency dental care . social services will be responsible for making necessary dental appointments .all requests for routine and emergency dental services should be directed to Social Services to assure that appointments can be made in a timely manner .residents with lost or damaged dentures will be promptly referred to a dentist.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 30) received food according to her preferences. This deficient practice resulted in Resident 30 not eating her preferred diet potentially resulting in decrease meal intake, weight loss, and malnutrition (lack of proper nutrition, caused by not eating enough). Findings: During a review of Resident 30's Admission Record, the Admission Record indicated Resident 30 was admitted to the facility under a Hospice (an agency that provides medical, emotional, and spiritual support for people who are terminally ill and nearing the end of their life) agency on 8/2/2024 with diagnoses included dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), anxiety disorder (a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation), palliative care (specialized medical care for people living with a serious illness providing relief from the symptoms and stress of the illness). During a review of Resident 30's Minimum Data Set ([MDS], a federally mandated resident assessment tool), dated 8/8/2024, the MDS indicated Resident 30 was severely impaired in cognitive skills (thought process) skills for daily decision-making and was dependent (helper does all of the effort to complete activities, the assistance of two or more helpers is required) on self-care abilities such as eating, oral hygiene, toileting, shower/bathing, upper and lower body dressing and mobility functions such as rolling left and right, sitting to lying, lying to sitting, bed to chair transfers and shower transfers. During a review of Resident 30's Order Summary Report, the Order Summary Report indicated fortified diet (foods that have been enhanced with additional nutrients, such as vitamins, minerals, protein, carbohydrates, or fats), mechanical soft texture (foods that are soft and easy to chew, less chewing than regular foods), regular liquid consistency (unmodified for thickness), ordered on 8/15/2024. During an observation and interview on 10/29/2024 at 12:55 p.m., with Certified Nursing Assistant (CNA) 2 in Resident 30's room, CNA 2 stated Resident 30 liked the potatoes on the meal tray. CNA 2 stated the potatoes were soft and started cutting Resident 30's potatoes into smaller pieces. Resident 30 had no teeth, took one small bite of the potatoes, and did not want to eat anymore after that. CNA 2 stated that Resident 30 liked the soups that the family would bring in for her. During an interview on 10/29/2024 at 1:00 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 30 tends to not eat solid food and preferred to eat puree food (food that have a soft, pudding-like consistency) and gets a nutritional Supplement. The LVN 5 stated Resident 30 was admitted with a mechanical soft diet on hospice. LVN 5 stated there was no discussion about possibly changing Resident 30's diet to a puree diet, the hospice team kept the same diet consistency since admission to the facility. LVN 5 stated Resident 30 ate about 25% of her meals and that Resident 30's intake was very low. During a concurrent telephone interview and record review on 10/31/2024 at 2:19 p.m. with the Registered Dietitian (RD), the RD stated there were no notes from the CNA or LVN about Resident 30's preferred diet consistency of puree diet. The RD stated if Resident 30 had a chewing problem, the RD would have downgraded the diet to lower-level diet consistency like a puree diet. The RD stated if a resident cannot consume the diet, because the diet cannot be tolerated by a resident, the resident was at risk for weight loss. The RD stated that Resident 30 did not verbalize any chewing or swallowing issues but since Resident 30 had a diagnosis of dementia, what Resident 30 says might not be valid. During an interview on 11/1/2024 at 2:30 p.m., with CNA 1, CNA 1 stated Resident 30 does not eat a lot during mealtimes. CNA 1 stated Resident 30 ate well this morning with breakfast, over 50% of food eaten since breakfast was puree diet and it was Resident 30's favorite meal, oatmeal. CNA 1 stated Resident 30 did not eat too much food when the diet was mechanical soft diet but Resident 30 ate a lot more with this puree diet. During an interview on 11/1/24 at 5:04 p.m. with the Director of Nursing (DON), the DON stated she did not know Resident 30 preferred a puree diet and if that was what Resident 30 preferred to eat, the speech language pathologist ([SLP], a professional who assesses and treats communication disorders) would have been consulted right away to evaluate Resident 30 and the RD can get the diet order changed to what Resident 30 wanted. A review of facility's policy and procedure (P/P) titled, Resident Food Preferences, revised July 2017, the P/P indicated staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes .nursing staff will document the resident's food and eating preferences in the care plan the dietitian and nursing staff will identify any nutritional issues and dietary recommendations that might be in conflict with the resident's food preferences the dietitian will discuss with the resident or representative the rationale of any prescribed therapeutic diet. The physician (another term for medical doctor, a health professional who practices medicine) and dietitian will communicate the risk and benefits of specialized therapeutic versus liberalized diets therapeutic diets will be ordered only after the resident/representative agrees with and consents to such diet.

Based on interview and record, the facility failed to ensure an injury of unknown origin was reported to the California Department of Public Health (CDPH) for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone). This deficient practice resulted in the inability of CDPH to investigate Resident 1 ' s injury of femur fracture in a timely manner and had the potential for facts related to the injury to be forgotten by staff. Findings: During a review of Resident 1 ' s Admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (damage or disease that affects the brain leading to the person to be confused), dementia (a condition of loss of cognitive functioning such as thinking, remembering, and reasoning that it interferes with a person ' s daily life and activities) and generalized weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/31/2024, the MDS indicated Resident 1 was not able to make decisions that were consistent and reasonable. During a review of Resident 1 ' s SBAR dated 5/20/2023 and timed at 10:38 a.m., the SBAR indicated Resident 1 was groaning and screaming while facility staff assisted her with lower body dressing (pulling Resident 1 ' s pants up). The SBAR indicated Resident 1 was noted with swelling to her right knee, Resident 1 ' s physician was informed and an order for a Stat (immediate) right knee X-ray was obtained. During a review of Resident 1 ' s X-ray report dated 5/20/2024, the X-ray report indicated Resident 1 sustained a moderately displaced fracture of the distal diaphysis of the femur of indeterminate age with moderate degenerative change of the knee with narrowing of the lateral joint compartment (the area on the outside portion of the knee joint). During a review of Resident 1 ' s Transfer Form dated 5/20/2024 at 5:05 p.m., the Transfer Form indicated Resident 1 was transferred to General Acute Care Hospital (GACH) for evaluation and treatment due to her femur fracture. During an interview on 6/7/2024 at 11:55 a.m., the Director of Nursing Services (DON) stated Resident 1 was transferred to the GACH because she (Resident 1) sustained a fracture to her right femur. The DON stated she did not report this injury to CDPH because Resident 1 ' s physician documented Resident 1 ' s fracture was unavoidable due to Resident 1 ' s diagnoses of osteoporosis (brittle bones). During an interview on 6/7/2024 at 12:55 p.m., the Administrator (ADM) stated the facility should have reported to CDPH when Resident 1 sustained an injury of an unknown. During a review of the facility ' s policy and procedure (P/P), titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/2021, the P/P indicated if an injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to the State law. The Administrator or the individual making the allegation immediately reports his or her suspicion to the State licensing/certification agency responsible for surveying/licensing the facility within two hours of an allegation involving abuse or result in serious bodily injury or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record, the facility failed to ensure an injury of unknown origin was investigated for one of five sampled residents (Resident 1) when Resident 1 sustained a moderately displaced (a break in the bone where the bones does not always crack all the way through) fracture (a break in the bone) of the distal (farther end) diaphysis (shaft; or a long tubular structure of the bone) of the femur (thigh bone) and the cause of the fracture was unknown to the resident and staff. This deficient practice resulted in the inability of the facility to determine what might have been the cause of Resident 1 ' s injury and had the potential to recur. Findings: During a review of Resident 1 ' s Admission Record (Face sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including encephalopathy (damage or disease that affects the brain leading to the person to be confused), dementia (a condition of loss of cognitive functioning such as thinking, remembering, and reasoning that it interferes with a person ' s daily life and activities) and generalized weakness. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/31/2024, the MDS indicated Resident 1 was not able to make decisions that were consistent and reasonable. During a review of Resident 1 ' s SBAR dated 5/20/2023 and timed at 10:38 a.m., the SBAR indicated Resident 1 was groaning and screaming while facility staff assisted her with lower body dressing (pulling Resident 1 ' s pants up). The SBAR indicated Resident 1 was noted with swelling to her right knee, Resident 1 ' s physician was informed and an order for a Stat (immediate) right knee X-ray was obtained. During a review of Resident 1 ' s X-ray report dated 5/20/2024, the X-ray report indicated Resident 1 sustained a moderately displaced fracture of the distal diaphysis of the femur of indeterminate age with moderate degenerative change of the knee with narrowing of the lateral joint compartment (the area on the outside portion of the knee joint). During a review of Resident 1 ' s Transfer Form dated 5/20/2024 at 5:05 p.m., the Transfer Form indicated Resident 1 was transferred to General Acute Care Hospital (GACH) for evaluation and treatment due to her femur fracture. During an interview on 6/7/2024 at 11:55 a.m., the Director of Nursing Services (DON) stated she did not investigate Resident 1 ' s injury of unknown origin because, per Resident 1 ' s physician it was unavoidable due to Resident 1 ' s diagnosis of osteoporosis (brittle bones). During an interview on 6/7/2024 at 12:55 p.m., the Administrator (ADM) stated the facility should have investigated Resident 1 ' s fracture to determine the root cause of Resident 1 ' s injury. During a review of the facility ' s Policy and Procedure (P/P), titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised 4/2021, the P/P indicated all reports of resident abuse, including injuries of unknown origin, are thoroughly investigated by facility management.

Based on interview and record review, the facility failed to update and document belongings brought by the family on the inventory list for three of four sampled residents (Resident 1, 4, 5). This failure resulted in residents losing items due to not having them written down on the inventory list. Findings: a. During a record review of Resident 1 Face Sheet (Admission record), the Face Sheet indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnosis including hypertensive heart (chronic blood pressure elevation) and chronic kidney disease (CKD: gradual loss of the kidney function), history of falling, and dementia (impaired ability to think, make decisions) with other behavioral disturbance (verbal and physical aggression, wandering). During a record review of Resident 1 ' s Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 1/10/2024, the MDS indicated Resident 1 ' s cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were severely impaired. The MDS indicated Resident 1 is dependent on bathing and transferring from chair/bed to chair transfer and required substantial/maximal assistance in performing activities of daily living (ADL: hygiene, dressing, eating) and utilizes a wheelchair. During a record review of Resident 1 ' s Inventory List (list of resident ' s belongings), it indicated Resident 1 was missing a green Christmas sweater, blue adidas suit, two radios, black and yellow pants outfit, black and white dress with hood, and a blue sweatshirt. During a record review of Resident 1 ' s Theft/Loss Report (document that indicates missing item information), Resident 1 ' s green sweater was seen on another resident and other items that have not been seen for month. During an interview on 2/13/2024 at 11:22am with Resident 1 ' s daughter, the daughter indicated Resident 1 has been missing some of her clothing ' s and stated she does Resident 1 ' s laundry at home to prevent items going missing at the facility and is not sure why the items are missing as she writes Resident 1 ' s name on the inside and outside of Resident 1 ' s clothes. The daughter indicated she has seen some of the residents wearing her Resident 1 ' s clothes. The daughter stated when she brings in new clothes, she notifies the staff to have the item listed on the inventory list. The daughter stated she does Resident 1 ' s laundry every two days and brings back whatever was washed. The daughter stated she will notify the staff if an item was thrown away so that it can be updated on the inventory list. b. During a record review of Resident 4 Face Sheet (Admission record), the Face Sheet indicated Resident 4 was admitted on [DATE] with diagnosis including seizures, hypertension (high blood pressure), and dementia without behavior (not acting out), psychotic (disconnection from reality), mood disturbances (feelings of distress, sadness, depression) and anxiety (uneasiness). During a record review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 4 ' s cognitive skills were intact. The MDS indicated Resident 4 is dependent on bathing, dressing the lower part of the body (pants), wearing shoes, required moderate assistance on toilet, shower, and chair to bed transfer, and personal hygiene. The MDS indicated Resident 4 has an impairment on the upper extremities (arms) and utilizes a wheelchair. During a record review of Resident 4 ' s Inventory List it does not indicate Resident 4 had a cell phone on 9/6/2024. During a record review of Resident 4 ' s Theft/Loss Report, Resident 4 had lost a Nokia (cell phone brand) cell phone on 1/16/2024 and indicated the cell phone was not on Resident 4 ' s inventory list. Additionally, it indicated Resident 4 does not remember and none of the staff has seen Resident 4 with a cell phone since the day of admission on 9/26/2023. c. During a record review of Resident 5 Face Sheet (Admission record), the Face Sheet indicated Resident 5 was admitted on [DATE] with diagnosis including anemia (not having healthy red blood cells to carry oxygen throughout the bodymuscle contracture of the right upper arm, and history of falling. During a record review of Resident 5 ' s MDS, dated [DATE] the MDS indicated Resident 5 ' s cognitive skills were mildly impaired. The MDS indicated Resident 5 is dependent on most of the aspect of activities of daily living and required partial assistance in personal and oral hygiene and dressing the upper (. The MDS indicated Resident 5 has an impairment on one side of the upper extremities (arms) and has impairments on both of the lower extremities. During a record review of Resident 5 ' s Inventory List, it does not indicate Resident 5 had a long yellow sleeve sweater on 10/15/2023. During a record review of Resident 5 ' s Theft/Loss Report, Resident 5 had lost a long yellow sleeve sweater on 12/18/2023 and indicated the sweater was not found. During a record review of the Lost and Stolen Property Log, in January, five residents reported to have missing items, December there were three residents that reported having missing items, and in November there were four residents that reported missing items. During a concurrent interview and record review on 2/1/2024 at 2:49p.m. with Social Service Director (SSD), SSD stated the inventory list is initiated at admission and is updated every year or when the family comes and brings new items in the facility for the resident. SSD stated when an item is lost, laundry will be notified, get the description of the missing item, check the residents room, and if the item does not show up within a day or two, the Administrator (ADMN) will determine whether to replace or reimburse the missing item. SSD stated not all of Resident 1 ' s items are missing; however, two or three items were not found. SSD stated the family does not notify the staffs at time when a new item is brought in and will have the family put the residents name on their clothing in case the belonging is laundered at the facility. SSD stated the blue adidas suit, two radios, and black and yellow pants outfit were on Resident 1 ' s inventory list, but the green Christmas sweater, black and white dress with hood, and a blue sweatshirt was not listed. SSD stated ADMN agreed to replace the missing items. SSD stated the inventory list is created to know whose belongings they belong to and is kept as a record in case the item gets lost. SSD stated personal items missing may upset the resident. During a concurrent interview and record review on 2/1/2024 at 3:48p.m. with Director of Nursing (DON), DON stated the inventory list has a list of the clothes the residents brought, so when there are new items, it will be written in the inventory list to track and update the items are there. DON stated when the family brings new item to the facility staff will update the inventory list. DON stated when an item goes missing, they will look at the inventory list and investigate where the item could be such as the laundry. DON stated when an item cannot be found, the item will be replaced or reimbursed. DON stated Resident 1 gets her laundry done at home, so the items that is allegedly missing might not have even been brought into the facility. DON stated there are only two residents that gets their clothing laundered at home. DON stated the family of Resident 1 is doing the laundry and they never tell them when they bring a new item. DON stated the items the family brings for Resident 1 does not have to be included on the inventory list since the laundry is done by the family, Resident 1 ' s item goes in and out of the facility and does not know whether the items that are missing were in the facility. DON stated the inventory list items and the theft/loss report should mirror one another as you would need to verify and confirm with the allegedly missing item on the inventory list. DON stated she did not see the long yellow sleeve missing item for Resident 5 listed on the inventory list. During a review of the facility ' s P&P titled, Residents ' Personal Property, revised December 2023, the P&P indicated the inventory will list the resident ' s clothing and other personal items brought to the facility and retained by the resident. The IDT will also review the resident ' s inventory for accuracy during the resident ' s quarterly care conference. Any changes of additions to the inventory will be made at this time.

Based on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA 1) provided a resident, who was asleep and who had impaired cognitive (thinking, reasoning, remembering, imagining, learning words, and using language) skills for daily decision-making, assistance with breakfast set up, thus failing to identify the hot water, left on Resident 2 ' s overbed table, as a potentially hazardous element, for one of three sampled residents (Resident 2). The facility failed to: 1. Ensure CNA 1 did not leave an unattended cup of hot water, used to make Resident 2 ' s tea, on Resident 2 ' s overbed table when the resident was not fully awake, without warning Resident 2 of the potential danger of the hot water. 2. Ensure CNA 1 set up Resident 2 ' s breakfast tray and provided the resident assistance with drinking the hot tea, per Resident 2 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) and per the facility ' s policy and procedure (P/P), titled Safety and Supervision of Residents. As a result of this deficient practice, Resident 2 sustained a second-degree burn (injury to the first and second layers of skin that appears red and blistered) and incurred pain to her right thigh, requiring a wound consult and treatment with Silvadene cream (a medicated cream used to treat burns) for seven days. This deficient practice had the potential for continued impairment of Resident 2 ' s skin, pain, and infection. Findings: During a review of Resident 2 ' s Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia (progressive loss of memory), neuralgia (nerve pain), and diabetes ([DM] high blood sugar). During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 2 had highly impaired vision, was unable to make decisions for herself and required extensive one-person physical assistance with eating. During a review of Resident 2 ' s History and Physical (H&P), dated 11/28/2022, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s Situational Background Assessment Recommendation [(SBAR) a communication tool between members of health care team about a resident ' s change in condition] dated 1/18/2023, and timed at 11:41 a.m., the SBAR indicated Resident 2 spilled hot tea on herself, and fluid filled blisters on her right inner thigh were present. During a review of Resident 2 ' s Skin Supplemental Assessment (SSA) dated 1/18/2023, and timed at 11:42 a.m., the SSA indicated Resident 2 had a fluid filled blister measuring 5.5 centimeters [(cm) a unit of measurement] by 2.8 cm. During an observation on 1/18/2023, at 11:18 a.m., a puddle of water was noted on the floor in Resident 2 ' s room next to her bed. Resident 2 appeared ungroomed, and her clothes and blanket were wet. Resident 2 was screaming and stated she was in pain and hurting as she pointed to her exposed right thigh. Resident 2 stated hot tea spilled on her and she had requested pain medication. Resident 2 ' s right thigh appeared red with diffuse (spread over a large area) blisters and an empty plastic mug was sitting on Resident 2 ' s overbed table, after it spilled on her. During an interview on 1/18/2023, at 12 p.m., with CNA 1, CNA 1 stated the breakfast tray with hot tea was provided to Resident 2 around 7:30 a.m. (1/18/2023). CNA 1 stated, Resident 2 was still half asleep when the breakfast tray was placed on Resident 2 ' s overbed table that morning. CNA 1 stated Resident 2 could eat on her own, but the tray needed to be set up. During an interview on 1/18/2023, at 1:43 p.m., with CNA 1, CNA 1 stated he obtained the hot water that was served to Resident 2 during breakfast from the kitchen. CNA 1 stated Resident 2 liked her tea hot, and Resident 2 would ask for hotter water if she did not think it was hot enough for her. CNA 1 stated Resident 2 would dip her finger into the water to check if the temperature was hot enough for her. CNA 1 stated he was responsible for picking up and setting up Resident 2 ' s tray and the last time he was in Resident 2 ' s room was around 7:40 a.m. (1/18/2023). CNA 1 stated it was not safe to leave hot tea on Resident 2 ' s overbed table when she was not fully awake because Resident 2 might accidentally spill the hot tea on herself and get burned. During a concurrent observation and interview on 1/18/2023, at 1:50 p.m., with Cook 1 (CK 1), CK 1 stated, hot water provided to residents comes from their coffee maker and the temperature of the coffee maker was about 140 to 160 degrees Fahrenheit ([F] a unit of measurement to determine temperature). CK 1 checked the temperature of the hot water in the coffee maker machine, using a thermometer, which showed a reading of 167 degrees F. During a review of facility ' s coffee maker Service Manual (SM) dated 2/2011, the SM indicated, water in the heating tank will require approximately a half hour before reaching operating temperature of 200 degrees. The SM indicated the temperature is programmable from 170 degrees F to 206 degrees F. During an interview on 1/18/2023, at 3:02 p.m., with the Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 2 had a second degree burn on her right thigh because of the spilled hot tea (1/18/2023), as verbalized by Resident 2. LVN 2 stated hot water could cause burns and produce blisters and should not be given to a resident who was not fully awake because the resident might spill the hot tea and burn herself. During a review of Resident 2 ' s Physician ' s Order (PO), dated 1/18/2023, the PO indicated to apply Silvadene Cream to Resident 2 ' s right inner thigh two times per day, for seven days, leave it open to air (LOA) and reassess in seven days. During a review of Resident 1 ' s Treatment Administration Record (TAR) dated 1/2023, the TAR indicated Silvadene cream was applied to Resident 2 ' s right inner thigh twice a day beginning 1/18/2023. During a review of Resident 1 ' s Wound Care Consultation Note (WCCN) dated 1/24/2023, the WCCN indicated, Resident 2 had a second degree burn on her right thigh which measured 5.5 cm in length and 2.0 x 2.0 cm in width. During an interview on 1/18/2023, at 3:27 p.m., with the Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated Resident 2 was confused, was a high risk for falls, and did not always use her call light when she needed assistance. RNS 1 stated, it was not acceptable to leave a cup of hot water with a resident who was not fully awake because the resident should be able to hold their cup of hot water to prevent accidents, such as burns, from occurring. RNS 1 stated staff should do frequent rounds on the residents, because most of them were confused. RNS 1 stated everyone was responsible for resident safety and although Resident 2 liked her water hot, all staff members should take precautions because Resident 2 could not decide for herself and process the information or instructions provided to her. During an interview on 1/18/2023, at 4:15 p.m., with the Director of Nursing (DON), the DON stated Resident 2 ' s room was close to the nursing station because of her confusion, high risk for falls, and her need for supervision. During an interview on 3/28/2023, at 3:15 p.m. with CNA 2, CNA 2 stated Resident 1 needed objects placed close to her to see and grab them. CNA 2 stated Resident 2 had only one eye that opened. During a review of the facility ' s P/P titled, Safety and Supervision of Residents, revised 7/2017, the P/P indicated resident supervision is a core component of the facility ' s approach to safety. The type and frequency of resident supervision is determined by individual resident ' s needs and identified hazards in their environment. During a review of the facility ' s P/P titled Water Temperatures, Safety of, revised 12/2009, the P/P indicated direct care staff shall be informed of risk factors for scalding burns that are common in the elderly such as decreased skin thickness, decreased skin sensitivity, peripheral neuropathy (weakness and numbness from nerve damage), reduced reaction time, decreased cognition, decreased mobility, and decreased communication. The length of exposure to warm or hot water, the amount of skin exposed, and the resident ' s current condition will affect whether exposure to certain temperatures will cause scalding or burns. The Nursing staff will be educated about signs and symptoms of burns so such injuries can be recognized and treated appropriately.

Based on interview and record review, the facility failed to honor resident's preferences, maintain resident's dignity, and clarify end of life wishes for three of four sampled residents (Residents 1, 2 and 3). The facility failed to: 1. Ensure Resident 1's Physician's Order for Life-Sustaining Treatment (POLST) indicating Do Not Resuscitate ([DNR] when the heart stops beating, or a person stops breathing, there are no rescue measures taken, including cardiopulmonary resuscitation [CPR] an emergency lifesaving procedure that is done when someone's breathing or heartbeat has stopped) was honored and carried out when the resident became unresponsive and went into cardiac arrest (when the heart suddenly stops beating). 2. Ensure Resident 1's POLST status was not changed from DNR to Full Code (when a person's heart stops beating or a person stops breathing, all resuscitation procedures will be provided to keep a person alive) without Resident 1's or Resident 1's representative's (FM 1) consent. 3. Ensure staff provided Resident 1's correct POLST, with DNR status, to the General Acute Care Hospital (GACH) at the time of Resident 1's transfer to the GACH ([DATE]) after becoming unresponsive. 4. Ensure staff clarified conflicting discrepancies in code status between Resident 2's POLST with DNR instructions and the Physician's Orders (PO) for a Full Code. 5. Ensure staff clarified conflicting discrepancies in code status between Resident 3's POLST with Full Code instructions for the end-of-life care and PO for DNR status. a. These deficient practices resulted in Resident 1 receiving CPR against her wishes and not in accordance with her documented POLST instructions ([DATE]) for DNR when Resident 1 experienced a sudden cardiac arrest on [DATE]. b. These deficient practices resulted in the facility providing the wrong POLST with a Full Code status to the GACH at the time of Resident 1's transfer ([DATE]), resulting in Resident 1 being intubated (a tube inserted into the throat for ventilation [a type of therapy that helps a person breathe or breathes for the person when a person cannot breathe on its own]). c. These deficient practices placed Resident's 2 and 3 at risk to have their end-of-life care wishes violated due to conflicting information between POLST and the POs directions for end-of-life care. Findings: A. During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a lung disease that blocks airflow and makes it difficult to breathe), chronic (persisting for a long time) hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). The Face Sheet indicated Resident 1's FM 1 was Resident 1's power of attorney ([POA] a person appointed to manage a person's property, medical and financial affairs). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated [DATE], the MDS indicated, Resident 1's cognitive (awareness of one's own strengths and limitation to make decisions) skills for daily decision-making were moderately impaired. During a review of Resident 1'a History and Physical (H&P), dated [DATE], the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's DPOA (a durable power of attorney prevents the loss of an agent's authority to act at a time when principals incapable of making their own decisions need someone to step in and make the) dated [DATE], the DPOA indicated FM 1 had the authority to make financial decisions if Resident 1 became disabled or incompetent. There was no indication that medical decisions were designated to FM 1. During a review of Resident 1's POLST dated [DATE], the POLST indicated documented instructions Do Not Resuscitate/DNR (allow natural death). During a review of Resident 1's POLST dated [DATE] (nine days later), the POLST indicated Resident 1 was a Full Code and had to have CPR if the heart stopped or the resident stopped breathing. This POLST was signed by LVN 1 and LVN 2 indicating a verbal consent was obtained from FM 1 at 11:43 a.m., on [DATE] to change Resident 1's code status from DNR to a Full Code. On [DATE] the physician signed this POLST after Resident 1 expired (died ). During a review of Resident 1's PO dated [DATE] and timed at 11:43 a.m., the PO indicated Resident 1's POLST was changed from DNR to a Full Code via verbal consent through a telephone call with FM 1 due to Resident 1's transfer via 911. During a review of Resident 1's Progress Notes (PN) dated [DATE] and timed at 11:44 a.m., documented by LVN 1, the PNs indicated at 11:20 a.m., Resident 1 was non-arousable with a blood pressure of ,d+[DATE] millimeters of mercury (mmHg) Referrence ranfe is ,d+[DATE] mmHg, a heart rate of 46 beats per minute (normal heart rate ,d+[DATE]) and an oxygen saturation (amount of oxygen in the blood with [normal range 95% or higher]) rate of 65% on room air. The PN indicated, paramedics were called at 11:28 a.m., and arrived at 11:36 a.m. The PN indicated at 11:43 a.m., two licensed nurses spoke with FM 1 and the POLST was changed to a Full Code via verbal consent. During a review of Resident 1's PNs, dated [DATE] and timed at 12:18 p.m., completed by the registered nurse (RN 1), the PNs indicated at 11:21 a.m., Resident 1 became unresponsive and at 11:30 a.m., Resident 1 stopped breathing. The PNs indicated Resident 1's chest compressions were started and at 11:36 a.m., the paramedics arrived at the facility and took over Resident 1's care. During an interview on [DATE] at 12:20 p.m. with Registered Nurse 1 (RN 1), RN 1 stated, Resident 1 was alert and oriented, the morning of her rounds ([DATE]). RN 1 stated, at 11:21 a.m., Licensed Vocational Nurse 1 (LVN 1) called her and said Resident 1 was unresponsive. RN 1 stated, the staff checked Resident 1's POLST which indicated Resident 1 was a DNR. RN 1 stated, LVN 1 called FM 1 at 11:43 a.m., ([DATE]) and FM 1 changed the POLST to a Full Code status. RN 1 stated, at 11:30 a.m., Resident 1 stopped breathing and had no pulse (heartbeat) and staff started chest compressions. RN 1 stated, DNR means do not resuscitate and the facility should have followed the resident's wishes. RN 1 stated, the Director of Nurses (DON) told her, Resident 1 was not self-responsible and did not have the capacity to make decisions. RN 1 stated, the POLST is a physician's order with directions for nurses should do for residents in an emergency. RN 1 stated, the POLST was signed on [DATE] at 11:43 a.m., by verbal consent from FM 1 via the telephone, LVN 1 spoke to FM 1 and LVN 2 was the witness. During an interview on [DATE] at 12:55 p.m., with LVN 1, LVN 1 stated, Resident 1 was unarousable at 11:20 a.m., ([DATE]) and CPR was started before the paramedics came to the facility. LVN 1 stated, she called FM 1 after the paramedics arrived and FM 1 told her to change Resident 1's code status to a Full Code, so she (LVN 1) created a new POLST with LVN 2 as a witness. LVN 1 admitted LVN 2 was not actually on or near the phone when FM 1 asked to change Resident 1's code status to a Full Code. LVN 1 stated, a POLST is a PO, and a nurse cannot change a PO without notifying the physician. During an interview on [DATE] at 8:52 a.m., with FM 1, FM 1 stated, the facility called her and said Resident 1 was unresponsive and was a Full Code. FM 1 stated she never gave consent to make changes to Resident 1's POLST to a Full Code and wanted Resident 1's status to remain a DNR. FM 1 stated the facility did not tell her they had already begun Resident 1's CPR and stated she later found out Resident 1 was intubated when the resident arrived at the GACH. FM 1 stated, Resident 1 told her she (Resident 1) did not want any tubes and wanted to be a DNR. FM 1 stated, Resident 1 would be so mad that this happened because they (FM 1 and Resident 1) had talked about it for decades, that Resident 1 did not want to be resuscitated. During an interview on [DATE] at 12:01 p.m., with LVN 2 and a concurrent review of Resident 1's POLST dated [DATE], the POLST indicated Resident 1 was a Full Code. LVN 2 stated, when he entered Resident 1's room, staff were already performing CPR. LVN 2 stated he was informed that Resident 1 was a DNR prior to him taking over CPR but was instructed to do CPR by LVN 1. LVN 2 stated, while he was doing compressions, LVN 1 came into Resident 1's room and said FM 1 wanted to send Resident 1 to the hospital via paramedics. LVN 2 stated, LVN 1 told him Resident 1's code status had been changed to a Full Code by FM 1. LVN 2 stated, he did not hear FM 1 say to change Resident 1's code status to Full Code but was told by LVN 1 to sign Resident 1's POLST as a witness and acknowledged he should not have signed the POLST. LVN 2 stated, if there was a verbal consent to change a code status, two licensed nurses needed to sign the POLST as a witness. LVN 2 confirmed his signature was on the POLST as the second witness to the code status change, although he did not actually witness FM 1 saying to change Resident 1 to Full Code. During an interview and concurrent record review on [DATE] at 12:46 p.m., with the DON, Resident 1's POLST, dated [DATE] was reviewed. The DON stated Resident 1's POLST indicated Resident 1 was a DNR. The DON stated she told RN 1 that Resident 1 did not have the capacity to make decisions but after reviewing Resident 1's H&P, stated she did not know Resident 1's physician indicated Resident 1 had the capacity to make decisions. During an interview on [DATE] at 1:08 p.m., with the Admissions Director (AD), the AD stated, she received an email on [DATE] with confirmation from FM 1 of Resident 1's wishes to be a DNR and she (AD) informed the Social Worker Assistant (SWA) regarding Resident 1's code status as a DNR. During an interview on [DATE] at 1:24 p.m., with the Social Worker Assistant (SWA), the SWA stated, she remembered an email that she received indicating Resident 1 wished to be a DNR. The SWA stated, when she saw the POLST ([DATE]) in Resident 1's clinical record stating Resident 1 was a DNR, she assumed everything was in place. The SWA stated, FM 1 was only the DPOA over Resident 1's finances. During an interview on [DATE] at 4:21 p.m., with FM 1, FM 1 stated, it was horrible seeing Resident 1 with a tube down her throat at the GACH and she asked them to take it out. FM 1 stated she was crying so much, bawling her eyes out and was very emotional and made such a scene in the emergency room (ER) because she was in shock!! FM 1 stated, Resident 1's fingers turned blue and looked like she was in pain when the tube was taken out, and the doctor at the GACH had to give Resident 1 Morphine (a medication used to relieve moderate to severe pain). FM 1 stated it was horrible watching Resident 1 go through all of that, Resident 1 died within an hour or two after the tube was taken out and she (FM 1) witnessed Resident 1 take her last breath. FM 1 stated, how did this happen? this was not the way Resident 1 was supposed to die! FM 1 stated, she was alone in the ER witnessing Resident 1 die, it was so hard to talk about and that was why she delayed reporting it to the DPH. FM 1 stated she was in great emotional pain, in a bad place and started drinking a lot of alcohol after Resident 1 died . FM 1 stated, she started seeing a grief counselor and the therapist helped her file a report with the DPH. During a review of Resident 1's GACH records (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the GACH on [DATE] at 12 p.m. During a review of the GACH's History of Present Illness (HPI), dated [DATE], the HPI indicated Resident 1 had a prior documented DNR code status. The HPI indicated EMT (emergency medical technician) reported that Resident 1's code status was recently changed to DNR with full treatment including a ventilator (breathing machine). During a review of the GACH's Reexamination/Reevaluation/ED Course, dated [DATE], the (RREC) indicated Resident 1 was intubated for respiratory failure and airway protection. When FM 1 arrived, it was confirmed that Resident 1 was a DNR with comfort care only. FM 1 wished Resident 1 to be extubated and verbalized understanding that Resident 1 would likely not get enough oxygen which could be fatal. During a review of the GACH's Staff Progress Notes (SPN) dated [DATE] and timed at 1:17 p.m., the SPN indicated FM 1 was at Resident 1's bedside stating Resident 1 would be so upset if she knew she was intubated. The SPN indicated the ER doctor was made aware and the plan was to create a new POLST to indicate DNR and comfort care instead of Full Code. During a review of the GACH's Hospital Course (HC), the HC indicated Resident 1 was brought to the GACH from a skilled facility, lethargic, for evaluation of respiratory distress (a life-threatening condition where the lungs cannot provide the body's vital organs with enough oxygen). In the ER Resident 1 was intubated but later FM 1 arrived, and Resident 1 was made a DNR and was extubated, per FM 1's wishes. Resident 1 expired on [DATE] at 6:53 p.m. B. During a review of Resident 2's Admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (loss of intellectual functioning), and hypertension ([HTN] high blood pressure). During a review of Resident 2's MDS, dated [DATE], the MDS indicated, Resident 2's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 2's POLST indicated, DNR for end of life wishes. During a review of Resident 2's POs dated [DATE] and [DATE], the POs indicated, Resident 2 was a Full Code. During a review of Resident 2's POLST dated [DATE], the POLST indicated, Resident 2 was a DNR. During an interview on [DATE] at 8:14 a.m., with FM 2, FM 2 stated, he did not want any drastic life saving measures done for Resident 2. FM 2 stated, he had a meeting with members of his family, and they all agreed that Resident 2 would be a DNR. FM 2 stated, he communicated this information to the facility on [DATE]. During an interview and review of Resident 2's POLST, on [DATE] at 12 p.m., with LVN 2, LVN 2 confirmed Resident 2's POLST was signed by FM 2 and it indicated Resident 2 was a DNR. LVN 2 stated DNR meant not to perform CPR, to provide comfort measures only such as keeping the resident's head up and making sure the resident was not in pain. During an interview and review Resident 2's POLST and POs on [DATE] at 1 p.m., with RN 1, RN 1 confirmed Resident 2's POLST indicated the resident was a DNR, but the resident's PO indicated Resident 2 was a Full Code. The POLST and PO had conflicting orders. During an interview and review of Resident 2's POLST and PO on [DATE] at 1:05 p.m., with the Administrator (ADM), the ADM stated, Resident 2 had two different end of life orders, one that indicated DNR and one that indicated a Full Code. The ADM stated Resident 2's end of life orders should have been clarified and corrected during Resident 1's Interdisciplinary Team (IDT) meeting. The ADM stated, if Resident 2 went into cardiac arrest, the facility would follow the orders on the POLST, even if they were not correct. C. During a review of Resident 3's Admission Records (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including HTN, and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). During a review of Resident 3's MDS dated [DATE], the MDS indicated, Resident 3's cognitive skills for daily decision-making were severely impaired. During a review of Resident 3's POLST dated [DATE], the POLST indicated, Resident 3 was a Full Code and wanted all life saving measures to be performed during an emergency. During a review of Resident 3's PO dated [DATE], the PO indicated, Resident 3 was a DNR. During an interview on [DATE] at 12:52 p.m., with the ADM and a concurrent review of the facility's DNR list, the ADM stated, Resident 3 was listed as a DNR on their DNR list. The ADM stated Resident 3's PO dated [DATE] indicated Resident 3 was a DNR but Resident 3's PO dated [DATE] indicated Resident 3 was a Full Code. The ADM stated, the Full Code order and POLST order were conflicting and would cause confusion to the staff if Resident 3 went into cardiac arrest. During a review of The National POLST form, according to www.polst.org, the National POLST form indicated a POLST is a set of medical orders, similar to the do-not resuscitate (allow natural death) order. The POLST form is completed as a result of the process of informed, shared decision-making. During the conversation, the patient discusses his or her values, beliefs, and goals for care, and the health care professional presents the patient's diagnosis, prognosis, and treatment alternatives, including the benefits and burdens of life-sustaining treatment. Together they reach an informed decision about desired treatment, based on the person's values, beliefs, and goals for care. No defibrillator (an apparatus used to control heart fibrillation [quivering of the heart] by an electric current to the chest wall) or chest compressions should be used if No CPR is chosen. (POLST.org) During a review of the facility's Policy and Procedure (P&P) titled Do Not Resuscitate Order, revised ,d+[DATE], the P&P indicated, the facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. During a review of the facility's P&P titled Residents Rights, dated ,d+[DATE], the P&P indicated, the residents have rights to participate in decision- making regarding his or her care, self-determination and to be informed of, and participate in, his or her care planning and treatment.

Based on interview and record review, the facility failed to provide supervision, one to one monitoring (1:1 monitoring- when an individual staff member is assigned to directly supervise no more than one resident and the staff shall stay within very close proximity to ensure constant supervision and immediate intervention if needed for safety reasons) for one of one sampled resident (Resident 1) by failing to: 1. Ensure Resident 1 who had history of delusional disorder (characterized by one or more firmly held false beliefs that persist for at least one month), received 1:1 monitoring when the Psychiatric (mental illness) Emergency Teams ([PET] mobile team operated by psychiatric hospital to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others) deemed Resident 1 was a threat to others and placed the resident on a 5150 (allows for a medical facility or law enforcement agency to place a 72 hour involuntary hold on an individual) hold on [DATE]. According to the Registered Nurse (RN)1, Resident 1 should have been placed on 1:1 monitoring. 2. Monitor Resident 1 while pending transfer to General Acute Care Hospital (GACH) for 5150 due to the resident exhibiting signs of a danger to others, after Resident 1 displayed aggressive and violent behavior (kicking and striking out staff.) As a result, Resident 1 was found hanging in the closet with a shoelace like rope/string around his neck, on [DATE] at 1:00 a.m. The resident was lowered to the floor, cardiopulmonary resuscitation ([CPR]-an emergency procedure that can save a person life if their breathing or heart stops) was initiated and 911 was called. The EMS (Emergency Medical Services- medical professionals providing emergency medical care) arrived at the facility and Resident 1 was pronounced dead on [DATE] at approximately 1:57 a.m. On [DATE] at 4:30 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called, in the presence of the facility's Administrator (ADM) 1, ADM 2, and Director of Nursing (DON), due to the facility's failure to provide supervision (1:1) monitoring for Resident 1. On [DATE] at 5:39 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After an onsite verification of the facility's IJRP implementation through observation, interview, and record review, the ADM 2, and DON, were notified the IJ situation was removed on [DATE] at 06:03 p.m. The following immediate corrective actions were included in the IJRP: 1. Staff on duty provided in-service training from [DATE] to [DATE] by the DON, Nurse consultant, and Director of Staff Development (DSD) on the following topics: a. Safety and Supervision for residents who were displaying aggressive and violent behaviors. b. How to handle residents with aggressive and violent behaviors. c. How to handle 5150 situations. Steps to follow for 5150 transfers and Violent or Aggressive behaviors: i. Place the resident on 1:1 monitoring. ii. Ensure resident safety was provided by removing hazardous materials that may be harmful or lethal out of the resident area. iii. Ensure the other residents ' safety was provided by removing roommates out of the area with the resident awaiting transport. iv. Ensure that caregivers avoid reaching over the resident or performing care have a way to call for back-up. Use telephone or paging system for back-up. v. RN Supervisor or designated licensed nurse to monitor every 15 minutes to ensure 1:1 monitoring was adhered to, and this will be documented on the monitoring log. vi. Provide interventions to deescalate the manifestations, remove the cause, remove stressors, offer food and beverages, other measures to ensure the environment was maintained safe until transport was available to transfer resident. vii. Make residents as comfortable as possible. Speak calmly, listen to resident concerns. viii. Update the physician and responsible party on the resident ' s transfer. d. How to identify residents who were depressed and have the tendency to harm themselves. The in-services will continue until all active staff had participated. Staff that had not attended the in-services will not be allowed to work until the in-services were completed. 2. On [DATE] the two roommates of the deceased resident (Resident1) were interviewed by the administrator; however, both were unable to respond to questions related to the deceased roommate. Both residents (Resident 2 and 3) were visited by the facility social services director and the assistant for three days to provide psychosocial [dynamic relationship between the psychological dimension of a person [ internal, emotional, and thought processes, feelings, and reactions] and the social dimension of a person [ includes relationships, family and community network, social values and cultural practices] support.) The two roommates were also referred to psychiatry (the medical specialty devoted to the diagnosis, prevention, and treatment of mental conditions) and was seen on [DATE] with the plan for continued behavioral interventions, and no criteria for immediate intervention or hospitalization . 3. The Nurse Consultant completed the knowledge competency with the DSD on resident safety and supervision on [DATE]. 4. Knowledge competency on resident safety and supervision will continue to be conducted to nursing staff by the DSD. Staff will not be allowed to work until the competency was completed. 5. The interdisciplinary team (IDT a team of departmental heads consisting of nursing, social service, activity, and psychiatrist) will conduct rounds three times weekly to interview alert residents and observe residents for signs and symptoms of depression with suicidal tendencies/ideation and aggressive/violent behaviors, this will immediately be reported to the RN supervisor or DON for assessment and need for psychiatric interventions including immediate transfer to psychiatric or acute care hospital. 6. The Charge Nurses will interview alert residents daily and monitor and observe residents for signs and symptoms of depression with suicidal tendencies/ideation and aggressive/violent behaviors every shift. Any residents identified showing signs and symptoms will immediately be reported to the RN supervisor or DON for assessment and the need for psychiatric interventions including immediate transfer to psychiatric or acute care hospital. Identified residents will immediately be provided with 1:1 supervision until the resident was transferred to the acute care facility. 7. Identified residents with symptoms of depression with aggressive behavior/violent behavior and other depressive symptoms will be discussed during the IDT meetings. The IDT will review medications to evaluate if the medication was effective to control symptoms of depression. The plan of care will be revised to include plans and recommendations. 8. The Charge Nurses and/or Nursing Supervisor will continue to remind nursing staff during huddles on how to handle the situation when residents were having aggressive and violent behavior, supervise residents who were displaying aggressive and violent behavior, how to handle 5150 situations and how to identify residents who were depressed and tend to harm self. 9. Residents who will be identified with major depression and refusing treatment, with aggressive and violent behavior, and a tendency to harm themselves will be communicated with the physician and a change of condition will be completed, 1:1 supervision/monitoring to keep resident safe will be immediately implemented and will be referred to the psychologist and/or psychiatrist for further evaluation and treatment, as appropriate. 10. The policy and procedures for Residents Safety and Supervision was revised on [DATE], to address the care of resident on 5150 holds, including 1:1 supervision as indicated for residents requiring emergency transfers and 5150 situations. 11. The DSD will incorporate in the new hire orientation program and in-service training to nursing staff on a quarterly and as-needed basis the following: a) How to handle the situation when residents are having aggressive and violent behavior. b) Supervising residents who are displaying aggressive and violent behavior. c) How to handle 5150 situations. d) How to identify residents who are depressed and tend to harm their selves. Monitoring Process: The DON and/or designee will track any trends or concerns related to resident supervision and residents ' safety; this will be communicated to the Quality Assurance and Assessment (QA&A) Committee monthly for further evaluation and recommendations. If it was determined that we have accomplished the objectives in the plan of corrections (POC) above and the results were successful, then the facility will consider the matter resolved. The QA & A committee will continue to review until such time that the deficiency has been proven to be resolved for 2 consecutive months and/or advised by the QA & A Committee. Findings: During a review of Resident 1 ' s admission record (Face Sheet), dated [DATE], the face sheet indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including delusional disorder, cardiac arrhythmia (irregular heartbeat), and had a cardiac pacemaker (a small device that was placed in the chest to help control the heartbeat). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was mildly impaired. The MDS further indicated Resident 1 had no active diagnosis of depression (serious mood disorder). During a review of Resident 1 ' s MDS section D (resident mood interview using PHQ-9 [nine [9] item Patient Health Questionnaire- a validated interview that screens for symptoms of depression.) The PHQ-9 questionnaire asked to say to resident if over the last two (2) weeks, have you been bothered by any of the following problems: a. Little interest or pleasure in doing things. b. Feeling down, depressed, or hopeless. c. Trouble falling or staying asleep or sleeping too much. d. Feeling tired or having little energy. e. Poor appetite or overeating. f. Feeling bad about your self- or that you are a failure or have let yourself or your family down. g. Trouble concentrating on things, such as reading the newspaper or watching television, h. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. i. Thoughts that you would be better off dead or hurting yourself in some way. The MDS PHQ-9 from [DATE] to [DATE] indicated the following: On [DATE], [DATE], [DATE] and [DATE], indicated Resident 1 had no symptoms of depression. On [DATE], indicated Resident 1 was feeling down, depressed, or hopeless for ,d+[DATE] days nearly half or more of the days. The MDS indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for ,d+[DATE] days nearly every day. On [DATE] and [DATE] indicated Resident 1 was feeling down, depressed, or hopeless for ,d+[DATE] days nearly every day. The MDS also indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for ,d+[DATE] days nearly every day. During a review of Resident Assessment Instrument (RAI) Manual for Long Term Care Facility 3.0 User ' s Manual Version 1.17 dated [DATE], RAI indicated Responses to PHQ-9 can indicate possible depression. Responses can be interpreted as follows: Minor Depressive Syndrome is suggested if, of the 9 items, (1) feeling down, depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much, or (3) feeling tired or having little energy are identified at a frequency of half or more of the days (,d+[DATE] days) during the look-back period and at least one of these, (1) little interest or pleasure in doing things, or (2) feeling down, depressed, or hopeless is identified at a frequency of half or more of the days (,d+[DATE] days). During a record review of Resident 1 ' s Social Service (SS) Assessment -Type Quarterly, dated [DATE] and [DATE], SS assessment indicated Resident 1 spent most of his time alone or watching television, naps regularly throughout the day. SS assessment indicated over the last two weeks, Resident 1 had been bothered by feeling or appearing down, depressed, or hopeless, feeling bad about himself, feeling of failure, or letting self or family down, expressed adjustment issues, expresses difficulty coping with current health status and rejection of care occurred daily. During a review of CAA (Care Area Assessment-provide guidance to focus on key issues identified in comprehensive MDS. Direct staff to evaluate triggered areas) worksheet dated [DATE], CAA indicated Resident 1 ' s mood interview total severity score, and frequency was greater than the prior assessment and triggered mood state as potential problem. CAA indicated to assess and refer accordingly, psychiatry consults as needed and proceed to care planning to focus on safety, nutritional status, health activity pattern, and was not a danger to self or others. During a review of CAA worksheet dated [DATE], CAA indicated behavioral symptoms was triggered potential problem due to Resident 1 rejected evaluation of care daily, changed in behavior, care rejection or wandering had gotten worse since prior assessment. Resident 1 rejected care that was necessary to achieve his goals for health and well-being and had episodes of refusing nursing care including medications. CAA indicated to proceed to care planning to focus on resident ' s safety, nutritional status, behavior approach, health activity pattern, and was not a danger to self and others. During a review of Resident 1 ' s care plan for non-compliance titled Behavior, date initiated [DATE] and was not revised until ,d+[DATE], care plan indicated Resident 1 manifested refusing medications, sudden outburst of anger, aggressive behavior, Resident 1 expressed feeling down, hopeless feeling bad about self. Care plan goal was to minimize adverse effects of non-compliant behavior of refusing medications and did not indicate a goal to ensure Resident 1 ' s depression will be resolved or improved. Care plan did not address how Resident 1 will be monitored and ensure Resident 1 will not harm himself or others as indicated on CAA. During an interview on [DATE] at 12:05 p.m., with Family 1, Family 1 stated that Resident 1 had some issues with depression and anxiety and on a lot of medications. During a review of Resident 1 ' s IDT ([Interdisciplinary Team]-comprises professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) meeting notes from [DATE] to [DATE], IDT notes did not indicate the IDT addressed a plan of care how to address Resident 1 ' s verbalization of feeling depressed and hopeless. During a review of Resident 1 ' s Physician Order Summary report with the last recap date of [DATE], indicated Resident 1 had an order on [DATE] that indicated Resident 1 may have psychology consultation and treatment as needed, and an order on [DATE] that indicated Resident 1 may have psychiatry consult and treatment as needed. During a review of Resident 1 ' s Psychiatrist Note, dated [DATE], Psychiatrist Note indicated Resident 1 continued to refuse to be seen by psychiatry. Per nursing no acute problematic or concerning behaviors not on a psychotropic (drugs that affect a person's mental state) regimen. Resident 1 was on Depakote for seizures. During a review of Resident 1 ' s Psychiatrist Note, dated [DATE], Psychiatrist Note indicated Resident 1 was refusing assessment and no concerning behavioral concerns per nursing. During a review of Resident 1 ' s Psychiatrist Note, dated [DATE], Psychiatrist Note indicated Resident 1 does not wish to be seen by psychiatry and per nursing no acute problematic behaviors or concerns and psychiatrist will remain available if Resident 1 willing to interview. The Psychiatrist Note indicated staff were aware of emergent option to call for PET. PET evaluation if needed. During a review of Resident 1 ' s Psychiatrist Note, dated [DATE], Psychiatrist Note indicated evaluation was requested by staff to see Resident 1 but Resident 1 refused psychiatric evaluation and that no acute problematic behaviors present. Psychiatrist Note indicated per staff, Resident 1 had been over all stable despite refusing care from psychiatry and advised staff that psychiatry to remain available for changes in behavior or to call PET team for any crisis if Resident 1 refuses to be evaluated. During a review of PET Assessment Form, dated [DATE], The PET assessment indicated that on [DATE] at 5:02 p.m., Resident 1 was seen and assessed via face-to-face video conference by a peace officer/ mental health professional. The PET assessment form indicated there was a probable cause to believe that Resident 1, as a result of mental health disorder, a danger to others, or to himself, or gravely disabled because of history of delusional disorder, being angry, and easily agitated. The PET assessment indicated Resident 1 should be transferred to a 5150 designated facility for up to 72 hours assessment, evaluation, and crisis intervention or placement for evaluation and treatment at a designated facility pursuant to section 5150. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation ([SBAR]-communication form between members of the healthcare team about a patient condition) dated [DATE], SBAR indicated that on [DATE] at 1:20 p.m., Resident 1 had episode of agitation, kicking, screaming, and striking out staff. Resident 1 left the facility and when staff attempted to stopped him, he became combative. SBAR indicated Resident 1 got agitated while RN 1 was talking to Resident 1 and Resident 1 suddenly took out a bread knife and flagged the bread knife in front of him and seemed that he was ready to strike whoever got close to him. RN 1 and staff (unspecified) was able to get the breadknife from Resident 1. During an interview on [DATE] at 10:00 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that Resident 1 left the facility through the front lobby and refuse to go back to the facility then Resident 1 became aggressive, striking out staff, and combative when staff tried to redirect him back to the facility. During an interview on [DATE] at 2:45 p.m., with Registered Nurse (RN) 1, RN 1 stated she was notified by Restorative Nurse Assistant (RNA 1) that Resident 1 was in front of a building outside the facility and refused to go back to the facility. 911 was called, two policemen came, talked to Resident 1, but Resident 1 refused to go back to the facility. RN 1 stated she called Resident 1 ' s primary physician and informed her about Resident 1 being outside the facility and refusing to go back to the facility. The primary physician ordered Ativan (a medication use to treat or relieve anxiety) for Resident 1 and instructed staff to notify Resident 1 ' s psychiatrist (Psychiatrist 1) of the situation. Psychiatrist 1 gave an order to send Resident 1 to acute hospital (GACH) under 5150. During an interview on [DATE] at 2:50 p.m., with RN 1, RN 1 stated Resident 1 spoke to PET via videoconference due to his aggressive behavior, striking out and kicking staff, eloping from the facility and uncooperative to go back into the facility. PET team evaluated Resident 1 and required Resident 1 to be transferred to a designated 5150 facility. RN 1 stated the facility (in which resident was resided) could not transfer Resident 1 to designated 5150 GACH facility because she was informed by ambulance and verified with GACH that admission closed at 5:30 p.m. RN 1 asked Resident 1 if he would like to go to another hospital and Resident 1 refused. RN 1 stated Resident 1 eventually came back into the facility at about 6:30 p.m., after much persuasion by staff. Resident 1 was placed on every 15 minutes visual monitoring while waiting to be transferred to a 5150 designated facility. During an interview on [DATE] at 10:10 a.m. with RN 2, RN 2 stated that she took over the care of Resident 1 for the night shift on [DATE] at 11:00 p.m. She checked on Resident 1 first at 11:20 p.m. Resident 1 was lying in bed appeared to be sleeping. RN 2 stated Resident 1 was being monitored every 15 minutes and last saw Resident 1 in bed on [DATE] at 12:45 a.m. RN 2 stated on [DATE] at about 1:00 am she responded to CNA 1 emergency call to Resident 1 ' s room. Resident 1 was hanging inside the closet in his room. RN 2 instructed the staff to cut the cord/string and start CPR. RN 2 called 911, the EMS came and took over the CPR and treatment. RN 2 stated that Resident 1 was pronounced dead by the EMS on [DATE] at approximately 1:57 a.m. During an interview on [DATE] at 8:16 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated when she checked on Resident 1 at about 11:10 p.m., Resident 1 was in bed, CNA 1 stated that she did not talk to Resident 1 because she did not want to wake up Resident 1. CNA 1 stated at about 1:00 a.m., she was passing out ice to residents, CNA 1 went to Resident 1 ' s room and the door was hard to open, and she (CNA1) had to push the door hard to open it. CNA 1 stated there was a wheelchair behind the door. CNA 1 stated Resident 1 was not in his bed, CNA 1checked the bathroom, and Resident 1was not in the bathroom. CNA1 stated as she was walking towards the door, she noticed a foot dangling at the lower part of the closet. CNA 1 opened the closet and saw Resident 1 hanging in the closet with what appears to be a shoelace around his neck. CNA 1screamed for help, the charge nurse, other staff and the supervisor came, moved Resident 1 away from the closet and initiated CPR. During an interview on [DATE] at 12:30 p.m., with Resident 1 ' s psychologist (Psychologist 1), Psychologist 1 stated the last time she saw and treated Resident 1 was on [DATE]. Resident 1 refused further evaluation and treatment at that time. During an interview on [DATE] at 2:45 p.m., with CNA 2, CNA 2 stated during her shift (3 to11 p.m.) on [DATE], Resident 1 came back to the facility at about 6 or 7 p.m. CNA 2 offered to warm up Resident 1 ' s dinner tray, but Resident 1 declined saying that he was not eating. By 9 p.m., Resident 1 was sitting in his wheelchair on the hallway close to his room. By 11 p.m. Resident 1 was in bed. CNA 2 stated Resident 1 was able to help himself in and out of the bed. During an interview on [DATE] at 3 p.m., with Director of Nursing, (DON) stated, on [DATE] when Resident 1 came back to the facility, he went back to his room. Resident 1 was placed on every 15 minutes monitoring. DON stated that she understands 5150 was used when a resident who was a danger to self or others refuses treatment or transfer to acute hospital. DON stated that the care for a resident under 5150 pending transfers to GACH depends on individual cases. If a resident was on 5150 holds for wanting to harm himself or others, such resident should be placed on one on one (1:1) monitoring. DON stated in the case of Resident 1, he was monitored every 15 minutes pending transfer to GACH because he tried to elope (leave unauthorize or unsupervised) from the facility. During an interview on [DATE] at 1:00 p.m., the PET RN, who evaluated Resident 1 during the elopement crisis, the PET RN stated, on [DATE] when she interviewed Resident 1, Resident 1 was angry and refused to go back to the facility. Resident 1 denied any suicidal thought. Resident 1 stated no, when asked if he had any intension of hurting himself. The PET RN stated she placed Resident 1 on 5150 for being a danger to others and does not know why Resident 1 was not picked up on [DATE] when the GACH was opened 24 hours. During a review of paramedic run sheet dated [DATE], run sheet indicated that paramedics arrived on scene on [DATE] at 01:25 a.m., Resident 1 was pulseless, apneic (temporal cessation of breathing),lying on ground, and CPR being performed by staff members. Run sheet indicated per staff members (unidentified), Resident 1 barricaded himself in closet and when staff got to Resident 1, he had wrapped shoestring around his neck. Runsheet indicated the closet was raised off ground and approximately four feet tall and Resident 1 ' s legs were on ground. There were ligature marks (marks made by an item of cord, rope, silk or some such material that had been used for the purposes of strangulation) noted around Resident 1 ' s neck. The run sheet indicated that per staff Resident 1 was last seen approximately two hours ago and upon EMS interventions the resident was in PEA ([pulseless electrical activity] a condition where your heart stops because the electrical activity in the heart was too weak to make your heartbeat. Four rounds (doses) of epinephrine (medication given to treat allergic reactions or to restore heart rhythm) was given and Resident 1 was pronounced dead on the scene on [DATE] at 1:57 a.m. During a review of the form Los Angeles County Department of Mental Health-MH 302 NCR (Mental Health form) dated [DATE], indicated Resident 1 was on a 5150-hold due to being a danger to others. During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, revised [DATE], indicated residents ' safety, supervision and assistance are priorities. The care team shall target interventions to include adequate supervision and the need for close monitoring.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided necessary behavioral health care and services for treatment of the resident ' s emotional and mental condition by ensuring: 1. Resident 1 who verbalized feeling depressed (serious mood disorder) for approximately five (5) months was assessed, monitored, and provided intervention to addressed Resident 1 ' s symptoms of depression. 2. Physician, psychiatrist (a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders), psychiatrist nurse practitioner, and interdisciplinary team ([IDT]-comprises professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological [mental and emotional) needs) were notified when Resident 1 verbalized feeling depressed. 3. Resident 1 ' s aggressive behavior, emotional and mental status were being monitored and supervised to prevent Resident 1 from harming self and others. These deficient practices resulted in a lack of care plan interventions to addressed Resident 1 ' s increasing symptoms of depression and Resident 1 did not receive the necessary care, services, and interventions to addressed Resident 1 ' s emotional, behavioral, and psychosocial (the psychological dimension [internal, emotional, and thought processes, feelings, and reactions] and the social dimension [ includes relationships, family and community network, social values and cultural practices] of a person) needs. Resident 1 had aggressive behavior, threatened staff with a knife. Eight hours later, Resident 1 committed suicide by hanging himself in the closet with a shoelace like rope/string wrapped around his neck and was pronounced dead on 3/19/2023 at 1:57 a.m. Findings: During a review of Resident 1 ' s Admission Record (face sheet), dated 3/21/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses including delusional disorder (characterized by one or more firmly held false beliefs that persist for at least one month), cardiac arrhythmia (irregular heartbeat), presence of cardiac pacemaker (a small device that was placed in the chest to help control the heartbeat to prevent the heart from beating slowly, and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/20/2023, MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was mildly impaired, and required supervision for activities of daily living. MDS indicated Resident 1 had no active diagnosis of depression. During a concurrent interview and record review of MDS section D (Mood) on 3/26/2023 at 10:00 a.m., with Social Service Assistant (SSA1), SSA 1 stated that she conducted Resident Mood Interview using PHQ9 (nine [9] item Patient Health Questionnaire- a validated interview that screens for symptoms of depression) questionnaires with Resident 1. SSA 1 stated she asked Resident 1 if over the last two weeks, was he bothered by any of the following problems listed on the PHQ 9 questionnaire: a. Little interest or pleasure in doing things. b. Feeling down, depressed, or hopeless. c. Trouble falling or staying asleep or sleeping too much. d. Feeling tired or having little energy. e. Poor appetite or overeating. f. Feeling bad about your self- or that you are a failure or have let yourself or your family down. g. Trouble concentrating on things, such as reading the newspaper or watching television, h. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. i. Thoughts that you would be better off dead or hurting yourself in some way. The MDS PHQ-9 from 10/2022 to 2/20/2023 indicated the following: On 10/25/2022, indicated Resident 1 was feeling down, depressed, or hopeless for 7-11 days nearly half or more of the days. The MDS indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day. On 1/23/2023 and 2/20/2023 indicated Resident 1 was feeling down, depressed, or hopeless for 12-14 days nearly every day. The MDS also indicated Resident 1 was feeling bad about self or that he was a failure or have let himself or family down for 12-14 days nearly every day. During a review of Resident Assessment Instrument (RAI) Manual for Long Term Care Facility 3.0 User ' s Manual Version 1.17 dated October 2019, RAI indicated Responses to PHQ-9 can indicate possible depression. Responses can be interpreted as follows: Minor Depressive Syndrome is suggested if, of the 9 items, (1) feeling down, depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much, or (3) feeling tired or having little energy are identified at a frequency of half or more of the days (7-11 days) during the look-back period and at least one of these, (1) little interest or pleasure in doing things, or (2) feeling down, depressed, or hopeless is identified at a frequency of half or more of the days (7-11 days). During a record review of Resident 1 ' s Social Service (SS) Assessment -Type Quarterly, dated 10/31/2022 and 1/23/2023, SS Assessment indicated Resident 1 spent most of his time alone or watching television, and naps regularly throughout the day. SS Assessment indicated over the last two weeks, Resident 1 had been bothered by feeling or appearing down, depressed, or hopeless, feeling bad about himself, feeling of failure, or letting self or family down, expressed adjustment issues, expresses difficulty coping with current health status and rejection of care occurred daily. Social Service Plan indicated the following: a. Establish/continue a positive, trusting relationship with resident and family. b. Communicate with resident, family, interdisciplinary team to assess for home care needs upon discharge and coordinate appropriate referrals c. Participate in ongoing communication with the interdisciplinary team to identify and accommodate resident specific needs. d. Address psychosocial needs (mood, behavior, communication, and mental status), invite to resident-to-resident council meetings e. Invite resident to care plan meetings. f. Covert/open conflict with or repeated criticism of staff. During an interview on 3/26/203 at 10:15 a.m., with the SSA 1, SSA 1 stated she was not sure if she mentioned Resident 1 ' s increasing symptoms of depression to the nurses and said she might have mentioned the result of Social Service Assessment to the Social Service Director (SSD) 1 but SSD 1 no longer work at the facility. The SSA 1 stated she did not document she notified the SSD 1 or any nurses and does not recall notifying the physician or psychiatrist to regarding Resident 1 ' s symptoms of depression. SSA 1 was unable to say or provide documentation how Resident 1 ' s symptoms of depression were addressed including social service plan. During an interview on 3/26/2023 at 10:45 a.m., with the Director of Nursing (DON), the DON stated SSD 1 last worked physically at the facility on 12/15/2022. The next SSD was SSD 2, who was hired on 1/19/2023 and last worked at the facility on 2/24/2023. The next SSD was SSD 3, who just started working on 3/20/2023. During a review of CAA (Care Area Assessment-provide guidance to focus on key issues identified in comprehensive MDS. Direct staff to evaluate triggered areas) worksheet dated 11/8/2022, CAA indicated Resident 1 ' s mood interview total severity score, and frequency was greater than the prior assessment and triggered mood state as potential problem. CAA indicated to assess and refer accordingly, psychiatry (the medical specialty devoted to the diagnosis, prevention, and treatment of mental conditions) consults as needed and proceed to care planning to focus on safety, nutritional status, health activity pattern, and was not a danger to self or others. During a review of CAA worksheet dated 11/8/2022, CAA indicated Behavioral symptoms was triggered potential problem due to Resident 1 rejected evaluation of care daily, changed in behavior, care rejection or wandering has gotten worse since prior assessment. Resident 1 rejected care that was necessary to achieve his goals for health and well-being. Resident 1 had episodes of refusing nursing care including medications. CAA indicated to proceed to care planning to focus on resident ' s safety, nutritional status, behavior approach, health activity pattern, and was not a danger to self and others. During a concurrent interview and record review on 3/26/2023 at 11:00 a.m., with SSA1, MDS Coordinator (MDSC 1), and the DON. Resident 1 ' s clinical record from January 1, 2022, to March 26, 2023, were reviewed including care plan, IDT notes, physician notes, nurses progress notes, Change of Condition ([COC] a clinical deviation from a resident's baseline), psychiatrist, and psychosocial notes. SSA1, MDSC 1, and the DON all verified and stated there were no documentation in Resident 1 ' s electronic or paper clinical record that indicated Resident 1 depression was communicated and addressed by the physician, psychiatrist, or psychologist. Social Service, MDSC 1 and the DON verified that the referral for psychiatrist and psychologist were for refusing medications and was not a referral to addressed Resident 1 ' s symptoms of depression. During an interview and concurrent review of Resident 1 ' s IDT meeting notes from January 1, 2022 to 3/26/2023, on 3/26/203 at 10:30 a.m., with MDSC 1, MDSC1 stated IDT notes did not indicate the IDT addressed a plan of care how to address Resident 1 ' s verbalization of feeling depressed and hopeless. During a review of Resident 1 ' s care plan for non-compliance titled Behavior, date initiated 12/1/2021 and revised 3/20/2023, care plan indicated Resident 1 manifested refusing medications, sudden outburst of anger, aggressive behavior, Resident 1 expressed feeling down, hopeless feeling bad about self. Care plan goal was to minimize adverse effects of non-compliant behavior of refusing medications and did not indicate a goal to ensure Resident 1 ' s depression will be resolved or improved. Care plan did not address how Resident 1 will be monitored and ensure Resident 1 will not harm himself or others as indicated on CAA. During a review of Resident 1 ' s Psychiatrist Note, dated 11/22/2022, Psychiatrist Note indicated Resident 1 continued to refuse to be seen by psychiatry, per nursing no acute problematic or concerning behaviors and Resident 1 was not on a psychotropic (drugs that affect a person's mental state) regimen. Resident 1 was receiving Depakote for seizures. During a review of Resident 1 ' s Psychiatrist Note, dated 1/11/2023, Psychiatrist Note indicated Resident 1 was refusing assessment and no behavioral concerns per nursing. During a review of Resident 1 ' s Psychiatrist Note, dated 2/8/2023, Psychiatrist Note indicated Resident 1 does not wish to be seen by psychiatry and per nursing no acute problematic behaviors or concerns. The psychiatrist will remain available if Resident 1 was willing to be interviewed. Psychiatric Note indicated staff aware of emergent option to call for Psychiatric Emergency Teams ([PET] mobile teams operated by psychiatric hospital to perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others or who are unable to provide food, clothing, or shelter because of a mental disorder) if needed. During a review of Resident 1 ' s Psychiatrist Note, dated 3/8/2023, Psychiatric Note indicated evaluation was requested by staff to see Resident 1 but Resident 1 refused psychiatric evaluation and Resident 1 had no acute problematic behaviors present. Psychiatric Note indicated per staff Resident 1 had been over all stable despite refusing care from psychiatry and advised staff that psychiatry to remain available for changes in behavior or to call PET team for any crisis if Resident 1 refuses to be evaluated. During a review of Resident 1 ' s PASRR ([Preadmission Screening and Resident Review federal requirement] to help ensure that individuals with a mental disorder or intellectual disability were not inappropriately placed in nursing homes for long term care) Level 1 screening, dated 6/16/2021, PASRR level 1 screen indicated negative and no need for PASRR level II evaluation (an in-depth psychosocial evaluation of the individual.) During a review of Resident 1 ' s PASRR I level screening, resident review status change dated 8/29/2022, PASRR level 1 screen indicated positive suspected mental illness. Resident 1 had diagnosis of mental disorder and was taking Depakote (used to prevent migraine headaches, seizures, or to treat manic episodes related to bipolar disorder [condition that causes extreme mood swings that include emotional highs mania or hypomania and lows depression]). During a review of Resident 1 ' s Medication Administration Record (MAR) for March 2023, The MAR indicated an order to for Depakote Sprinkles capsule 125 mg (milligram-unit of measurement) two (2) capsules by mouth three times a day for seizure disorder. Record indicated Resident 1 refused 20 times out of 54 scheduled times of medication administration on March 1 to March 19, 2023. During a review of Resident 1 ' s PASRR Level II evaluation letter, dated 9/7/2022, letter indicated after reviewing the positive Level I Screen and speaking with staff, a level II Mental health evaluation was not scheduled due to Resident 1 does not have serious mental illness. The case was closed and to reopen, submit a new level 1 screening. During an interview on 3/26/2023 at 11:00 a.m., with the DON, the DON stated she was responsible for making the referral for PASRR. The DON stated she was not aware that Resident 1 had history or symptoms of depression and was not aware about the result of the PHQ9. The DON stated she should have followed up and ensure that PASSR Level II was done. The DON stated new onset or changes in behavior that indicated newly evident or possible serious mental disorder, intellectual disability, or a related disorder should be referred for a PASRR level II to find out if Resident 1 should stay at the facility or could get the necessary services and treatment to address depression. During an interview on 3/27/2023 at 11:00 a.m., with the DON, the DON stated that PASRR level II was evaluated not necessary because on 9/7/2023 when the PASRR level II had been evaluated, Resident 1 was not yet verbalizing symptoms of depression. The DON stated that she should have initiated another PASRR reevaluation for change of condition when Resident 1 continued to verbalize being depressed. During an interview on 3/25/2023 at 09:10 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she took care of Resident 1 and was not aware Resident 1 had history of depression or that he was verbalizing feeling sad. LVN 2 stated she did not receive any report that Resident 1 was depressed. During an interview on 3/26/2023 at 09:38 a.m., with LVN 3, LVN 3 stated he was not aware Resident 1 had history of depression. LVN 3 stated the facility staff were not monitoring Resident 1 for depression and that Resident 1 was just quiet, liked to be by himself and seemed like he does not want to talk to anyone. LVN 3 stated no one told him that Resident 1 had depression. LVN 3 stated if he knew that Resident 1 was depressed, he would have seen the signs that Resident 1 was depressed like when he was refusing his medications consistently, being isolated, and refusing to eat. LVN 3 stated he asked a Certified Nurse Assistant (CNA) (unable to remember name) on 3/18/2023 at 09:00 a.m. why Resident 1 was so quiet, not engaging in conversation and seemed to be upset. LVN 3 stated the CNA (unidentified) told him Resident 1 was just having a bad mood. LVN 3 stated if he knew he was depressed he could have investigated more and see if there was anything he could have done. During an interview on 3/26/2023 at 10:03 a.m., with LVN 4, LVN 4 stated he took care of Resident 1 more than 10 times but was not aware that Resident 1 had history of depression or that he was verbalizing being sad and depressed. LVN 4 stated the facility staff were monitoring Resident 1 for refusal of medication but not for depression. LVN 4 stated Resident 1 was always upset, liked to be by himself but did not think Resident 1 was depressed. LVN 4 stated no one mentioned Resident 1 had history of depression. During an interview on 3/23/2023 at 12:05 p.m., with Family 1, Family 1 stated that Resident 1 had some issues with depression and anxiety. During an interview on 3/26/2023 at 3:12 p.m., with Registered Nurse (RN 1), RN 1 stated that Resident 1 became agitated on 3/18/2023 around 1:20 p.m., while trying to elope from the facility. RN 1 stated Resident 1 spoke to the PET via videoconference due to aggressive behavior, striking out and kicking staff, eloping from the facility and uncooperative to go back to the facility. The PET team evaluated Resident 1 was required to be transferred to a designated 5150 (allows for a medical facility or law enforcement agency to place a 72 hour involuntary hold on an individual who they believe was a danger to himself or others because of a mental illness or condition)facility. During a review of PET Assessment Form, dated 3/18/2023, The PET assessment indicated that on 3/18/2023 at 5:02 p.m., Resident 1 was seen and assessed via face to face video conference by a peace officer/ mental health professional. The PET assessment form indicated there was a probable cause to believe that Resident 1, because of mental health disorder, a danger to others, or to himself, or gravely disabled because of history of delusional disorder, being angry, and easily agitated. The PET assessment indicated Resident 1 should be transferred to a 5150 designated facility for up to 72 hours assessment, evaluation, and crisis intervention or placement for evaluation and treatment at a designated facility pursuant to section 5150. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, communication form) dated 3/18/2023, SBAR indicated that on 3/18/2023 at 1:20 p.m., Resident 1 had episode of agitation, kicking, screaming, and striking out staff. Resident 1 left the facility and when staff attempted to stopped him, he became combative. SBAR indicated Resident 1 got agitated while RN 1 was talking to Resident 1. Resident 1 suddenly took out a bread knife and flagged the bread knife in front of him and seemed that he was ready to strike whoever got close to him. RN 1 and staff (unspecified) was able to get the breadknife from Resident 1. During an interview on 3/26/2023 at 3:20 p.m., with RN 1, RN 1 stated after Resident 1 was evaluated by the PET, Resident 1 suddenly took out a bread knife, was holding the knife in front of him, knife directed to the staff, and threatened the staff not to come close to him. RN 1 stated they (CNA 2, LVN 1 and RN 1) panicked, was afraid that Resident 1 could hurt himself or others but were able to forcedly take the bread knife from Resident 1. RN 1 stated the PET, nor the law enforcer were not made aware Resident 1 threatened the staff with a bread knife because the incident happened after law enforcer came to see Resident 1 and after the PET spoke to Resident 1. During a review of Resident 1 ' s Physician Order, dated 3/18/2023, the physician order indicated an order to transfer Resident 1 to a designated 5150 General Acute Care Hospital (GACH) for 5150 Hold. During an interview on 3/27/2023 at 6:30 a.m., with RN 2, RN 2 stated she got preoccupied trying to make the arrangement for transportation for Resident 1, was doing the staff assignment schedule then she was called to respond to an emergency because Resident 1 was found hanging inside the closet. RN 2 stated they (CNA 1 and RN 2) did monitor Resident 1 but not one to one monitoring (when an individual staff member is assigned to directly supervise no more than one resident and the staff shall stay within very close proximity to ensure constant supervision and immediate intervention if needed for safety reasons). RN 2 stated they just made frequent rounds and ensure Resident 1 will not try to leave the facility unsupervised. RN 2 stated she was not aware Resident 2 had depression because he was just quiet and not really talking about harming himself. RN 2 stated Resident 1 was just in his bed sleeping most of the time. RN 2 stated at around 1 am, CNA 1 found Resident1 ' s door closed, blocked by a wheelchair, and found Resident 1 hanging in the closet with a shoelace like rope/string wrapped around his neck. RN 2 stated on 3/19/2023 at 1:57 a.m. Resident 1 was pronounced dead by paramedics. During an interview on 3/29/2023 at 09:24 a.m., with Resident 1 ' s Psychiatric Nurse Practitioner (NP) 1, NP1 stated she was not aware that Resident 1 was verbalizing he was depressed, and the nurses were telling her that Resident 1 had no concern and refusing psychiatric assessment. NP 1 stated she remembered Resident 1 being irritable, but no one mentioned about him verbalizing he was depressed and relied so much on the nurses ' communication because the nurses were the one who saw the resident every day. NP 1 stated it was important for the nurses to report to the psychiatrist what the residents ' daily behaviors were so the NP, physicians or psychiatrist can make the correct recommendations or prescriptions. NP 1 stated if she was informed that Resident 1 was verbalizing being depressed, she could have addressed Resident 1 ' s concern and could have made recommendations even if Resident 1 was refusing to be seen. During an interview on 3/30/2023 at 09:02 a.m. with Resident 1 ' s Psychiatrist (Psychiatrist 1), Psychiatrist 1 stated he never saw Resident 1 at the facility and Psychiatrist Nurse Practitioner 1 was the one who saw Resident 1 while at the facility. Psychiatrist 1 stated he was not informed that Resident 1 was verbalizing any symptoms of depression and that Resident 1 threatened the staff with a knife. Psychiatrist 1 stated the staff should have been more assertive of notifying the physicians including the psychiatrist of the changes in residents' behavior so proper intervention could have been provided. During an interview on 4/3/2023 at 09:30 a.m., with the DON, the DON stated the nursing staff should have notified the physician and psychiatrist when Resident 1 was verbalizing feeling depressed and should have created an individualized plan of care when the CAA triggered to create a care plan for behavioral and mood concerns. The DON stated the care plan should have addressed how Resident 1 will be monitored and ensure Resident 1 will not harm himself or others as indicated on CAA. The DON stated if Resident 1 ' s symptoms of depression were reevaluated Resident 1 could have gotten the proper interventions and could have prevented Resident 1 from committing suicide. During a review of the facility ' s policy and procedure (P&P) titled, Behavioral Assessment, Intervention and Monitoring, dated revised March 2019, the P&P indicated: 1. The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practical physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and plan of care. 2. Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. 3. Behavioral services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents. 4. Residents will have minimal complications associated with the management of altered or impaired behavior. 5. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident ' s usual patterns of cognition, mood, and behavior. b. The resident ' s typical or past response to stress, fatigue, fear, anxiety, frustration, and other triggers; and the residents' previous patterns of coping with stress, anxiety, and depression. 6. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual ' s mental status, behavior and cognition including: a. Onset, duration, intensity, and frequency of behavioral symptoms. b. Any recent precipitating or relevant factors or environmental triggers. c. Appearance and alertness of the resident related observations. 7. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR level II evaluation. 8. The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident ' s change in condition including: a. Physical or medical changes. b. Emotional, psychiatric, and or/ psychological stressors (for example depression, boredom, loneliness, anxiety and or fear.

Based on interview and record review, the facility failed to follow its policy titled, Change in Condition Notification, and a resident's care plan titled, At risk for Infection, that stipulated the staff would obtain laboratory tests as ordered and report the abnormal results to the physician and when there was a change in a resident's condition for one of three sampled residents (Resident 1). Resident 1, who had history of developing pneumonia ((PNA) a lung infection that caused coughing and difficulty in breathing), had an elevated White Blood Count (WBC, an important part of the immune system; help to fight infections by attacking bacteria, viruses, and germs) level, but Resident 1's physician was not notified, as per policy and the resident's plan of care. This deficient practice of not reporting Resident 1's elevated WBC to the physician resulted in a delay in providing timely care, [DIAGNOSES REDACTED].=levels 4.00 -10.00)). Resident 1 required a transfer to a general acute care hospital (GACH) with a 5-day hospital admission due to [DIAGNOSES REDACTED]. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], and recently re-admitted on [DATE]. Resident 1 had [DIAGNOSES REDACTED]. directly to the stomach) and [MEDICAL CONDITION] (a heart condition characterized by irregular and often faster heart beat). A review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated [DATE], indicated the resident was severely impaired in cognitive skills (thought process). The MDS indicated that Resident 1 required a two-person physical assist in moving from a lying position and turning in bed, but a one-person physical assist in transferring from a bed/chair to a standing position, moving from one location to another, dressing, eating, toilet use and personal hygiene. According to the MDS, Resident 1 used a wheelchair for mobility, was always incontinent (inability to control) of bowel and bladder functions. A review of Resident 1's physician's orders [REDACTED]. A review of a Physician's Progress Note, dated [DATE] and timed at 10:58 p.m., indicated Resident 1 was seen and examined, by a physician's Assistant ((PA 1) practices medicine on teams with physicians, surgeons, and other healthcare workers; examine, diagnose, and treat patients). It also indicated Resident 1 was recently treated at the GACH for aspiration PNA. According to the note, Resident 1 was assessed by PA 1 to be congested (excessive secretions making breathing difficult ) and required suctioning (to remove secretions with a suction machine from the throat and/or oral airway) while laying flat, but improved when Resident 1 was sitting up and suctioned. A review of a physician's progress note, dated [DATE] and timed at 1:56 p.m., indicated Resident 1 had a follow-up visit with PA1 for Resident 1's [DIAGNOSES REDACTED]. According to the note, Resident 1 was treated for [REDACTED]. The PA's progress note emphasized that a chest x-ray was to be done on [DATE], but was not done as ordered. A review of Resident 1's Lab Results Report, dated [DATE] and timed 7:51 a.m., indicated the resident's WBC result was elevated at 14.39 ul (NRR 4.00 - 10.00). A review of a physician's progress note, dated [DATE] and timed at 6:22 p.m., written by PA 1, indicated there was no documented evidence to indicate that PA 1 had reviewed Resident 1's elevated WBC results and/or was notified by the staff of the abnormal results. A review of Resident 1's Nurse's Notes, dated from [DATE] through [DATE], indicated there was no documentation to indicate that the physician was notified of Resident 1's elevated WBC results. A review of Resident 1's care plan, dated [DATE], indicated Resident 1 was at risk for respiratory complications related to shortness of breath (SOB) and having a GT tube. The staff's interventions included to obtain labs as ordered and report to the physician as indicated, observe for respiratory status and assess for changes, provide respiratory treatment as ordered and monitor for effectiveness. A review of Resident 1's care plan, dated [DATE] indicated Resident 1 has an enteral feeding tube (GT). The staff's interventions included to monitor for aspiration precautions, keep head of bed elevated at ,[DATE] degrees during feeding, and monitor labs and report results to physician. A review of a care plan, dated [DATE] indicated Resident 1 was at risk for an infection. The staff's interventions included to monitor for signs and symptoms of infection and report to the physician, obtain labs/cultures as ordered and report the results to the physician as indicated. A review of Resident 1's Infusion Medication Administration Record [REDACTED]. A review of the Resident 1's Nurse's Note, dated [DATE] and timed at 9:23 a.m., indicated a Registered Nurse (RN) called 911 (an emergency service) due to the resident having shortness of breath, eight days after Resident 1's WBC was elevated (14.39 ul) and the PA nor physician were notified. According to the note, Resident 1 was transferred to a GACH by the paramedics at 9:40 a.m. A review of Resident 1's Emergency Department (ED) documentation, dated [DATE] and timed 12:21 p.m., indicated Resident 1 was hypoxic (low oxygen level) with a oxygen saturation of 86 percent (%) (NRR is ,[DATE]%) and had an elevated WBC of 33.9 ul(that had increased over 2 times since [DATE]). The ED note indicated Resident 1 was treated with IV Abx and fluids. A review of the GACH's Discharge Summary, dated [DATE] and timed at 3 p.m., indicated Resident 1 was admitted to the hospital on [DATE] and discharged on [DATE] after the WBC had decreased to 15.2. Resident 1's admission [DIAGNOSES REDACTED]. A review of Progress Notes, dated [DATE] and timed 12:50 a.m., indicated Resident 1 expired and that the staff was unable to get the resident's vital signs and was pronounced deceased . A review of Resident 1's Death Certificate, indicated the resident expired on [DATE] with the immediate cause of death listed as an acute [MEDICAL CONDITION] (kidneys suddenly are unable to filter waste products from the blood). On [DATE] at 1:28 p.m., during an interview, the Director of Staff Development (DSD) stated that licensed nurses were supposed to communicate all lab results to the physician as soon as the results were received. The DSD stated, The physician should have been notified of Resident 1's abnormal labs (WBC) for prompt treatment interventions because without interventions, the residents could die. On [DATE], at 2:26 p.m., during a concurrent interview and record review the Director of Nurses (DON) stated that there was no documentation to indicate that Resident 1's elevated WBC results dated [DATE] of 10.90 and [DATE] of 14.39 were reported to the resident's physician. The DON stated that an elevated WBC could be a sign of infection that could lead to death of a resident if not treated. According to the DON, the staff assigned to Resident 1 were supposed to follow-up with the elevated WBCs and also ensure that the resident's chest x-ray was done as ordered to prevent an exacerbation (worsening) of the PNA. According to the DON, the failure of the nurses to document that the physician was notified meant it was not done. On [DATE] at 9:44 a.m., during a telephone interview, a Licensed Vocational Nurse (LVN 1) stated that everything pertaining to patient care was supposed to be documented for care continuity. LVN 1 stated that although she does always document all the time, it was important to document the receipt of critical lab results or any changes in residents' conditions for prompt treatment. On [DATE] at 11:37 a.m., during an interview, a Laboratory Quality Assurance personnel (LQA) who the facility had a contract with to perform lab test, stated that any abnormal or critical lab results were directly communicated to the licensed nurse assigned to the resident over the telephone and then a fax. On [DATE] at 11:39 a.m., during a concurrent interview and record review, RN 1 stated that as soon as a licensed nurse received lab results, the physician or designee for the physician were supposed to be notified. RN 1 stated that not alerting the physician of any abnormal lab results could delay care and treatment and place the resident at risk for deterioration of condition. RN 1, who reviewed Resident 1's clinical record, indicated that there was no note to indicate that Resident 1 had a change in condition, such as an elevated WBC with congestion. On [DATE] at 12:07 p.m., during a concurrent interview and record review, Resident 1's Physician Assistant (PA 1) stated that the resident's lab results, dated [DATE], were not reviewed because she did not see them. PA 1 stated that if she had seen the lab and/or was informed of the elevated WBC results of 14.39, she could have ordered a chest x-ray, urine culture (a lab test to check for bacteria or other germs in a urine sample) and a repeat of the CBC levels. On [DATE] at 3:23 p.m., during a telephone interview, Resident 1's family member (FM 1) stated that on [DATE] Resident 1, who was recently treated for [REDACTED]. FM 1 stated the lack of intervention resulted in Resident 1 having a change of condition, being admitted to the GACH with WBCs elevated at 33.9. A review of the facility's policy, with a revised date of [DATE] and titled, Diagnostic Tests, indicated the purpose of the policy was to ensure patient's medical condition and therapeutic response, was monitored, as well as provide a timely physician notification of the results. A review of an undated policy titled, Change in Condition: Notification of, indicated that the facility must immediately inform the patient, consult with patient's physician, an notify, consistent with his/her authority the patient's Health care Decision Maker (HCDM), when there was a significant change in the patient's condition.

Based on interview and record review, the facility failed to provide emergency care service, when a resident's condition changed for one of three sampled residents (Resident 1) and ensure medications with contraindications (something that makes a certain treatment inadvisable) were not given. Resident 1 had difficulty in breathing, facial twitching, an ongoing abnormal laboratory results that was worsening for indication for heart failure, while receiving Black Box drugs (the most serious type of warning mandated by the U.S. Food and Drug Administration (FDA) warning drugs. The facility failed to follow its policy regarding providing emergency care and services and waited for over an hour for an ambulance service to transfer Resident 1 to the hospital instead of calling 911. This deficient practice resulted in a delay in care, diagnosis, and treatment to Resident 1, who had to be resuscitated (the action or process of reviving someone from unconsciousness or apparent death) once the Emergency Medical Technicians (EMTs) ambulance service team arrived after her heart stopped. Resident 1 was transferred to the general acute care hospital (GACH), intubated (medical procedure in which a tube is inserted into the trachea (windpipe) to allow for ventilation (oxygen exchange)) and placed on life support. Resident 1 was admitted to the intensive care unit and expired five days later ([DATE]). Findings: A review of Resident 1's Admission Record indicated the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated [DATE], indicated Resident 1 had the ability usually to understand and be understood by others. Resident 1 had moderate cognitive impairment (poor decisions, cues with supervision required) with a Brief Interview for Mental Status ((BIMS) a mental status assessment score of 99 (which indicated the resident was unable to complete the interview). Resident 1 required total assistance in all activities of daily living (ADLs). According to the MDS, Resident 1 had dysphagia (difficulty in swallowing) and required the use of a feeding tube (gastrostomy tube (([DEVICE]) a tube place surgically into the stomach to provide nutrition and hydration). A review of Resident 1's Initial Nursing Assessment, dated [DATE], indicated the resident was confused and had unclear speech. The assessment indicated Resident 1 had a productive cough (cough that expels a thick liquid) and required the use of a hand-held nebulizer (a device used to deliver medication into the lungs) for respiratory care needs. A review of Resident 1's physician's orders [REDACTED]. [MEDICATION NAME] (antipsychotic) was started on [DATE], 1 mg every day, receiving both antipsychotics, [MEDICATION NAME] and [MEDICATION NAME] concurrently for two days via the [DEVICE]. A review of DailyMed, an online drug reference site, indicated a WARNING for the use of [MEDICATION NAME]. Increased Mortality in Elderly Patients with Dementia-Related [MEDICAL CONDITION]. Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. The causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Cardiovascular Effects Cases of sudden death have been reported in patients receiving [MEDICATION NAME], and was contraindicated to administer to patients with heart conditions. In addition, [MEDICATION NAME], the reference indicated elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME]® is not approved for use in patients with dementia-related [MEDICAL CONDITION]. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6cf978f[DATE]-a103-b 7101a2 A review of the Initial Nursing Assessment, following Resident 1's re-admission to the facility, dated [DATE], indicated the resident had [MEDICAL CONDITION] disorder (a disorder causing periodic loss of consciousness with or without convulsions). A review of Resident 1's Discharge Summary, dated [DATE], indicated the resident was being transferred to the general acute care hospital (GACH) for further evaluation of abnormal laboratory results. A review of a physician's orders [REDACTED]. A review of Resident 1's Patient Transfer Record, dated [DATE], indicated the reason for Resident 1's transfer included worsening blood urea nitrogen ((BUN) test that reveals how well the liver and kidneys are functioning), creatinine ((Creat) test to determine how kidneys are functioning normally), brain (B-type) natriuric peptide ((BNP) a test to indicate how well the heart is working), and lethargy (drowsy/sluggish). A review of Resident 1's laboratory results, dated [DATE], and timed at 12:18 p.m., indicated Resident 1's BUN level was elevated at 74 mg/dl (normal reference range (NRR) is ,[DATE] milligrams (mg) per deciliter (dL), Creat level was elevated at 2.32 (NRR 0.60 - 1.20 mg/dl), and a BNP level elevated at 2688 (NRR of ,[DATE] picograms (pg) per milliliter (ml). According to the lab results handwritten on the right bottom corner, Resident 1's physician was notified by phone of the worsening results on [DATE] at 3 p.m. A review of Resident 1's BNP results, dated as far back as [DATE], indicated the resident's BNP was elevated at 932.0 pg/ml. According to WebMD, an online medical reference, an elevated BNP was an indication of the heart failing and the higher the number the worse the heart is. The article indicated that the BNP test was one of the most sensitive indicator of the heart's condition (https://www.webmd.com/heart-disease/heart-failure/bnp-blood-test). A review of Resident 1's Skilled Nursing Progress Note, dated [DATE], and timed at 5:05 p.m., indicated Resident 1 was stable during the shift, had no nausea or vomiting or complaint of pain/discomfort. A review of a Change in Condition Progress Note, dated [DATE], and timed at 4:43 p.m., indicated Resident 1 was having SOB with wheezing ([MEDICATION NAME] sound during breathing) during expiration (breathing out). A routine breathing treatment was administered, wheezing and SOB had decreased. The note indicated the physician was notified of the resident's change in condition on [DATE] at 1:30 p.m. Resident 1's family member (FM 1) was notified in person on [DATE] at 3 p.m. A review of a General Progress Note, dated [DATE], and timed at 9:51 p.m., written by Registered Nurse 2 (RN 2), indicated at 5:10 p.m., on that day, the resident's family member (FM 1) informed RN 2 that she noticed Resident 1's tongue was sticking out with her opened mouth. The note indicated RN 2 went to check the resident and Resident 2 appeared to be sleeping with her mouth open and tongue slightly visible to the right side of the mouth. Resident 1's chin was observed with nodding movements. According to the note, RN 2 called Resident 1's physician at 5:30 p.m., on [DATE] and the physician returned the call at 6 p.m. the same day. The physician ordered for Resident 1 to be transferred to the GACH for worsening laboratory results . The basic life support ((BLS) technicians are limited to what care they can provide) ambulance arrived to the facility at 6:25 p.m., one hour and fifteen minutes after RN 2 was alerted by FM 1 of Resident 1's worsening condition and approximately five hours after the resident's Change in Condition. According to the General Progress Note, dated [DATE], and timed at 9:51 p.m., while waiting for paperwork, one emergency medical technician (EMT) took Resident 1's vital signs and asked the facility's staff to give oxygen to the resident since the resident's oxygen level was lower than what the facility's staff reported. The EMT noticed Resident 1 had turned pale and informed the staff that he thought the resident was coding. Cardiopulmonary Resuscitation ((CPR) act of providing chest compressions and breathing) was started immediately, at the same time 911 was called at 6:45 p.m., after the EMTs were not able to get a pulse (heart rate). The note indicated Resident 1's pulse and breathing were restored after six rounds of 30 chest compressions and oxygen was delivered. The resident was transferred to the GACH via 911 at 7:20 p.m. On [DATE], at 3:15 p.m., during an interview, RN 1 stated Resident 1 was non-verbal, received tube feedings, and received laboratory test frequently because of high BUN and Creat. Levels. RN 1 stated they were sending Resident 1 to the GACH, but she could not remember the reason, but stated the resident stopped breathing and they had to initiate CPR and called 911. On [DATE] at 3:25 p.m., during an interview, RN 2 stated on the day of the incident ([DATE]), FM 1 stated something was wrong with Resident 1. RN 2 stated she observed Resident 1's body relaxed, but her lower jaw was twitching so they called the physician and checked her vital signs (temperature, pulse rate, rate of breathing, and level of blood pressure). RN 2 stated the physician ordered the resident to be transferred to the GACH via basic ambulance service because the vital signs were stable. RN 2 stated the ambulance took less than an hour to arrive to the facility and while giving report the EMT, Resident 1's oxygen saturation ((O2 sat) amount of oxygen in the blood) was low and the EMT asked her to give the resident oxygen. RN 2 stated the other EMT stated that he thought Resident 1 was coding (term used when a person goes into cardiopulmonary arrest (heart stops beating)) and was not breathing, and they then started CPR right away. RN 2 stated the resident was pale at that time, they gave the resident 15 liters per minute (L/m) of oxygen and started chest compressions, when Resident 1 began breathing on her own. RN 2 stated Resident 1 had a pulse when she was transferred to the GACH. RN 2 stated Resident 1 did not have a [MEDICAL CONDITION] (uncontrollable shaking of the body). RN 2 stated Resident 1 never had [MEDICAL CONDITION] during her stay at the facility. RN 2 stated when she called the physician and informed him of Resident 1's twitching of the resident's lower jaw and he stated to transfer the resident to the GACH because her labs were not good. RN 2 stated Resident 1 was breathing when the paramedics arrived, but had a low O2 SAT of 84 percent (%) (NRR ,[DATE]%) and they placed the resident on 5 L/m of oxygen. During an interview, on [DATE], at 3:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on [DATE], Resident 1 began having [MEDICAL CONDITION] movements. LVN 1 stated they called Resident 1's physician and he gave an order for [REDACTED]. LVN 1 stated the resident's skin color was pale and her whole body was shaking. LVN 1 stated Resident 1 was receiving [MEDICATION NAME] [MEDICATION]) routinely for agitation. A review of Resident 1's physician's orders [REDACTED]. A review of a physician's orders [REDACTED]. At 10:22 a.m., on [DATE], during a telephone interview, FM 1 stated on [DATE], Resident 1 had a palpable (able to be touched or felt) [MEDICAL CONDITION] and she had to call out for help to the nurses, because the nurses would not come. FM 1 stated the head nurse on duty (RN 2) came into Resident 1's room and stated the resident was not having a [MEDICAL CONDITION]. FM 1 stated the nurse finally agreed to call 911 to transfer the resident to the hospital. FM 1 stated she left Resident 1's bedside to drive to the GACH, so she could be there at the time Resident 1 arrived. After an hour of waiting at the GACH, FM 1 stated she called the facility and was told Resident 1 stopped breathing and they called 911. FM 1 stated after the resident arrived to the GACH, they found food in the resident's throat and she had the wrong identification wristband on her arm. FM 1 stated Resident 1 had no prior history of [MEDICAL CONDITION]. A review of Resident 1's EMS (emergency medical services) 911 Report, dated [DATE], indicated the paramedics found the resident lying in bed altered. The report indicated the staff informed the paramedics that the resident was being prepped for a transfer by an ambulance company. The paramedics documented they found Resident 1 pulseless and apneic (not breathing) and pale. The paramedics were informed the resident received six rounds of CPR. A review of Resident 1's GACH's records indicated upon arrival to the emergency department (ED), on [DATE] at 7:27 p.m., Resident 1 was bradycardic (slow heart rate) and had what appeared to be [DEVICE] feeding formula in her mouth. Resident 1 was emergently intubated (medical procedure in which a tube is inserted into the trachea (windpipe) to allow for ventilation) and admitted to the intensive care unit (ICU) and continued on mechanical ventilation. A review of the ED Physician's Note, dated [DATE], and timed at 8:53 p.m., indicated it was unclear if Resident 1 truly had a [MEDICAL CONDITION] as reported by FM 1, but the staff at the nursing home did not feel it was a [MEDICAL CONDITION]. The ED note indicated, per FM 1, Resident 1 continued having difficulty breathing and 911 was not called, but arrangements were made for an inter-facility transfer to the hospital. According to the note, when the transfer team (EMTs) arrived, the patient (Resident 1) was found not to be breathing very well and they could not feel pulses. CPR was initiated and the resident received chest compressions and bagging ((BVM) bag valve mask, (Ambu bag) a hand-held device commonly used to provide positive pressure ventilation for breathing) and apparently had a spontaneous return of circulation. 911 was called and the patient was transported. According to Resident 1 GACH's history and physical (H/P), dated [DATE], indicated the physician discussed with the resident's family of her poor prognosis with an abnormal EEG ((electroencephalogram) a test for brain activity) findings. The H/P indicated the family and the POA (power of attorney) will proceed will comfort care. A review of the GACH's Death Summary, dated [DATE], and timed at 7:19 p.m., indicated Resident 1 was extubated (removal of a tube inserted into the trachea) on [DATE], and was pronounced deceased on [DATE] at 1:25 a.m. A review of the facility's policy and procedure titled, [MEDICAL CONDITION] Precautions, revised on [DATE], indicated to review the history with patient and/or health care decision maker regarding patient's [MEDICAL CONDITION] including any specific characteristics or conditions that precipitate [MEDICAL CONDITION]. Identify patient-specific interventions and update care plan. If a patient had a [MEDICAL CONDITION] monitor patient's vital signs and mental status every 30 minutes for two hours, notify physician and family, and suction if needed. A review of the facility's policy and procedure titled, Emergency: Medical Response, revised on [DATE], indicated to respond to the identified emergency by performing the following: 1. Evaluate the patient 2. Initiate appropriate medical intervention (CPR, burns, bleeding, [MEDICAL CONDITION], choking, etc.) 3. Obtain automated external defibrillator ((AED) electronic device that analyzes the heart's rhythm), if applicable, emergency cart, emergency drug box 4. Monitor vital signs 5. Call physician/mid-level provider and family 6. Call 911, as appropriate A review of Resident 1's death certificate indicated the resident expired on [DATE] at 1:25 a.m. The immediate cause of death was listed as [MEDICAL CONDITIONS]-non-traumatic (results as a major lack of oxygen to the brain); cardiopulmonary arrest (results due to a major lack of oxygen to the brain) ; aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach); and senile dementia (brain diseases that cause a long term and often gradual decrease in the ability to think and remember).

Based on observation, review of facility documents, resident council meeting, family and staff interviews, the facility failed to ensure that residents were provided with a nourishing, well-balanced diet that met their daily nutritional and special dietary needs, when the facility's dietary services supervisor (DSS) consistently deviated from the planned menu and failed to ensure the cooks followed recipes resulting in inadequate food, incorrect portions, incorrect textures, incorrect substitutions and provision of items not allowed on some therapeutic diets (renal diets). The changes were not approved by the facility's registered dietitian and resulted in meals not meeting all the daily nutrition parameters (Daily Reference Intake) as was planned and described in the facility's diet manual. These failures had the potential to result in weight loss for all residents who ate (103 residents), including residents on mechanical soft diets had increased potential for choking and six residents on renal diets had the potential for altered laboratory values and deterioration of their health status. These deviations according to the DSS were as a result of financial and other unverifiable reasons such as some residents not liking some of the menu items. On 05/22/14 at 2:25 pm, due to concerns that the DSS may make more drastic changes as a result of her desire to keep costs down, the facility administrator, the regional dietitian, and facility dietitian were informed of the immediate jeopardy situation. The IJ was lifted when the facility provided an acceptable immediate plan of correction on 05/23/14 at 3:50 pm. The remedy for the abatement of the IJs included the relieving of the dietary services supervisor (DSS) of supervisory responsibilities and replacing with a temporary DSS; removal of the cook (Cook A) and replacement with a cook who could articulate (able to speak and express clearly) and follow menus correctly; competency evaluation of all dietary employees. Other components of the immediate plan of correction were to have the regional Director of Nutrition Services provide direct oversight over the facility RD and dietary department. The facility RD services will be dedicated to supporting the facility only. Menus were reviewed for accuracy and corrected; a substitution list was developed to document menu changes and to confirm that a nutritional equivalent was provided, with RD verification. Findings: Due to concerns with the multiple food changes and substitutions and complaints during the resident council meeting on 05/19/14 the facility menu was reviewed. The five week menu cycle titled" Skilled Healthcare cycle 3:2013" showed that the menu was planned for use from November 2013 through June 2014. There were items planned for seven days a week, three meals a day and alternate entrees, vegetables and starches for lunch and dinner. Further review of the menu showed check marks next to menu items, items were crossed thru and items were written in as replacement. On some days the check marks were next to the main menu and other times it was next to the alternate indicating that those meals were served in place of the main menu. On other days items were written in, for example taco, pizza, grilled cheese, chicken tenders, chicken nuggets which indicated that these items were served in place of the main entree. The standard of practice is that both the main entree and alternates are prepared to ensure that resident preferences are honored. Both resident and family interviews conducted from 05/19/14 and 05/23/14 revealed concerns that there was" too much mashed potato" being served. Review of the five week cycle menu showed mashed potato planned only once per week. The DSS was asked in an interview on 05/20/14 at 8 am, to provide a copy of the menu as served for the previous month. She provided the five week cycle menu with no documentation of what was served on specific dates for the previous month. For example, menu for Monday Week I was planned for use for "11/17; 12/02; 1/26; 3/2; 4/6 and 5/11." None of the dates were circled or marked to show that the menu was followed for that date. It could not be determined what was served and on dates that had cross outs (line marked across) or write-ins, it was unclear when the items were served. The DSS did not provide evidence that mashed potatoes was not served in place of other starches throughout the month. She stated that she prints out what is served every meal and does not keep a copy of it. Meal observation on 05/21/14 at 8:30 am of a tray left untouched (in the food cart) served to an unsampled resident on a Mechanical Soft diet showed the following items: chopped sausage, one small Danish, small glass of milk, a small bowl of Malto meal. Review of the menu for breakfast for that day showed that a resident on a mechanical soft diet should have received ? cup Juice of Choice, ? cup cereal of choice, #30 (1-1? ounces) ground sausage link, 2 oz egg with cream gravy, Danish/ margarine 1 cup (8oz) milk, coffee or tea. The tray was shown to the registered dietitian (RD). The look on her face was that of astonishment. The unsampled resident's tray was missing the 2 ounces egg and cream gravy, the milk was 4 ounces not 8 ounces and the Danish was not cut-up. In an interview with the DSS on 05/21/14 at 8:57 am, in response to the missing items on the resident's tray, she stated the resident was not served eggs because "residents are tired of eggs," so she gave sausage and bread. The DSS was asked whether the Danish should have been cut up since the resident was on a mechanical soft diet. The DSS stated the menu did not specify that it should be cut-up. The RD who was present during the interview stated the Danish should have been cut up to prevent choking. In a concurrent interview with the cook, (Cook A) she was asked why the resident did not receive eggs as leftover eggs were observed on the steam table. Cook A stated she just did not serve the resident. She also did not prepare cream gravy for service for breakfast. Diet Aide 1 who was responsible for placing beverages on the trays was asked why she served the resident 4 ounces of milk instead of 8 ounces of milk, she stated that most tray slips would specify amounts and since the resident ' s slip did not specify 8 ounces so she served 4 ounces. The diet manual was reviewed to determine the appropriateness of the textures provided. The diet manual face sheet showed it was last approved by the patient care committee in 2012. It was not approved by the current RD and there was no signature line for her approval. In addition, the diet manual was revised in 2002. The standard of practice is that diet manuals be revised every five years and approved by the registered dietitian. Interview with the registered dietitian (RD) on 05/21/14 at 8:15 am revealed that she had been hired six months earlier. She stated that she was not aware of the changes made by the DSS. At 11:45 pm on 05/21/14, Cook A was observed layering cooked spaghetti in a pan and pouring meat sauce over it. She stated that she was getting ready to mix it together. When asked how will she ensure that each resident served will receive the correct portion of meat? She stated she had always prepared spaghetti in this manner and had been trained to prepare it by the previous DSS. The DSS, who was present during the interview, stated that she thought the cook had been preparing something else. Review of the recipe indicated that the residents were to be served ? cup of spaghetti with 2 ounces of sauce poured over it. The DSS instructed the cook to stop mixing and serve as was instructed on the recipe. According to the recipe for the meat sauce, mushrooms were to be added to the meat sauce. Review of the menu showed that for lunch the following items were to be served: Spaghetti with meat sauce, mixed green salad with dressing, garlic toast, margarine, seasonal fresh fruit, ? cup milk garnish with parmesan cheese. At 12:45 pm on 05/21/14, lunch tray line observation was conducted; the meat sauce on the spaghetti did not have any visible mushrooms, garlic toast was not served; in its place was 2 slices of whole wheat bread, fresh fruit was not served, canned mandarin oranges were served instead. These changes were printed on a piece of paper posted on the tray carts and in the dining room. Cook A was interviewed at 12:50 pm on lack of visible mushrooms in the meat sauce. She stated that she had blended the mushroom and that was why there were no visible pieces. The DSS was asked if there were canned mushrooms on hand and why the mushrooms were not added to the sauce as required by the recipe. The DSS brought out a can of mushrooms to show that there was mushrooms on hand. After the surveyor, in the presence of the DSS, regional RD and other kitchen staff checked the used cans of food prepared that morning, it was determined that Cook A did not add the mushrooms. There was no clear reason why it was not added. Mushrooms are a good source of protein, fiber, vitamin D, potassium and B vitamins. Observation of the spaghetti on tray line being served showed residents on mechanically altered diets should have received spaghetti that was cut into bite sized pieces. None of the residents on mechanical soft diets were observed to receive bite sized spaghetti. The DSS, Cook A and regional RD were present during the observation. The failure to cut up the spaghetti into bite sized pieces could pose a choking hazard. The DSS stated in response to why the garlic bread was not prepared that she was, "cutting back on labor cost" because she was over budget. She stated that she had substituted bread in place of the garlic bread. The RD had not been consulted regarding the changes. The Regional RD (RD2) who was present during the interview stated she was not sure why the substitution was made since she had not cut back on the number of staff that had been assigned to work. According to the facility policy titled, "Menu Substitutions" dated 07/31/08 "substitutions of a menu item may occur when (a) item or ingredient is unavailable; (b) item was prepared incorrectly; (c) Holiday or special occasion indicates a change and (d) season availability of an item changes ... Record of substitutions will be available in the dietary department .... substitutions must be of equal nutritive value taking into consideration vitamins, minerals and calories .... Records are maintained for a minimum of 30 days or in accordance with local/state regulations." The DSS failed to follow the facility policies and procedures. Review of the partially loaded carts revealed slices of whole wheat bread added to all carts including three residents on renal diets. Dietary Aides 3 and 4 were asked if other carts that had been sent out had whole bread added to the trays. The aides all replied "yes". Whole wheat bread is of concern to patients with kidney disease because it contains potassium and phosphorous, two nutrients which have to be carefully monitored to prevent further complications such as the softening of bones. Review of the facility document titled, "Master Resident", showed there were six residents in the facility on renal diets. (Residents 8, N2, N3, N4, N5 and N6). Resident record review showed of the six residents only two had laboratory values that included phosphorous. In April 2014 (actual date not specified), Resident 8 had blood phosphorous of 6.9. The normal value is 2.4 to 4.1 mg/dl . On 04/15/14 there was an order for [REDACTED]. On 05/22/14 at 11:00 am, lunch meal preparation was made. The menu indicated Orange glazed turkey, mashed potatoes, seasoned beets, biscuits, brownie and ? cup of milk was to be served. Observations of the entree showed mandarin orange slices on top of the turkey in the oven and not a glaze. Review of the recipe showed that the turkey was to be covered with orange marmalade glaze. DSS 2 who was providing supervision to Cook A stated that she had asked Cook A to get the orange marmalade from the storage room and did not verify that Cook A had added the mandarin oranges instead. At 12:00 pm on 05/22/14, during lunch trayline observation, random observation showed that a resident on small portion was served small portions of the main entree, starch and vegetables. Instructions on the menu for small portion is 1 portion entree, ? portion starch, 1 portion vegetable, ? slice bread, 1 portion dessert. The Cook B was not observed using the therapeutic spreadsheet as a guide to serve meals to ensure accuracy of the diets. The cook failed to follow the recipes and facility diet manual.