Every finding on record at Bellflower Post Acute

Based on observation, interview, and record review, the facility failed to ensure their ice machine - used to produce ice for resident distribution and consumption - was clean for safe and sanitary operation.This failure had the potential to result in at least 50 out of 56 residents in the facility suffering waterborne illness, increasing the risk for negative outcomes such as nausea, vomiting, diarrhea, and dehydration.Findings:During a concurrent observation and interview on April 15, 2026, at 1:55 PM with the Maintenance Director (MS) in the facility's kitchen, the facility's ice machine was observed for inspection. The following was observed during the facility ice machine's internal components inspection:- The ice cube product chute underneath the machine's ice cube forming plate, where the formed ice cube product deposited through to enter and rest in the machine's ice collection bin, contained white-colored matter that could be removed by hand with a folded paper towel.- Along the interior wall of the ice machine's housing, enclosing a section of the ice cube product chute's rim, black-colored matter was present on the surface.- Along the submerged surface of the feed water collection basin - positioned underneath the ice cube forming plate and collected the feed water that constantly circulated over the ice cube forming plate to form ice cube product - large surface areas of white-colored matter was present on the collection basin surface and was submerged in the feed water used to produce the machine's ice product.During a concurrent observation and interview on April 15, 2026, at 2:32 PM with the Dietary Supervisor (DS) in the facility's kitchen, the DS also observed the facility's ice machine during the inspection. The DS stated the ice machine was not clean, and residents can get sick and have diarrhea and other illnesses from dirty ice. The DS stated 55 residents out of the facility's 56 residents were subject to ingesting ice from the facility's ice machine.During a review of the facility's Diet Information [Name of Facility] as of 4/14/2026, dated April 14, 2026, the documentation indicated, 50 residents out of the facility's 55 residents listed were subject to receiving and consuming ice product from the facility's ice machine.During a review of the facility's policy and procedure (P&P) titled, Manual: Maintenance, Subject: Cleaning the Ice Machine, dated April 2017, the P&P indicated, Purpose: The ice machine shall be cleaned for maintenance of sanitary conditions in order to prevent food contamination and the growth of disease-producing organisms and toxins.During a review of the facility ice machine's user manual titled, [Name of Manufacturer] Ice Systems Installation and User's Manual for Air and Water Cooled Modular Cube [Name and Series of varying manufacturer models], dated June 2022, the document indicated, . This ice system requires three types of maintenance: . Sanitize the ice machine's water system and the ice storage bin or dispenser. It is the User's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Without human intervention, sanitation will not be maintained.

Based on interviews and record review, the facility failed to follow their Quality Assurance (QA) /Quality Assurance and Performance Improvement (QAPI]-a data driven proactive approach to improvement used to ensure services are meeting quality standards) to develop a corrective action plan or performance activities to address problems and opportunities for improvement.This had the potential to result in unsafe practices and harm to the residents.Findings:During a concurrent interview and record review on 4/16/2026 at 2:38 p.m. with the Administrator (ADM), the facility's QAPI binder was reviewed. The ADM stated the facility has identified falls, pressure injuries, and legionella water management as active QAPI topics. The ADM stated falls and pressure injury interventions and corrective actions are implemented on an individual level. The ADM did not provide documented plans or corrective actions that the facility has implemented to address falls, pressure injuries, and legionella water management.During a concurrent interview and record review on 4/16/2026 at 3:30 p.m. with the ADM, the facility's policy and procedure (P&P), titled Quality Assurance Performance Improvement Plan & Committee (QAPI), dated December 2026, was reviewed. The ADM stated the P&P indicated The QAPI plan will identify and use data to monitor its performance; establish goals and thresholds for performance measurement; utilize resident and staff input; identify and prioritize problems and opportunities for improvement; systemically analyze underlying causes of systemic problems and adverse events; and develop corrective action plans or performance improvement activities. The ADM stated not following the QAPI policy could result in unsafe practices.During a review of the facility's policy and procedure (P&P), titled Quality Assurance Performance Improvement Plan & Committee (QAPI), dated December 2026, the P&P indicated At the beginning of each performance improvement project goals, scope, timing, milestones, team roles and responsibilities will be developed and clearly established by the QAA committee and given to the team that will carry out the performance.

Based on observation, interview, and record review, the facility failed to ensure the call light device was within reach for one of eight sampled residents (Resident 53).This failure had the potential to prevent Resident 53 from receiving necessary care and services. Findings:During an observation on 4/13/2026, at 9:43 a.m., in Resident 53's room, Resident 53's call light was wrapped around the plug on the wall. Resident 53's right hand groped for something constantly.During a review of Resident 53's admission record, the admission record indicated Resident 53 was admitted to the facility on [DATE] with diagnosis including legal blindness (severe visual impairment or low vision), deafness (hearing loss that precludes a person from understanding spoken language), and congenital Rubella Syndrome (CRS- a condition occurring in newborns when a pregnant woman contracts the rubella virus, leading to severe, often permanent birth defects like heart issues, blindness, and deafness).During a review of Resident 53's History and Physical (H&P), dated 12/13/2025, the H&P indicated, Resident 53 had no capacity (ability) to understand and make decisions.During a review of Resident 53's Minimum Data Set (MDS-a resident assessment tool), dated 3/20/2026, the MDS indicated Resident 53 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, transfer, bed mobility, dressing, hygiene, and maximal assistance (Helper does more than half the effort) from one staff for eating, oral hygiene.During a review of Resident 53's Care Plan (CP) titled, Resident 53 is at risk for fall and injury related poor safety awareness, revised 3/24/2026, the CP Goal indicated, Resident 53 will minimize risk for falls and recurrence daily until reevaluation date on 6/26/2026. The CP Approach Plan (Interventions) indicated, implementing fall precautions such as keeping call light withing reach and answer promptly. During an interview on 4/13/2026, at 9:46 a.m., with Licensed Vocational Nurse (LVN) 2 in Resident 53's room, LVN 2 stated, Resident 53 used the call light frequently and some staff got frustrated. LVN 2 stated that the call light should be placed within reach regardless of how frequently it was used. LVN 2 stated, if the call light was not within reach, Resident 53 would not be able to call for help during the emergency.During an interview on 4/14/2026, at 3:42 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, the call light should always be accessible and within the resident's reach. RNS 1 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 needs met. RNS 1 stated, the residents who were at risk of falling should be able to reach the call light to prevent fall related injuries.During a review of the facility's Policy and Procedure (P&P) titled, Call Lights revised 1/2017, the P&P indicated, Policy: It is the policy of the facility to respond to the resident's requests and needs. Procedure: When the resident is in bed or in the wheelchair or chair in the room, staff should make sure that the call light is within easy reach of the resident. If a resident is unable to use the call light, staff should check on the resident frequently. Call lights should be answered promptly.

Based on interview and record review, the facility failed to ensure residents or responsible party ([RP] individual that exercises ultimate control, management, or decision-making authority over a business, asset, or legal obligation) had the opportunity to formulate an advance directive for three of four sampled residents (Resident 1, Resident 6, and Resident 25).This deficient practice had the potential to violate the resident's right to be fully informed of the option to formulate their advance directives and cause conflict with the residents' wishes regarding health care. Findings: A. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure (condition where the lungs are unable to adequately deliver oxygen to the blood or remove carbon dioxide) with hypoxia (when the body or a specific part does not receive enough oxygen to maintain normal function), and chronic kidney disease on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and dementia (a progressive state of decline in mental abilities). The admission Record indicated Resident 6 had a responsible party designated to make decisions.During a review of Resident 6's History and Physical (H&P), dated 2/24/2026, the H&P indicated Resident 6 did not have the capacity to understand and make decisions.During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool), dated 2/22/2026, the MDS indicated Resident 6 had severe cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision for eating and oral hygiene, required maximal assistance (helper does more than half of the effort) for toileting hygiene, and was dependent for bathing and lower body dressing. During a concurrent interview and record review on 4/15/2026 at 1:50 p.m. with the Social Services Director (SSD), Resident 6's Psycho-social assessment form dated 2/15/2026, Physician Orders for Life Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) dated 3/30/2026, and advance directive form was reviewed. The SSD stated Resident 6's Psycho-social assessment form indicated resident did not have an advance directive. The SSD stated Resident 6's POLST indicated Resident 6 did not have an advance directive. The SSD stated Resident 6's advance directive form was blank and did not indicate that Resident 6 or their Responsible Party was offered or educated about their rights to formulate an advance directive.B. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, urinary tract infection (UTI - an infection in the bladder/urinary tract), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of right ankle and foot.During a review of Resident 25's H&P, dated 4/12/2026, the H&P indicated Resident 25 does not have the capacity to understand and make decisions. During a review of Resident 25's MDS, dated [DATE], the MDS indicated Resident 25's cognition was intact, required setup assistance when eating, required supervision for oral hygiene, required moderate assistance (helper does less than half the effort) for upper body dressing, and required maximal assistance (helper does more than half the effort) for toileting hygiene, bathing, and lower body dressing. During a concurrent interview and record review on 4/15/2026 at 1:58 p.m. with the SSD, Resident 25's Advance Directive form was reviewed. The SSD stated Resident 25's advance directive form is blank. The SSD stated Resident 25's advance directive acknowledgement should be completed on every readmission. C. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), pneumonia (an infection/inflammation in the lungs), and malignant neoplasm (cancer) of left breast and bone. The admission Record indicated Resident 1 had a responsible party designated to make decisions. During a review of Resident 1's H&P, dated 2/15/2026, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had severe cognitive impairment, and was dependent for eating, oral hygiene, toileting hygiene, bathing, and upper and lower body dressing. During a concurrent interview and record review on 4/15/2026 at 2:01 p.m. with the SSD, Resident 1's POLST dated 3/24/2026 and advance directive form dated 2/6/2026 was reviewed. The SSD stated Resident 1's POLST indicated Resident 1 did not have an advance directive. The SSD stated Resident 1's advance directive form did not indicate that Resident 1 or their Responsible Party was offered or educated about their rights to formulate an advance directive. The SSD stated that when the resident or responsible party is not educated or offered to formulate an advance directive, there is a risk of violating the resident's right to autonomy (freedom to act on one's own will). During an interview on 4/16/2026 at 1:32 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the SSD should educate and offer the advance directive acknowledgement form to residents on admission. RNS 1 stated if residents are not offered or educated about formulating an advance directive, there is a risk of violating the residents' rights.During a review of the facility's policy and procedure (P&P), titled Advance Directives, dated April 2017, the P&P indicated prior to, or upon admission, resident's will be provided with written information concerning the resident's right under state law to accept or refuse medical or surgical treatment and the resident's right to prepare an advance directive. During a review of the facility's policy and procedure (P&P), titled POLST - Physician Orders for Life Sustaining Treatment, dated January 2017, the P&P indicated the POLST does not replace an advance directive.

Based on interview and record review, the facility failed to ensure 2 of 3 sampled residents (Resident 8 and Resident 42) were provided the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN - written notice issued by the facility to inform the resident of the cost of services that Medicare [federally funded health insurance for individuals aged 65 or older] may not cover and the reason why) in a manner the resident's understood. This deficient practice had the potential to result in violating the residents' rights to appeal the Medicare decision and cause financial burden on Resident 8 and Resident 42.Findings:A. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (damage of the nerves that can cause weakness, numbness, and burning pain), cellulitis (infection of the skin) of right lower limb, and chronic obstructive pulmonary disease (COPD - lung disease that causes obstruction of airflow and can limit normal breathing).During a review of Resident 8's History and Physical (H&P), dated 11/23/2025, 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 resident assessment tool), dated 1/30/2026, the MDS indicated Resident 8's cognition (ability to learn, reason, remember, understand, and make decisions) was intact, required setup assistance when eating and oral hygiene, and required maximal assistance (helper does more than half the effort) for toileting, lower body dressing, and personal hygiene.During an interview on 4/13/2026 at 10:41 a.m. with Resident 8, Resident 8 stated they did not understand the share of cost that the facility is charging monthly. During a concurrent interview and record review on 4/15/2026 at 2:32 p.m. with the Business Office Manager (BOM), Resident 8's Notice of Medicare Non-Coverage (NOMNC-a standardized and required (Center for Medicare & Medicaid Services (CMS - federal agency that manages Medicare, Medicaid, and other federally funded health programs) form informing residents when Medicare-covered services are ending and the resident's right to appeal the decision), signed 1/23/2026, and SNF ABN, signed 1/23/2026, were reviewed. The BOM stated Resident 8's last covered date (LCD - last day of final day Medicare pays for skilled services) was 1/27/2026. The SNF ABN did not indicate which option Resident 8 chose regarding whether to continue to receive the skilled services of Physical therapy, Occupational therapy, and/or Daily Skilled Nursing Care and who Resident 8 designated to pay the bill. The BOM stated Resident 8 did not select an option listed on the SNF ABN.B. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy, heart failure, and COPD. During a review of Resident 42's History and Physical (H&P), dated 3/9/2026, the H&P indicated Resident 42 had the capacity to understand and make decisions.During a review of Resident 42's MDS dated [DATE], the MDS indicated Resident 42's cognition (ability to learn, reason, remember, understand, and make decisions) was intact, required setup assistance when eating, required supervision for oral hygiene, required moderate assistance (helper does less than half the effort) for upper body dressing, and required maximal assistance for toileting hygiene, bathing, and lower body dressing. During a concurrent interview and record review on 4/15/2026 at 2:32 p.m. with the BOM, Resident 42's NOMNC, signed 9/15/2025, and SNF ABN, signed 9/15/2025, were reviewed. The BOM stated Resident 42's LCD was 9/18/2025. The BOM stated the SNF ABN did not indicate which option Resident 42 chose regarding whether continue to receive the skilled services of Physical therapy, Occupational therapy, and/or Daily Skilled Nursing Care and who Resident 42 designated to pay for the bill. The BOM stated Resident 42 did not select an option listed on the SNF ABN. The BOM stated it was the BOM's responsibility to explain the SNF ABN to Resident 42, ensure the resident understood the form, and ensure the SNF ABN option was selected by the resident.During an interview on 4/16/2026 at 8:40 a.m. with Resident 42, Resident 42 stated they (Resident 42) remembered receiving the SNF ABN, but did not understand why the facility is taking so much money.During an interview on 4/16/2026 at 1:39 p.m. with Registered Nurse Supervisor (RNS) 1, it was important for residents to receive and understand NOMNC and the SNF ABN because it notifies the resident of the LCD, informs the resident of their right to appeal the decision, and indicates the resident decision of continuing to receive the skilled services and who the resident designated to pay for the bill. The RNS stated for SNF ABN forms are incomplete without the options checked off. During a review of the facility's policy and procedure (P&P), titled Medicare Beneficiary Notice, dated August 2018, the P&P indicated it is the facility's responsibility to ensure forms are completed as per Medicare guideline and given to the resident and or representative timely.

Based on observation, interview, and record review, the facility failed to identify, assess, monitor, and document the use of abdominal binder (a wide, elastic compression belt worn around the abdomen is used with patients who have removed essential lines or tubes on more than one occasion) to prevent the resident from pulling out the gastrostomy tube ([G-tube]- a tube inserted through the belly that brings nutrition directly to the stomach) for one of eight sampled residents (Resident 7).These failures had the potential to result in entrapment, skin injury/breakdown, and compromised circulation.Findings:During an observation on 4/13/2026, at 11:26 a.m., in Resident 7's room, there was splint (a medical device that stabilizes a part of your body and holds it in place) for Resident 7's right hand and right arm and abdominal binder on Resident 7 was noted. Resident 7 had difficulty moving the right arm and both legs. Resident 7 was able to move left arm but noted weakness.During a review of Resident 7's admission Record, the admission Record indicated, Resident 7 was initially admitted to the facility on [DATE] and last readmission was on 10/2/2025 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), cerebral infarction (loss of blood flow to a part of the brain), pathological fracture (broken bone caused by disease), and dementia (a progressive state of decline in mental abilities).During a review of Resident 7's History and Physical (H&P), dated 10/4/2025, the H&P indicated, Resident 7 had no capacity (ability) to understand and make decision.During a review of Resident 7's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/26/2026, the MDS indicated Resident 7 required dependent assistance (Helper does all of the effort) from two or more staff for dressing, hygiene, bed mobility, and transfer. The MDS indicated, Resident 7 had impairment (A loss of part or all of a physical or mental ability) on one side of upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) for both sides.During a concurrent interview and record review on 4/14/2026, at 3:09 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 7's Order Summary Report (OSR), dated 4/15/2026 was reviewed. The OSR indicated to place an abdominal binder at all times to prevent pulling out of G-tube with a start date of 10/30/2025. RNS 1 stated there was no order to monitor and assess skin under abdominal binder every two hours. RNS 1 stated, there was no documentation regarding monitoring and assessment of skin integrity and abdominal binder use. RNS 1 stated, Resident 7 was at risk for skin breakdown and compromised circulation due to prolonged abdominal binder use. RNS 7 stated, without assessment, monitoring, and documentation, it would be hard to prevent skin breakdown and compromised circulation.During a concurrent interview and record review on 4/15/2026, at 9:40 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 7's MDS section P ([Restraint -any manual method, physical/mechanical device, or medication used to intentionally limit a patient's movement, freedom, or normal access to their body] and alarm), dated 1/26/2026 was reviewed. The MDS Section P indicated Resident 7 did not have any trunk or limb restraints in use. The MDSC stated, she did not realize that Resident 7's abdominal binder could be considered as restraints because it prevented her from access to her body and she could not remove it by herself. The MDSC stated nursing staff should re-evaluate and assess the needs of the restraints and use less restrictive measures. The MDSC stated that nursing staff should monitor every two hours for pain, circulation, and skin breakdown to prevent unintentional injuries related to the restraint use.During a concurrent interview and record review on 4/15/2026, at 3:02 p.m., with the Director of Staff Development (DSD), Resident 7's Informed Consent for Abdominal Binder, undated was reviewed. The Informed Consent for Abdominal Binder indicated, Resident's Responsible Party (RP- an individual, including the patient's relative or health care surrogate decisionmaker, who assists the resident in placement or assumes varying degrees of responsibility for the well-being of the resident) gave a verbal consent via telephone, but there was no date of the consent given documented. The DSD stated the informed consent for abdominal binder was incomplete and invalid. The DSD stated, the informed consent should be completed prior to applying restraints after less restricted measures were tried. The DSD stated, restraint should be monitored every two hours and documented to prevent unintended injury. The DSD stated that the staff failed to identify as a restraint. The DSD stated that the staff failed to assess, monitor and document use of the restraint (abdominal binder) to prevent injury.During a review of the facility's Policy and Procedure (P&P) titled, Physical Restraints, reviewed 9/2017, the P&P indicated, Policy: It is the policy of the facility that restraints will only be used after other alternatives have been tried unsuccessfully and only with a thorough assessment, informed consent from the resident or their responsible party, a physician's order and a plan of care to address the use of the restraint. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: The resident must be physically and cognitively able to self-release devices such as Velcro lap trays or tables, seat belts with Velcro, or easy snap seat belts) If a resident cannot mentally or physically self-release, then the device is considered a restraint. Procedure: Upon admission, quarterly and with a change of condition, residents shall be assessed for the need or lack of physical restraints. Least restrictive measures shall be assessed prior to the use of an actual restraint. Approaches may include the use of transfer poles, trapeze bars, self-release seat belt . If restraints are utilized, the opportunity for motion and exercise should be provided for a period of not less than ten (10) minutes during each two (2) hour period in which the restraints are utilized. Restrained residents should be repositioned at least every two (2) hours on all shifts.During a review of the facility's Policy and Procedure (P&P) titled, Informed Consent Policy, reviewed 4/2024, the P&P indicated, Policy: It is the policy of the facility that if the attending physician, physician assistant (PA) or nurse practitioner (NP) for a resident the use of siderails for the resident as a restraint, enabler, or assistive device, the physician, PA or NP or facility shall do the following: There is a requirement for the facility to renew informed consent every six months . The facility shall verify that informed consent has been obtained prior to use of a restraint . The information material to a decision concerning the use of a restraint, enable for assistive device shall include: 1. That less restrictive alternative approaches have proven ineffective, and the less restrictive approaches should be listed on the consent form. 2. The potential benefits include prevention of falls, which might result in injury and an increased feeling of safety and security. 3. The potential risks, which shall include accidental injury, increased incidence of falls and other accidents, such as strangulation and entrapment.

Based on observation, interview, and record review, the facility failed to ensure accurate resident assessments and the status were reflected on medical records for one of three sampled residents (Resident 7) by failing to ensure the assessment entries on the Minimum Data Set (MDS-a resident assessment tool) for abdominal binder (a wide, elastic compression belt worn around the abdomen is used with patients who have removed essential lines or tubes on more than one occasion) that was a physical restraint (any manual method, physical/mechanical device, or medication used to intentionally limit a patient's movement, freedom, or normal access to their body) was accurately reflected and documented.This failure had the potential to result in a negative effect on Resident 7's plan of care and delivery of necessary services, care, and treatment.Findings:During an observation on 4/13/2026, at 11:26 a.m., in Resident 7's room, there was an abdominal binder on Resident 7. Resident 7 had difficulty moving right arm and both legs. Resident 7 was able to move left arm but noted weakness.During a review of Resident 7's admission Record, the admission Record indicated, Resident 7 was initially admitted to the facility on [DATE] and last readmission was on 10/2/2025 with diagnoses including Quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), cerebral infarction (loss of blood flow to a part of the brain), pathological fracture (broken bone caused by disease), and dementia (a progressive state of decline in mental abilities).During a review of Resident 7's History and Physical (H&P), dated 10/4/2025, the H&P indicated, Resident 7 had no capacity (ability) to understand and make decision.During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 required dependent assistance (Helper does all of the effort) from two or more staff for dressing, hygiene, bed mobility, and transfer. The MDS indicated, Resident 7 had impairment (A loss of part or all of a physical or mental ability) on one side of upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) for both sides.During a review of Resident 7's Order Summary Report (OSR), dated 4/15/2026, the OSR indicated to place an abdominal binder at all times to prevent pulling out of gastrostomy tube ([G-tube]- a tube inserted through the belly that brings nutrition directly to the stomach) with a start date of 10/30/2026.During a concurrent interview and record review on 4/15/2026, at 9:40 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 7's MDS section P (Restraint and alarm), dated 1/26/2026 was reviewed. The MDS Section P indicated Resident 7 did not have any trunk or limb restraints in use. The MDSC stated, she did not realize that Resident 7's abdominal binder could be considered as restraints because it prevented her from access to her body and she could not remove it by herself. The MDSC stated that MDS coding should be done accurately because it affects the residents' plan of care and treatment.During an interview on 4/15/2026, at 3:02 p.m., with the Director of Staff Development (DSD), the DSD stated, all assessments in MDS should be coded correctly because this would affect resident's overall care and treatment negatively. The DSD stated, assessments should be accurate to get a clear representation of the residents.During a review of the facility's Policy and Procedure (P&P) titled, Resident Assessment Instrument (RAI) Process, revised 4/2017, the P&P indicated, Policy: The facility will utilize the Resident Assessment Instrument (RAI) process for the accurate assessment of each resident's functional capacity and health status. Procedure: The facility must maintain all resident assessments completed within the previous 15 months in an easily accessible location and retrievable and use the results of the assessments to develop, review and revise the resident's comprehensive care plan . The last comprehensive assessment with the most recent assessment completed must be maintained in the active clinical record.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of eight sampled residents (Resident 5 and Resident 7) by failing to:A. Develop a comprehensive care plan for Gentamicin (medication to treat severe bacterial infections) for Resident 5.B. Implement a comprehensive person-centered care plan for abdominal binder (a wide, elastic compression belt worn around the abdomen is used with patients who have removed essential lines or tubes on more than one occasion) use for Resident 7.These failures had the potential to result in Resident 5 and Resident 7's needs not being met, affecting the residents' well-being, and poor patient outcomes.Findings: A. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD - chronic kidney disease that causes gradual loss of kidney function), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and cellulitis (infection of the skin). During a review of Resident 5's History and Physical (H&P), dated 3/19/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS – a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 5 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, required supervision for oral hygiene and upper body dressing, and required maximal assistance (helper does more than half the effort) for toileting hygiene, bathing, and lower body dressing. During a review of Resident 5's Order Summary Report dated 4/23/2026, the Order Summary Report indicated Resident 5 had an order for gentamicin sulfate ophthalmic (eye) solution in the left ear two times a day for an ear infection for 7 days starting 4/9/2026. During a review of Resident 5's Medication April 2026 Medication Administration Record (MAR), the April 2026 MAR indicated Resident 5 received the gentamicin sulfate drops from 4/9/2026 – 4/16/2026 as scheduled. During a concurrent interview and record review on 4/15/2026 at 9:33 a.m. with the infection Prevention Nurse (IPN), the Resident 5's Physician Orders and Care Plans were reviewed. The IPN stated Resident 5's Physician Orders indicated that resident was prescribed gentamicin sulfate starting 4/9/2026. The IPN stated Resident 5 did not have a care plan for antibiotic therapy related to the use of gentamicin. The IPN stated a care plan for gentamicin should be initiated so the facility would know what to monitor and the plan of care. The IPN stated if a care plan for antibiotics is not initiated, the resident may be at risk for not receiving appropriate care or may not meet their goals. During an interview on 4/16/2026 at 1:44 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated care plans are initiated on admission, quarterly, annually, and as needed for significant changes or changes of conditions. RNS 1 stated if a care plan is not initiated for gentamicin, the staff may not know what to monitor, the type of antibiotic, the plan, or know when to evaluate if or when it is effective. B. During an observation on 4/13/2026, at 11:26 a.m., in Resident 7's room, there was an observation of an abdominal binder on Resident 7. During a review of Resident 7's admission Record, the admission Record indicated, Resident 7 was initially admitted to the facility on [DATE] and last readmission was on 10/2/2025 with diagnoses including Quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), cerebral infarction (loss of blood flow to a part of the brain), pathological fracture (broken bone caused by disease), and dementia (a progressive state of decline in mental abilities). During a review of Resident 7's H&P, dated 10/4/2025, the H&P indicated Resident 7 had no capacity (ability) to understand and make decisions. During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7 required dependent assistance (helper does all of the effort) from two or more staff for dressing, hygiene, bed mobility, and transfer. The MDS indicated Resident 7 had impairment (a loss of part or all of a physical or mental ability) on one side of upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) for both sides. During a concurrent interview and record review on 4/14/2026, at 3:09 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 7's Order Summary Report (OSR), dated 4/15/2026 was reviewed. The OSR indicated, place abdominal binder at all times to prevent pulling out of gastrostomy tube ([G-tube]- a tube inserted through the belly that brings nutrition directly to the stomach) was ordered on 10/30/2025. RNS 1 stated there was no order to monitor and assess skin under abdominal binder every two hours. RNS 1 stated, there was no documentation regarding monitoring and assessment of skin integrity and abdominal binder use. RNS 1 stated, Resident 7 was at risk for skin breakdown and compromised circulation due to prolonged abdominal binder use. RNS 7 stated, without assessment, monitoring, and documentation, it would be hard to prevent skin breakdown and compromised circulation. During a concurrent interview and record review on 4/15/2026, at 9:40 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 7's Care Plan (CP) titled, Resident 7 requires the use of abdominal binder secondary to pulling out feeding tube, initiated on 10/28/2025 was reviewed. The CP goal indicated that Resident 7 would have no skin impairments and minimize the risks for complications related to abdominal binder by 4/26/2026. The CP interventions indicated, assess resident for use of abdominal binder, assess skin underneath abdominal binder for impairments routinely, and assess for possible discontinuance of abdominal binder. The MDSC stated, all care plan interventions were reflecting Interdisciplinary team (IDT-a group of different experts who work together to help the residents with complex needs) meeting recommendations and should be implemented to prevent unintended skin breakdown and injury. During an interview on 4/15/2026, at 3:02 p.m., with the Director of Staff Development (DSD), the DSD stated, the Resident 7's care plan is a specific plan of care, and it should be implemented as it stated. The DSD stated, care plan interventions should be implemented and reevaluated. The DSD stated care plan interventions were from the IDT meeting and should be implemented to prevent recurrent problems and unintended injuries. The DSD stated, the staff should have followed care plan interventions to assess, monitor, and document regarding the use of abdominal binder to prevent skin injuries and complications such as compromised circulation and entrapment. The DSD stated, she reviewed Resident 7's chart and realized interventions were not followed by the staff. During a review of the facility's Policy and Procedure (P&P) titled, Comprehensive Care Planning, revised 3/2019, the P&P indicated, Policy: It is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment . Procedure: A comprehensive care plan is completed by the Interdisciplinary Team (IDT) within seven days of the completion of the residents Minimum Data Set (MDS) . The care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident and the services provided or arranged must be consistent with each resident's written plan.

Based on observation, interview and record review, the facility failed to ensure a resident was provided with a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) and language translating service with the language that the resident was able to understand for one of eight sample residents (Resident 58).These failures had the potential to result in preventing Resident 58 from communicating with the staff and had the potential to delay receiving appropriate care/treatment and safety for Resident 58.Findings:During a record review of Resident 58's admission Record, the admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of breast (cancerous, abnormal cell growth arising from breast tissue), chronic pain, and history of falling.During a review of Resident 58's History and Physical (H&P), dated 4/13/2026, the H&P indicated, Resident 58 had no capacity to make decisions.During a record review of Resident 58's Minimum Data Set (MDS- a resident assessment tool), dated 4/13/2026, the MDS indicated, Resident 58 required maximal assistance (Helper does more than half the effort) from one staff for bed mobility, moderate assistance (Helper does less than half the effort) from one staff for shower, dressing, toileting hygiene, supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for personal hygiene, oral hygiene, and setup or clean-up assistance (Helper sets up or cleans up; resident completes activity) from one staff for eating.During a review of Resident 58's Care Plan (CP) titled, Resident 58 was at risk for impaired communication skills initiated on 4/7/2026, the CP goal indicated, Resident 58's needs would be met daily until reevaluation date on 7/2026. The CP indicated the use of a communication device to anticipate needs and meet them.During a concurrent observation and interview on 4/13/2026, at 9:50 a.m., with Certified Nurse Assistant (CNA) 2 in Resident 58's room, Resident 58 tried to explain something in Spanish, but CNA 2 told Resident 58 that she could not understand. Resident 58 frowned with frustration and there was no communication board at the bedside. CNA 2 stated, she did not speak Spanish, and she could not find anyone on the floor who could speak Spanish. CNA 2 stated that the communication board should have been provided for Resident 58 to communicate her needs, especially during the emergency. CNA 2 stated, she had never used language translating service and did not know how to use it.During a concurrent observation and interview on 4/13/2026, at 10:10 a.m., with Payroll Staff (PS) 1, CNA 2 brought PS 1 for translation. PS 1 started speaking Spanish and Resident 58 was smiling and thanking her. PS 1 stated, Resident 58 told her that sometimes it was hard to get what she needed when there was no Spanish speaking staff available. PS 1 stated, she did not have any medical related background, and she might not help Resident 58 if Resident 58 needs medical related help. PS 1 stated, she understood Resident 58's frustration and the staff should have provided communication board.During an interview on 4/15/2026, at 9:15 a.m., with the Social Service Director (SSD), the SSD stated, the facility had a contract with language translating service company via I-Pad (a small portable tablet computer activated by touching a screen), but she had never used it and there was no instruction available. The SSD stated, there should be the password and username to access service, but she thought that only medical records staff have them. The SSD stated that the staff might not be able to access it if it were off hours or holidays due to availability of medical record staff. The SSD stated, she provided language board to staff for residents, and she did not know how she missed providing it to Resident 58. The SSD stated it was important to have the way of communication with non-English speaking resident.During an interview on 4/15/2026, at 3:02 p.m., with the Director of Staff Development (DSD), the DSD stated, it was important to provide a way of communication for Resident 58 to accommodate their needs and to provide proper treatment, especially for emergencies. The DSD stated that the communication board should always be available to the residents and the instruction including the password and username for language translating services should be available for the staff to accommodate the residents' needs.During a review of the facility's policy and procedure (P&P) titled, Residents Who Present with Communication Barriers, undated, the P&P indicated, it is the policy of this facility to meet the needs of residents who present with communication barriers. RATIONALE: Communication supports psychosocial well-being by enabling residents to participate in their care. Procedure: Communication boards will be provided at no charge to the resident so that non-English speakers, or aphasic residents can use pictograms to communicate needs and desires.

Based on observation, interview and record review, the facility failed to properly store medications safely in a locked crash cart (a supply cart stocked with equipment and medications used for emergency situations) located by Nursing station 1.This had the potential to result in adverse medication effects, medication tampering and medication theft.Findings: During an observation on 4/13/2026 at 10:22 a.m., the crash cart located across from nursing station 1 was observed unattended with a key inserted in the lock of the cart. During a concurrent observation and interview on 4/13/2026 at 10:28 a.m. with Licensed Vocational Nurse (LVN) 1, the crash cart was observed with the key inserted in the lock of the cart. LVN 1 stated the crash cart had a box of glucose gels (medication used to treat rapid-onset low blood sugar in residents with diabetes) and normal saline syringes (pre-filled syringe, used to clear, maintain, or assess the patency of intravenous (IV) catheter) located in the top drawer. LVN 1 stated the key are always left in the lock of the crash cart so that it is available for emergencies.During an interview on 4/16/2026 at 10:45 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated glucose gels are medications that are given for emergencies such as hypoglycemia (excessively low blood sugar). RNS 1 stated normal saline syringes are medications and require an order for use. RNS 1 stated only licensed staff should have keys to access medications. During a concurrent observation and interview on 4/16/2026 at 11:05 a.m. with RNS 1, the crash cart was observed with the key inserted in the lock of the cart. RNS 1 stated the key is always here for emergencies. RNS 1 stated glucose gels and normal saline syringes should not be freely accessible. RNS 1 stated it is important that only licensed nursing staff have access to medications to prevent adverse medication effects. RNS 1 stated if residents access the unattended cart with glucose gels and normal saline syringes, the resident could be at risk for high blood sugar levels.During a review of the facility's policy and procedure (P&P), titled Medication Storage in the Facility, dated April 2008, the P&P indicated only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview and record review, the facility failed to ensure food served was palatable (food or drink that is pleasant, savory, or agreeable to the taste) and/or at the preferred temperature for three of 54 sampled residents (Resident 19, Resident 60, and Resident 53).This failure had the potential for residents' poor meal intake and which could lead to weight loss. Findings:A. During a review of Resident 19's admission record, the admission record indicated Resident 19 was admitted to the facility on [DATE] with diagnosis including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), and essential hypertension (high blood pressure that is not due to another medical condition).During a review of Resident 19's History and Physical (H&P), dated 1/1/2026, the H&P indicated, Resident 19 had the capacity (ability) to understand and make decisions.During a review of Resident 19's Minimum Data Set (MDS-a resident assessment tool), dated 1/8/2026, the MDS indicated Resident 19 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, transfer, bed mobility, dressing, hygiene, and dependent assistance (Helper does ALL of the effort) from one staff for transfer, dressing, maximal assistance (Helper does more than half the effort) from one staff for shower, toilet hygiene, and moderate assistance (Helper does less than half the effort) from one staff for eating, oral hygiene, bed mobility.During a review of Resident 19's Order Summary Report (OSR), dated 4/15/2026, the OSR indicated, Regular texture, consistent carbohydrate (eating the same amount of carbohydrates every day), no added salt, and thin liquid diet was ordered on 1/30/2026. During an interview on 4/13/2026, at 10:53 a.m., with Resident 19 in his room, Resident 19 stated, he was upset about the food he was getting. Resident 19 stated, food was served cold with no seasoning. Resident 19 stated, breakfast meals were usually the worst. Resident 19 stated, vegetables were so bland and flavorless. Resident 19 stated, he asked his nephew to bring meal from home twice a week. Resident 19 stated, he understood if they used less salt because of high blood pressure, but there was no seasoning on vegetables.During a concurrent observation and interview on 4/14/2026, at 7:45 a.m., in Resident 19's room, Resident 19 received breakfast tray and was frowning. There was Southwestern casserole, wheat toast, oatmeal, a cup of fruit punch juice, and a cup of milk on the tray. Resident 19 stated, he wanted his oatmeal to be served hot, but it was lukewarm and tasteless. Resident 19 stated, the casserole was bland. Resident 19 refused to eat and asked for ham and cheese sandwich.B. During a review of Resident 60's admission record, the admission record indicated Resident 60 was admitted to the facility on [DATE] with diagnosis including cellulitis (a skin infection that causes swelling and redness) of right arm, essential hypertension, and acute kidney failure (a sudden, often reversible, loss of kidney function occurring within hours or days).During a review of Resident 60's H&P, dated 4/7/2026, the H&P indicated, Resident 60 had the capacity (ability) to understand and make decisions.During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60 required moderate assistance from one staff for dressing, supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from one staff for hygiene, shower, transfer, bed mobility, and setup or clean-up assistance (Helper sets up or cleans up; resident completes activity) from one staff for eating.During a review of Resident 60's Order Summary Report (OSR), dated 4/15/2026, the OSR indicated, Regular texture with thin liquid diet was ordered on 4/5/2026. During an interview on 4/13/2026, at 11:06 a.m., with Resident 60 in his room, Resident 60 stated, hot food has been served lukewarm or cold frequently. Resident 60 stated, steamed vegetables looked unappetizing and bland. Resident 60 stated he had to ask the staff to reheat, but microwaving altered the texture of food in a very unpleasant way. Resident 60 stated, he skipped the meals sometimes.During an interview on 4/14/2026, at 11:40 a.m., with Resident 60 in a hallway, Resident 60 stated, he was upset about lunch tray. Resident 60 stated, he did not want to eat lunch because steamed carrots were not seasoned at all and looked mushy. Resident 60 stated, he lost his appetite.C. During a review of Resident 53's admission record, the admission record indicated Resident 53 was admitted to the facility on [DATE] with diagnosis including legal blindness (severe visual impairment or low vision), deafness (hearing loss that precludes a person from understanding spoken language), Congenital Rubella Syndrome (CRS- a condition occurring in newborns when a pregnant woman contracts the rubella virus, leading to severe, often permanent birth defects like heart issues, blindness, and deafness), and dysphagia (difficulty swallow).During a review of Resident 53's H&P, dated 12/13/2025, the H&P indicated, Resident 53 had no capacity to understand and make decisions.During a review of Resident 53's MDS, dated [DATE], the MDS indicated Resident 53 required dependent assistance from two or more staff for shower/bath, transfer, bed mobility, dressing, hygiene, and maximal assistance (Helper does more than half the effort) from one staff for eating.During a review of Resident 53's Order Summary Report (OSR), dated 4/15/2026, the OSR indicated, pureed texture, consistent carbohydrate, honey thick liquid consistency double portion diet was ordered on 1/22/2026. During a concurrent observation and interview on 4/14/2026, at 11:50 a.m., with Certified Nurse Assistant (CNA) 2 in Resident 53's room, CNA 2 was assisting with feeding for Resident 53. Resident 53 received pureed (cooked, blended, or strained into a thick, smooth, and lump-free paste with a pudding-like consistency) barbeque chicken, pureed carrots, pureed wheat roll, pureed potato salad. Resident 53 tasted pureed carrots and pureed wheat roll. CNA 2 tried to give him more, but Resident 53 shut his mouth tightly. CNA 2 stated, Resident 53 shut his mouth tightly when he did not want to eat. Resident 53 ate pureed barbeque chicken. CNA 2 stated, she could tell that Resident 53 did not like the pureed carrots and pureed wheat roll.During a concurrent observation and interview on 4/14/2026, at 11:57 a.m., with the Dietary Supervisor (DS), the DS brought the test trays for regular lunch tray and pureed lunch tray. There was wheat roll with butter packet, steamed carrots, barbeque chicken, and macaroni salad in a disposable plastic container for regular diet tray. There was pureed wheat roll, pureed carrots, and pureed barbeque chicken on a disposable plastic container with plastic spoons and knives for pureed diet tray. The DS tried the regular carrots and stated he agreed that it was bland. The DS tried pureed carrots and pureed wheat roll. The DS agreed they are little bland. The DS stated they were bland, but they are probably better for the residents who had restriction on salt intake. The DS stated, he should have used salt substitute [alternatives to salt (sodium chloride) that contain varying amounts of potassium chloride] to enhance the flavor. The DS stated, he should have brought test trays in proper plates with silverware for better presentation. The DS state, pureed food items were blended only with flavorless thickener [a substance added to liquids to increase viscosity (stiffness) without changing other properties].During a concurrent interview and record review on 4/14/2026, at 12:17 p.m., with the DS, the facility's Recipe for Pureed Breads and Pureed Vegetables, dated 2025 was reviewed. The Recipe for Pureed Breads indicated, put blender on low speed and add milk gradually and add food thickener if needed. The Recipe for Pureed vegetables indicated, place a blender on low speed and add warm liquid such as low sodium broth or milk gradually. The Recipe for Pureed vegetables indicated, add food thickener if needed and adjust seasoning as needed after tasting it. The DS stated, he should have ensured that the cook followed the recipes to enhance the flavors to prevent unintended weight loss. During an interview on 4/15/2026, at 4 p.m., with the Registered Dietitian (RD), the RD stated, food should be presented palatable and appetizing for all residents regardless of types of diets. The RD stated, the cook should have followed the recipes, and the DS should have ensured recipes were followed during the preparation. The RD stated, if the residents were on a sodium restricted diet, salt substitute should be used to enhance the flavor without adding salt. The RD stated that preferred food temperature should be honored as well, and the DS should have assessed for preference. The RD stated, the dietary staff had responsibility for food to be served with palatable, appetizing, and proper/ preferred temperature to prevent poor intake and unintended weight loss.During a review of the facility's Policy and Procedure (P&P) titled, Meal Service, dated 5/2019, the P&P indicated, Policy: It is the policy of the facility to provide meals that meet the nutritional needs of the residents and they will be served in an accurate and efficient manner and served at the appropriate temperatures. Procedure: Temperature of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot.During a review of the facility's Policy and Procedure (P&P) titled, Dietary-Food and Nutrition Preparation and Service, dated 1/2017, the P&P indicated, Policy: It is the policy of the facility to provide each resident with a nourishing, palatable, well balanced diet that meets the daily nutritional and dietary needs. Procedure: Each resident will be provided a nourishing, palatable, well-balanced diet that meets their daily nutritional and dietary needs while taking into account the preferences of the resident.

Based on interview and record review, the facility failed to follow their antibiotic stewardship policy for one of three sampled residents (Resident 5) when the facility did not inform the physician when Resident 5, who was prescribed gentamicin (antibiotic to treat bacterial infections) eye drops did not meet McGeer's criteria (criteria used to detect infections based on symptoms and laboratory values).This resulted in Resident 5 receiving inappropriate antibiotic eye drops and the potential to develop antibiotic resistance.Findings: During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD - chronic kidney disease that causes gradual loss of kidney function), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine), and cellulitis (infection of the skin).During a review of Resident 5's History and Physical (H&P), dated 3/19/2026, the H&P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 3/25/2026, the MDS indicated Resident 5 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required setup assistance when eating, required supervision for oral hygiene and upper body dressing, and required maximal assistance (helper does more than half the effort) for toileting hygiene, bathing, and lower body dressing. During a review of Resident 5's Order Summary Report dated 4/23/2026, the Order Summary Report indicated Resident 5 had an order dated 4/9/20206 for gentamicin sulfate ophthalmic (eye) solution 0.3% two drops in left ear two times a day for ear infection for 7 days.During a review of Resident 5's Medication April 2026 Medication Administration Record (MAR), the April 2026 MAR indicated Resident 5 received the gentamicin sulfate drops from 4/9/2026 - 4/16/2026 as scheduled.During a concurrent interview and record review on 4/15/2026 at 9:33 a.m. with the infection Prevention Nurse (IPN), the April 2026 Infection Prevention and Control Surveillance Log, Resident 5's Surveillance Data Collection Form, dated 4/9/2026, and Resident 5 Nursing notes were reviewed. The April 2026 Infection Prevention and Control Surveillance Log indicated Resident 5's did not meet McGeer's criteria. The IPN stated the Surveillance Data Collection Form indicated Resident 5 had a left earache that was red and tender. The IPN stated Resident 5 was oriented and stated having the symptoms of an ear infection before. The IPN stated they (IPN) did not inform the physician that Resident 5 did not meet McGeer's criteria for an infection, because they (IPN) did not find it right to stop something if you know the resident needed it.During a concurrent interview and record review on 4/16/2026 at 1:48 p.m. with Registered Nurse Supervisor (RNS) 1, the April 2026 Infection Prevention and Control Surveillance Log and Resident 5's Surveillance Data Collection Form, dated 4/9/2026, were reviewed. RNS 1 stated it was the licensed nurse's responsibility to inform the physician when residents were prescribed an antibiotic and do not meet criteria for an infection to prevent the use of unnecessary antibiotics and developing antibiotic resistance.During a review of the facility's policy and procedure (P&P), titled Infection Control - Antibiotic Stewardship, dated January 2018, the P&P indicated feedback will be given to physicians on their individual prescribing patterns of cultures ordered and antibiotics prescribed, on a regular basis.

Based on interview and record review, the facility failed to educate and offer the COVID-19 vaccination for the 2025-2026 respiratory season for two of five sampled staff (Physician 1 and Physician 2).These failures had the potential to result in spreading the COVID-19 virus throughout the facility. Findings:During a concurrent interview and record review on 4/15/2026 at 10:26 a.m. with the Infection Prevention Nurse (IPN), the staff vaccination records were reviewed. The IPN stated there was no documentation that Physician 1 and Physician 2 were offered the COVID-19 vaccination for the 2025-2026 respiratory season and educated on the risks and benefits of receiving the vaccination. The IPN stated both Physician 1 and Physician 2 actively cared for current residents.During an interview on 4/16/2026 at 1:52 p.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated it was important to offer the COVID-19 vaccine and educate all staff to prevent the spread of the COVID-19 virus to residents. RNS 1 state the COVID-19 consent form is proof that the facility encouraged and educated the staff about the COVID-19 vaccine.During a review of the facility's policy and procedure (P&P), titled Coronavirus Vaccine Policy (COVID-19 Vaccine Policy), dated February 2025, the P&P indicated COVID-19 vaccinations will be offered to all staff and residents per Centers of Disease Control (CDC) and/or Food and Drug Administration (FDA) guidelines.All staff and residents/representatives will be educated on the COVID-19 vaccine they are offered in a manner they can understand.The facility will maintain documentation for all resident and staff on COVID-19 vaccination status. For staff, the information will be documented in their personnel file.

Based on observation. interview and record review, the facility failed to implement infection control measures by failing to:A. Ensure implementing the water management plan (comprehensive plan aimed to prevent waterborne illnesses by controlling germs in the water) by monitoring and documenting control measures (actions taken to eliminate or reduce the likelihood or severity of exposure to a hazard) and limit (a specific, measurable, and quantitative range for a particular parameter that indicates when a water system is operating acceptably).B. Identify, follow through, and report Resident 1's positive result of Legionella (a type of bacteria that is naturally found in [NAME] environments) Urine Antigen Test [UAT-a diagnostic test used to detect Legionella (bacteria in the urine of individuals suspected of having Legionnaires' disease (a severe form of a lung infection called pneumonia that is caused by a bacterium known as legionella)] to California Department of Public Health (CDPH-the state department responsible for public health in California) as an Unusual Occurrence (a form used to report unusual or significant events that occur in healthcare facilities, residential care facilities, and other licensed facilities in California) within 24 hours.C. Review, revise, and update the water management program and infection control and prevention policy annually.These failures had the potential to result in compromised infection control measures to prevent the potential spread of Legionnaires' disease among residents, staff, and visitors.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including pneumonia (an infection/inflammation in the lungs), sepsis (a life-threatening blood infection), and chronic pulmonary edema (a condition where fluid accumulates in the lungs over an extended period, leading to shortness of breath and other symptoms).During a review of Resident 1's History and Physical (H&P), dated 10/8/2024, the H&P indicated, Resident 1 had baseline cognitive impairment (a decline in one or more cognitive functions, such as memory, attention, language, problem-solving, and decision-making).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/13/2025, the MDS indicated Resident 1 required dependent assistance (Helper does all of the effort) from two or more staff for dressing, maximal assistance (Helper does more than half the effort) from one staff for bed mobility, bathing/shower, toilet hygiene, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and /or contact guard assistance as resident competes activity) from one staff for eating.A. During a concurrent interview and record review on 10/17/2025 at 12:47 p.m., with the Maintenance Supervisor (MS), the facility's Water Management Binder, dated from 2/2025 to 10/2025 was reviewed. The Water Management Binder indicated, there were daily water temperature logs for documenting water temperature for shower rooms, kitchen, resident room (randomly selected), and laundry. There were no other monitoring logs for control measures and control limits. The MS stated, he was not sure what other control measures and limits should be monitored. The MS stated, the facility did not have a customized water management plan.During a concurrent interview and record review on 10/17/2025 at 3:05 p.m. with the Infection Preventionist Nurse (IPN), the CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/5/2017, was reviewed. The Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings indicated, Control measures and limits should be established for each control point. You will need to monitor to ensure your control measures are performing as designed. Control limits, in which a chemical or physical parameter must be maintained, should include a minimum and a maximum value. Water quality should be measured throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine levels) are not occurring. Water heaters should be maintained at appropriate temperatures. Disinfectant (a chemical liquid that destroys bacteria) and other chemical levels should be continuously maintained and regularly monitored. Surfaces with any visible biofilm (slime) should be cleaned. The IPN stated, the facility did not have the water management policy and followed CDC's water management program guidelines. The IPN stated, the facility should have implemented all control measures and control limit according to CDC's guidelines since the facility followed as the policy and procedures. The IPN stated, the MS should have monitored and documented the water quality, water temperature, and disinfectant level to reduce risk of Legionella growth. During a review of the facility's Policy and Procedures(P&P) titled, Policy for Legionnaire's Disease, revised 6/2017, the P&P indicated, Process to Develop a Water Management Program: The facility will determine risk areas by completing the Building Water System Process Flowchart and implement controls and indicate where these controls are located by completing the Control Area Monitoring Flowchart.During a review of the CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/5/2017, the Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings indicated, Documentation: written program should include at least the following: Water system description, including general summary, uses of water, aerosol-generating devices (e.g., hot tubs, decorative fountains, cooling towers), and process flow diagrams. Control measures, including points in the system where critical limits can be monitored and where control can be applied.B. During an interview on 10/17/2025, at 11:46 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, Resident 1 had respiratory symptoms such as coughing and shortness of breath on 9/29/2025. RNS 1 stated, Resident 1 was transferred to General Acute Care Hospital (GACH) due to change of condition on 9/30/2025 and re-admitted to the facility on [DATE]. RNS 1 stated, she did not receive information regarding the positive result of Legionella UAT from GACH for Resident 1, and staff did not know about it until the Public Health Nurse notified IPN on 10/15/2025.During a concurrent interview and record review on 10/17/2025, at 2:24 p.m., with RNS 1, Resident 1's GACH Progress Note, dated 10/4/2025, the GACH Progress Note indicated, Resident 1 was diagnosed with Legionella pneumonia and was on Levaquin (a medication to treat a variety of bacterial infections). RNS 1 stated, it was RN Supervisors' responsibility to review all the pre-admission documents upon admission and the admission RNS should have reviewed Resident 1's GACH medical record thoroughly. RNS 1 stated, if the staff did not review the admission documentation thoroughly, critical information like this could delay the resident's treatment and care.During an interview on 10/17/2025, at 2:30 p.m., with the IPN, IPN stated, she would have reported the unusual occurrence (any condition or event which has jeopardized or could jeopardize the health, safety, security or well-being of any patient, employee or any other person while in the facility) within 24 hours if she knew about Resident 1 having legionella infection. The IPN stated, GACH did not inform it, but she realized that it was indicated on Resident 1's medical record. The IPN stated, this would place all the residents at the facility at risk of being exposed to infectious disease unknowingly and delay the care. The IPN stated, the facility was notified by Public Health Nurse Liaison (a registered nurse who acts as a crucial communication bridge between public health agencies and other healthcare settings to improve disease reporting, surveillance, and public health initiatives) on 10/15/2025.During a concurrent interview and record review on 10/17/2025, at 2:42 p.m., with the Director of Nursing (DON), Resident 1's History and Physical (H&P), dated 10/8/2025 was reviewed. The H&P indicated, admission to the facility for continued rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) and medical management following hospitalization for acute hypoxic respiratory failure (the lungs cannot adequately oxygenate the blood) secondary to Legionella pneumonia. The DON stated, the staff, including herself, failed to review Resident 1's medical record thoroughly. The DON stated, this would delay the proper care and treatment. The DON stated, if she knew about Resident 1's legionella infection, she would have reported it to CDPH right away to investigate the case. The DON stated, missing critical information regarding certain infections could result in spreading infection and exposing vulnerable residents to danger.During a review of Resident 1's GACH Legionella UAT , dated 10/2/2025, the GACH Legionella UAT positive result was reported on 10/2/2025 at 10:35 a.m During a review of Resident1's Discharge Summary EMR, dated 10/6/2025, the Discharge Summary EMR indicated, Resident 1 had legionella pneumonia and received Levaquin.During a review of the facility's Policy and Procedure (P&P) titled, Unusual Occurrence Reporting, revised 8/2018, the P&P indicated, Policy: It is the facility policy that, in accordance with federal and/or state regulations, unusual occurrences or other reportable events which affect the health, safety or welfare of residents, employees or visitors be reported. Procedure: 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. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations.During a review of the facility's Policy and Procedure (P&P) titled, Policy for Legionnaire's Disease, revised 6/2017, the P&P indicated, Policy: Policy: It is the policy of the facility to have a plan for the prevention of Legionnaire's disease, recognize the signs and symptoms of the disease, test as appropriate with a physician's order and report confirmed cases to the local and state health department. Legionella is a reportable disease and the local county and state health departments should be notified of confirmed disease.C. During a concurrent interview and record review on 10/17/2025, at 3:05 p.m., with the IPN, the facility's Policy and Procedure(P&P) titled, Policy for Legionnaire's Disease, revised 6/2017 was reviewed. The P&P indicated, The facility will develop a Water Management Program which will be reviewed annually. The IPN stated, last revised policy was on 6/2017, and it was supposed to be reviewed and updated annually. The IPN stated, she could not provide evidence that indicated it was reviewed and updated annually. The IPN stated, P&P should be reviewed and updated for any changes to accommodate new health orders (a written directive issued by a government's public health authority to control or prevent risks to public health).During a concurrent interview and record review on 10/17/2025, at 3:30 p.m., with the Administrator (ADM), the facility's Quality Assurance and Performance Improvement (QAPI Improvement-a data driven proactive approach to improvement used to ensure services are meeting quality standards) binder, dated from 2/2025 to 10/2025 was reviewed. There was no documentation regarding review, revise, and update the infection control and water management policies annually. The ADM stated, he believed QAPI team discussed the policy and procedure during the QAPI meeting, but he could not provide evidence or documentation. The ADM stated, review and update the P&P was important to let the staff know any recent changes on practice and guidance.During a review of the facility's Policy and Procedure(P&P) titled, Infection Control Program, revised 7/2022, the P&P indicated, Educational Component: The Quality Improvement Program will include a structured system with stated guideline and regular, active participants; standard procedures for inspection and action.Infection Control Plan: The Infection Control Committee will establish policies and procedures for the investigation, control and prevention of transmission of disease and infections within the facility.Establish and implement guidelines and procedures. Assist each department in establishing policies and procedures for infection control and provide ongoing evaluation of current measures and policies within each department

Based on observation, interview, and record review, the facility failed to ensure Jello items were stored and maintained at the required temperature of 41-degree Fahrenheit (a temperature scale, range for cold food is below 41 degrees). This failure had the potential to result in food spoilage, compromised taste for residents as proper temperature control is essential to ensure food safety and quality. Findings: During an observation on 2/18/2025 at 11:35 a.m., in the kitchen, observed that the Dietary Supervisor (DS) pulled out one cup of Jello from the refrigerator and checked its temperature, which measured 54 degrees. During an observation on 2/18/2025 at 11:48 a.m., in the kitchen, observed that the DS checked temperature of another Jello, which measured 48 degrees. During an observation on 2/18/2025 at 12:22 p.m. in the kitchen, observed that Dining cart #1, #2 were being transported from the kitchen with the Jello items. Before cart #3 left the kitchen, the DS checked temperature of Jello again, and the thermometer indicated at 48 degrees. During an interview on 2/19/2025, the DS stated that the Jello item on the lunch menu should be kept at 41 degrees or lower. The DS also stated that if not stored properly, the Jello could spoil which would also impact its taste. During a review of the facility's policy and procedure titled, Meal Service, dated 2023, the P&P indicated, cold food items will be placed on the trays as close to serving time as possible to assure the temperature is below 41degrees.

Based on interview and record review the facility's Quality Assessment and Assurance (QAA) Committee, thereby affecting 47 out of 47 residents, failed to identify and implement corrective action to the systemic problems identified: a. Ensure medication parameters are followed when administering medication to residents b. Ensure dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) residents are assessed before departing for dialysis and after residents return from outpatient dialysis. c. Ensure the kitchen store, prepare and distribute food in accordance with professional standards for food service safety. These deficient practices placed the residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being. Findings: During an interview on 2/21/2025 at 9:26 a.m., with the Administrator (ADM), the ADM stated the following systemic issues identified were not identified by the QAA committee: a) ensure medication parameters are followed wen medicating residents b) ensure dialysis residents are assessed before departing for dialysis and after residents return from outpatient dialysis. c) ensure the kitchen store, prepare and distribute food in accordance with professional standards for food service safety. During a record review of the facility's policy and procedure (P&P) titled, Quality assurance performance Improvement Plan and Committee, revised 12/2024, the P&P indicated the QAA committee will identify and address specific care and quality issues and implement actions plan to resolve these issues. Cross Reference F760, F698, F812

Based on interview and record review, the facility failed to ensure nurses would document resident's pain level before removing pain medication from inventory, and document resident's refusal of administration, for one of one residents (Resident 43). This deficient practice had the potential of medication error and/or narcotic diversion. Findings: During an observation at the medication cart 1 on 2/19/25 at 3:45 PM, there was a multiple-dose blister pill pack (bubble pack) for Resident 43. The medications in the bubble pack were labeled as oxycodone with acetaminophen (generic for Percocet, a potent opioid to treat severe pain) 10/325 milligrams (mg, an unit of measuring mass). During an interview and a concurrent review of Resident 43's controlled drug record (an accountability record or count sheet for narcotics) for Percocet, the licensed vocational nurse (LVN 3) stated the count sheet indicated there were two doses marked wasted, one each on 12/4/24 (no time noted) and 2/13/25 (6 AM). LVN 3 reviewed Resident 43's electronic medication administration record (eMAR) and stated the eMAR did not have a documentation of Resident's pain episode and/or the refusal of Percocet on 12/4/24 and 2/13/25. During an interview on 2/20/25 at 11:32 AM, the registered nurse (RN 1) stated the facility process of administering as needed (PRN, not routine) medication for pain starts with the resident requesting their pain medication, then the LVN would ask the resident's pain level and document in the eMAR, before preparing the administration of the pain medication. RN 1 stated the nurse would also perform nonpharmacological interventions. During an interview on 2/20/25 at 11:38 AM, RN 1 confirmed nurses failed to document Resident 43's pain level before removing Resident 43's Percocet from the inventory. A review of Resident 43's physician order, dated 11/30/24 on 8:34 PM, indicated to give 1 tablet of Percocet 10/325 mg by mouth every 4 hours as needed for moderate to severe pain (pain level) 4-10. A concurrent review of Resident 43's weights and vitals summary indicated a pain level of 3 on 2/13/25 at 9 AM and on 12/4/24 at 5:06 AM. During an interview on 2/20/25 at 11:49 AM, the director of nursing (DON) stated nurses should not access or remove the narcotic medication from the bubble pack if the pain level did not meet the criteria (a rating of 4-10) as stated in the order. A review of the Resident 43's eMAR on 12/4/24 and 2/13/25 did not indicate non-pharmacological interventions were performed after the pain assessment. A review of the facility policy and procedures, Medication Administration-General Guidelines (dated 10/2017), indicated . Medications are administered in accordance with written orders of the attending physician .

Based on observation, interview and record review, the facility failed to appropriately assess and monitor one of one sampled resident (Resident 15) during the use of an abdominal binder (a wide belt that provides light compression around the stomach) placed over Resident 15's a gastrostomy (g-tube: a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This deficient practice had the potential to place the resident on unnecessary restraints. Findings: During a review of Resident 15's Admission Record, the Admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including gastrostomy, dysphagia (difficulty swallowing), and Huntington's Disease (a progressive inherited neurodegenerative disorder that affects the brain). During a review of Resident 15's History and Physical (H&P), dated 6/22/2024, 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] a resident assessment tool), dated 1/24/2025, the MDS indicated Resident 15's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills were severely impaired. The MDS indicated Resident 15 was dependent on all aspects of activities of daily living (ADL: bathing, chair/bed-to-chair transfer, personal hygiene, toileting hygiene, oral hygiene). The MDS indicated Resident 15 did not have any physical restraints, which are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. During a review of the Order Summary (physician notes) dated 2/20/2025, the Order Summary indicated an active order dated 6/21/2024 for an abdominal binder at all times to prevent Resident 15 from pulling out g-tube due to diagnosis of Huntington's disease (may remove abdominal binder during ADL's). During a review of Resident 15's Care Plan, the Care Plan indicated Resident 15 required an abdominal binder at all times, except during ADLs to prevent Resident 15 from pulling out the g-tube due to a diagnosis of Huntington's Disease. The Care Plan approach indicated to ensure the abdominal binder was properly fitted and secured at all times during ADLs, monitor skin integrity daily for any signs of irritation or breakdown. The Care Plan indicated to document and report any signs of discomfort, skin breakdown, or non-compliance. During a review of the Medication Administration Record (MAR: documentation of medications administered to residents) dated 2/1/2025 to 2/28/2025, the MAR indicated the section for monitoring the abdominal binder at all times to prevent pulling out g-tube do to (d/t) diagnosis of Huntington's disease (may remove during ADL's) were all documented as X. During a concurrent observation of Resident 15, and interview on 2/20/2025 at 9:52 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 15 had an abdominal binder on where his g-tube was located. LVN 3 stated Resident 15 was always wearing an abdominal binder so he did not pull out the g-tube as he could not control his movements. During a concurrent interview and record review of the MAR dated 2/1/2025 to 2/28/2025 on 2/20/2025 at 3:18p.m. with the Director of Staff Development (DSD), the DSD stated the section that indicated the abdominal binder on at all times should have contained documentation of Resident 15's abdominal binder assessments, and the X that staff have been documenting meant nothing. The DSD stated this abdominal binder should have had better monitoring. The DSD stated it should be monitored to ensure the abdominal binder is in place or if the resident is tugging on it. During an interview on 2/20/2025 at 4:26p.m. with the Director of Nursing (DON), the DON stated restraints are particular devices that restrict mobility of residents, and an abdominal binder can be a form of restraint depending on the condition of the resident. The DON stated if a resident has a diagnosis of Huntington's Disease that causes uncontrollable moving and jerking, an abdominal binder will protect his g-tube and does not restrict him from moving. The DON stated an abdominal binder is a physical device and requires a consent, needs to monitor the skin integrity of sight, and release during ADL to monitor for skin breakdown. The DON stated restraints are reassessed quarterly for appropriateness. During a review of the facility's policies and Procedures (P&P), titled Restraint Assessments: Chemical (Psychotropic Meds) and Physical, revised 1/2014, the P&P indicated the facility shall engage in a systematic and gradual process towards reducing restraints for those residents whose care plans indicate the need for restraints. Physical restraints: are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or movement or normal access to one's body. Includes but not limited to leg restraints, arm restraints, hand mittens, soft ties or vests .the resident cannot remove easily. Institute a trial period where less restrictive measures are used. Document the types and duration of the less restrictive measures used and the results. The need for the restraint shall be periodically reevaluated and attempts shall be made to engage in a systematic and gradual process to minimize and/or eliminate their use whenever possible. The resident's functional status shall be regularly reassessed regarding the resident's ongoing medical indication for a restraint and the resident's care plan shall be updated accordingly. During a review of the facility's P&P, titled Physical Restraints, revised 9/2017, the P&P indicated upon admission, quarterly and with a change of condition, residents shall be assessed for the need or lack of physical restraints. The need for restraints will be re-evaluated at least quarterly to determine their continued need. Every effort will be made to eliminate their use.

Based on interview and record review the facility failed to ensure one of two sampled resident's (Resident 37) care plans were reviewed and updated on a quarterly basis. This deficient practice had the potential to result in poor quality of care and a delay in care and services. Findings: During a review of Resident 37's Admission Record, the admission record indicated Resident 37 was admitted to the facility on [DATE] with diagnosis including acute respiratory failure (when the air sacs of the lungs cannot release enough oxygen into the blood), type 2 diabetes (long-term condition in which the body has trouble controlling blood sugar and using it for energy), hypertension (condition in which the force of the blood against the artery walls is too high), and dementia (a progressive state of decline in mental abilities). During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool) dated 11/8/2024, the MDS indicated Resident 37's cognition (ability to think and reason) was moderately impaired. The MDS indicated Resident 37 was dependent on staff for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 37's Care Plans, the following eight care plans were all created 8/28/2024 and were due for review on 11/2024, but have not been reviewed as of 2/18/2025, Care plans titled, Cognitive Loss, Communication, Oral/Dental, Weight loss/gain/dehydration, Cardiac circulation, Elopement, Aging process, and Breathing pattern. During an interview and record review on 2/18/2025 at 4:26 p.m. with the MDS Coordinator (MDSN) 2, Resident 37's care plans were reviewed. The MDSN 2 stated Resident 37's care plans should have been reviewed and reevaluated since November 2024 but have not been. During an interview on 2/20/2025 at 4:26 p.m. with the Director of Nursing (DON), the DON stated care plans need to be reviewed at least quarterly to make sure if it still applies or if it needs to be revised. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated a comprehensive, person-centered care plan must be reviewed and revised periodically, at least quarterly and on an ongoing basis to reflect changes in the resident and the services provided or arranged must be consistent with each resident's written plan.

Based onobservation, interview and record review, the facility failed to 1.Ensure nurses would document resident's pain level before removing pain medication from inventory, and document resident's refusal of administration, for one of one residents (Resident 43). These deficient practices had the potential of medication error and/or narcotic diversion. 2. Ensure one of one sampled residenst (Resident 48) had a urology (a medical specialty that focuses on the diagnosis, treatment, and prevention of diseases and disorders related to the urinary system) consult and received services to meet professional standards of practice. These failures had the potential for Resident 48's penile (located on the penis) open wound to get infected. Findings: 1. During an observation at the medication cart 1 on 2/19/25 at 3:45 PM, there was a multiple-dose blister pill pack (bubble pack) for Resident 43. The medications in the bubble pack were labeled as oxycodone with acetaminophen (generic for Percocet, a potent opioid to treat severe pain) 10/325 milligrams (mg, an unit of measuring mass). During an interview and a concurrent review of Resident 43's controlled drug record (an accountability record or count sheet for narcotics) for Percocet, the licensed vocational nurse (LVN 3) stated the count sheet indicated there were two doses marked wasted, one each on 12/4/24 (no time noted) and 2/13/25 (6 AM). LVN 3 reviewed Resident 43's electronic medication administration record (eMAR) and stated the eMAR did not have a documentation of Resident's pain episode and/or the refusal of Percocet on 12/4/24 and 2/13/25. During an interview on 2/20/25 at 11:32 AM, the registered nurse (RN 1) stated the facility process of administering as needed (PRN, not routine) medication for pain starts with the resident requesting their pain medication, then the LVN would ask the resident's pain level and document in the eMAR, before preparing the administration of the pain medication. RN 1 stated the nurse would also perform nonpharmacological interventions. During an interview on 2/20/25 at 11:38 AM, RN 1 confirmed nurses failed to document Resident 43's pain level before removing Resident 43's Percocet from the inventory. During a review of Resident 43's physician order, dated 11/30/24 on 8:34 PM, indicated to give 1 tablet of Percocet 10/325 mg by mouth every 4 hours as needed for moderate to severe pain (pain level) 4-10. During a concurrent review of Resident 43's weights and vitals summary indicated a pain level of 3 on 2/13/25 at 9 AM and on 12/4/24 at 5:06 AM. During an interview on 2/20/25 at 11:49 AM, the director of nursing (DON) stated nurses should not access or remove the narcotic medication from the bubble pack if the pain level did not meet the criteria (a rating of 4-10) as stated in the order. During a review of the Resident 43's eMAR on 12/4/24 and 2/13/25 did not indicate non-pharmacological interventions were performed after the pain assessment. A review of the facility policy and procedures, Medication Administration-General Guidelines (dated 10/2017), indicated . Medications are administered in accordance with written orders of the attending physician . 50387 2. During a review of Resident 48's Admission Record, the Admission Record indicated the facility admitted Resident 48 on 4/29/2024 and readmitted on [DATE] with diagnoses including urinary tract infection (UTI-a bacterial infection in they urinary system, which includes the kidneys, ureters, bladder, and urethra) and pressure ulcer (localized damage to the skin or underlying tissue due to unrelieved pressure) of sacral region (tailbone), stage 3 (full-thickness loss of skin, dead and black tissue may be visible). During a review of Resident 48's History and Physical (H&P), dated 12/18/2024, the H&P indicated Resident 48 could make needs known but not make medical decisions. During a review of Resident 48's Minimum Data Set (MDS- a resident assessment tool), dated 12/22/2024, the MDS indicated Resident 48 was cognitively (related to thinking) intact. The MDS indicated Resident 48 had functional limitation in range of motion (the distance and direction a joint can move) on both upper extremities (arm, including your shoulder, elbow, wrist, and hand) and both lower extremities (leg, including your hip, thigh, knee, shin, ankle, and foot). During a review of Resident 48's Initial Nursing History and Assessment, dated 12/17/2024, the Initial Nursing History and Assessment indicated that Resident 48 had penile erosion ([pressure ulcer] a gradual wearing away or eating away of a surface layer of tissue) upon admission, measuring of 4 centimeter (cm a unit of measure of length)x2cmx0.5cm with red appearance. During a review of Resident 48's Order Summary Report, orders as of 2/19/2025, the Order Summary Report indicated a physician order dated 12/17/2024 to place a wound consult for evaluation and a physician order dated 2/6/2025 for an appointment with a urologist. During a review of Resident 48's Wound Physicians Progress Note, dated 12/24/2024, the Wound Physicians Progress Note indicated Resident 48 had an indwelling Foley catheter (a thin, flexible tube inserted into the bladder through the urethra, which stays in place to continuously drain urine into a collection bag). The Wound Physicians Progress Note indicated Resident 48 had penile erosion and a urology appointment was scheduled on 2/6/2025. The Wound Physicians Progress Note indicated the wound's measurement were 4 cmx2 cmx0.5 cm, exudate (a fluid that leaks out of blood vessels into nearby tissues, usually as a result of an injury or inflammation): serous (watery), minimal amount of exudate. During a review of Resident 48's Wound Physicians Progress Note, dated 12/31/2024, the Wound Physicians Progress Note indicated Resident 48's penile wound was due to the foley catheter, and Resident 48 had an appointment with a urologist on 2/6/2025. During a review of Resident 48's care plan for alteration (a change or modification made to something) in skin integrity, created on 12/17/2024, the care plan indicated, Resident 48 had skin erosion on the penile area, and the measurement upon admission was 4 cmx2 cmx0.5 cm, with moderate serous drainage. The care plan goal indicated Resident 48 would be free from infection. The care plan's approaches and plan included calling physician if treatment is ineffective and provide a wound consult. During a review of Resident 48's care plan for skin break down, initiated on 12/19/2024, the care plan indicated Resident 48 was high risk for further skin break down. The care plan approaches and interventions included notifying the physician if no noted progress towards healing. During a concurrent observation and interview on 2/19/2025 at 9:29 a.m., with Licensed Vocational Nurse (LVN) 4, in Resident 48's room, LVN 4 was changing the Resident 48's penile wound dressing. LVN 4 stated that the penile wound had drainage like and the wound had a split at the tip. During an interview on 2/19/2025 at 1:30 p.m., with LVN 4, LVN 4 stated that wound physician evaluated Resident 48 on 12/24/2024 and a week later 12/31/24 which the wound physician signed off from the consult and referred Resident 48 to a urologist. LVN 4 stated, she was present at Resident 48's bedside when the wound physician explained that Resident 48 might need a procedure to close the wound, based on the urologist's evaluation. LVN 4 stated that Resident 48 had a scheduled appointment on 2/6/2025 but missed the appointment with the urologist due to transportation issues. LVN 4 stated the next appointment was rescheduled for 3/27/2025, but LVN 4 stated she did not notify a physician that Resident 48 had missed his appointment with the urologist on 2/6/2025, assuming it was not urgent since the wound remained unchanged. During an interview on 2/19/2025 at 12:51 p.m., with the Director or Nursing (DON), the DON stated that Resident 48 was at high risk for infection, due to age, bowel incontinence (no voluntary control of bowel movements), poor skin turgor (the elasticity of skin, or its ability to change shape and return to normal), decreased mobility, and existing wounds. The DON stated that Resident 48's care plan identified high infection risk, making it unacceptable to delay the urologists consult appointment without notifying the physician that Resident 48 missed the appointment scheduled for 2/6/2025 . The DON stated that LVN 4 should have sought alternatives and notified the physician, as failing to do so did not meet the standard of practice. The DON stated that this failure could lead to infections. During the facility's policy and procedure (P&P) titled, Treatment nurse job description, not dated, the P&P indicated treatment nurse must initiate communication to physician and other disciplines regarding negative response to treatment administration or changes in resident's condition as per policy and nursing practices. During the facility's P&P titled, Quality of Care, Routine Resident Monitoring and Scope of Services, revised 1/2017, indicated the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. The P&P indicated the facility will provide care consistent with professional standards for residents to prevent pressure injuries.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided active range of motion ([AROM] movement at a given joint when the person moves voluntarily) to his left and right upper extremities (upper arm, forearm, wrist, hand and fingers and thumb) from 3/28/2022 through 7/11/2023. ` This deficient practice resulted in Resident 1 developing a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, leading to deformity and rigidity of joints) to his left hand, pain upon movement of his left hand, the inability to fully straighten the 1st, 3rd, 4th, and 5th fingers of his left hand or use his left hand as needed to complete his activities of daily living ([ADLs] task such as eating, bathing, dressing, grooming and toileting). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (bacterial infection of the skin), a fracture (a break) of the right toe, and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) of the right ankle and foot. A review of the facility's undated Resident Census (record of hospitalization s, room changes, and payer source changes), indicated Resident 1 remained in the facility since his admission on 2/12/2022 to present with no hospitalization s. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/12/2022, indicated Resident 1 was able to make independent decisions that were reasonable and consistent. The MDS indicated Resident 1 required extensive one-person physical assist for bed mobility, transfers, locomotion on the unit (how a resident moves between locations in his/her room and adjacent), dressing, toilet use and personal hygiene and limited one-person physical assist when bathing. The MDS indicated Resident 1 had no functional limitations in the ROM (the direction a joint can move to its full potential) to both of his arms. A review of the Resident 1's History and Physical (H&P), dated 2/9/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Nursing Admission Assessment (NAA), dated 2/12/2022, indicated Resident 1's joints (part of the body where two or more bones meet to allow movement) were normal and did not present with contractures. A review of Resident 1's Physical Therapy Evaluation and Plan of Treatment (PTEPC), dated 2/14/2022 indicated Resident 1 did not present with contractures. A review of Resident 1's undated Restorative Nursing (a nurse with special training, skills, and knowledge in rehabilitative techniques) Orders (RNO), indicated Resident 1 was to receive AROM to both his upper extremities, every day five times a week or as tolerated beginning 3/23/2022. A review of Resident 1's Occupational Discharge Summary Evaluation (ODSE), dated 3/26/2022, indicated the restorative nursing program's (RNP) goal was to facilitate Resident 1 to maintain his current level of performance and prevent decline. A review of Resident 1's Physician's Telephone Order (TO), dated 7/27/2022 indicated Resident 1 was to receive AROM to his bilateral (both) upper extremities (BUE) every day, five times a week or as tolerated, by the RNA. During an observation on 7/11/2023, at 3:10 p.m., Resident 1 was observed lying in bed and his left hand was observed closed in fist. During an interview on 7/11/2023, at 3:10 p.m., Resident 1 stated he was currently bedridden (weak and unable to get out of bed) and needed help to get dressed and to pick up items because he could not straighten his fingers or grasp things with his left hand. Resident 1 stated, when he was admitted to the facility in 2022, he did not have any problems with his left hand but sometime last year (2022) he could no longer straighten his fingers on his left hand without using his right hand to straighten his fingers. Resident 1 stated, he felt frustrated because he could not use his left hand anymore like he used to. Resident 1 stated, it was painful whenever he tried to straighten the fingers in his left hand and the staff does not help him exercise his hands. During a concurrent observation and interview on 7/12/2023, at 12 p.m., with Resident 1, in the facility's dining room, Resident 1's left hand was observed resting on top of the dining room table, Resident 1's fingers of the hand were noted to be bent in a ball and Resident 1 was observed using only his right hand to eat. Resident 1 stated, he eats slower because he could only use his right hand and was unable to use his left hand to grasp the utensils, steady his plate or assist in anyway. A review of Resident 1's MDS, date 5/17/2023, indicated Resident 1's functional limitation in ROM was for his upper extremities was 0 (indicating no decline). A review of Resident 1's Occupational Therapist Evaluation and Plan of Treatment (OTEPT), dated 7/12/2023, indicated Resident 1 had a left-hand contracture. The OTEPT indicated Resident 1's ROM assessment of his left upper extremity indicated his left hand was impaired (moderate flexion [bent joint, cannot be straightened] with a contracture at the proximal interphalangeal ([PIP] finger joint) joint of the 3rd, 4th and 5th fingers of his left hand and a mild flexion contracture at PIP joint of the 1st finger of his left hand. A review of Resident 1's SBAR ([Situation Background Assessment Recommendation] a form of communication between members of a health care team, created after the concern was brought to the attention of the facility), dated 7/12/2023, indicated Resident 1's hand could not fully flex ([contract] to shorten, become reduced in size) and extend (to straighten out). The SBAR indicated Resident 1 was unable to grasp objects easily with his left hand and experienced pain upon exercising his left hand. The SBAR indicated Resident 1's physician was notified and an order for Hydrocodone -Acetaminophen (a narcotic [a drug or other substance that affects mood or behavior] used to relieve moderate to severe pain) 10-325 milligrams ([mg] a unit of measurement), by mouth, once a day 30 minutes prior to RNA exercises. A review of Resident 1's Restorative Nursing Weekly Summaries (RNWS) indicated there was no documentation to show that Resident 1 received ROM therapy to his right and left hands, including his fingers, from 3/28/2023 through 7/11/2023. A review of Resident 1's Rehabilitation Screening Form, indicated the last screening was completed on 8/26/2022. A review of Resident 1's Joint Mobility Screening, indicated the last screening was completed on 5/18/2022. During an interview on 7/13/2023, at 9 a.m., the Director of Staff Development (DSD) stated, the RNA program falls under the direction of the nursing department. The DSD and the Director of Nursing (DON) were responsible for RNA skills training and ensuring RNA staff competencies were completed through a competency checklist. The DSD stated, the therapy department provides additional training to RNAs, but the facility does not maintain records of the RNAs competencies. During an interview on 7/13/2023, at 9:35 a.m., RNA 2 stated, she did not perform ROM exercises on any Residents' hands unless there was a specific order from the doctor or if the residents had a splint (an appliance made of different materials for the fixation [the action of making something firm or stable], union or protection of an injured part of the body) RNA 2 stated, Resident 1 had orders for AROM on his B (both) UEs but that did not include his hands. During an interview on 7/13/2023, at 9:57 a.m., RNA 1 stated, AROM exercises to the upper extremities meant for them (RNAs) to direct and observe the resident while they (the residents) exercised their shoulders, elbows, and forearms independently. RNA 1 stated, AROM did not include exercising of the hands, unless there was an order to that indicated specifically to exercise hands. RNA 1 stated, if there was a change in residents' ROM, they (RNAs) were instructed to inform the charge nurse and staff in the therapy department. During a concurrent record review and interview, on 7/13/2023 at 10:30 a.m., with the DSD, the Certified Nursing Assistant Skills, and Competency Validation (CV) for RNA 1, dated 9/1/2015, RNA 2, dated 7/22/2021, and RNA 3, dated 7/29/2019 were reviewed. During a concurrent record review and interview on 7/14/2023, at 11:46 a.m., with the Physical Therapy Regional Director (PTRD), Resident 1's Restorative Nursing Program Referral Care Plan (RNP-CP), dated 3/23/2022 was reviewed. The PTRD stated, the RNA-CP indicated Resident 1 was discharged from physical and occupational therapy on 3/23/2022 and was at risk for weakness to his BUEs. The PTRD stated the RNP-CP's goal was for Resident 1 to maintain ROM and strength to all of his extremities and orders on the RNP-CP for Resident 1 to receive AROM exercises to his BUEs, daily, five time per week or as tolerated. The PTRD stated AROM means Resident 1 would perform ROM exercises independently without physical assistance from the RNA, but the RNA would direct and observe Resident 1 for any pain, discomfort, or limitations as he (Resident 1) performed the ROM exercises. The PTRD stated, BUEs are defined as shoulders, arms, elbows, wrists, hands, and all fingers to both left and right side of the body. The PTRD stated, if AROM exercises were not performed as ordered, the RNAs might not observe a decline in the resident's function and the resident would be at risk for a decline in their ROM. During an interview on 7/14/2023, at 1:30 p.m., RNA 3 stated, during AROM exercises to resident's upper extremities he directs and observes as they (the resident) exercise their shoulders, elbows, and forearms. RNA 3 stated, AROM of the upper extremities does not include hands and fingers, unless there is an order from the physician that indicates to exercise the resident's hands and fingers. RNA 3 stated he received training from RNA 1 and sometimes a physical therapist would train him during resident hand off (when a resident is discharged from physical and/or occupational therapy and received by the RNP). During a concurrent record review and interview on 7/14/2023, at 4 p.m., with the Registered Occupational Therapist (ROT), Resident 1's Occupational Therapy Evaluation and Plan of Treatment (OTEPT), dated 2/14/2022 was reviewed. The ROT stated Resident 1's OTEPT indicated Resident 1's left hand's ROM was within functional limits ([WFL] within what is considered normal movement for that joint), meaning Resident 1 was able to use his left hand to pick up items and accomplish daily tasks at that time. The ROT stated, Resident 1's current OTEPT, dated 7/12/2023, indicated a moderate contracture (26-50% loss in ROM) to his 3rd, 4th, 5th PIP joint and a mild flexion contracture at his 1st finger PIP joint was noted. The ROT stated, she was the therapist who performed Resident 1's OT evaluation on 7/12/2023. The ROT stated, Resident 1 could not straighten the fingers on his left hand which demonstrated a decline in Resident 1's ROM in comparison to the OT evaluation on 7/14/2022. A review of the facility's job description (JD) for RNAs, dated 11/2014, indicated the RNA is delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties. The RNAs JD included following general duties and responsibilities, recording on flow sheets, notes and charts when applicable, reporting significant changes in the resident's condition to the licensed vocational nurse (LVN)/registered nurse (RN) as soon as practical, providing range of motion and general strengthening exercises, documenting daily and weekly on residents in the restorative program, reports, charts, and communicates to occupation therapy any observed problems or any changes in the residents condition, motivation level, mobility level and resident complaints of pain. A review of the facility's Policy and Procedure (P/P) titled, Limitations in Range of Motion and Mobility and Referrals for Therapy, revised 10/2017, indicated a resident who enters the facility without limited range of motion does not experience a reduction in range of motion unless the resident's clinical condition demonstrates that the reduction in range of motion is unavoidable. The facility will ensure that ongoing communication and caregiver training takes place between the Restorative Nursing Assistants (RNA) and the therapy department. Upon admission and quarterly, the appropriate therapy department will screen residents unless there is a physician's order upon admission for therapy evaluations. If the resident receives rehabilitation services and it is determined that the resident is to be referred for RNA services at the completion of the therapy, the appropriate referral form will be completed by the therapist and the therapy department will provide caregiver training to the RNA. The RNA and the therapist providing the training will both sign the appropriate form to document the training.

Based on interview and record review, the facility failed to ensure the licensed nurses notified a physician of the resident's vomiting episodes per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices resulted in Resident 1's continuous vomiting on [DATE], becoming unresponsive, and subsequently dying in the facility on [DATE] at 7:17 AM. Resident 1 died from complications of [CONDITION(S)] (blood infection) secondary to bilateral acute pneumonia (infection of the lungs) likely caused by aspiration (when something enters the airways by accident) of contaminated gastric contents.] Findings: During a review of Resident 1's Face Sheet (admission record), the Face Sheet indicated the facility initially admitted Resident 1 on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 had the capacity to express ideas and wants and had a clear understanding of others, and required an extensive assistance (resident involved in activity and staff provided one-person physical assist) from staff with activities of daily living (ADLs, tasks of everyday life, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet) including eating with one-person physical assist. During a record review of the care plan, Constipation, initiated [DATE], the care plan indicated that Resident 1 will be free from fecal impaction (large, hard, immobile mass of stool that gets stuck in the colon [large intestines] or rectum). An intervention implemented to reach the goal was to observe Resident 1 closely for signs and symptoms of fecal impaction such as: watery stool, straining (difficult for stool to pass through), distended abdomen (bloating and swelling in the belly area), vomiting, and fever. During a record review of the care plan, At Risk for Fluid Volume Deficit/Complications Related to Nausea/Vomiting, dated [DATE], the care plan indicated Resident 1's goal was to be free from signs and symptoms or complication related to nausea and vomiting. An intervention implemented to reach the goal was to monitor for persistent nausea/vomiting and report to the physician. During a record review of Resident 1's summary of physician orders, dated [DATE] through [DATE], the summary of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician further ordered to monitor the side effects of [MEDICATION(S)] every shift and that common side effects included drowsiness, [CONDITION(S)] (continued problems falling and staying asleep), dry mouth, nausea (urge to vomit), vomiting, tremor (involuntary shaking or movement), increased agitation (state of nervous excitement), and to notify the physician if noted. During a record review of Licensed Vocational Nurse 3's (LVN 3) licensed nurse progress notes dated [DATE], at 3:45 PM, LVN 3's progress note indicated that on [DATE], at approximately 3:30 PM, Resident 1 was noted to have tan colored vomitus (matter that was expelled from the stomach) on Resident 1's gown. LVN 3's note indicated, the previous charge nurse (LVN 2) also reported that Resident 1 vomited during the 7:00 AM- 3:00 PM shift on [DATE]. Further review indicated no documented evidence of physician or family notification of Resident 1's episodes of emesis. During a phone interview on [DATE], at 2:29 PM, with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated that on [DATE] at the end of the morning shift (7:00 AM through 3:00 PM), LVN 2 stated that Resident 1 vomited. CNA 2 stated she cleaned up Resident 1 and had to change the bed linen. CNA 2 stated the vomitus was brown and a large amount was all over the bed. During a phone interview on [DATE], at 3:25 PM, with CNA 4, CNA 4 stated that on [DATE] at 4:30 PM, during routine rounding (timely rounding to routinely meet resident's needs), CNA 4 noted that Resident 1 vomited a large amount, enough to cover the entire bed and the whole bed, requiring the bed linens to be changed. CNA 4 stated she notified LVN 3. CNA 4 stated, during the shift when she came back from break, CNA 5 reported to CNA 4 that Resident 1 vomited a smaller amount. CNA 4 stated she notified LVN 3 of the episode of vomiting reported by CNA 5. During an interview on [DATE], at 4:06 PM, with the physician (MD 1), MD 1 stated that he was not notified that Resident 1 vomited on [DATE] or on [DATE]. MD 1 stated that he should have been notified of the vomiting incident and any changes in resident condition. During a phone interview, on [DATE], at 4:00 AM, with Licensed Vocational Nurse 6 (LVN 6, Resident 1's assigned nurse for [DATE] 11:00 PM through [DATE] 7:00 AM), LVN 6 stated that there was no documented evidence that the physician was notified of Resident 1's episodes of vomiting. LVN 6 stated he received report (on [DATE] at around 11:00 PM) from LVN 3 that everything was fine with Resident 1. LVN 6 stated on [DATE] at 6:45 AM, a CNA prompted him and all the nurses to check Resident 1 because Resident 1 was unresponsive. LVN 6 immediately responded, attempted to check Resident 1's pulse (heartbeat per minute) and vital signs (respiratory rate, blood pressure [BP, force that moves blood in the body, and temperature) but was unsuccessful. LVN 6 stated cardiopulmonary resuscitation (CPR, lifesaving technique combining chest compressions and artificial ventilation [means of assisting or stimulating respiration] to help restore spontaneous blood circulation and breathing in a person who was in [CONDITION(S)] [sudden, unexpected loss of heart function, breathing, and consciousness]) was immediately started and 911 was called. LVN 6 stated he did not observe Resident 1 vomiting but observed a small amount of vomitus on Resident 1's gown. During an interview on [DATE], at 10:40 AM, with Registered Nurse 1 (RN 1), RN 1 stated Resident 1's vomiting should have been addressed by thoroughly assessing Resident 1 and notifying the physician and family. RN 1 stated there was no documented evidence Resident 1 was thoroughly assessed and that the physician was notified after the episodes of vomiting. During a record review of Resident 2's undated Face Sheet, the Face Sheet indicated the facility admitted Resident 2 on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 2's MDS dated [DATE], indicated Resident 2 had the capacity to express ideas and wants and had a clear comprehension and understanding of others. Resident 2 had clear speech and was able to hear. During a record review of the facility's census dated [DATE], the census indicated Resident 1 and Resident 2 were roommates. During a phone interview on [DATE], at 5:41 PM, with Resident 2, Resident 2 stated that Resident 1 was his roommate. Resident 2 stated on [DATE], the day before Resident 1's death, Resident 2 heard and saw Resident 1 vomit three to four times and recalls that two certified nurse assistants (could not verbalize which CNAs) cleaned up Resident 1. On the morning of [DATE], Resident 2 stated that Resident 1 was vomiting and choking. Resident 2 stated that upon hearing Resident 1 vomiting and choking, Resident 2 pressed the call light (device used in facilities to signal staff for assistance) to get help. Resident 2 stated that the staff did not respond right away. Resident 2 could not verbalize how long it took staff to respond. During a record review of the Resident 1's prehospital care report from the fire department in the county of Los Angeles, dated [DATE], the prehospital care report indicated paramedics arrived in the facility on [DATE] at 6:54 AM and the paramedics took over CPR; automated external defibrillator (AED, a portable electronic device that automatically diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's record from the paramedics indicated an assessment exam performed on [DATE] at 6:57 AM showed that Resident 1 had fixed and dilated pupils (pupils that do not respond to light or other stimuli). Resident 1 was unresponsive and had no blood pressure, no pulse, and no respirations. The paramedics medicated Resident 1 with [MEDICATION(S)] (medication give in emergencies to restore the heartbeat) at 7:02 AM, 7:07 AM, and at 7:14 AM. On [DATE] at 7:17 AM the paramedics halted resuscitation efforts and Resident 1 was pronounced dead. During a record review of Resident 1 certificate of death, dated [DATE], the death certificate indicated Resident 1's cause of death was acute cardiopulmonary arrest. During a record review of Resident 1's final autopsy (exam done after death to discover the cause of death) report, completed on [DATE] at 5:00 AM, the final autopsy report indicated that Resident 1died from complications of [CONDITION(S)] (blood infection) secondary to bilateral acute pneumonia (infection of the lungs) likely caused by aspiration of contaminated gastric contents. The autopsy indicated that agonal aspiration had occurred with formed food particles present in the upper airways. The autopsy indicated significant fecal impaction with 1,800 grams (a unit of weight) of fecal material in the sigmoid colon (portion of the large intestines before reaching the rectum) and rectum (last several inches of the large intestine leading to the anus, the opening to the outside of the body), likely causing toxic megacolon (life threatening condition characterized by extreme inflammation [localized reaction that produces redness, warmth, swelling and pain], and distention [swelling] of the colon), adding to the infectious nature of the death. The immediate cause of death was [CONDITION(S)] and acute pneumonia due to the above conditions. During a phone interview with RN 1 on [DATE] at 3:38 PM, RN 1 confirmed Resident 1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated from [DATE] through [DATE], there were 21 missed opportunities where the CNAs did not document the consistency, color, and characteristics of Resident 1's bowel movement, were noted on the following dates: [DATE] 10:39 AM [DATE] 12:01 PM [DATE] 2:54 PM [DATE] 6:53 AM [DATE] 10:47 AM [DATE] 6:36 AM [DATE] 10:00 AM [DATE] 1:30 PM [DATE] 1:31 PM [DATE] 12:55 PM [DATE] 6:53 AM [DATE] 9:25 AM [DATE] 6:53 AM [DATE] 9:50 AM [DATE] 9:35 AM [DATE] 6:47 AM [DATE] 12:54 PM [DATE] 10:10 PM [DATE] 5:10 PM [DATE] 10:14 PM [DATE] 9:55 PM RN 1 stated it was important to document the size, amount, consistency, color, frequency, and characteristics of the bowel movement because this information can be used to prevent serious complications like bowel obstruction (when something blocks the bowels). RN 1 also confirmed that Resident 1 had a care plan for constipation where an intervention indicated to observe closely for signs and symptoms of fecal impaction such as watery stool, straining, distended abdomen, vomiting, fever etc. RN 1 stated if Resident 1 were to experience any symptoms of fecal impaction, the physician must be notified. RN 1 also confirmed that Resident 1 had a care plan for nausea and vomiting where an intervention indicated to monitor for persistent nausea and vomiting and report to the physician. RN 1 stated that Resident 1's episodes of vomiting on [DATE] warranted a change of condition and physician notification. RN 1 stated Resident 1 should not have had anything by mouth until Resident 1 was thoroughly assessed and evaluated and that the physician determined that it was safe. During a record review of the change of condition policy, revised [DATE], the policy indicated that any significant changes in the residents' condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. Policy further stated that the physician was responsible for making the decisions for the resident to be treated at the facility or to be transferred to the acute hospital for treatment. During a record review of the Comprehensive Care Planning policy, revised [DATE], the policy indicated a care plan must address effective and resident centered care that meets professional standards for quality of care. The plan of care must include measurable objectives and time frames and describe the services that are to be furnished to attain or maintain the resident's highest practicable level of well-being. During a review of an undated charge nurse's job description, the job description indicated the primary purpose of the charge nurses' job was to provide direct nursing care to the residents and supervise the day-to-day nursing activities by certified nursing assistants. The charge nurse job description included the following general duties and responsibilities: perform resident assessments and develop, implement and evaluate care plans as necessary; and perform treatments-administer medications, and/or implement other nursing interventions as indicated by the resident care plan or as ordered by the physician. Notify doctor timely as needed.

Based on interview and record review, the facility failed to provide one of two sampled residents (Resident 1) with quality of care consistent with maintaining Resident 1's highest practicable physical well-being, by failing to: a. Thoroughly assess and evaluate Resident 1 after having episodes of vomiting (forcefully expelling the stomach's contents out of the mouth). b. Notify the physician when Resident 1 had episodes of vomiting in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] c. Stop Resident's 1 oral intake until the physician was notified and determined it was safe to restart oral intake after Resident 1's episodes of vomiting. d. Monitor Resident 1's stool for consistency, color, and characteristics. These deficient practices resulted in Resident 1's continued emesis on [DATE]; and at 6:45 AM, Resident 1 was found unresponsive and he subsequently expired in the facility, on [DATE] at 7:17 AM. Resident 1 died from complications of [CONDITION(S)] (blood infection) secondary to bilateral acute pneumonia (infection of the lungs) likely caused by aspiration (when something enters the airways by accident) of contaminated gastric contents.] Findings: During a record review of Resident 1's undated Face Sheet (admission record), the Face Sheet indicated the facility originally admitted Resident 1 on [DATE] and readmitted from the hospital on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated [DATE], the MDS indicated Resident 1 had the capacity to express ideas and wants and had a clear understanding of others. Resident 1 needed extensive assistance (resident involved in activity and staff provided one-person physical assist) with activities of daily living (ADLs, tasks of everyday life, dressing, getting into or out of a bed or chair, taking a bath or shower and using the toilet). The MDS indicated Resident 1 required extensive assistance when eating with one-person physical assist. During a record review of the care plan, Constipation, initiated [DATE], the care plan indicated that Resident 1 will be free from fecal impaction (large, hard, immobile mass of stool that gets stuck in the colon [large intestines] or rectum). An intervention implemented to reach the goal was to observe Resident 1 closely for signs and symptoms of fecal impaction such as: watery stool, straining (difficult for stool to pass through), distended abdomen (bloating and swelling in the belly area), vomiting, and fever. During a record review of the care plan, At Risk for Fluid Volume Deficit/Complications Related to Nausea/Vomiting, dated [DATE], the care plan indicated Resident 1's goal was to be free from signs and symptoms or complication related to nausea and vomiting. An intervention implemented to reach the goal was to monitor for persistent nausea/vomiting and report to the physician. During a record review of Resident 1's summary of physician orders, dated [DATE] through [DATE], the summary of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician further ordered to monitor the side effects of [MEDICATION(S)] every shift and that common side effects included drowsiness, [CONDITION(S)] (continued problems falling and staying asleep), dry mouth, nausea (urge to vomit), vomiting, tremor (involuntary shaking or movement), increased agitation (state of nervous excitement), and to notify the physician if noted. During a record review of Licensed Vocational Nurse 3's (LVN 3) licensed nurse progress notes dated [DATE], at 3:45 PM, LVN 3's progress note indicated that on [DATE], at approximately 3:30 PM, Resident 1 was noted to have tan colored vomitus (matter that was expelled from the stomach) on Resident 1's gown. LVN 3's note indicated, the previous charge nurse (LVN 2) also reported that Resident 1 vomited during the 7:00 AM- 3:00 PM shift on [DATE]. Further review indicated no documented evidence of physician or family notification of Resident 1's episodes of emesis. During a record review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. Routine oral medications at 5:00 PM: 1. [MEDICATION(S)], 50 mg one (1) tablet (tab) 2. [MEDICATION(S)] sodium (stool softener) 100 mg 1 tab 3. Lactobacillus acidophilus (supplement to aid digestion) 1 tab 4. [MEDICATION(S)] (vitamin C supplement) 500 mg 1 tab 5. [MEDICATION(S)] (blood thinner) two and one-half (2.5) mg 1 tab 6. Calcium-vitamin D (supplement) 500 mg-125 international units 1 tab b. Dinner at 5:30 PM: 1. Fifty percent (50%) of mechanical soft (texturally altered meal that allows for easier chewing and swallowing) 2. Four (4) ounces of no sugar added (NSA) Healthshake (nutritional supplement) 3. 120 milliliters (mL, a unit if measure) of Diabetic Advanced Control (AC) source (feeding formula to provide for added nutrients). c. Bedtime at 9:00 PM: 1. Snack 2. Atrovastatin (to lower cholesterol) 10 mg 1 tab 3. [MEDICATION(S)] sulfate (supplement) 325 mg 1 tab 4. [MEDICATION(S)] (to treat confusion related to Alzheimer's Disease, a brain disorder slowly destroying memory and thinking skills, and, eventually, the inability to carry out the simplest tasks) 5 mg 1 tab During a phone interview on [DATE], at 2:29 PM, with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated that on [DATE] at the end of the morning shift (7:00 AM through 3:00 PM), LVN 2 stated that Resident 1 vomited. CNA 2 stated she cleaned up Resident 1 and had to change the bed linen. CNA 2 stated the vomitus was brown and a large amount was all over the bed. During a phone interview on [DATE], at 3:25 PM, with CNA 4, CNA 4 stated that on [DATE] at 4:30 PM, during routine rounding (timely rounding to routinely meet resident's needs), CNA 4 noted that Resident 1 vomited a large amount, enough to cover the entire bed and the whole bed, requiring the bed linens to be changed. CNA 4 stated she notified LVN 3. CNA 4 stated, during the shift when she came back from break, CNA 5 reported to CNA 4 that Resident 1 vomited a smaller amount. CNA 4 stated she notified LVN 3 of the episode of vomiting reported by CNA 5. During an interview on [DATE], at 4:06 PM, with the physician (MD 1), MD 1 stated that he was not notified that Resident 1 vomited on [DATE] or on [DATE]. MD 1 stated that he should have been notified of the vomiting incident and any changes in resident condition. During a phone interview, on [DATE], at 4:00 AM, with Licensed Vocational Nurse 6 (LVN 6, Resident 1's assigned nurse for [DATE] 11:00 PM through [DATE] 7:00 AM), LVN 6 stated he did not receive verbal or written report and endorsement of a completed change of condition (COC) from the two (2) previous nurses (LVN 3 and 2) that Resident 1 had vomited multiple times on [DATE]. LVN 6 stated that there was no documented evidence that the physician was notified of Resident 1's episodes of vomiting. LVN 6 stated he received report (on [DATE] at around 11:00 PM) from LVN 3 that everything was fine with Resident 1. LVN 6 stated on [DATE] at 6:45 AM, a CNA prompted him and all the nurses to check Resident 1 because Resident 1 was unresponsive. LVN 6 immediately responded, attempted to check Resident 1's pulse (heartbeat per minute) and vital signs (respiratory rate, blood pressure [BP, force that moves blood in the body, and temperature) but was unsuccessful. LVN 6 stated cardiopulmonary resuscitation (CPR, lifesaving technique combining chest compressions and artificial ventilation [means of assisting or stimulating respiration] to help restore spontaneous blood circulation and breathing in a person who was in [CONDITION(S)] [sudden, unexpected loss of heart function, breathing, and consciousness]) was immediately started and 911 was called. LVN 6 stated he did not observe Resident 1 vomiting but observed a small amount of vomitus on Resident 1's gown. During an interview on [DATE], at 10:40 AM, with Registered Nurse 1 (RN 1), RN 1 stated Resident 1's vomiting should have been addressed by thoroughly assessing Resident 1 and notifying the physician and family. RN 1 stated there was no documented evidence Resident 1 was thoroughly assessed and that the physician was notified after the episodes of vomiting. During a record review of Resident 2's undated Face Sheet, the Face Sheet indicated the facility admitted Resident 2 on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident 2's MDS dated [DATE], indicated Resident 2 had the capacity to express ideas and wants and had a clear comprehension and understanding of others. Resident 2 had clear speech and was able to hear. During a record review of the facility's census dated [DATE], the census indicated Resident 1 and Resident 2 were roommates. During a phone interview on [DATE], at 5:41 PM, with Resident 2, Resident 2 stated that Resident 1 was his roommate. Resident 2 stated on [DATE], the day before Resident 1's death, Resident 2 heard and saw Resident 1 vomit three to four times and recalls that two certified nurse assistants (could not verbalize which CNAs) cleaned up Resident 1. On the morning of [DATE], Resident 2 stated that Resident 1 was vomiting and choking. Resident 2 stated that upon hearing Resident 1 vomiting and choking, Resident 2 pressed the call light (device used in facilities to signal staff for assistance) to get help. Resident 2 stated that the staff did not respond right away. Resident 2 could not verbalize how long it took staff to respond. During a record review of the Resident 1's prehospital care report from the fire department in the county of Los Angeles, dated [DATE], the prehospital care report indicated paramedics arrived in the facility on [DATE] at 6:54 AM and the paramedics took over CPR; automated external defibrillator (AED, a portable electronic device that automatically diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's record from the paramedics indicated an assessment exam performed on [DATE] at 6:57 AM showed that Resident 1 had fixed and dilated pupils (pupils that do not respond to light or other stimuli). Resident 1 was unresponsive and had no blood pressure, no pulse, and no respirations. The paramedics medicated Resident 1 with [MEDICATION(S)] (medication give in emergencies to restore the heartbeat) at 7:02 AM, 7:07 AM, and at 7:14 AM. On [DATE] at 7:17 AM the paramedics halted resuscitation efforts and Resident 1 was pronounced dead. During a record review of Resident 1 certificate of death, dated [DATE], the death certificate indicated Resident 1's cause of death was acute cardiopulmonary arrest. During a record review of Resident 1's final autopsy (exam done after death to discover the cause of death) report, completed on [DATE] at 5:00 AM, the final autopsy report indicated that Resident 1died from complications of [CONDITION(S)] (blood infection) secondary to bilateral acute pneumonia (infection of the lungs) likely caused by aspiration of contaminated gastric contents. The autopsy indicated that agonal aspiration had occurred with formed food particles present in the upper airways. The autopsy indicated significant fecal impaction with 1,800 grams (a unit of weight) of fecal material in the sigmoid colon (portion of the large intestines before reaching the rectum) and rectum (last several inches of the large intestine leading to the anus, the opening to the outside of the body), likely causing toxic megacolon (life threatening condition characterized by extreme inflammation [localized reaction that produces redness, warmth, swelling and pain], and distention [swelling] of the colon), adding to the infectious nature of the death. The immediate cause of death was [CONDITION(S)] and acute pneumonia due to the above conditions. During a phone interview with RN 1 on [DATE] at 3:38 PM, RN 1 confirmed Resident 1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 1 stated from [DATE] through [DATE], there were 21 missed opportunities where the CNAs did not document the consistency, color, and characteristics of Resident 1's bowel movement, were noted on the following dates: [DATE] 10:39 AM [DATE] 12:01 PM [DATE] 2:54 PM [DATE] 6:53 AM [DATE] 10:47 AM [DATE] 6:36 AM [DATE] 10:00 AM [DATE] 1:30 PM [DATE] 1:31 PM [DATE] 12:55 PM [DATE] 6:53 AM [DATE] 9:25 AM [DATE] 6:53 AM [DATE] 9:50 AM [DATE] 9:35 AM [DATE] 6:47 AM [DATE] 12:54 PM [DATE] 10:10 PM [DATE] 5:10 PM [DATE] 10:14 PM [DATE] 9:55 PM RN 1 stated it was important to document the size, amount, consistency, color, frequency, and characteristics of the bowel movement because this information can be used to prevent serious complications like bowel obstruction (when something blocks the bowels). RN 1 also confirmed that Resident 1 had a care plan for constipation where an intervention indicated to observe closely for signs and symptoms of fecal impaction such as watery stool, straining, distended abdomen, vomiting, fever etc. RN 1 stated if Resident 1 were to experience any symptoms of fecal impaction, the physician must be notified. RN 1 also confirmed that Resident 1 had a care plan for nausea and vomiting where an intervention indicated to monitor for persistent nausea and vomiting and report to the physician. RN 1 stated that Resident 1's episodes of vomiting on [DATE] warranted a change of condition and physician notification. RN 1 stated Resident 1 should not have had anything by mouth until Resident 1 was thoroughly assessed and evaluated and that the physician determined that it was safe. During a phone interview on [DATE], at 12:57 PM, with the director of nursing (DON), the DON stated she would withhold oral intake for a resident who had at least one episode of vomiting to assess for appropriateness of continued food consumption, as it was the standard of nursing practice. The DON stated a physician consultation and order would be needed prior to resuming Resident 1's oral intake after the episodes of vomiting. During a record review of the change of condition policy, revised [DATE], the policy indicated that any significant changes in the residents' condition be thoroughly assessed and evaluated with physician notification for early clinical management to avoid unnecessary readmissions to acute hospitals. Policy further stated that the physician was responsible for making the decisions for the resident to be treated at the facility or to be transferred to the acute hospital for treatment. During a record review of the Comprehensive Care Planning policy, revised [DATE], the policy indicated a care plan must address effective and resident centered care that meets professional standards for quality of care. The plan of care must include measurable objectives and time frames and describe the services that are to be furnished to attain or maintain the resident's highest practicable level of well-being. During a review of an undated charge nurse's job description, the job description indicated the primary purpose of the charge nurses' job was to provide direct nursing care to the residents and supervise the day-to-day nursing activities by certified nursing assistants. The charge nurse job description included the following general duties and responsibilities: perform resident assessments and develop, implement and evaluate care plans as necessary; and perform treatments-administer medications, and/or implement other nursing interventions as indicated by the resident care plan or as ordered by the physician. Notify doctor timely as needed.

Based on observation, interview, and record review, the facility failed to implement its policy, the Care Plan Conference (CPC) recommendations, and thoroughly investigate and protect two of three sampled residents (Residents 2 and 3) from Resident 1's alleged verbal and physical sexual abuse. On 9/11/18, Resident 1 asked Resident 2 to have sex with him, and on 9/13/18, Resident 1 was found in Resident 3's room with her adult brief and pants off, while Resident 1 was standing over Resident 3 and the room door was closed. As a result of the facility's system failure to implement its policies and protect residents from Resident 1's sexual abuse, Resident 2 and 3 were subjected to inappropriate sexual advances and sexual abuse and put other residents at risk for sexual abuse. On 9/25/18 at 6:18 p.m., an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared for abuse. The facility's administrator (ADM), Compliance Officer (CO), and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened. The facility submitted a Plan of Action (POA) for the correction of the IJ which included: 1. The ADM was in-serviced by the Corporate Compliance Officer (CCO) on 9/25/18, regarding policy on Abuse Reporting, Prevention and Investigation; the remaining department heads (DON, Minimum Data Set Nurse (MDS), Social Services Director (SSD), Director of Staff Development (DSD), Medical Records (MR), Dietary Supervisor (DS), and Business Office (BO)) will be in-service by the CCO by Wednesday 9/26/18 on the Abuse Reporting Policy. 2. The alleged perpetrator was transferred on 9/25/18 to a General Acute Care Hospital (GACH) for evaluation. 3. The facility's staff started interviews with residents on 9/25/18, completed by 9/26/18, to identify if any other abuse occurred with the residents. 4. Any abuse allegations identified will be reported to the Abuse Coordinator, will be investigated immediately and reported to appropriate agencies as per Abuse Reporting policy guidelines. 5. Residents with abuse allegations identified will be provided psychological support, primary physician and responsible party will be notified, psychiatrist will be notified to see and resident effected will be placed on monitoring. 6. In-service will be provided to the facility's staff on 9/26/18 regarding abuse reporting and prevention. 7. In the event Resident 1 is discharged from the GACH and readmitted , the facility will contract for a 24-hour security guard to watch the resident, until the resident can be transferred to a more suitable psychiatric facility. 8. The DON or designee will conduct clinical review of possible admission to the facility. Any patients that will be admitted , the DON will create a plan of care to address the main concern prior to entering the facility based on information provided. 9. In the event a future resident was admitted or a current resident exhibits newly identified behaviors the facility will do the following: a. One-on-one monitoring for at least 72-hours b. Follow changes of conditions (C[NAME]) procedures. c. Contact psychiatrist, physician, and responsible party. d. Transfer resident to the GACH for evaluation or Contact 5151 (72 hours hold). e. Inform the GACH, responsible party and MD, that facility will not be readmitting the resident. On 9/26/18 at 4:47 p.m., the ADM, CCO and DON were notified that the IJ was lifted, after the team verified that the POA was followed and implemented. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was originally admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of a History and Physical (H/P), dated 9/14/18, indicated Resident 1 had the capacity to understand and to make decisions. A review of a Situation Background Assessment Reevaluation (SBAR), dated 9/11/18, indicated the need for Resident 1 to have a psychological evaluation (assessment of an individual's behavior, personality, mood, and cognitive abilities) due to the resident asking Resident 2 to have sex. A review of Resident 2's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of the facility's document tiled, Change of Condition (C[NAME]), for the month of 9/2018 indicated that Resident 1 was on behavior monitoring. According to the C[NAME], dated 9/11/18, indicated Resident 1 was exhibiting sexual behavior of asking other residents to have sex and on 9/16/18 Resident 1 was monitored for inappropriate sexual behavior towards other residents and staff. A review of Resident 2's Minimum Data Set (MDS), a care screening and assessment tool, dated 9/7/18, indicated a Brief Interview for Mental Status (BIMS) score of 14 (13-15 cognitively intact), which indicated that Resident 2 had no problems remembering or with cognition (thought process). The MDS indicated Resident 2 required supervision assistance of a two-person physical assist for bed mobility and a one-person physical assist for personal hygiene. A review of a care plan titled, Behavior, dated 9/11/18 indicated that Resident 1 had alteration in behavior manifested by pacing back and forth, going into residents' room and closing the door, asking to have sex with residents and staff. The care plan indicated that the goal was for Resident 1 to not manifest such behaviors. The staff's interventions included behavioral management and identifying the reason for the behavior and provide the appropriate interventions. A review of the CPC meeting notes, dated 9/11/18, indicated that the SSD and ADM, met with Resident 1's family to discuss the resident's inappropriate sexual behavior. The Interdisciplinary Team ((IDT) coordinated group of experts from several different fields who work together toward a common business goal) note indicated that the facility interventions included placing Resident 1 on one-to-one monitoring. A review of the CPC meeting notes, dated 9/14/18 indicated that the SSD and the ADM discussed with Resident 1's family the incident that occurred on 9/13/18 at 6 p.m., indicating that Resident 1 walked into Resident 3's room, closed the door and displayed inappropriate sexual behavior. Resident 1's physician (Physician 1) was at the conference and recommended Resident 1 to be sent out for further psychiatric evaluation with the family consent. A review of the untimed SSD progress notes, dated 9/11/18, indicated that Resident 2 was offered a room changed after Resident 1 approached and asked him to have sex. The progress note indicated that Resident 2 informed Licensed Vocational Nurse 1 (LVN 1) of Resident's 1 proposal of sex. On 9/25/18 at 12:47 p.m., during an observation and interview, Resident 1 was in the smoking patio area with other residents. Resident 1 stated that on 9/13/18 Resident 3 called him to go to her room. At 3:18 p.m., on 9/25/18, during an interview, the SSD stated that the DON 2 notified her of the incident that happened on 9/11/18 between Resident's 1 and 2, during the stand-up meeting, and 9/14/18 DON 2 made her aware of the second incident that occurred on 9/13/18, between Resident's 1 and 3. The SSD stated that Resident 3 was unable to verbalize what happened due to her confusion during the interview. A review of Resident 3's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE]. Resident 3's [DIAGNOSES REDACTED]. A review of a IDT note, dated 9/14/18 and timed at 8:30 a.m., indicated Resident 3 was confused and disoriented upon admission on 9/11/18. On 9/25/18 at 3:39 p.m., during an interview, Resident 1 stated that whatever happened in the room between him and Resident 3 was of No body's concern. A review of an SBAR, dated 9/13/18 and timed at 7 p.m., indicated Resident 1 was found unsupervised with the door closed in Resident 3's room. According to the SBAR, Resident 3 had no pants or adult brief on. A review of a Licensed Nurses Progress note, dated 9/13/18 and timed at 10 p.m., indicated that Resident 1 was found by CNA 1 in Resident 3's room with the door closed. The progress note indicated Resident 3 had her briefs and pants down and had a white milky discharge from the vaginal area upon assessment. A review of the physician's orders [REDACTED].>On 9/25/18 at 4:21 p.m., during an interview, Certified Nurse Assistant 2 (CNA 2) stated that other staff members have seen Resident 1 masturbating (stimulate one's own genitals for sexual pleasure). CNA 2 stated that Resident 1 had demanded from his roommate (Resident 2) to have sex with him while standing over him. CNA 2 stated that she was present while LVN 1 examined Resident 3. CNA 2 stated that Resident 3 had white color discharge in her adult brief and that LVN 1 refused to send the resident to the GACH for an exam. On 9/25/18 at 4:42 p.m., during an interview, Resident 2 stated that on 9/11/18 Resident 1 approached him in two separate occasions asking him if he wanted to have sex. Resident 2 stated that he was afraid of falling asleep, because of Resident 1 possibly doing something to him while sleeping. Resident 2 stated that he heard Resident 1 was arguing with someone on 9/13/18 about sexually penetrating but did not remember who or with whom Resident 1 was talking. At 7:19 p.m., on 9/25/18, during concurrent interview and record review, LVN 1 stated that on 9/13/18, during Resident 3's body assessment, the resident had white milky discharge on the vaginal area. LVN 1 stated that Resident 1 was placed on 1:1 on 9/11/18, but they did not have a specific staff monitoring him. On 9/25/18 at 8:03 p.m., during a telephone interview, Physician 2 stated he was called on 9/13/18 and notified about Resident 1's sexual behavior, but was not informed that Resident 1 was found in Resident 3's room with the door closed. Physician 2 stated that Resident 3 having her adult brief off required an immediate transfer to the GACH for a possible sexual assault exam (package of items used by medical personnel for gathering and preserving evidence of sexual assault). On 9/26/18 at 10:35 a.m., during an interview, DON 2 stated that LVN 1 notified her on 9/13/18 of Resident 1 found in Resident 3's room with the door closed. DON 2 stated that the ADM was informed of the sexual abuse and that he would take care of the investigation. DON 2 stated that the policy of the facility of an sexual assault, was to send a resident to the GACH for evaluation for possible assault. On 9/26/18 at 1:45 p.m., during a telephone interview in the presence of the ADM and the CCO, Physician 1 stated that he was called at night on 9/13/18 and was notified that Resident 1 was found in Resident 3's room, but no harm was done. Physician 1 stated that if he would had been informed that Resident 3 had her pants and adult brief off, he would had sent the resident to the GACH for a sexual assault exam. Physician 1 stated that LVN 1 also did not informed him that Resident 3 had white milky discharge upon the vaginal area assessment. On 9/26/18 at 3:41 p.m., during an interview, CNA 1 stated that on 9/13/18 she left Resident 3's room door open to go feed another resident. CNA 1 stated she returned after 45 minutes to check on Resident 3 and noted the room door closed. CNA 1 stated that upon opening the door, she observed Resident 3 with her pants and adult brief pulled down and on the floor and Resident 1 was trying to exit the room quickly. CNA 1 stated that she notified LVN 1 immediately. A review of the facility's policy titled, Abuse Reporting and Prevention, revised 8/2018, indicated that the facility would provide a safe environment for residents as indicated by the situation. If a suspected abuser is another resident, the facility should separate the residents so they do not interact with each, notify the residents' attending physician regarding the alleged incident assessment findings.

Based on interview and record review the facility failed to implement the plan of care to monitor stool consistency and follow the bowel-training program (the program involves trying to go to the bathroom at the same time every day in an attempt to help train your body to have regular bowel movements) for one of four-sampled resident (Resident 1). Resident 1 was assessed at risk for constipation (bowel movements that are hard to pass). (Cross Reference F 726). This deficient practice resulted in a delay of care, which resulted in Resident 1's transfer to a General Acute Care Hospital (GACH) and expiring of fecal impaction (hardened stool that's stuck in the rectum or lower colon due to chronic constipation) and bowel obstruction (condition in which digested food is prevented from passing through the bowel). Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS) a standardized care screening and assessment tool, dated 3/21/18, indicated a Brief Interview for Mental Status (BIMS) score of 14 (13-15 = intact cognitive skills (thought process)) with no memory problems. The MDS indicated Resident 1 required an extensive assistance of a one-person physical assist for toilet use and was occasionally incontinent of bowel and bladder (involuntary control of urination or defecation (passing bowel movement)). The MDS indicated Resident 1 was on a bowel toileting program. A review of Resident 1's History and Physical (H/P), dated 12/11/17 indicated constipation as one of the residents' diagnosis. A review of Resident 1's care plan titled, Bowel Function, re-evaluated on 3/2018, indicated Resident 1 would have a bowel movement at least every three days for 90 days. The staff approach plan included to monitor Resident 1's bowel movements frequency, consistency, and amount. A review of Resident 1's care plan titled, Bowel and Bladder Toileting, re-evaluated on 3/2018 indicated that the resident would have less than two episodes of incontinence (involuntary control of urination and defecation) daily till next review 6/2018. The approach plan included for staff to start Resident 1 on a scheduled retraining program for two weeks, re-evaluate and continue program for seven (7) days, and then 14 days individualized training and re-evaluate. A record review of the document titled, Nursing Daily Flow Sheet (NDFS), did not indicated evidence that the facility staff was documenting Resident 1's stool consistency, amount, and frequency in accordance with the plan of care for the month of 3/2018. The NDFS Record dated 3/2018 indicated Resident 1 had 52 stool smears during the review period of 3/1/18 through 3/30/18. On 4/3/18 at 10:44 a.m., during a telephone interview, CNA 2 stated that on 3/30/18, Resident 1 was observed uncomfortable not wanting to get out from bed, making faces and his abdomen very distended because of being constipated for many days. CNA 2 stated on 3/30/18 that the Director of Nursing (DON) gave Resident 1 water, tea, an enema, and was getting Resident 1 up and down from the bed. CNA 2 stated that the DON appeared concerned about Resident 1's constipation. CNA 2 stated that the DON mention that Resident 1 was being sent to the GACH at 9 a.m., but six hours later at 3 p.m., Resident 1 was still at the facility. CNA 2 stated that Resident 1 was uncomfortable and had no BM. A review of a SBAR (situation, background, assessment and recommendations (internal communication)) form, dated 3/30/18 and timed at 9:30 a.m., indicated Resident 1 had abdominal distention with pain, decreased appetite and fluid intake, and constipation that the resident was unable to remember the last time he had a bowel movement. A review of GACH's document titled, Death Summary, indicated that Resident 1's final [DIAGNOSES REDACTED]. On 4/3/18 at 12:18 p.m., during an interview and record review, Licensed Vocational Nurse 1 (LVN 1) stated that on 3/30/18 at 8:30 a.m., Resident 1 complained of abdominal pain of 6 out of 10 (10 being the worst) on a pain scale. LVN 1 stated that upon assessment of Resident 1's abdomen, there was no bowel sounds (movement of the stomach and intestine contents downwards that cause gurgling sounds), and the resident's right side of the abdomen was hard. LVN 1 stated Resident 1 was grimacing upon palpation of the abdomen and was saying ouch, when she touched his abdomen. LVN 1 stated that Resident 1's stomach was normally flat and having a distended abdomen was considered a change in condition (C[NAME]) LVN 1 stated the physician should had been notified of Resident 1's C[NAME] and no bowel sounds. LVN 1 stated that the facility's staff taking care of Resident 1's diaper change did not informed her that Resident 1 was smearing the diaper. LVN 1 stated that smears of stool were not considered BMs. On 4/3/18 at 2 p.m., during an interview and record review, the DON stated that she was called on 3/30/18 to Resident 1's room to assess his abdomen distention. The DON stated, after the review of Resident 1's Nursing Daily Flow Sheet (NDFS) that a normal BM was soft and, smears of stool were not considered a regular BM. The DON stated that at 2 p.m., on 3/30/18, the physician was notified that Resident 1 had no bowel sounds and had a distended abdomen. On 5/8/18 at 8:45 a.m., during a concurrent interview and record review, LVN 2 stated that Resident 1 was in a bowel and bladder training program since (YEAR) and the Interdisciplinary Team (IDT) decided for Resident 1 to continue on the program. LVN 2 stated that residents' in the training program are encouraged to go to the bathroom every two hours by the facility staff. On 6/5/18 at 3:15 p.m., during a concurrent interview and record review, the DON stated that on 3/30/18, she initially assessed Resident 1's bowel sounds at 9:30 a.m., and a second time at 2 p.m. The DON stated that there was no documentation on Resident 1's clinical record of the bowel sounds assessments she performed. The DON stated that Resident 1 should had been assessed four (4) hours after her initial assessment. The DON stated that LVN 1 was in charge of assessing Resident 1. A review of the facility's policy and procedures titled, Bowel and Bladder Retraining Program, revised 1/2017 indicated that the resident should be encouraged to toilet based in the resident's needs and history such as every 2-3 hours, upon walking in the morning, prior to meals, after nap, before activities, or during the night. The policy indicated that staff would document time for scheduled toileting on the care plan and evaluate effectiveness for any changes in the retraining program. Based on an accurate assessment, a comprehensive care plan with consistent implementation and monitoring, the facility will provide treatment and services to maintain the resident's highest practicable level of functioning. A review of the facility's care plan titled, Comprehensive Care Plan, revised 1/2017, indicated that the assessment process must include direct observation and communication with the resident, as well as licensed and non-licensed direct care staff members on all shifts. The plan of care must include measurable objectives and periods and describe the services that are to be furnished to attain or maintain the resident's highest practicable level of wellbeing.

Based on interview and record review, the facility failed to follow its policy and a resident's care plan for one of four sampled residents (Resident 1). Resident 1, who had a [DIAGNOSES REDACTED]. These deficient practices resulted in Resident 1 being transferred to a general acute care hospital (GACH) for abdominal pain with distention. Resident 1 was diagnosed with [REDACTED]. Resident 1 expired 20 hours after the transfer to GACH on [DATE]. Findings: A review of Resident 1's Face Sheet (Admission Record) indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a standardized care screening and assessment tool, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 14 (,[DATE] = intact cognitive skills (thought process)) with no memory problems. The MDS indicated Resident 1 required an extensive assistance of a one-person physical assist for toilet use and was occasionally incontinent of bowel and bladder (involuntary control of urination and defecation (passing bowel movement)). The MDS indicated Resident 1 was on a bowel toileting program (the program involves trying to go to the bathroom at the same time every day in an attempt to help train your body to have regular bowel movements). A review of Resident 1's History and Physical (H/P), dated [DATE], indicated constipation was one of the residents' diagnoses. A review of Resident 1's care plan titled, Bowel Function, re-evaluated on ,[DATE], indicated Resident 1 would have a bowel movement at least every three days for 90 days. The staff approach plan included to monitor Resident 1's bowel movements frequency, consistency, and amount. On [DATE] at 10:30 a.m., during a telephone interview, Certified Nurse Assistant 1 (CNA 1) stated that Resident 1 had bowel movements (BM) after 2 p.m., every day. CNA 1 stated that the stool consistency was dark brown in color, but only smears (mark or streak of a greasy or sticky substance) of stool was observed on the resident's brief (diaper). On [DATE] at 10:44 a.m., during a telephone interview, CNA 2 stated that on [DATE], Resident 1 was observed uncomfortable not wanting to get out from bed, making faces and his abdomen very distended because of being constipated for many days. CNA 2 stated on [DATE] that the Director of Nursing (DON) gave Resident 1 water, tea, an enema, and was getting Resident 1 up and down from the bed. CNA 2 stated that the DON appeared concerned about Resident 1's constipation. CNA 2 stated that the DON mention that Resident 1 was being sent to the GACH at 9 a.m., but six hours later at 3 p.m., Resident 1 was still at the facility. CNA 2 stated that Resident 1 was uncomfortable and had no BM. On [DATE] at 11:40 a.m., during a telephone interview, Restorative Nurse Assistant 1 (RNA 1) stated that on [DATE] she observed a brown smear in Resident 1's diaper. RNA 1 stated that she did not notified the charge nurse, because she considered a smear to be a BM. On [DATE] at 12:18 p.m., during an interview and record review, Licensed Vocational Nurse 1 (LVN 1) stated that on [DATE] at 8:30 a.m., Resident 1 complained of abdominal pain of 6 out of 10 (10 being the worst) on a pain scale. LVN 1 stated that upon assessment of Resident 1's abdomen, there was no bowel sounds (movement of the stomach and intestine contents downwards that cause gurgling sounds), and the resident's right side of the abdomen was hard. LVN 1 stated Resident 1 was grimacing upon palpation of the abdomen and was saying ouch, when she touched his abdomen. LVN 1 stated that Resident 1's stomach was normally flat and having a distended abdomen was considered a change in condition (C[NAME]) LVN 1 stated the physician should had been notified of Resident 1's C[NAME] and no bowel sounds. LVN 1 stated that the facility's staff taking care of Resident 1's diaper change did not informed her that Resident 1 was smearing the diaper. LVN 1 stated that smears of stool were not considered BMs. A review of the Licensed Nurses Progress Notes, dated [DATE] indicated the following events: At 8:30 a.m., Resident 1 complained of abdominal pain; upon assessment, abdominal distention with discomfort was observed. Resident 1 informed the staff that the last BM was several days prior and he was unable to urinate. The note indicated the physician was notified and gave orders to transfer Resident 1 to the GACH and to perform a straight in-and-out catheterization (thin hollow medical tube that can be inserted in different parts of the body). At 9:30 a.m., Resident 1 was encourage to increase fluid intake, ambulate with staff, and MOM (Milk of Magnesium (laxative)) was given. At 10 a.m., a message was left for the physician regarding Resident 1 refusing transfer to a GACH. At 2 p.m., Resident 1's abdomen was distended with no bowel sounds upon assessment and no bowel movement. At 5:30 p.m., the physician was called for a KUB (plain film of the abdomen, providing information about the abdominal organs such as the kidneys, ureters, and bladder (KUB)). At 6 p.m., the physician called with the results of the KUB with orders for an enema (procedure in which liquid is instilled into the rectum, typically to expel its contents) now and repeat in two hours if needed. The KUB completed on [DATE] and timed at 6:45 p.m., indicated Resident 1 had a marked colonic dilation consistent with ileus (inability of the bowel to contract normally and move waste out of the body) or obstruction (blockage). The KUB report indicated that there was a very large amount of stool (human waste) in the colon and rectum. The KUB report, also indicated a follow-up was advised. At 6:34 p.m., an enema was administered. At 6:45 p.m., Resident 1 observed pale with labored breathing, oxygen saturation on room air was 88 percent (%), (normal reference range (NRR) ,[DATE]% for [MEDICAL CONDITION] patients) the abdomen was distended with no bowel sounds. At 7:40 p.m., Resident 1 was transferred to the GACH via an ambulance 911 (emergency services). On [DATE] at 2 p.m., during an interview and record review, the DON stated that she was called on [DATE] to Resident 1's room to assess his abdomen distention. The DON stated, after the review of Resident 1's Nursing Daily Flow Sheet (NDFS) that a normal BM was soft and, smears of stool were not considered a regular BM. The DON stated that at 2 p.m., on [DATE], the physician was notified that Resident 1 had no bowel sounds and had a distended abdomen. A review of the ,[DATE] Medication Administration Record [REDACTED]½ hours after the initial order). The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of the physician's orders [REDACTED]. On [DATE] at 2:20 p.m., during a concurrent interview and record review, the DON stated that Resident 1's transfer to the GACH should had been considered earlier than 6:30 p.m., since Resident 1 had no bowel sounds present and was complaining of pain and abdominal distention. The DON stated if she would had assessed Resident 1's bowel sounds in the morning of [DATE] she could have notified the physician earlier. On [DATE] at 2:30 p.m., during an interview, Registered Nurse 1 (RN 1) stated that on [DATE] at 6:30 p.m., an enema was attempted to be administered to Resident 1, but was unsuccessful. RN 1 stated that Resident 1 appeared pale in color and his abdomen remained distended during the attempted enema. RN 1 stated that 911 was called to transfer Resident 1 due to his abdomen been firm and the enema tip could not been be inserted for administration. On [DATE] at 3:42 p.m., during a telephone interview, CNA 5 stated that redness around Resident 1's anal area was observed during diaper change and it was not reported to the charge nurse. CNA 5 stated that Resident 1 did not have daily BMs just a smear of stool in the diaper, never formed. CNA 5 stated not remembered the day she observed the redness. A review of a SBAR (situation, background, assessment and recommendations (internal communication)) form, dated [DATE] and timed at 9:30 a.m., indicated Resident 1 had abdominal distention with pain, decreased appetite and fluid intake, and constipation that the resident was unable to remember the last time he had a bowel movement. On [DATE] at 5:37 p.m., during a telephone interview, Social Services 1 (SS1-GACH) stated that Assistant Administrator (AADM) called the GACH to follow-up with Resident 1's status and reported to SS1 that the facility was aware that Resident 1 did not have a BM for several days. A review of the paramedic run-sheet titled, Prehospital Care Report Summary (PCRS), dated [DATE] and timed at 7:18 p.m., indicated the facility's staff called 911 at 7:08 p.m., and they arrived at 7:17 p.m. According to the PCRS Resident 1 had distended abdomen and ridged asides (fluid accumulation within the abdominal cavity) upon transfer to the GACH at 7:30 p.m., on [DATE]. A review of the GACH's Emergency/Urgent Care sheet, dated [DATE] and timed at 8:15 p.m., indicated Resident 1 arrived to the Emergency Department (ED) chronically ill, cachectic (marked weight loss and muscle loss), unable to answer question, staring blank in the ceiling, with low blood pressure, and in respiratory distress (unable to breath). The ED sheet indicated Resident 1's blood pressure was ,[DATE] (Normal Reference Range (NRR) is ,[DATE] to ,[DATE]), heart rate 92 beats per minute (NRR is ,[DATE] BpM), respiratory rate of 24 breaths per minute (NRR is 12 to 18 BpM). The ED indicated Resident 1's x-ray taken upon arrival indicated Resident 1 had a distended colon with stool, the Computed Tomography ((CT-scan) x-ray test that produce image of the body) showed the entire colon was severely distended with impaction. According to the ED note, manual disimpaction (removing stool with hands) was unsuccessful. Resident 1 was treated for [REDACTED]. A review of the GACH consultation dated, [DATE] indicated clearance of the stool was attempted using a large channel scope and copious (excessive) amounts of stool was encounter that was not able to be irrigated or removed. The consultation note indicated a cecostomy tube (administer an enema to quickly and completely empty the large intestines through the anus) was attempted with [MEDICATION NAME] enema (medication to treat constipation) and was unsuccessful. A review of the GACH's H/P, dated [DATE] indicated Resident 1 had history of chronic constipation had markedly distended and stony hard abdomen, no bowel sounds and mottled (patchy) bilateral lower extremities. A review of Resident 1's CT-scan results, dated [DATE] and timed at 10:06 p.m., indicated that Resident 1 had a massive distention of the colon (large intestine) filled with feces (stool); massive rectal fecal impaction combined with generalized colonic dysmotility (condition in which muscles of the digestive system become impaired); severe anasarca (tissue swelling); distal sigmoid (hollow tube approximately 2.5 inches (7 centimeters-cm) in diameter) distended measuring 14 cm in diameter, extending to the anus; small bowels fluid-filled; and the pancreas (large gland behind the stomach that secretes digestive enzymes) compressed by the enlarged colon. A review of GACH's document titled, Death Summary, dated [DATE] indicated that Resident 1's final [DIAGNOSES REDACTED]. On [DATE] at 2 p.m., during a telephone interview, Physician 2 (GACH physician) stated that Resident 1 arrived to the GACH in bad condition with his abdomen distended and stony hard. Physician 2 stated that Resident 1's lungs were being pushed by the fecal impaction. Physician 2 stated that multiple healthcare providers attempted to insert a gastrostomy tube (([DEVICE]) tube inserted through the abdomen that delivers nutrition directly to the stomach) perform a colonoscopy (examination of the large bowel and the distal part of the small bowel with a camera), but all attempts were unsuccessful due to the hard stool. On [DATE] at 2:30 p.m., during a telephone interview, Physician 1 ((Skill Nursing Facility) SNF's physician) stated Resident 1's constipation was a problem, and stated that an enema was ordered due to Resident 1's bowel sounds not being present. Physician 1 stated that he did not think Resident 1 needed to be sent to GACH via 911. Physician 1 stated, A review of a written declaration by Physician 3 (Skilled Nursing Facility (SNF)) and provided by the facility's AADM and acknowledge by Physicians 1 and 4 (SNF), dated [DATE] and [DATE] indicated that acute colon distention and toxic megacolon (abnormal distention of the colon), accompanied by abdominal distention, abdominal pain, or shock) can develop with little warning in frail, elderly patients or with no warnings. Physician 3 stated that Resident 1 fecal impaction could had been foreseen or predicted. A review of the online article provided by Physician 3, dated [DATE], indicated that toxic megacolon is rare and it can develop within a few days and be life threatening . When toxic megacolon occurs, the colon is unable to remove gas or feces from the body eventually causing rupture of the large intestine. Rupture of the intestine can cause serious infection and death .toxic megacolon symptoms include abdominal distention, pain and tenderness, rapid heart rate and shock .toxic megacolon is life threatening and immediate medical attention should be provided if symptoms develop .if toxic megacolon is suspected, the physician should check for tender abdomen and bowel sounds using an stethoscope (medical instrument for listening to the action of someone's body sounds) .treatment for [REDACTED]. https:www.healthline.com/health/toxic-megacolon On [DATE] at 10:45 a.m., during a telephone interview, RN 2 from the GACH, stated that upon Resident 1's arrival to the ED he had to be intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) because of shortness of breath (SOB) and low blood pressure. RN 2 stated that Resident 1 arrived with severe abdominal distention from his nipple line to his hips, round like a ball and hard as a rock. On [DATE] at 11:23 a.m., during a telephone interview, the DON stated that Resident 1 was on a toilet program, but was unable to locate the forms indicating the times the resident was taken to the bathroom. A review of Resident 1's death certificate, dated [DATE], indicated the immediate cause of death as septic shock (severe infection), peritonitis (inflammation of the membrane lining the abdominal wall and covering the abdominal organs), bowel obstruction, and fecal impaction contributing to the death. A review of the facility's undated RN job description indicated that the primary job of the RN was to provide direct nursing care to the residents, supervise the day-to-day nursing activities performed by CNA, and make independent decisions when the circumstances warrant for action. A review of the facility's policy titled, Bowel Disorders Clinical Protocol, revised ,[DATE], indicated that the facility's staff should assess for the presence of fecal impaction, conduct abdominal assessment, check for localized tenderness, and listen for bowel sounds. The policy also indicated the physician and staff would monitor resident's response to interventions and progress of distress, frequency, consistency of bowel movement and duration of pain.

Based on interview and record review, the facility failed to arrange a psychiatric consultation as prescribed by the physician for one of three sampled residents (Resident 1). Cross reference to F323. This deficient practice resulted in Resident 1 not receiving an evaluation and treatment to manage problematic behaviors, such as delusions (a type of serious mental illness in which a person cannot tell what is real from what is imagined). On 10/24/15, Resident 1 left the facility's premises with a false belief that her son was waiting across the street. Due to Resident 1's impaired safety awareness, Resident 1 left the facility unsupervised, ran crossed the street and was hit by a car. Findings: A review of Resident 1's admission record indicated that Resident 1 was initially admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. On 10/27/15 at 12:15 p.m., during a telephone interview, Resident 1's family member (FM 1) stated that Resident 1 was admitted to the facility under hospice care (a program that helps people who are dying to have peace, comfort, and dignity). FM 1 stated that Resident 1 had dementia and she sees and imagines things. According to FM 1, Resident 1's condition had not advanced drastically so she was discharged from hospice care. During the interview, FM 1 stated a nurse from the facility called him on 10/24/15, at approximately 10 p.m., and stated the nurse sounded very distraught and told him that a car bumped Resident 1 when she crossed the street. FM 1 stated that the nurse had explained to him that Resident 1 was saying that she was going to meet him across the street. FM 1 stated that he had not arranged to meet with Resident 1 across the street. FM 1 stated, She's (Resident 1) imagining things and they know that. FM 1 stated, The facility's staff knew that Resident 1 says weird stuff like she bought the building across the street (from the facility). FM 1 stated, She (Resident 1) was supposed to have a psych (psychiatric) consult, but they never did anything. A review of a licensed nurses progress note, dated 7/5/15 (7 a.m. to 3 p.m. shift) indicated Resident 1 displayed periods of confusion and disorientation. Per the nurses' note, Resident 1 gets easily irritated and preferred to be left alone. A review Resident 1's Medication Administration Records (MARs), for the months of September and October 2015, indicated Resident was not receiving any antipsychotic/psychotropic medications (used for treatment of [REDACTED]. A review of Resident 1's social work progress note, dated 8/12/15, and timed at 10:30 a.m., indicated Resident 1 had become more confused and disoriented. The social service designee (SSD) documented, Resident (Resident 1) confused again this morning. She says she bought the building across the street. According to the SSD's note, Resident 1 stated, I am going across the street to take a shower and I will be back. A review of the licensed nurse weekly summary, dated 8/24/15 indicated Resident 1 had delusions of people stealing her money. The note further indicated that Resident 1 was resistive with nursing care. A review of Resident 1's Activity Assessment conducted by the SSD, dated 9/17/15, indicated Resident 1 was known to refuse care, was irritable, yelled at others, and can become combative. The SSD documented that Resident 1 displayed, No real change. A review of Resident 1's physician's progress note, dated 8/22/15, the physician documented, Very agitated, loud, using foul language and refuses to be examined or give her medical history. The physician indicated that a psychiatric consultation was advised for Resident 1. A review of Resident 1's physician's orders [REDACTED]. [REDACTED]. On 10/27/15 at 1:58 p.m., during an interview, the SSD stated that it was not necessary to address Resident 1's prior behavior of wanting to go to the building across the facility. The SSD stated, It's not a behavior, she's always stayed inside the building. When the SSD was asked if the psychiatrist had seen and examined Resident 1, the SSD stated, while reviewing Resident 1's record, she could not find documented evidence that it was done. At 3:30 p.m., on 10/27/15., during an interview, a licensed vocational nurse (LVN B) stated he went after Resident 1 when she exited the facility on 10/24/15. LVN B stated he was surprised about the incident because it was only his third day on the job. LVN B stated they were discussing what to do with the resident and trying to get her to go back in. According to LVN B, Resident 1 walked toward the sidewalk and ran into the street. According to Resident 1's progress note, dated 10/24/15, and timed at 7:40 p.m., indicated that 911/paramedics were called and arrived at the facility and took the resident to a general acute care hospital (GACH). On 10/27/15 at 5:30 p.m., during an interview, the director of nursing (DON) stated that there was no documentation of an interdisciplinary team meeting conducted to discuss Resident 1's care (since admission 7/2015). The DON stated she was not aware why Resident 1 never received a psychiatric consultation and stated, We are still in the process of cleaning up the facility. A review of Resident 1's psychiatric consultation note from the GACH, dated 10/30/15, indicated Resident 1 had visual hallucinations and poor judgement. A review of the facility's policy and procedure titled, Care for Residents with Dementia dated 8/2015, indicated that individuals with dementia may also have underlying mental disorders or other conditions causing or contributing to impaired cognition and problematic behavior. These residents will be assessed by the physician or referred for psychiatric consultation for proper diagnosis.

Based on interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1). Resident 1, who had dementia (loss of memory and other mental abilities severe enough to interfere with daily life) and was experiencing delusional behavior (a type of serious mental illness in which a person cannot tell what is real from what is imagined), that the facility failed to address, was stating she wanted to leave the facility. Resident 1 left the facility unsupervised and was brought back, only to leave the facility again unsupervised within minutes. Cross referenced to F250. This deficient practice resulted in Resident 1 leaving the facility unsupervised twice in one day, running across a busy street in front of the facility and was struck by a car. Resident 1 was transported to a general acute care hospital (GACH) after the accident and was diagnosed with [REDACTED]. Resident 1 was admitted to the GACH for nine days. Findings: On 10/26/15, the Department received a letter from the facility's administrator reporting an incident that occurred on 10/24/15, at approximated 7:30 p.m. The letter indicated Resident 1 left the facility, attempted to cross the street, fell over, and sustained lacerations on the left side of the head and on the left arm. A review of Resident 1's admission record indicated that Resident 1 was initially admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. At 11 a.m. on 10/27/15, during an interview, the director of nursing (DON) stated that Resident 1 was sent to a GACH after the incident on 10/24/15. The DON stated at approximately 7 p.m., on 10/24/15, Resident 1 went out of the facility using the front door and the facility's staff went after Resident 1 and redirected Resident 1 back to the facility. According to the DON, the staff took Resident 1 back to her room but after a few minutes, Resident 1 went outside again. The DON stated two licensed vocational nurses (LVNs A and B) and one certified nursing assistant (CNA A) had to run after Resident 1 when the resident went out of the facility the second time. Per the DON, Resident 1 was telling the staff, who ran after her to leave her alone and for the staff to go away. The DON stated, Suddenly she ran across the street. The DON stated that the incident happened all of a sudden and it was unexpected. The DON stated Resident 1 had no prior behavior of wandering or elopement. A review of a progress note written by LVN A, dated 10/24/15, and timed at 7:30 p.m., indicated the resident abruptly begin to run from the staff entering the street and onto incoming traffic flow. The progress note indicated Resident 1 fell in the street on the left side. LVN A documented that Resident 1's head was bleeding from a laceration (a deep cut or tear in skin or flesh) and Resident 1 was assisted onto a wheelchair and brought back inside the facility. LVN A documented, Asked resident why she ran across the street and she stated, 'My son is across the street and taxi is waiting.' LVN A documented that she had spoken with Resident 1's family member (FM 1) and that FM 1 denied being at the facility and/ or making arrangements to be with Resident 1 that day. A review of Resident 1's progress note, dated 10/24/15, and timed at 7:40 p.m., indicated 911/paramedics arrived at the facility and took Resident 1 to the GACH. A review of Resident 1's discharge summary from the GACH, dated 11/4/15, indicated the resident was brought to the emergency room via paramedics with final [DIAGNOSES REDACTED]. The record indicated Resident 1 sustained a small intracranial brain hemorrhage (bleeding into the brain), a small left pneumothorax (lung collapse), a transverse process fracture of the left lumbar ((L1 through L4) break in the lower bones in the spine), and a hematoma in the left psoas muscle (solid swelling of clotted blood in the muscles of the left side of the spine) after being struck by a car, rolling on the car's hood and falling to the ground. Resident 1 received a battery of exams and test and required nine days of hospital admission, which included intensive care and neurology (the branch of medicine or biology that deals with the anatomy, functions, and organic disorders of nerves and the nervous system) monitoring, pain medications, and trauma, psychiatry (devoted to the diagnosis, prevention, study and treatment of [REDACTED]. A review of a GACH's psychiatry consultation, dated 10/30/15, indicated Resident 1 had poor insight and judgment, and exhibiting visual hallucinations. The psychiatrist recommended social service involvement regarding the resident's psychosocial (pertaining to or involving both psychic(relating to the soul or mind) and social aspects) issues with a possible placement needed in a locked facility. The psychiatrist ordered for Resident 1 to start on Haldol (antipsychotic medication (a class of psychiatric medications primarily used to manage psychosis)). On 10/27/15 at 12:15 p.m., during a telephone interview, Resident 1's family member (FM 1) stated Resident 1 was initially admitted to the facility under hospice care (a program that helps people who are dying to have peace, comfort, and dignity). FM 1 stated Resident 1 had dementia and sees and imagine things. According to FM 1, Resident 1's condition had not advanced drastically so she was discharged from hospice care. FM 1 stated a facility ' s nurse called him on 10/24/15, at approximately 10 p.m., and he stated the nurse sounded very distraught, and told him that a car bumped Resident 1 when she crossed the street. FM 1 stated the nurse had explained to him that Resident 1 was saying that she was going to meet him across the street. FM 1 stated he had not made any arrangements to meet with Resident 1 across the street. FM 1 stated, She's (Resident 1) imagining things and they should have known that. FM 1 indicated that facility ' s staff knew that Resident 1 would say weird stuff, like she bought the building across the street (from the facility). FM 1 stated, She was supposed to get a psych (psychiatric) consult but they never did anything. A review of a licensed nurses progress note, dated 7/5/15 (7 a.m. to 3 p.m. shift), indicated Resident 1 displayed periods of confusion and disorientation and gets easily irritated, and preferred to be left alone. A review of the social work progress notes, dated 8/12/15, and timed at 10:30 a.m., indicated Resident 1 had become more confused and disoriented. The social service designee (SSD) indicated, Resident confused again this morning, saying she bought the building across the street. According to the SSD's note, Resident 1 stated, I am going across the street take a shower and will be back. A review of Resident 1's physicians progress note, dated 8/22/15, the physician documented, Very agitated, loud, using foul language and refuses to be examined or give her medical history. The physician's note indicated that a psychiatric consultation was advised for Resident 1. A review of Resident 1's physician's orders [REDACTED]. A review of a licensed nurse weekly summary, dated 8/24/15 indicated Resident 1 had delusions of people stealing her money. The note further indicated that Resident 1 was resistive with nursing care. A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated 9/18/15, indicated the facility staff did not identify Resident 1 as having potential indicators of psychosis (occurs when a person loses contact with reality. The person may have false beliefs about what is taking place, or see or hear things that are not there). The MDS indicated that Resident 1 did not manifest behavioral symptoms and did not exhibit refusal of care. According to the MDS, Resident 1 was ambulatory and only required oversight when moving to and from distant areas. A review of Resident 1's care plan titled, Mood States and Cognitive Loss/Dementia, dated 10/1/15, did not identify Resident 1 has having behavioral symptoms of having false beliefs, yelling, and rejection of care. The care plan area to describe Resident 1's behavior manifestations was left blank and did not indicate Resident 1's actual behaviors. During an interview on 10/27/15 at 1:58 p.m., the SSD stated it was not necessary to address Resident 1's prior behavior of wanting to go to the building across the facility. The SSD stated, It's not a behavior, she's always stayed inside the building. When the SSD was asked if the psychiatrist had seen and examined Resident 1, the SSD stated she could not find documented evidence that it was done. During an interview on 10/27/15 at 3 p.m., LVN A stated she was on-duty on the day of the incident (10/24/15). LVN A stated she was passing medications when she noticed Resident 1 pacing in and out of the room and to the restroom located in the front hallway. LVN A stated Resident 1 exited the facility through the front door and she asked CNA A to keep an eye on the resident after they had brought Resident 1 back to her room after leaving the building the first time. According to LVN A, CNA A had to help another resident and was not able to watch and Resident 1 left the facility again. LVN A stated she was unable to convince Resident 1 to come back in the facility and thought it was abuse if she had persisted to ask Resident 1 to come back in the facility. LVN A stated Resident 1 was yelling back at them and did not want to come back inside the facility. On 10/27/15 at 3:30 p.m., during an interview, LVN B stated he ran after Resident 1 when she exited the facility on 10/24/15. LVN B stated he was surprised about the incident happening, because it was his third day on the job. LVN B stated they (the staff) were discussing what to do with Resident 1, while trying to get her to go back in. According to LVN B, Resident 1 walked toward the sidewalk and ran into the street. At 5:45 p.m., on 10/27/15, during an interview, the assistant DON (ADON) stated she reviewed and revised Resident 1's care plans. The ADON stated that she used information on the MDS, MARs, and input from the interdisciplinary team (IDT) to update Resident 1's care plans. When asked about the IDT meetings for Resident 1, the ADON was unable to provide documentation of one occurring. A review of the facility's policy and procedure titled, Care for Residents with Dementia dated 8/2015, indicated that the IDT will review the treatment plan of a resident with dementia to address the physical, psychological, behavioral symptoms and underlying causes. The IDT will monitor the effectiveness of interventions and provide an ongoing assessment as to whether they (the residents) are improving or stabilizing the resident's status or causing adverse consequences. The policy stipulated additional approaches for care included the following: - Activities that divert resident's attention. - Ensure that staff establish familiarity with residents and are aware of resident's preferences regarding care. - The physician must be immediately consulted when there is significant change in the resident's physical, mental, or psychosocial status.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of disease and infection for 45 of 45 facility residents, plus staff, and visitors. The facility failed to implement and maintain its policies and procedures; 1. Failed to provide the laundry room with hand washing sinks for the use of laundry staff members after handling, processing, transporting and storing soiled linen; 2. Failed to provide appropriate Personal Protective Equipment (PPE, equipment worn to minimize exposure to infections) such as protective garments, gloves and face mask and/or ensure the use of PPE; 3. Ensure facility staff perform hand washing before and after direct contact with residents and after removing gloves; 4. Failed to provide a door to the soiled linen shed; 5. Ensure stethoscopes (a medical device used for listening to sounds inside the body) were cleaned and disinfected between each use. 6. Ensure residents' urinals were labeled and clean; 7. Ensure cords used for overbed lights and emergency pull cords were made of material that could be cleaned or sanitized. These deficient practices that included the failure to provide handwashing sinks in the laundry and PPE for laundry employee during laundry services, provide door at the soiled linen shed, labelling, cleaning and disinfecting resident care equipment and personal items and implementing hand hygiene (hand washing) practices consistent with accepted standards of practice had the potential to promote the spread of infections and disease outbreaks. On 6/10/15 at 6:40 p.m., the facility administrator and director of nursing were notified of an Immediate Jeopardy (IJ) situation related to F441 Infection Control. The facility closed the laundry room and was no longer in use. The facility had an outside vendor that provided laundry services for linens and beddings. The facility provided appropriate and required PPE for the staff and completed infection control in-services for all staff. The facility implemented hand washing practices that was consistent with accepted standards of practice to reduce the potential spread of infections and prevent cross contamination. The immediate Jeopardy violation was corrected and the IJ was LIFTED on 6/11/15 at 3:20 p. m. with the facility administrator and director of nursing. Findings: 1. On 6/8/15, at 11:25 a.m., during the general observation of the laundry areas, the laundry staff member (LS1) was observed sorting and storing soiled linen into linen bags without using PPEs. At 11:30 a.m., LS1 called the janitor (JS1) to assist her with transporting the soiled linen bags to the large soiled linen containers. JS1 transported the soiled linen bags with bare hands to the soiled linen container without putting on PPEs. On 6/8/15, at 11:35 a.m., LS1 stated during an interview that both the janitor and she were supposed to wear gloves when handling soiled linen but she forgot to use the gloves. Both LS1 and JS1 went back to the facility and continued their duties without washing their hands after handling the soiled linen. LS1 was seen handling a clean linen cart and JS1 went through the back hallway into one of the residents' room. At 11:50 a.m., during laundry room observation in the presence of LS1, plastic bags containing bed spreads, blankets and privacy curtains were observed stored on laundry room floors. There was no hand washing sink and PPE products in the laundry room. There was water leak observed at the back of the washer onto the floor. There was a backyard shed labeled soiled linen in front of the laundry room. Inside the soiled linen room shed were soiled linen bags, hampers and stored items such as plumbing equipment, floor buffing machine and dusters. The door on soiled linen storage shed was observed missing. In an interview at 11:55 a.m., LS1 stated there was no hand washing sink in the laundry area. She stated she washed her hands inside the bathroom located at the back nurses' station which was approximately 30 feet from the laundry room. The laundry staff stated she was responsible for washing bed spreads, blankets, curtains and resident's personal clothes but the facility uses a professional laundry service to wash linen and towels. On 6/9/15, at 10:05 a.m., during the general observation of the facility's interior environment, in the presence of the maintenance supervisor, LS1was observed outside the soiled linen shed sorting and bagging soiled linen. LS1had a pair of gloves on but had no outer garment. During an interview on 6/9/15, at 10:10 a.m., LS1stated,l never put soiled linen or soiled linen bag close to my body. LS1did not wash her hands after handling the soiled linen. On 6/9/15, at 11:05 a.m., during an interview, the administrator acknowledged the findings and provided the facility laundry department an infection control policy. The administrator stated LS1and JS1 were supposed to wear PPE when handling soiled linen. The administrator stated that the facility's director of staff development (DSD) was responsible for training and monitoring laundry employees on how to handle, process, transport and store soiled linen in order to prevent the spread of infectious diseases. On 6/11/15, at 9:10 a.m., the DSD stated, during an interview, that he was the one responsible for providing in-service training program for license nurses, certified nurse assistants (CNAs), housekeepers and laundry employees. However, he stated he could not remember the last time he provided an in-service training and monitoring to laundry employees. A review of the facility' s Laundry Department Infection Control Policy and Procedures indicated that the following precautionary procedures must be followed by laundry employees to prevent the spread of infectious diseases to residents, staff members and visitors: * Employees in the soiled areas shall wear an outer garment over their uniforms and gloves. * Do not hold linen against the uniform when transporting. * Keep doors leading from the soiled area closed when not in use. * Protective garments shall be removed and hands washed each time the employee leaves the soiled area or after handling soiled linen. * Place all soiled linen in designated marked Soiled Linen. * Soiled linen shall not come into contact with floor and furniture. * Soiled linen container shall be emptied as needed and not allowed to overflow. * All directives on laundry procedures cleaning schedules will be in writing and every laundry and housekeeping staff member will be trained to follow them. * All laundry employees will be expected to attend in-service programs pertaining to infection control. 2. On 6/9/15 at 8:20 a.m., during the medication pass observation, Licensed Vocational Nurse 1 (LVN 1) checked the placement of Resident 1's gastrostomy tube (GT, a tube inserted through a small incision in the abdomen into the stomach and is used for long-term nutrition and medication administration) using a stethoscope (a medical device used for listening to sounds inside the body). LVN 1 did not clean/disinfect the stethoscope prior to and after use. After preparing Resident 1's medications, LVN 1 wore gloves and then picked up a tissue paper on the floor. LVN 1 did not wash her hands and change gloves. While wearing the same gloves, LVN 1 proceeded to give oral medications to Resident 1. At 8:45 a.m., LVN 1 checked the placement of Randomly Selected Resident 21's (RSR 21) GT using the same stethoscope used for Resident 1. LVN 1 did not clean/disinfect the stethoscope prior to and after use for RSR 21. After preparing RSR 21's artificial tear drops (an eye drop medication), LVN 1 wore gloves, touched the bed crank to elevate RSR 21's head of bed (HOB), and then proceeded to administer the eye drop medication to RSR 21 while wearing the same gloves. LVN 1 did not wash her hands and change gloves before administering the eye drop medication. A review of the clinical record indicated Resident 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment and care screening tool, dated 4/7/15, indicated Resident 1 had no memory problem, was independent in daily decision making, and was totally dependent (full staff performance) with activities of daily living (ADL). A review of the clinical record indicated RSR 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated RSR 21 had long and short-term memory problems, was severely impaired in cognitive skills for daily decision making, and needed limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from staff with ADL. On 6/10/15 at 2:30 p.m., during an interview, LVN 1 stated she failed to clean/disinfect the stethoscope with germicidal disposable cloth prior to and after use for Resident 1 and RSR 21. LVN 1 stated she failed to wash her hands and change gloves after picking up a dirty tissue paper on the floor and before giving the medications to Resident 1. LVN 1 stated she failed to wash her hands and change gloves after touching the bed crank to elevate RSR 21's HOB and prior to giving the resident the eye drop medication. On 6/10/15 at 3 p.m., during an interview, LVN 2 stated prior to and after checking the placement of all residents' GT using a stethoscope, the stethoscope must be cleansed/disinfected with germicidal disposable cloth to prevent infection or cross contamination among residents and staff. LVN 2 stated LVN 1 should have washed her hands and changed gloves after touching the bed crank and prior to giving the eye drop medication. 3. On 6/8/15 at 8:05 a.m., during rounds (facility tour) with the social service director (SSD), Resident 3 was observed awake, lying in bed with a suprapubic catheter (a tube inserted into the bladder through a small hole in the belly to drain urine). In the common bathroom being used by Resident 3 and RSR 24, an unlabeled, gray-stained (like mold) urinal was observed, which the SSD stated belonged to Resident 3. A review of the clinical record indicated Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated Resident 3 had no memory problems, was independent in cognitive skills for daily decision making, and needed limited assistance from staff with ADL. On 6/8/15 at 3 p.m., during an interview, LVN 1 verified the urinal was unlabeled and dirty and stated the urinal was being used by the staff to empty Resident 3's suprapubic catheter bag. LVN 1 stated the dirty urinal must not be used for Resident 3 and to any other resident to prevent infection or cross contamination among residents and staff. On 6/8/15 at 5 p.m., during an interview, the director of nursing (DON) stated resident care equipment and reusable items were to be cleansed and disinfected or sterilized between residents to prevent the exposure of residents to pathogenic organisms (infection) and to prevent the transmission of infection in the facility. A review of the facility's policies and procedure titled, Cleaning and Disinfection of Resident-Care Equipment revised 10/2009, indicated resident care equipment including reusable items and durable medical equipment is cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Blood borne Pathogens Standard. The policy indicated non-critical items are those that come in contact with skin but not the mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). The facility's policy titled, Infection Control Guidelines for all Nursing Procedures, revised 4/2013, indicated employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water before and after direct contact with residents, when hands are visibly dirty or soiled with blood or other dirty fluids, and after removing gloves. The policy indicated the preferred method of hand hygiene is with the use of an alcohol based hand rub. 4. On 6/8/15, at 7:40 a.m., during the initial tour of the facility, all over bed lights and emergency pull cords in the facility restrooms were observed to be braided cotton cords, with visible soiling. There were a total of 71 braided cotton cords observed. These cords could not be cleaned or sanitized. On 6/8/15, at 8:50 a.m., during a tour of the facility with the DON, observed soiled cotton braided pull cords on the residents ' overbed lights and in all the facility restrooms and stated, during an interview, that the cords should be cleanable and were not appropriate. 5. On 6/8/15, during the initial tour of the facility, Certified Nursing Assistant 2 (CNA 2) was observed providing care to RSR 27. CNA 2 positioned RSR 27 and straightened the covers of her bed. CNA 2 then proceeded to RSR 26, and initiated the same care. On 6/8/15, at 7:45 a.m., CNA 2 was interviewed during the initial tour. CNA 2 stated that she should wash her hands between residents to prevent infections but that she forgot this time. 6. On 6/8/15, at 8:45 a.m., during the medication pass observation, LVN 1 was observed preparing and administering medications to Resident 4 via [DEVICE]. The LVN proceeded to administer medications to RSR 23, via [DEVICE]. LVN 1 failed to wash hands between residents and also failed to sanitize the stethoscope used to verify the placement of the [DEVICE] for the two residents. On 6/10/15, at 9:35 a.m., immediately following the medication pass observation, LVN 1 stated, during an interview, that hand washing between residents must be done and the stethoscope and other equipment must be sanitized between residents for infection control. The medication cart was opened and the cart contained the facility approved supplies for hand sanitation and equipment sanitation. 7. On 6/10/15, at 7 a.m., on the floor outside the administrator's office, there was a green/brown, foul smelling object, the size of a small potato on the floor. The object was identified as fecal material by the activity director (AD). A caution sign was placed on the floor and the activity director picked up the fecal material with a dry paper towel retrieved from the closest restroom. After picking up the majority of the fecal material, and disposing of it in the restroom, the activity director returned to the site and, using more dry paper towels, wiped up the remaining residue from the floor. No gloves were worn, and no disinfectant cleaners were used. On 6/10/15, at 12:15 p.m., during an interview, the activity director stated she forgot to wear gloves, but was aware that personal protective equipment should always be used when coming in contact with body fluids or waste. The activity director stated she should have used a disinfectant when cleaning waste, not dry towels. On 6/12/15, at 8:45 a.m., during an interview, the director of staff development (DSD) stated that the facility had regular in-services for handwashing, and all staff knew the importance of hand washing or the use of alcohol based hand sanitizers. A facility policy titled, Infection Control Guidelines for all Nursing Procedures, revised 4/2013, indicated that employees must wash their hands for 10-15 seconds using antimicrobial or non-antimicrobial soap and water before and after direct contact with residents. The policy also indicated that the preferred method of hand hygiene for hands that are not visibly soiled is using an alcohol based had rub. The policy indicated that staff will employ Standard Precautions in all situations where blood, body fluids, secretions and excretions are present.