Every finding on record at Bixby Towers Post-Acute Rehab

Based on interview, and record review, the facility's staff failed to immediately initiate Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of five sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 and CNA 2, who were CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), failed to check Residents 1's pulse, breathing and obtain immediate assistance to initiate CPR, activate a code blue (a specific code used to signal a patient who is having a life threatening medical emergency, typically a patient experiencing sudden cardiac arrest [when the heart stops] and/or respiratory arrest [when a person stops breathing), and call 911 on [DATE] at approximately 7:30 a.m., when Resident 1 was found unresponsive (a person is unconscious and fails to react to any external stimulation). In addition, the facility failed to implement its Policy and Procedure (P&P), titled Cardiopulmonary Resuscitation that indicated staff should engage in concurrent/coordinated response activities, to include assessing the individual (quickly evaluating responsiveness breathlessness, pulselessness), activating 911, positioning the individual for CPR, initiating chest compressions and performing rescue efforts as indicated when Resident 1 was found unresponsive. These deficient practices resulted in a delay in providing CPR to Resident 1 and at 8:10 a.m., 40 minutes after Resident 1 was found unresponsive, Resident 1 was pronounced dead by the paramedics. On [DATE] at 5:25 p.m., an Immediate Jeopardy ([IJ] a situation in which a 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 called in the presence of the facility's Administrator (ADM) due to the facility's failure to provide timely BLS to Resident 1, including immediate initiation of CPR, which potentially contributed to Resident 1's death. An IJ Removal Plan ([IJRP] a plan to immediately correct the deficient practices) was requested. On [DATE], the facility submitted an acceptable IJRP. After onsite verification of the facility's IJRP implementation through observation, interview, and record review, the IJ was removed on [DATE] at 3:55 p.m., in the presence of the facility's Director of Nursing (DON), ADM, and Consultant. Non-compliance of F678 remained at the scope and severity of D no actual harm with potential for more than minimal harm that is not immediate Jeopardy. The IJRP included the following: Immediately upon identification of Immediate Jeopardy (IJ) on [DATE], the facility initiated emergency corrective actions to ensure the safety of all residents. On [DATE], all licensed nurses and CNAs on duty were immediately re-educated by the DON and the Director of Staff Development (DSD). A total of 32 licensed nurses (LN), 51 CNAs, and 7 therapy staff were educated on [DATE]. All LNs, CNAs, and therapy staff who were not present for training prior to or on [DATE] (including those on vacation, leave of absence, or off duty) will be re-educated prior to returning to work. Re-education will be provided by the DON, DSD. Reeducation consisted of immediate initiation of CPR for any resident found pulseless and/or unresponsive, immediate activation of Code Blue and calling 911 without delay, ensuring the resident was never left unattended when found unresponsive. Provide return demonstration to validate competency in immediate recognition, Code Blue activation, calling 911, and initiation of CPR. All staff demonstrated competency through return demonstration. Ensure staff follows the AHA and BLS response guidelines: Recognize unresponsiveness immediately by observing for absence of normal breathing and check for a pulse immediately. If the resident is pulseless and unresponsive, treat it as a medical emergency. Activate Code Blue immediately and direct staff to bring emergency equipment/crash cart. Call 911 immediately or direct another staff member to call 911 without delay. Initiate CPR immediately when the resident is found unresponsive, not breathing normally, and pulseless. Begin chest compressions without delay and continue until relieved by another qualified responder, the resident shows signs of life, or EMS assumes care. Do not leave the resident unattended once found unresponsive. Facility nursing staff will have every shift huddles wherein any DNR status residents will be reported and disclosed at the time of handoff to the next shift. On [DATE], DON Provided 1 to 1 (individualized instruction where a single educator works directly with one learner) re-education to CNA on duty at time of incident on following: Immediate initiation of CPR for any resident found pulseless and/or unresponsive Immediate activation of Code Blue and calling 911 without delay No delay in initiating CPR for assessments or other interventions Ensuring the resident is never left unattended when found unresponsive Follows the AHA, and BLS response guidelines A facility-wide audit was conducted to verify code status for all residents on [DATE] by Resource Nurse Consultant. On [DATE], a mock Code Blue drill was conducted by Resource Nursing Consultant and DON. Staff demonstrated immediate response, CPR initiated without delay and emergency system activated appropriately. On [DATE] facility scheduled outside CPR training. All licensed nurses and CNAs were audited on [DATE] for current CPR certification and all were identified as active and current by the DSD. A total 47 LNs, of the 47 LNs, 46 are active and 1 is on leave of absence (LOA). A total of 74 CNAs of the 74 CNAs, 73 are active and 1 is on leave of absence. A total 20 Therapy staff, of 20 Therapy staff, 20 are active.Findings: During a review of Resident 1's admission Record (Face Sheet) the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1 had diagnoses including atrial fibrillation ([a-Fib] an irregular rapid heartbeat), arteriosclerosis of aorta (hardening of the arteries), and cardiomegaly (enlargement of the heart). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 1's cognition (ability to think, understand, learn and remember) was intact. Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required substantial/maximum assistance (helper provides more than half the effort) with toileting hygiene, showering/bathing, dressing, rolling left to right, lying to sitting on side of bed sitting to standing, transferring from chair/bed to chair, and toileting transfers. During a review of Resident 1's Physicians 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 [DATE], the POLST indicated if Resident 1 had no pulse and was not breathing to attempt resuscitation/CPR. During a review of Resident 1's Order Summary Report (Physician's Order) dated [DATE], the Physician's Order indicated CPR/Full Code. During a review of Resident 1's Nurses Progress Note dated [DATE] and timed 9:09 a.m., the Nurses Progress Note indicated at 7:47 a.m. ([DATE]), CNA 1 found Resident 1 unresponsive in his room. The Nurses Progress Note indicated (CNA 1) checked Resident 1 for a pulse and found none. CNA 1 yelled code blue and initiated CPR immediately. The Charge Nurse (Licensed Vocational Nurse 1 [LVN 1]) brought the crash cart and helped CNA 1 with CPR. During a review of the Emergency Medical Service Report ([EMS] a detailed document completed by emergency medical personnel that serves as a record of the resident's assessment and the care the resident received) dated [DATE], the EMS Report indicated the paramedics arrived at the facility on [DATE] at 7:56 a.m. and found Resident 1 lying in a supine (lying flat on their back with their face and torso facing upward) position in bed. Resident 1 was pulseless, apneic (not breathing), and in cardiac arrest. During an interview on [DATE] at 11 a.m., CNA 2 stated at approximately 7:45 a.m. ([DATE]) as she was walking down the hallway, CNA 1 called her name and asked her to come to Resident 1's room. When she arrived in Resident 1's room, CNA 1 asked her if Resident 1 looked ok. Resident 1 was in bed in a sitting position (at a 90 degree angle), he had a nasal cannula ([n/c] a small plastic tube, which fits into the person's nostrils) in his mouth, his skin was pink, his hand warm to touch, his left leg was hanging off the bed, and he looked like he was sleeping. She (CNA 2) tried shaking Resident 1 because he sometimes would be in a deep sleep and this was what she usually did to wake him. She did not think to check his pulse or if he was breathing. She told CNA 1 to stay with the resident, while she got help. She left Resident 1's room and ran down the hallway to retrieve the crash cart (a set of trays/drawers/shelves on wheels used in hospitals or skilled nursing facility for transportation and dispensing of emergency medication/equipment), which was located across from the second floor Nurse's Station, which was about 15 feet from Resident 1's room. She saw LVN 1 in the hallway, near the Nurse's Station and notified her that Resident 1 was not waking up. She (CNA 2) then took the crash cart to Resident 1's room and LVN 1, LVN 3, and the Assistant Director of Nursing (ADON) all ran into Resident 1's room. When she entered Resident 1's room CNA 1 was attempting to wake Resident 1 up. LVN 3 gave instructions to put a back board under Resident 1 and begin CPR. She (CNA 2) placed the back board under Resident 1 and began chest compressions. CNA 2 stated she received an in-service on what to do when a resident was found unresponsive, but she did not think to check Resident 1 for breathing or a pulse, she stated it happened so fast she could not think. During an interview on [DATE] at 12:30 p.m., LVN 1 stated on [DATE] she was in the hallway (time unknown) when she saw CNA 2 and heard her say Resident 1 was not waking up. LVN 1 stated she announced code blue at 7:47 a.m. and she and CNA 2 took the crash cart to Resident 1's room. When she entered Resident 1's room CNA 1 was attempting to wake Resident 1 up. She (LVN 1) checked for a pulse, but there was none. LVN 1 stated CNA 2 began chest compressions and LVN 3 bagged Resident 1. LVN 1 stated when a resident was pulseless and not breathing staff was supposed to initiate CPR immediately to increase the resident's chance of survival. During a telephone interview on [DATE] at 1 p.m., CNA 1 stated she arrived in Resident 1's room at approximately 7:30 a.m. ([DATE]) to give him his breakfast tray, she said good morning to Resident 1, your breakfast is here, but Resident 1 did not respond. She shook Resident 1 for a couple minutes but did not check to see if he was breathing, or if he had a pulse, and she did not begin CPR because she thought Resident was sleeping. She called CNA 2 to come to Resident 1's room and told her that Resident 1 was unresponsive. CNA 2 came to Resident 1's room and shook him for a couple of minutes, then instructed me to stay with the resident while she (CNA 2) went to get help. During an interview on [DATE] at 4 p.m., the DON stated the staff have had in-services and participated regularly in mock codes (a simulated emergency drill in healthcare settings used to practice and evaluate a medical team's response to life-threatening crises, such as a cardiac arrest). They were instructed to check for breathing, a pulse, call for help, call 911, and begin chest compressions immediately when a resident is found unresponsive. During a review of the facilities policy & procedure (P&P) titled, Cardiopulmonary Resuscitation (CPR) revised [DATE], The P&P indicated properly trained personnel will be available to provide basic life support, including cardiopulmonary resuscitation (CPR), to those requiring emergency care, prior to arrival of emergency medical personnel, and subject to accepted professional guidelines, advance directives and physicians orders. The P&P indicated facility staff should engage in concurrent/coordinated response activities , to include assessing individual (i.e. quickly evaluating responsiveness, breathlessness, pulselessness), activating 911, positioning individual for CPR, initiating chest compressions and performing rescue efforts as indicated, retrieving crash cart, verifying code status, and preparing records for emergency transfer as indicated.

Based on interview, and record review, the facility's QA/QAPI ([Quality Assurance/Quality Assurance Performance Improvement] data driven proactive approach to improvement used to ensure services are meeting quality standards) committee failed to ensure continued oversight of the facility's IJ Removal Plan ([IJRP] a plan to immediately correct the deficient practices) of a deficient practice identified during a previous abbreviated survey ([DATE]) that resulted in an Immediate Jeopardy ([IJ] a situation in which a 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) being called. This deficient practice resulted in a repeat deficiency in Quality of Care (F678) and a delay in Cardiopulmonary Resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) for one of five sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 and CNA 2, who were CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), failed to check Residents 1's pulse, breathing and obtain immediate assistance to initiate CPR, activate a code blue (a specific code used to signal a patient who is having a life threatening medical emergency, typically a patient experiencing sudden cardiac arrest [when the heart stops] and/or respiratory arrest [when a person stops breathing), and call 911 on [DATE] at approximately 7:30 a.m., when Resident 1 was found unresponsive (a person is unconscious and fails to react to any external stimulation).Findings: During a review of the facility's QAPI Plan dated [DATE], the QAPI Plan indicated on [DATE] and [DATE], in response to an IJ they received ([DATE]) the facility conducted audits of all current resident's code status, licensed nurses and Certified Nursing Assistants (CNA) CPR certification and competency as well as a mock code (a simulated medical emergency drill) was conducted. Continued review of the QAPI indicated other than a possible one time mock code there was no documentation to indicate verification staff was competent and confident in actually responding to a code blue and subsequent performance of CPR, there was only paperwork compliance and audits conducted. During an interview on [DATE] at 4 p.m., the Administrator (ADM) stated staff were educated on how to respond during a code blue, per the QAPI plan, but staff were not consistently monitored to determine if they were confident/comfortable initiating and conducting CPR. During a review of the policies and procedures (P&P), dated 7/2016 titled Quality Assurance and Performance Improvement (QAPI) Committee. The P&P indicates this facility must establish and maintain a Quality Assurance and Performance Improvement Committee (QAPI) that oversees the implementation of the QAPI program. 1. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals; and 2. Coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents, and family members.

The facility failed to ensure the bed for one of three sampled residents (Resident 2) was locked at all times. This deficient practice resulted in Resident 2 feeling unsafe when his bed moved on several occasions when he attempted to get in it. This deficient practice had the potential for Resident 2 to be subjected to falls and injury.Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including orthopedic aftercare (care and services for a person who underwent a surgery involving bones, muscles and ligaments of the body) following a surgical amputation (the surgical removal of a part of the body, such as an arm or leg), gait (the pattern or style of movement involved in walking) and mobility abnormality, and end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 4/8/2026, the MDS indicated Resident 2 was able to make decisions that were reasonable and consistent and he required one to two person assist to complete his activities of daily living ([ADLs] routine tasks/activities such as bathing, dressing, toileting hygiene, and repositioning in bed. During an interview on 5/26/2026 at 10:50 a.m., Resident 2 stated he goes to hemodialysis (a treatment to cleanse the blood of waste and extra fluids artificially through a machine when the kidney[s] have failed) three times a week and when he comes back from hemodialysis, his bed would always be unlocked. Resident 2 stated three times in the past while waiting for a nurse to help him back to bed, his bed would sway away from him, which worried him and made him feel unsafe. During an interview on 5/26/2026 at 11:14 a.m., with Certified Nursing Assistant (CNA) 1 and a concurrent observation of Resident 2's bed, Resident 2's bed was noted to be unlocked and moved easily when pushed against it. CNA 1 stated Resident 1's bed should always be locked to make sure Resident 2 was safe. During an interview on 5/26/2026 at 11:15 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 2 needed supervision and assistance when transferring from his wheelchair to bed and vice versa, and his bed should be locked at all times to prevent an accident and injury. During an interview on 5/26/2026 at 11:22 a.m., CNA 2 stated she should have checked to make sure Resident 2's bed was locked because Resident 2 was a fall risk. During an interview on 5/27/2026 at 12:45 p.m., the DON stated it was CNA 2's responsibility to make sure Resident 2's bed was locked to prevent accidents from occurring. During a review of the facility's Policy and Procedure (P/P) titled, Safety and Supervision of Residents revised 7/2017, the P/P indicated the facility shall strive to make the residents' environment free from environmental hazards including, but not limited to:a. bed safety

Based on interview and record review, the facility failed to ensure the medical records for one of three sampled residents (Resident 1) was accurately documented to reflect activity visits by the facility's activity staff, the activity provided, and Resident 1's participation level and response to the activities. This deficient practice resulted in the inability to track activity provided to Resident 1 and had the potential for Resident 1 be socially isolated and suffer from depression and loneliness. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses including autistic disorder (a condition related to brain development that affects how people see others and socialize with them), hypertension ([HTN] high blood pressure) and lymphocytic leukemia (a type of cancer in the blood cells). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/8/2026, the MDS indicated Resident 1 was able to make decisions that were reasonable and consistent and he required a one-person assist to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). The MDS indicated it was important for Resident 1 to do his favorite activities while at the facility. During a review of Resident 1's untitled Care Plan dated 5/6/2025, the Care Plan's goal was for Resident 1 to express satisfaction with the facility's accommodations of his preferences and to utilize his strength to improve his quality life. The Care Plan's interventions included respecting Resident 1's activity preferences and providing Resident 1's activity preference in a timely manner. During a review of Resident 1's Activities Note dated 3/31/2026 and timed at 1:07 p.m., the Activities Note indicated Resident 1 would continue to have regular room visits by the activity staff twice a week as requested and as preferred by Resident 1. During a review of the facility's Room Visit Sign In Sheet, the Room Visit Sign In Sheet indicated Resident 1 was visited by the activity staff on 5/2/2026, 5/5/2026, and 5/9/2026. During an interview on 5/26/2026 at 11:58 a.m., Resident 1 stated he preferred room visits twice a week, but the activity staff had not been consistent with the visits and there were times during the month of 5/2026 when the activity staff only visited him once a week. Resident 1 stated he felt deprived of social interaction. During an interview on 5/27/2026 at 11:14 a.m., with the Activity Director (AD), and a concurrent review of Resident 1's Room Visit Sign In Sheet, dated 5/2026, the Room Visit Sign In Sheet indicated only three room visits were documented by activity staff, and the Room visit Sign In Sheet did not indicate the specific activities provided to Resident 1 during each visit. The AD stated Resident 1 preferred room visits twice a week but she and the other activity staff who visited him did not document in Resident 1's medical record each time they conducted room visits. She and the other activity personnel should have documented in Resident 1's medical record after a room visit was conducted to indicate the specific individualized activities provided to Resident 1, Resident 1's participation and response to the activities provided. During an interview on 5/27/2026, the Director of Nursing (DON) stated the activity staff should have documented in Resident 1's medical record to show the specific activity provided to Resident 1, track his responses to the activities provided to ensure his satisfaction. During a review of the facility's Policy and Procedures (P/P) titled, Activity Programs revised 6/2018, the P/P indicated the facility shall design and provide activity programs that include group activities, independent/individualized activities and assisted individual activities that meet the interests and preferences of the residents. These activities shall be provided in an ongoing manner to ensure the residents' sense of well-being and to promote and/or enhance their physical, cognitive and emotional health. The P/P indicated all activities provided shall be documented in the residents' medical record. During a review of facility's P/P titled, Charting and Documentation revised 7/2017, the P/P indicated all services provided to the residents, progress toward care plan goals, or any changes in the residents' medical, physical, functional or psychosocial condition, shall be documented in the residents' medical record. The P/P indicated the medical record shall facilitate communication between the interdisciplinary team regarding the residents' condition and response to care and services.

Based on observation, interview, and record review, the facility failed to provide consistent monthly billing statements, maintain appropriate billing record practices, and ensure financial privacy for two of three sampled residents (Resident 2 and Resident 3).These deficient practices resulted in Resident 2 and Resident 3 being unable to receive clear, accurate, and confidential billing information regarding charges and account balances while in the facility.Findings:1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including, End-stage renal disease (ESRD-chronic kidney disease), Unspecified cirrhosis of the liver (advanced liver scarring where normal tissue is replaced by hard fibrous tissue), and Hyperkalemia ( a serious condition where the potassium level in your blood is too high).During a review of Resident 2's MDS Minimum Data Set (a resident assessment tool) dated 02/27/2026, the MDS indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 need setup or clean up assistance (helper set and or clean up) with eating and oral hygiene, supervision or touching assistance for personal and upper body dressing.During an interview on 05/22/2026 at 09:49 am with Resident 2, Resident 2 reported the facility was very poor in providing billing statements. Resident 2 stated the last billing statement he recalled seeing was months ago on top of his food tray and reported no one was accountable for properly delivering billing statements. Resident 2 stated he never received receipts from the facility and did not know exactly what he was being charged for, and staff verbally informed him of payment amounts. Resident 2 stated the facility needed to improve the way billing statements were distributed and stated he wanted his billing statements handed directly to him instead of being left on the bedside table where others could view his private financial information.During an interview on 05/22/2026 at 12:58 pm with the Activity Director (AD), the AD stated she is responsible for delivering mail to residents. The AD stated, if a resident was not in their room, she would leave the mail on the bedside table. The AD stated that for Resident 2, who regularly leaves the facility for dialysis treatments, mail was also left on the bedside table when Resident 2 was not present. The AD stated there was no system for obtaining proof of delivery or resident acknowledgment of receipt. The AD stated that leaving mail unattended on bedside tables does not ensure residents receive their correspondence. The AD stated moving forward, staff will ensure mail is handed directly to residents and will no longer leave mail unattended in resident rooms because there is no proof the residents received it.2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including, Chronic Obstructive Pulmonary Disease (inflammatory lung disease that restricts airflow and causes breathing difficulties), Cardiomegaly (enlarged heart), and Essential hypertension (chronic elevation of blood pressure).During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 was cognitively intact. The MDS indicated Resident 3 need setup or clean up assistance with eating and personal hygiene.During an interview on 05/22/2026 at 09:16 a.m. with Resident 3, Resident 3 reported she never consistently received billing statements from the facility and could not recall the last time she was provided one. Resident 3 stated, It has been a while since she received a billing statement. Resident 3 stated the facility was supposed to bring the billing statements for her review.During an interview on 05/22/2026 at 10:06 am with the Business Office Director (BOD), the BOD stated she was not responsible for handing out billing statements to residents and reported the Activity Director distributed the statements. The BOD stated that moving forward the facility would develop a better process for delivering billing statements, including implementing a log and resident signature process to track distribution. The BOD acknowledged there was currently no tracking system in place for residents receiving mailed billing statements and agreed residents had the right to review their billing statements.During an interview on 05/22/2026 at 1:04 p.m. with the Director of Nursing (DON), the DON stated billing statements should have been given to Resident 2 and Resident 3 and not placed on bedside table, so they could acknowledge the mail was received. The DON stated the facility will put a system in place to track mail that is sent out and delivered to the residents in the facility.During a review of the facility's P&P titled, Billings undated, the P&P indicated, Each resident will receive an itemized statement for services rendered during billing cycle.

Based on interview, and record review, the facility failed to implement its policy and procedure (P&P) titled Cardiopulmonary Resuscitation (CPR an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) which required staff to immediately activate a Code Blue (announcement used in facilities when a resident is experiencing medical emergency), call 911(phone number used to contact the emergency services), and provide basic life support (BLS, a set of emergency medical procedures designed to sustain life by maintaining breathing and circulation), including CPR for one of three residents (Resident 1) who was a full code (a medical term indicating a patient's consent to receive all possible life-saving measures in the event of a cardiac arrest [when the heart stops breathing] or respiratory arrest [when a person stops breathing]).The facility failed to:1.Ensure Certified Nursing Assistant (CNA) 1 who was CPR certified (successfully completed a training course and received a credential that qualifies a person to perform BLS) initiated CPR and stayed with Resident 1 per the facility's P&P titled, Cardiopulmonary Resuscitation, and the American Heart Association (AHA) Guidelines when Resident 1 was found unresponsive , not breathing and without pulse on [DATE] at approximately 10:30 p.m.2.Ensure staff called 911 as soon as Resident 1 was found unresponsive, not breathing and without a pulse on [DATE] at approximately 10:30 p.m. The Paramedics Run Sheet records indicated the Paramedics were dispatched to Resident 1 at 10:39 p.m. and arrived at the facility at 10:49 p.m.3.Ensure Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 did not delay the initiation of CPR by checking Resident 1's blood pressure (pressure that occurs when blood pushes against the walls of patient arteries [blood vessel]), oxygen saturation (measures the percentage of oxygen in the blood) performing a sternal rub (a technique doctors, nurses, or paramedics use to see if a person who is passed out [unconscious] can feel pain), and checking Resident 1's eyes when Resident 1 was found unresponsive and without a pulse by CNA 1.These failures resulted in a delay in calling 911 and initiating CPR on Resident 1 who was found unresponsive, not breathing and without pulse on [DATE] at approximately 10:30 p.m. Resident 1 was pronounced dead at 11:12 p.m.These failures placed 53 residents, who were full code at risk of not receiving life saving measures timely and increased their chances for death.On [DATE] at 3:31 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 called in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to provide timely basic life support (BLS), to Resident 1, including immediate initiation of CPR. J Removal Plan (IJRP, a plan to immediately correct the deficient practices) was immediately requested. On [DATE] at 4:17 p.m., the facility submitted an acceptable IJRP. After onsite verification of the IJRP implementation through observations, interviews, and record review the IJ was removed on [DATE] at 5:20 p.m. in the presence of the ADM and DON. Non-compliance of F-678 remained at the scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy.The IJRP included the following immediate actions: 1.Resident 1 expired (die) on [DATE] and no longer resided in the facility.2.Immediately upon identification of the IJ on [DATE], the facility initiated emergency corrective actions to ensure the safety of all residents. On [DATE], all licensed nurses and certified nursing assistants (CNAs) on duty, including the Director of Nursing (DON) and the Director of Staff Development (DSD), were immediately re-educated by the Resource Nurse Consultant on immediate initiation of CPR for any resident found pulseless (no pulse) and/or unresponsive, immediate activation of Code Blue and calling 911 without delay, no delay in initiating CPR for assessments or other interventions, ensuring the resident is never left unattended when found unresponsive, and follows American Heart Association (AHA) Basic Life Support (BLS) response guidelines:a. Recognize unresponsiveness immediately by assessing responsiveness and observing for absence of normal breathing.b. Check for pulse immediately and, if the resident is pulseless and unresponsive, treat it as a medical emergency.c. Activate Code Blue immediately and direct staff to bring emergency equipment/crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations).d. Call 911 immediately or direct another staff member to call 911 without delay.e. Initiate CPR immediately when the resident is found unresponsive, not breathing normally, and pulseless.f. Begin chest compressions (manual pushes on the center of a resident's chest to keep blood flowing to vital organs during cardiac arrest) without delay and continue until relieved by another qualified responder, the resident shows signs of life, or Emergency Medical Services (EMS) assumes care.g. Do not leave the residents unattended once they are found unresponsive.h. Identify code status (a medical order of what emergency resuscitation measures a resident wishes to receive) without delaying CPR by verifying the resident's code status through the Point Click Care (PCC-electronic health record) header, medical record, Physician Orders for Life-Sustaining Treatment (POLST- an actionable medical order form for seriously ill or frail individuals, outlining specific treatment preferences like CPR that emergency personnel must follow) , and/or in the order listing report placed in the crash cart printed daily. Facility nursing staff will have every shift huddles (daily meetings held at the start of a shift to improve communication, teamwork, and resident safety) wherein any Do Not Resuscitate (DNR- a legally binding medical document signed by a doctor instructing healthcare professionals not to perform CPR if a resident's heart stops or they stop breathing) status residents will be reported and disclosed at the time of handoff to the next shift.i. Coordinate staff response during the emergency, including Responder 1(who found resident unresponsive) call for help and remain with resident initiating compressions, Responder 2 activating Code Blue/911, and Responder 3 obtaining emergency equipment, as available.j. Provide return demonstration to validate competency in immediate recognition, Code Blue activation, calling 911, and initiation of CPR.All staff demonstrated competency through return demonstration. A total of 33 licensed nurses (LNs) and 43 certified nursing assistants (CNAs) were re-educated.On [DATE], the DON provided one on one (1:1) re-education to LVN 1 and CNA 1 on duty at time of incident on following:Immediate initiation of CPR for any resident found pulseless and/or unresponsiveImmediate activation of Code Blue and calling 911 without delayNo delay in initiating CPR for assessments or other interventionsEnsuring the resident is never left unattended when found unresponsiveFollows AHA BLS response guidelinesA facility-wide audit was conducted to verify code status for all residents on [DATE] by Resource Nurse Consultant. All full code residents were verified for accuracy in PCC, POLST placed in the chart and POC. Code status is now clearly visible and readily accessible during emergencies via PCC header on resident profile, in resident orders, via POLST or Advance Directives (a legal document that specifies a person's preferences for medical treatment if they become unable to make decisions due to serious illness or injury) in physical chart, and/or in the order listing report placed in the crash cart printed daily.On [DATE], a mock Code Blue (training exercise designed to improve team response to cardiac arrest) drill was conducted by Resource Nursing Consultant. Staff demonstrated immediate response, CPR initiated without delay and emergency system activated appropriately.Facility nursing staff will have every shift huddles wherein any DNR status residents will be reported and disclosed at the time of handoff to the next shift.2. Identification of Residents Affected or Likely to be AffectedOn [DATE] a 100% audit of current residents was initiated by Resource Nurse Consultant to ensure code status orders are present and accurate. Code status is correctly documented in electronic health record (EMR) and reflected on the PCC patient header.All licensed nurses and CNAs were audited on [DATE] for current CPR certification and all were identified as active and current by DSD,3. Actions to Prevent Occurrence/RecurrenceOn [DATE] re-education was initiated with licensed nurses and CNAs by the DON/DSD or Designee on: AHA CPR guidelines, facility CPR policy and immediate emergency response protocol (no delay).On [DATE] mock Code Blue was initiated on all shifts by DON/DSD.Re -Education included: Recognition of unresponsiveness, immediate activation of Code Blue, immediate 911 activation, CPR initiation, not leaving resident unattended if resident found unresponsive, elimination of delays (no vital signs prior to CPR if pulseless) and identification of code status via the PCC Dashboard or POLST.On [DATE], Medical Records staff received re-training on: Auditing code status orders for accuracy and accessibility by DON. Medical record staff will continue this audit weekly, if there are any changes in code status, medical record staff or RN supervisor will be responsible for updating POLST and orders. 4. How Facility Will Monitor Process and Sustain Compliance / Integrate into Quality Assurance (QA- process designed to ensure the highest standards of care and patient safety) System.The DON/ DSD or designee will conduct annual CPR competency validation to include new hires and registry. Mock Code Blue drills will be randomly completed on various shifts weekly for four weeks, then monthly for three months.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including elevated white blood cell count (a condition where the number of white blood cells in the blood is higher than normal), anemia ( low blood count), acute kidney failure (AKI, the sudden loss of kidney function), and chronic kidney disease (CKD, slow, progressive loss of kidney function over months or years),During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 had the capacity to make medical decisions.During a review of Resident 1's POLST dated [DATE], the POLST indicated if Resident 1 was in cardiopulmonary arrest (a sudden stop of function of the heart) CPR was required.During a review of Resident 1's Nursing Progress Note, dated [DATE], the Nursing Progress Note indicated at about 10:30 p.m., RN 1 was notified that Resident 1 was unresponsive, and upon assessment, CPR was initiated (unknown time ) and 911 was called at 10:37 p.m. The Nursing Progress Note indicated paramedics arrived at the facility at 10:47 p.m. and took over CPR. The Nursing Progress Note indicated Resident 1 was pronounced dead at 11:13 p.m.During a review of Resident 1's Fire Call History, dated [DATE], the Fire Call History indicated the 911 call regarding Resident 1 was placed at 10:37 p.m.During a review of Resident 1's Paramedic Run Sheet, dated [DATE], the Paramedic Run Sheet indicated paramedics were dispatched at 10:39 p.m., and were at Resident 1's bedside at 10:49 p.m. The Paramedic Run Sheet indicated Resident 1 was treated per their cardiac arrest protocol with high quality CPR initiated, ventilation (delivery of rescue breaths [artificial respiration] to provide oxygen) provided via bag valve mask (BVM, a handheld, self-inflating device used to provide emergency ventilation to patients who are not breathing or are breathing inadequately), and three rounds of cardiac epinephrine (lifesaving medication ) given, but no change in condition throughout the efforts. The Paramedic Run Sheet indicated resuscitation efforts ceased.During a review of Resident 1's Certificate of Death (undated), the Certificate of Death indicated Resident 1 died on [DATE] at 11:13 p.m., and the immediate cause of death was cardiopulmonary arrest and the underlying cause was arteriosclerotic cardiovascular disease (disease that affects the heart or blood vessels).During an interview on [DATE], at 2:40 p.m., with CNA 1 (who was CPR certified) , CNA 1 stated on [DATE] at around 10:30 p.m. she found Resident 1 unresponsive, not breathing and without a carotid pulse (the pulse felt on the neck) after checking the pulse twice. CNA 1 stated instead of calling code blue and initiating CPR, at 10:30 p.m., she left the room to get help from LVN 1. CNA 1 stated she did not return to Resident 1's room after she informed LVN 1 and continued with her assignment.During an interview on [DATE] at 3:10 p.m., with RN 1, RN 1 stated on [DATE] at around 10:30 p.m., LVN 1 informed her Resident 1 was unresponsive, and LVN 1 and RN 1 went to Resident 1's room with a crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations). RN 1 stated when they arrived no other staff was in the room. RN 1 stated LVN 1 checked Resident 1's blood pressure and placed a pulse oximeter (device that measures blood oxygen saturation [blood oxygen level] and heart rate) on Resident 1's finger to detect a pulse, while she shook the resident to assess for responsiveness. RN 1 stated the pulse oximeter did not detect a pulse, then she checked Resident 1's carotid pulse and confirmed Resident 1 did not have a pulse. RN 1 stated she began chest compressions, called out for someone to call 911 and LVN 1 provided rescue breathing (used on a resident who has stopped breathing). RN 1 stated three to four minutes passed between the time LVN 1 notified her Resident 1 was unresponsive and the time 911 was called. RN 1 stated LVN 2 called 911 at 10:37 p.m. and the paramedics arrived at 10:47 p.m. and took over CPR. RN 1 stated the paramedics stopped CPR and resuscitation efforts at 11:13 p.m. RN 1 stated she was not aware Resident 1 had no pulse when CNA 1 found him at 10:30 p.m. RN 1 stated if she was aware, she could have initiated CPR immediately for a possibility of saving the Resident 1's life. RN 1 stated any delay in initiating CPR can cause brain damage (injury of brain cells) or death. RN 1 stated even a one-minute delay in starting chest compression after observing a resident without a pulse was too long.During an interview on [DATE], at 11:05 a.m., with the DSD, the DSD stated when staff finds a resident unresponsive staff should not leave the resident alone. The DSD stated staff should call a Code Blue or call for help and delegate someone to call 911 and get the crash cart. The DSD stated as soon as staff discovered Resident 1 without a pulse, chest compressions should have been initiated immediately. The DSD stated she did not know that CNAs were allowed to check for a pulse. The DSD stated CNA 1 leaving Resident 1 alone on [DATE] after finding him unresponsive with no pulse did not follow AHA BLS guidelines.During an interview on [DATE], at 12:03 p.m., with LVN 1, LVN 1 stated on [DATE] (unknown time), CNA 1 approached her near the Nursing Station 1 and reported Resident 1 was unresponsive. LVN 1 immediately informed RN 1 and they both went down to Resident 1's room with the crash cart while LVN 2 looked up Resident 1's code status in resident medical record (chart). LVN 1 stated when they entered the room no other staff were present and Resident 1 was unresponsive. LVN 1 stated RN 1 performed a sternal rub, and attempted to open the resident's eyes while she attempted to take Resident 1's blood pressure on the left arm and applied a pulse oximeter to his finger. LVN 1 stated they were unable to obtain blood pressure or pulse using the pulse oximeter. LVN 1 stated RN 1 then checked Resident 1's carotid pulse. LVN 1 stated LVN 2 arrived in the hallway outside the room and informed them (LVN 1 and RN 1) Resident 1 was a full code and they initiated CPR.During an interview on [DATE], at 10:26 a.m., with LVN 2, LVN 2 stated at around 10:35 p.m., LVN 1 and RN 1 told her Resident 1 was unresponsive. LVN 2 stated LVN 1 and RN 1 took the crash cart to Resident 1's room. LVN 2 stated she checked Resident 1's medical record for his POLST status and called 911. LVN 2 stated she later heard one of the nurses in Resident 1's room call out Code blue. LVN 2 stated she did not enter Resident 1's room but confirmed from outside the doorway CPR had been initiated.During an interview on [DATE] at 11:05 a.m., with the DON, the DON stated their policy titled Cardiopulmonary Resuscitation based on AHA guidelines does not include taking a blood pressure when a resident was found unresponsive. The DON stated if a resident had no pulse, the heart was not pumping blood, and a blood pressure reading could not be obtained. The DON stated if a resident was pulseless, within three to seven minutes it could result in tissue damage to the brain from the lack of oxygen. The DON stated 911 was called so paramedics could administer cardiac (heart) medications to help revive Resident 1 as staff at the facility were not trained to give advanced cardiac medications such as epinephrine. During a review of facility's P/P titled Cardiopulmonary Resuscitation dated [DATE], the P/P indicated Properly trained personnel will be available to provide basic life support, including CPR, to those requiring emergency care, prior to arrival of emergency medical personnel, and subject to accepted professional guidelines, advance directives, and physician orders. The P/P indicated the facility shall follow current AHA guidelines regarding CPR. The P/P indicated the general procedural guidelines include:Immediately initiating a code blue emergency response in a cardiopulmonary emergency to facilitate additional assistance and activating emergency services.Engage in concurrent/coordinated emergency response efforts such as quickly evaluating resident responsiveness, breathlessness, and pulselessness, and activating 911, positioning the individual for CPR, initiating chest compressions and performing rescue efforts, retrieving crash cart, verifying code status, and preparing records for emergency transfer.During a review of the AHA Guidelines, dated 2025, the AHA Guidelines indicated for adult basic life support for healthcare professionals the algorithmic (sequence of instructions) steps were to:Verify scene safetyCheck for responsiveness.Shout for help nearby.Activate the emergency response system.Send someone to get the Automated External Defibrillator (AED-portable lifesaving medical device).Look for breathing and check a pulse simultaneously within 10 seconds.If there is no pulse start CPR by performing 30 compressions to 2-breath until an AED/defibrillator arrives.Once AED arrives check for a shockable rhythm (abnormal heartbeat treated with an AED).If not shockable resume CPR immediately for 2 minutes until prompted by the AED machine, and to continue until Advanced Life Support professionals (ALS-healthcare provider trained to provide high level medical care in life threatening situations) take over or the person starts to move. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc guidelines/algorithms

Based on interviews and record review, the facility failed to ensure staff were competent in basic life support (BLS, a set of emergency medical procedures designed to sustain life by maintain breathing and circulation) when Resident 1 was found pulseless by Certified Nursing Assistant (CNA) 1 on [DATE].This failure resulted in delay in initiating Cardiopulmonary Resuscitation (CPR an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to Resident 1 when Resident 1 was found unresponsive and no pulse on [DATE] at 10:30 p.m. Resident 1 was pronounced dead at 11:12 p.m.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including elevated white blood cell count (a condition where the number of white blood cells in the blood is higher than normal), anemia ( low blood count), acute kidney failure (AKI, the sudden loss of kidney function), and chronic kidney disease (CKD, slow, progressive loss of kidney function over months or years),During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 had the capacity to make medical decisions.During a review of Resident 1's Physician Orders for Life-Sustaining Treatment (POLST- an actionable medical order form for seriously ill or frail individuals, outlining specific treatment preferences like CPR that emergency personnel must follow) dated [DATE], the POLST indicated if Resident 1 was in cardiopulmonary arrest (a sudden stop of function of the heart) CPR was required.During a review of Resident 1's Nursing Progress Note, dated [DATE], the Nursing Progress Note indicated at about 10:30 p.m., RN 1 was notified that Resident 1 was unresponsive, and upon assessment, CPR was initiated (unknown time) and 911 was called at 10:37 p.m. The Nursing Progress Note indicated paramedics arrived at the facility at 10:47 p.m. and took over CPR. The Nursing Progress Note indicated Resident 1 was pronounced dead at 11:13 p.m.During a review of Resident 1's Fire Call History, dated [DATE], the Fire Call History indicated the 911 call regarding Resident 1 was placed at 10:37 p.m.During a review of Resident 1's Paramedic Run Sheet, dated [DATE], the Paramedic Run Sheet indicated paramedics were dispatched at 10:39 p.m., and were at Resident 1's bedside at 10:49 p.m. The Paramedic Run Sheet indicated Resident 1 was treated per their cardiac arrest protocol with high quality CPR initiated, ventilation (delivery of rescue breaths [artificial respiration] to provide oxygen) provided via bag valve mask (BVM, a handheld, self-inflating device used to provide emergency ventilation to patients who are not breathing or are breathing inadequately), and three rounds of cardiac epinephrine (lifesaving medication ) given, but no change in condition throughout the efforts. The Paramedic Run Sheet indicated resuscitation efforts ceased.During a review of Resident 1's Certificate of Death (undated), the Certificate of Death indicated Resident 1 died on [DATE] at 11:13 p.m., and the immediate cause of death was cardiopulmonary arrest and the underlying cause was arteriosclerotic cardiovascular disease (disease that affects the heart or blood vessels).During an interview on [DATE], at 2:40 p.m., with CNA 1 (who was CPR certified) , CNA 1 stated on [DATE] at around 10:30 p.m. she found Resident 1 unresponsive, not breathing and without a carotid pulse (the pulse felt on the neck) after checking the pulse twice. CNA 1 stated instead of calling code blue and initiating CPR, at 10:30 p.m., she left the room to get help from LVN 1. CNA 1 stated she did not return to Resident 1's room after she informed LVN 1 and continued with her assignment.During an interview on [DATE] at 3:10 p.m., with RN 1, RN 1 stated on [DATE] at around 10:30 p.m., LVN 1 informed her Resident 1 was unresponsive, and LVN 1 and RN 1 went to Resident 1's room with a crash cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations). RN 1 stated when they arrived no other staff was in the room. RN 1 stated LVN 1 checked Resident 1's blood pressure and placed a pulse oximeter (device that measures blood oxygen saturation [blood oxygen level] and heart rate) on Resident 1's finger to detect a pulse, while she shook the resident to assess for responsiveness. RN 1 stated the pulse oximeter did not detect a pulse, then she checked Resident 1's carotid pulse and confirmed Resident 1 did not have a pulse. RN 1 stated she began chest compressions, called out for someone to call 911 and LVN 1 provided rescue breathing (used on a resident who has stopped breathing). RN 1 stated three to four minutes passed between the time LVN 1 notified her Resident 1 was unresponsive and the time 911 was called. RN 1 stated LVN 2 called 911 at 10:37 p.m. and the paramedics arrived at 10:47 p.m. and took over CPR. RN 1 stated the paramedics stopped CPR and resuscitation efforts at 11:13 p.m. RN 1 stated she was not aware Resident 1 had no pulse when CNA 1 found him at 10:30 p.m. RN 1 stated if she was aware, she could have initiated CPR immediately for a possibility of saving the Resident 1's life. RN 1 stated any delay in initiating CPR can cause brain damage (injury of brain cells) or death. RN 1 stated even a one-minute delay in starting chest compression after observing a resident without a pulse was too long.During an interview on [DATE], at 11:05 a.m., with the DSD, the DSD stated when staff finds a resident unresponsive staff should not leave the resident alone. The DSD stated staff should call a Code Blue or call for help and delegate someone to call 911 and get the crash cart. The DSD stated as soon as staff discovered Resident 1 without a pulse, chest compressions should have been initiated immediately. The DSD stated she did not know that CNAs were allowed to check for a pulse. The DSD stated CNA 1 leaving Resident 1 alone on [DATE] after finding him unresponsive with no pulse did not follow AHA BLS guidelines.During an interview on [DATE] at 11:05 a.m., with the DON, the DON stated she was not aware CNA 1 found Resident 1 without a pulse on [DATE], prior to notifying LVN 1. The DON stated when CNA 1 found Resident 1 unresponsive and pulseless it was acceptable for CNA 1 to leave Resident 1 to get help because CNA 1 cannot initiate CPR without knowing Resident 1's code status.The DON stated their policy titled Cardiopulmonary Resuscitation based on AHA guidelines does not include taking a blood pressure when a resident was found unresponsive. The DON stated if a resident had no pulse, the heart was not pumping blood, and a blood pressure reading could not be obtained. The DON stated if a resident was pulseless, within three to seven minutes it could result in tissue damage to the brain from the lack of oxygen. The DON stated 911 was called so paramedics could administer cardiac (heart) medications to help revive Resident 1 as staff at the facility were not trained to give advanced cardiac medications such as epinephrine. During a review of facility's P/P titled Cardiopulmonary Resuscitation (CPR) dated [DATE], the P/P indicated Properly trained personnel will be available to provide basic life support, including CPR, to those requiring emergency care, prior to arrival of emergency medical personnel, and subject to accepted professional guidelines, advance directives, and physician orders. The P/P indicated the facility shall follow current American Heart Association (AHA) guidelines regarding CPR. The P/P indicated the general procedural guidelines include:Immediately initiating a code blue emergency response in a cardiopulmonary emergency to facilitate additional assistance and activating emergency services.Engage in concurrent/coordinated emergency response efforts such as quickly evaluating resident responsiveness, breathlessness, and pulselessness, and activating 911, positioning the individual for CPR, initiating chest compressions and performing rescue efforts, retrieving crash cart, verifying code status, and preparing records for emergency transfer.During a review of the AHA Guidelines, dated 2025, the AHA Guidelines indicated for adult basic life support for healthcare professionals the algorithmic steps are:Verify scene safetyCheck for responsiveness.Shout for help nearby.Activate the emergency response system.Send someone to get the AED/defibrillator.Look for breathing and check a pulse simultaneously within 10 seconds.If there is no pulse start CPR by performing 30 compressions to 2-breath until an AED/defibrillator arrives.Once AED arrives check for a shockable rhythmIf not shockable resume CPR immediately for 2 minutes until prompted by the AED machine, and to continue until ALS professionals take over or the person starts to move. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithmsDuring a review of facility's P/P titled Competency of Nursing Staff dated 10/2017, the P/P indicated all nursing staff must meet specific requirements of their respective licensure and certification requirements defined by state law.During a review of the facility's CNA job description, dated 2003, the CNA job description indicated the CNAs' job duties and responsibilities included to:Report all changes in resident's condition to the Nurse Supervisor/Charge Nurse as soon as practical.Perform all assigned tasks in accordance with the established policies and procedures, and as instructed by supervisors.During a review of the facility's Charge Nurse (Licensed Vocational Nurse) job description, dated 2003, the Charge Nurse job description indicated the charge nurses' duties and responsibilities included to:Perform all assigned tasks in accordance with the established policies and procedures, and as instructed by supervisors.Ensure all department personnel, residents, and visitors follow the department's established policies and procedures at all times.During a review of the facility's Nurse Supervisor (Registered Nurse) job description, dated 2003, the Nurse Supervisor job description indicated the Nurse Supervisors' duties and responsibilities included to:Interpret the facility's policies and procedures to personnel, residents, visitors, and government agencies as required.Ensure that established policies and procedures are followed by all departmental personnel. Cross Reference F678

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) did not elope from the facility. This deficient practice resulted in Resident 1 eloping from the facility on 9/27/2025 at approximately 6:04 p.m., unbeknownst to staff. Resident 1 was returned to the facility on the same day (9/27/2025) after being found by family at a gas station four blocks from the facility at approximately 11:15 p.m. This deficient practice place Resident 1 at risk for harm because of in climate weather, motor vehicle accidents, fall, violence at the hands of others and death. Findings: During a review of Resident 1's admission Record , the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including ventricular tachycardia (fast heart rate), hypotension (low blood pressure), and depression (a feeling of sadness). During a review of Resident 1's History and Physical (H& P) dated 8/20/2025, the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Minimum Data Set (MDS] resident assessment tool) dated 8/22/2025, the MDS indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort). The MDS indicated maximum assistance with toileting hygiene, shower/bath, and personal hygiene. During a review of Resident 1's Progress Notes dated 9/27/2025, the Progress Notes indicated Resident 1 was not in his assigned room. A search for Resident 1 was initiated. The Progress Notes indicated Resident 1's family was contacted. The Director of Nursing (DON) and Administrator were also notified. The Progress Notes indicate that at 11:15 p.m., Resident 1 returned to the facility after family members found Resident 1 at a nearby gas station. During an interview on 9/30/2025 at 9:05 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated that he was working on the unit on 9/27/2025 when Resident 1 exited the facility unsupervised. CNA 1 stated that during routine rounds at approximately 3:30 p.m., he noticed that Resident 1 was not in his assigned room. He immediately checked the surrounding area and notified the Registered Nurse Supervisor (RNS). CNA 1 stated, the RNS informed him that Resident 1 was downstairs with his wife and expressed no concern that the resident might leave the facility. CNA 1 further stated that at approximately 5:30 p.m., during another routine round, he observed Resident 1 lying in bed. CNA 1 stated Resident 1 was observed attempting to pull out his gastrostomy tube (G-tube) and was trying to get out of bed. CNA 1 stated he reported this behavior to Licensed Vocational Nurse (LVN) 1 and the RNS but stated that no further interventions or actions were taken by the nursing staff. CNA 1 stated that he monitors residents every two hours and as needed. CNA 1 stated at approximately 10:00 p.m., and he discovered that Resident 1 was no longer in the facility. CNA 1 immediately notified LVN 1 and the RNS. CNA 1 stated that both nurses initiated a search of the facility, including both interior and exterior areas, in an effort to locate the resident. CNA 1 stated that residents were not permitted to go downstairs without staff supervision, and that if a resident leaves the facility or moves about unsupervised, resident were at risk for harm such as falls, injury, becoming lost, or encountering unsafe situations in the community. During an interview conducted on 9/30/2025 at 9:30 a.m. with Licensed Vocational Nurse (LVN) 1, he stated that he was responsible for the care of Resident 1 at the time of the elopement on 9/27/2025. LVN 1 stated that at approximately 3:00 p.m., during routine rounds, he observed Resident 1 in his room with his wife and another family member. LVN 1 stated approximately 5:00 p.m., while passing medications, he saw Resident 1 sitting alone in a wheelchair in the hallway. LVN 1 offered the resident his medications, which the resident refused. LVN 1 stated that at approximately 10:00 p.m., CNA 1 informed him that Resident 1 was missing from the facility. LVN 1 stated upon receiving this report, LVN 1 immediately notified the Registered Nurse Supervisor (RNS) and initiated a search of the facility, both inside and outside. LVN 1 contacted Resident 1's wife, who confirmed that the resident was not with her and stated she would come to the facility to assist in locating him. LVN 1 stated that Resident 1 was out of the facility for approximately five hours. LVN 1 stated residents must be supervised at all times when going downstairs. LVN 1 stated that if a resident elopes from the facility without supervision, they were at risk for injury, becoming lost, or encountering environmental hazards. During an interview conducted on 9/30/2025 at 11:55 a.m. with LVN 2, LVN 2 stated that residents were not permitted to go downstairs without staff supervision. LVN 2 stated that there was no nursing personnel assigned to the first floor, and it was unclear who was responsible for monitoring residents in that area. LVN 2 stated that residents who go downstairs unsupervised could be at risk for falls, medical emergencies, or elopement, which could result in injury. LVN 2 further stated that Resident 1 wears a life vest, an external medical device used for patients at risk of sudden cardiac arrest and therefore requires continuous monitoring and supervision. LVN 2 emphasized that if the vest were to become dislodged or malfunction, the resident could require immediate medical assistance. During an interview on 9/30/2025 at 11:55 a.m. with License Vocational Nurse (LVN) 2, LVN 2 stated that the residents were not allowed to go downstairs unsupervised. LVN 2 stated that there were no nursing personnel on the first floor to supervise residents, and it is unclear who is responsible for their monitoring. LVN 2 stated Residents could fall, have an emergency medical, or could leave the facility and become injured. LVN 2 stated that Resident 1 wears a life vest ( an external medical device worn by patients at risk of sudden [cardiac death]-when the heart stops working) and requires continuous monitoring and supervision, as the vest could come off and the resident may need immediate assistance. During a concurrent observation and interview conducted on 9/30/2027 at 12:27 p.m. with the Maintenance Supervisor (MS), the dining room exit doors were observed to be locked from the outside, while staff were able to open the doors freely from the inside. The MS stated that the dining room exit doors can be secured externally but emphasized that residents and visitors were still able to exit the facility from the inside at any time. The MS acknowledged that this setup poses a safety concern for residents, stating that it was potentially dangerous and could compromise resident safety in the event of an emergency. During a concurrent observation and interview on 9/30/2027 at 1:30 p.m. with the Director of Nursing (DON), the DON stated that residents were not permitted to go downstairs, as there was no nursing personnel stationed in that area to provide supervision. The DON further stated that Resident 1 requires monitoring and supervision due to wearing a life vest, and that elopement poses a significant risk to Resident 1's safety. The DON confirmed that Resident 1 was unsupervised and away from the facility for approximately five hours. Reviewed the facility's video surveillance footage from 9/27/2025, between 5:55 p.m. and 6:04 p.m., was conducted. The footage showed Resident 1 in a wheelchair exiting through the dining room exit doors at 6:04 p.m. The DON reviewed and validated the footage, confirming that the individual captured in the video appeared to be Resident 1. During a review of the facility's policy and procedure (P&P) titled, “Safety and Supervision of Residents,” dated 2017, the P&P indicated, “Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision to prevent accidents are facility-wide priorities.”

Based on interview and record review, the facility failed to ensure the resident, who had developed behavioral symptoms manifested by increased confusion, cursing staff, yelling at staff, and refusing personal care and treatment, had a medical doctor's (MD) order for urinalysis with cultures and sensitivity (a urine diagnostic test used to detect presence of bacteria) carried out to determine the presence of urinary tract infection (UTI- an infection in the bladder/urinary tract) and to prevent a delay in treatment for one of one sampled resident (Resident 100). The facility failed to:1. Ensure Resident 100's urine was collected for urinalysis with cultures and sensitivity as ordered by the resident's MD on 7/4/2025 due to Resident 100's onset of behavioral symptoms (cursing staff, yelling at staff, refused care and refusal of breathing treatment) to rule out (exclude) UTI.2. Ensure Resident 100's MD was informed when a urine for urinalysis was not sent on 7/7/2025 as ordered by the resident's MD on 7/4/2025. 3. Follow the facility's policy and procedure (P&P) titled, Lab and Diagnostic Test Results-Clinical Protocol, revised 11/2018, which indicated the staff will process ordered tests requisitions and arrange for a diagnostic test. These failures resulted in Resident 100 transferring to the General Acute Care Hospital (GACH) on 7/9/2025 where the resident was found to have pyuria (the presence of pus in the urine) and was diagnosed with acute urinary tract infection. Resident 100 was treated with intravenous (IV- into the vein) antibiotic (medication to treat infection) administration and was discharged from the GACH on 7/23/2025 with diagnosis of acute UTI. Findings:During a review of Resident 100's admission Record, the admission indicated Resident 100 was admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of the sacrum (triangular bone at the base of the spine that connects the spine to the pelvis), respiratory failure (the lungs cannot properly exchange gases, causing abnormal levels of carbon dioxide and/or oxygen in the arteries), chronic kidney disease (condition where the kidneys are damaged and cannot filter blood effectively), anxiety (emotion characterized by feelings of tension, worried thoughts ), and depression (persistent feeling of sadness and loss of interest). During a review of Resident 100's History and Physical (H&P) dated 6/17/2025, the H&P indicated, Resident 100 had the capacity to make decisions for herself.During a review of Resident 100's Minimum Data Set (MDS-a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 100 did not have any evidence of an acute change in mental status including inattention (difficulty focusing and easily distracted), disorganized thinking (irrelevant conversation or unclear flow of ideas), and altered level of consciousness (when a patient is not acting like their baseline, seems confused and disoriented, or is not acting normally). The MDS indicated Resident 100 did not have behavioral symptoms including physical behavior (hitting, kicking, pushing), and verbal behavior (threatening others, screaming at others, cursing at others). The MDS indicated Resident 100 did not exhibit rejection of care (blood work, taking medications and assistance with activities of daily living [ADL]) The MDS indicated Resident 100 did not hallucinate (sights, sounds, smells, tastes, or touches that a person believes to be real but are not real) or had delusions (false beliefs). The MDS indicated Resident 100 was dependent (helper does all the effort, assistance of two or more helpers is required) on nursing staff with toileting hygiene, showering, putting on and taking off footwear. The MDS indicated Resident 100 needed substantial to maximal assistance from nursing staff with dressing, rolling from left to right, sitting, and lying down. The MDS indicated Resident 100 had urinary and bowel incontinence (inability to control urination and defecation [feces]). During a review of Resident 100's Physician's Order Summary Report dated 6/27/2025, the Physician's Order Summary Report indicated an order for urinalysis with urine cultures related to chronic kidney disease. The Physician's Order Summary Report indicated Resident 100 may have an in and out catheter (a thin, flexible tube inserted into the bladder to drain urine and then removed immediately after) to collect a urine specimen.During a review of Resident 100's Laboratory Results Report dated 6/30/2025, the Laboratory Results Report indicated that urine culture resulted in no growth of bacteria (tiny organisms that can cause infections and illnesses).During review of Resident 100's Change of Condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, understand, learn, and remember] behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation dated 7/4/2025, the COC Evaluation indicated Resident 100 had an increased confusion, was cursing staff, yelling at staff, refusing personal care and treatment. The COC indicated Resident 100 had altered level of consciousness. The COC Evaluation indicated Resident 100's MD was notified on 7/4/2025 at 10 a.m., of Resident 100's COC and ordered urinalysis with cultures and sensitivity, Ativan (medication used to treat anxiety) 1.0 milligram ([mg]-unit of measurement) every six hours as necessary (PRN), and Seroquel (medication used to treat depression) 25 mg every six hours as necessary. During a review of Resident 100's Physician's Order Summary Report dated 7/4/2025, the Physician's Order Summary Report indicated an order for urinalysis with culture and sensitivity scheduled to be collected on 7/7/2025.During a concurrent interview and record review on 7/29/2025 at 2:30 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 100's COC Evaluation dated 7/4/2025 and 7/9/2025 were reviewed. The COC Evaluation dated 7/4/2025 indicated Resident 100 refused care, treatment, and was striking, hitting, cursing, and yelling at the staff. The COC Evaluation dated 7/4/2025 indicated an order for urinalysis with culture. The COC Evaluation dated 7/9/2025 indicated Resident 100 was transferred to a GACH for a psychiatric (relating to mental illness) evaluation and treatment of inappropriate behavior on 7/9/2025 at around 11 a.m. LVN 1 stated Resident 100 had a urine culture ordered on 7/4/2025 to be collected on 7/7/2025. LVN 1 stated the urine culture was not done because the night shift (7/6/2025) Registered Nurse Supervisor (RNS)1 did not print the order for the urine culture in the requisition book. LVN 1 stated the RNS 1 should have endorsed (hand off) the urine culture order to the incoming day shift (7/7/2025) so it could have been collected and send to the laboratory. LVN 1 stated there was no documentation on 7/7/2025 that Resident 100's MD was notified that urine culture test was not done on 7/7/2025 as ordered on Resident 100's Progress Notes. During an interview on 8/1/2025 at 9:57 a.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated Resident 100 was not agitated, and was not yelling or screaming when was admitted to the facility on [DATE]. RNS 2 stated on 6/16/2025 at 4:24 a.m., Resident 100 became combative and was striking at staff. RNS 2 stated the MD came to see Resident 100 on 6/17/2025 but there was no documentation the doctor was notified regarding Resident 100's combative behavior. RNS 2 stated Resident 100 was seen by the MD but did not address Resident 100's confusion and per resident and family request a psychiatrist ( a medical doctor specializing in mental health) evaluation was scheduled for 7/17/2025. RNS 2 stated Resident 100 continued to have periods of confusion. RNS 2 stated on 6/27/2025 the doctor ordered to have Computed Tomography (CT-imaging) scan, Complete Blood Count (CBC- laboratory test), Basic Metabolic Profile (BMP- laboratory test), Ammonia (NH3 laboratory test), urinalysis (UA) with culture and sensitivity. RNS 2 stated on 6/30/2025 Resident 100 continued to have confusion and forgetfulness. RNS 2 stated on 6/30/2025 Resident 100 had a CT scan of the brain. RNS 2 stated on 7/4/2025 Resident 100 became agitated with increased confusion, verbal aggression, and was crying. RNS 2 stated Resident 100's MD ordered Ativan 1.0 mg every six hours and Seroquel 25 mg every six hours for agitation, refusal of care, and cursing at staff. RNS 2 stated a repeat urine culture was ordered to be collected on 7/7/2025. RNS 2 stated Resident 100 continued to be confused and started speaking gibberish (meaningless speech) and yelling. RNS 2 stated on 7/8/2025 the antipsychotic medication (used to treat psychosis) was ineffective, and the resident was still agitated, refused to be changed, was verbally aggressive and threatened to be physically aggressive. RNS 2 stated on 7/9/2025 at 11:09 a.m., Resident 100 was transferred to the GACH for evaluation and treatment of inappropriate behavior. RNS 2 stated the urine culture ordered on 7/7/2025 was not collected and Resident 100's MD was not notified. RNS 2 stated elderly residents can have confusion from a UTI and if remained untreated could have more confusion, behavioral changes and urosepsis (a life-threatening condition where UTI spreads to the bloodstream). During an interview on 8/1/2025 at 3:34 p.m., with the Director of Nursing (DON), the DON stated Resident 100 was alert and oriented, not altered, not combative, not yelling and not screaming upon admission to the facility on 6/12/2025. The DON stated on 6/16/2025 there was no notification to the resident's medical doctor about Resident 100 combativeness and yelling. The DON stated the medical doctor should have been notified to make sure the resident was assessed and got the proper care and treatment. The DON stated on 7/4/2025 Resident 100's medical doctor ordered urine culture when informed of Resident 100's behavioral symptoms (cursing staff, yelling at staff, refused care). The DON stated Resident 100's urine was not collected on 7/7/2025 as ordered. The DON stated UTI can cause confusion and behavioral changes in elderly residents. During a review of Resident 100's emergency room (ER) admission History and Physical, dated 7/9/2025, the ER admission and H&P indicated Resident 100 was alert and oriented to name, place and time. The ER admission H&P indicated Resident 100 was brought by paramedics (medical professionals who provide emergency medical care) from the facility due to increased agitation and to rule out sepsis (a life-threatening complication of an infection) /UTI. During a review of Resident 100's Physician Emergency Department Note, dated 7/9/2025, the Physician Emergency Department Note indicated the urine sample collected via the urinary catheterization (the process of inserting a flexible tube, called a catheter, into the bladder to drain urine) was very thick and suggestive of pus. The Physician Emergency Department Note indicated the laboratory had a difficult time performing the urinalysis secondary to the fact that the urine was too thick. The Physician Emergency Department Note indicated Resident 100 was then given intravenous (IV into a vein) fluids and antibiotics (medication used to treat infection) and then a repeat urinalysis was obtained. The repeat urinalysis dated 7/9/2025, resulted in a high number of white blood cells (WBC-{blood cells that help the body fight infection and other diseases} of 430 cells per microliter [cells/uL], reference range is 0-5 cells/uL) and presence of 4+ bacteria (reference range is 0). The Physician Emergency Department Note indicated Resident 100 had pyuria indicative of infection in the urinary tract and that the resident was not medically stable. The Physician Emergency Department Note indicated Resident 100 was admitted to the GACH and was started on IV Rocephin (antibiotic) for UTI and UA cultures indicated the presence of Proteus Mirabilis (type of bacteria) resistant (ineffective) to nitrofurantoin (antibiotic) otherwise sensitive (effective) to all other antibiotics. During a review of the facility's policy and procedure (P&P) titled, Quality of Life (undated), the P&P indicated Each resident will receive, and the facility will provide the necessary care and services to attain and maintain the highest physical, mental, and psychosocial wellbeing, consistent with the resident's comprehensive assessment and plan of care. During a review of the facility's policy and procedure (P&P) titled Lab and Diagnostic Test Results-Clinical Protocol, revised 11/2018, the P&P indicated The MD will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process test requisitions and arrange for a test.

Based on interview and record review, the facility failed to implement its abuse/neglect policy and procedures for two of three sampled residents (Resident 15 and Resident 74). Facility failed to:1. Report Resident 74's allegation of Certified Nursing Assistant (CNA 1) physical abuse. 2. Report Resident 15's fracture (broken bone) of unknown origin to California Department of Public Health ( CDPH), law enforcement, or the Ombudsman. These deficient practices resulted in a delay of an investigation and potentially increased the risk of abuse, neglect, and mistreatment of other residents. Findings1.During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) and rheumatoid arthritis (a chronic-progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment and required maximal (helper does more than half the effort) assistant with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During an interview on 7/29/2025 at 1:03 p.m., with Resident 74's family member, Resident 74's family member stated there was a CNA (unknown) that was rough with Resident 74 while changing her diaper (incontinent pad). At this time, Resident 74 took out her personal cell phone and showed me a picture she took of the CNA involved. Resident 74's family member stated they informed the staff of what had happened. During an interview on 7/30/2025 at 10:20 a.m., with the Assistant Director of Nursing (ADON), ADON stated Resident 74 told her a CNA on the night shift was rough with her when changing her. ADON stated depends on the situation when asked if she considers being rough with a resident a form of abuse. The ADON stated she did not report the allegation because Resident 74 told her she was fine. During an interview on 7/30/2025 at 10:50 a.m., with CNA 3, CNA 3 stated being rough with a resident was considered a form of abuse. During a phone interview on 7/30/2025 at 11:23 a.m., with CNA 1, CNA 1 stated she made aware that Resident 74 accused her of being rough with her while changing her and was going to be suspended by the facility. During an interview on 7/30/2025 at 11:39 a.m., with the Director of Staff Development (DSD), the DSD stated if a resident stated a staff member was rough with them, it was considered a form of abuse and should be reported to CDPH and investigated immediately. The DSD stated it was important to report and investigate the allegation of abuse to ensure it does not happen to another resident. During an interview on 8/1/2025 at 3:03 p.m., with the Director of Nursing (DON), the DON stated she was told Resident 74 was refusing to be changed but CNA 1 changed her anyways. The DON stated the allegation should have been reported and investigated but at the time they did not consider it a form of abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 12/1/2022, the P&P indicated, To promote an environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. Staff training will include identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. 2.During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety (a common mental health condition characterized by excessive worry, fear, and nervousness), and recurrent dislocation (when bones in a joint are forced out of their normal position) of right shoulder. During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) dated 5/26/2025, the MDS indicated Resident 15's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 15 was dependent (helper does all the effort) with her activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 15's Progress Notes written by the Assistant Director of Nursing (ADON) dated 7/31/2025 at 2:34 p.m., the Progress Notes indicated the ADON received information from the General Acute Care Hospital (GACH) that Resident 15 had a right shoulder fracture (broken bone) on 7/31/2025. During a review of Resident 15's GACH Consultant Note indicated Resident 15's X-ray (images that produce pictures of the inside of the body) of the right shoulder on 7/30/2025 indicated an acute displaced fracture of the proximal (closer to the center) right humeral (upper arm bone) neck as a displaced (a broken bone where the pieces have moved out of their normal alignment) fracture of the humeral shaft. During an interview on 7/31/2025 at 1:23 p.m., with Certified Nurse Assistant (CNA) 6, CNA 6 indicated Resident 15 appeared to have increased pain in her right arm with movement the last couple of days (7/29/2025-7/31/2025). During an interview on 8/1/2025 at 1:48 p.m., with the ADON, the ADON indicated she was informed by the GACH that Resident 15 had a right shoulder fracture on 7/31/2025. The ADON stated she only informed the Director of Nursing (DON) of Resident 15's fracture but did not report to the California Department of Health (CDPH), law enforcement, or the Ombudsman. The ADON stated not reporting Resident 15's fracture of unknown origin had the potential to result in placing Resident 15 for continued harm.During an interview on 8/1/2025 at 3:03 p.m., with the DON, the DON stated she was just made aware of Resident 15's fracture on 7/31/2025 afternoon by ADON. The DON stated she was unaware of how Resident 15 got a fracture and it should have been reported by the ADON to CDPH, law enforcement and the Ombudsman. The DON stated it was important to report and investigate immediately to ensure there was no abuse because it could happen to another resident.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 12/2007, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors.During a review of the facility's P&P titled, Abuse Reporting and Investigation, dated 1/10/2024, the P&P indicated, All allegations of abuse, neglect, mistreatment, exploitation or injury of unknown cause/origin shall be reported to the Abuse Prevention Coordinator (APC) immediately. When the APC receives a report of an incident or suspected incident of abuse, mistreatment, neglect, exploitation or injuries of unknown source, the APC shall initiate an investigation immediately. During a review of the facility's P&P titled, Abuse Prevention Program, dated 12/1/2022, the P&P indicated, Injury of unknown source, an injury that meets both the following conditions: the source of the injury was not observed by any person or the source of the injury is suspicious because of the extent of the injury, the location of the injury.

Based on observation, interview, and record review, the facility failed to ensure two of nine sampled residents (Residents 21 and 36) received appropriate services to prevent a decline in the range of motion (ROM, full movement potential of a joint) and mobility by failing to:1. Initiate a Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) program timely for Resident 21's lower extremities (hip, knee, ankle, feet) for passive range of motion (PROM, movement at a given joint with full assistance from another person) upon completion of Rehab Joint Mobility Assessment ([JMA] evaluates the range of motion, flexibility, and overall health of a joint) on 7/17/2025. 2. Complete a quarterly Rehab JMA for Resident 36's upper extremities (BUE, shoulder, elbow, wrist/hand) on 9/20/2024. Findings: 1. During a review of Resident 21's admission Record (AR), the AR indicated Resident 21 initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following unspecified cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain) affecting left dominant side, aphasia (a disorder that makes it difficult to speak), stiffness of left wrist, stiffness of left hand, and pain in left elbow. During a review of Resident 21's Minimum Data Set (MDS, resident assessment tool) dated 4/22/2025, the MDS indicated Resident 21 had functional ROM limitations on one side of the upper extremity (UE, shoulder, elbow, wrist, hands) and on both sides of the lower extremity (BLE, hip, knee, ankle/foot). The MDS also indicated Resident 21 required dependent assistance from staff for oral hygiene, bathing, dressing, and bed to chair transfers. The MDS indicated Resident 21 rarely understood others.During a review of Resident 21's History and Physical Examination (H&P) dated 7/18/2025, the H&P indicated Resident 21 did not have the capacity to understand and make decisions. During a review of Resident 21's Rehab JMA dated 7/17/2025, the JMA indicated Resident 21 had moderate ROM limitation in left shoulder flexion (moving arm up and down) abduction (moving arm away from the body), moderate limitation in left elbow, minimal limitation in left wrist and left hand/fingers. The JMA indicated Resident 21 had minimal limitation in right shoulder flexion and abduction, full (no limitation to within functional limits) ROM in right elbow, right wrist, and right hand/fingers. The JMA indicated Resident 21 had full ROM in both hips and both knees, and severe ROM limitation in both ankles. The JMA indicated will place on RNA ROM program to both [lower extremities].During a review of Resident 21's Order Summary Report (OSR) dated 7/29/2025, the OSR indicated an order dated 7/28/2025 for RNA for PROM BLE once a day, five times a week or as tolerated. During a review of Resident 21's Care Plan (CP) dated 7/28/2025, the CP indicated Resident 21 was at high risk for further decline in ROM related to impaired mobility and decreased strength for BLE. The CP goal indicated Resident 21 will maintain ROM to BLE through next review date. The CP interventions indicated PROM of BLE with RNA five days a week. During an observation on 7/30/2025 in Resident 21's room, Resident 21 was lying in bed with eyes open. Resident 21 did not respond to verbal or visual cues. Resident 21's left elbow was bent more than halfway, the left wrist was straight, and the left fingers were in a fisted position with the left thumb in between the third and fourth fingers. Resident 21's right arm was straight. Resident 21's right knee was bent more than halfway and rotated away from the body. Resident 21 was able to move the right leg towards the body a little. Resident 21's left leg was straight. During a concurrent interview and record review on 7/30/2025 at 11:15 a.m. with the Rehab Director (RHB), the RHB stated physical therapy staff completed a JMA on 7/17/2025 and recommended an RNA program for PROM to BLE. The RHB stated the RNA program was not ordered until 7/28/2025 and there was a delay in the start of RNA services for Resident 21. The RHB stated Resident 21's RNA program should have started on 7/17/2025. The RHB stated Resident 21 was at risk for a decline ROM if RNA for PROM was not started timely. During an interview on 7/30/2025 at 3:36 p.m., the Director of Nursing (DON), the DON stated the RNA program was a nursing program to help prevent a resident's overall decline and could include ROM, ambulation (walking), and putting on splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint). The DON stated it was important for RNA to be ordered and completed timely, because if the RNA order was not completed timely a resident could experience a decline in mobility and ROM. During a review of the facility's policies and procedures (P&P) revised 7/2017, titled, Restorative Nursing Services, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. 2. During a review of Resident 36's AR, the AR indicated Resident 36 was admitted to the facility on [DATE] with diagnoses including, contracture (loss of motion of a joint) of right ankle, contracture left ankle, nontraumatic intracerebral hemorrhage (bleeding in the brain). During a review of Resident 36's MDS, dated [DATE], the MDS indicated Resident 36 was severely impaired in cognitive skills (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving) for daily decision making. The MDS indicated Resident 36 had functional ROM limitations on both sides of the upper extremities and both sides of the lower extremities. The MDS indicated Resident 36 was dependent on staff for oral hygiene, bathing, dressing and chair to bed transfers. During a review of Resident 36's CP revised 1/7/2024, the CP indicated Resident 36 was at risk for developing joint limitations and contractures related to impaired mobility. The CP goal indicated Resident 36 will not develop complications from existing contractures. The CP interventions indicated to observe/report changes in range of motion status and monitor for signs and symptoms of pain or discomfort related to contractures. During a review of Resident 36's quarterly Rehab JMA dated 9/20/2024, the JMA indicated Resident 36 had moderate ROM limitations in both hips, both knees, and both ankles. The JMA was blank, and no entries were made for the upper extremity joints.During an observation on 7/28/2025 at 10:25 a.m., Resident 36 was lying in bed and was wearing elbow splints on both elbows. Resident 36's wrists were mostly straight, and fingers were slightly bent. Resident 36 was not able to answer any questions. During a concurrent interview and record review on 7/30/2025 at 11:15 a.m., Resident 36's Rehab JMA dated 9/20/2024 was reviewed. The RHB stated the JMA was not completed for Resident 36's upper extremities. The RHB stated therapy staff completed JMA upon admission, quarterly, annually, and as needed for BUE and BLE to check for any changes in joint mobility. The RHB stated it was important to monitor ROM because a resident used their extremities for their daily activities and mobility. The RHB stated if a resident had a decline or difference in ROM, it would affect a resident's functional mobility. The RHB stated Resident 36's quarterly JMA for BUE was missed and should have been completed on 9/20/2024. The RHB stated Resident 36 was at risk for decline in ROM in BUE because Resident 36 had contractures in both elbows and staff needed to monitor Resident 36 for any further decline in ROM. During a review of the facility's policies and procedures (P&P) revised 7/30/2018, titled, Joint Mobility Assessment Review, the P&P indicated the facility will provide a regular review system of ongoing observation of ROM and functional range for each resident and an additional quarterly and annual confirmation of maintaining joint status.

Based on interview and record review, the facility failed to ensure their staff had:1.Competence on reporting alleged allegations of abuse and injury of unknow origin by failing to: 1a. Ensure an injury of unknown origin was reported to the California Department of Health (CDPH), the Ombudsman, and law enforcement and investigated for Resident 15.1b. Ensure an abuse allegation was reported to CDPH, the Ombudsman, and law enforcement and investigated for Resident 74.These deficient practices potentially increased the risk of abuse, neglect, and mistreatment of other residents. 2. Annual competencies (regularly scheduled evaluations that gauge an individual's knowledge, skills, and abilities in a specific role or area, typically within a healthcare or professional setting) completed for three of five sampled staff (Director of Staff Development (DSD), Activities Director (AD) and Certified Nursing Assistant (CNA) 5)This deficient practice had the potential for the facility not to be able to assess the skills necessary to provide nursing services to assure resident safety and to ensure facility staff will be performed within the acceptable standards of practice.Findings1.During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) and rheumatoid arthritis (a chronic-progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment and required maximal (helper does more than half the effort) assistant with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During an interview on 7/29/2025 at 1:03 p.m., with Resident 74's family member, Resident 74's family member stated there was a CNA (unknown) that was rough with Resident 74 while changing her diaper (incontinent pad). At this time, Resident 74 took out her personal cell phone and showed me a picture she took of the CNA involved. Resident 74's family member stated they informed the staff of what had happened. During an interview on 7/30/2025 at 10:20 a.m., with the Assistant Director of Nursing (ADON), ADON stated Resident 74 told her a CNA on the night shift was rough with her when changing her. ADON stated depends on the situation when asked if she considers being rough with a resident a form of abuse. The ADON stated she did not report the allegation because Resident 74 told her she was fine. During an interview on 7/30/2025 at 10:50 a.m., with CNA 3, CNA 3 stated being rough with a resident was considered a form of abuse. During a phone interview on 7/30/2025 at 11:23 a.m., with CNA 1, CNA 1 stated she made aware that Resident 74 accused her of being rough with her while changing her and was going to be suspended by the facility. During an interview on 7/30/2025 at 11:39 a.m., with the Director of Staff Development (DSD), the DSD stated if a resident stated a staff member was rough with them, it was considered a form of abuse and should be reported to CDPH and investigated immediately. The DSD stated it was important to report and investigate the allegation of abuse to ensure it does not happen to another resident. During an interview on 8/1/2025 at 3:03 p.m., with the Director of Nursing (DON), the DON stated she was told Resident 74 was refusing to be changed but CNA 1 changed her anyways. The DON stated the allegation should have been reported and investigated but at the time they did not consider it a form of abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 12/1/2022, the P&P indicated, To promote an environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. Staff training will include identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. 2.During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety (a common mental health condition characterized by excessive worry, fear, and nervousness), and recurrent dislocation (when bones in a joint are forced out of their normal position) of right shoulder. During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) dated 5/26/2025, the MDS indicated Resident 15's cognition (ability to think, understand, learn, and remember) was severely impaired. The MDS indicated Resident 15 was dependent (helper does all the effort) with her activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 15's Progress Notes written by the Assistant Director of Nursing (ADON) dated 7/31/2025 at 2:34 p.m., the Progress Notes indicated the ADON received information from the General Acute Care Hospital (GACH) that Resident 15 had a right shoulder fracture (broken bone) on 7/31/2025. During a review of Resident 15's GACH Consultant Note indicated Resident 15's X-ray (images that produce pictures of the inside of the body) of the right shoulder on 7/30/2025 indicated an acute displaced fracture of the proximal (closer to the center) right humeral (upper arm bone) neck as a displaced (a broken bone where the pieces have moved out of their normal alignment) fracture of the humeral shaft. During an interview on 7/31/2025 at 1:23 p.m., with Certified Nurse Assistant (CNA) 6, CNA 6 indicated Resident 15 appeared to have increased pain in her right arm with movement the last couple of days (7/29/2025-7/31/2025). During an interview on 8/1/2025 at 1:48 p.m., with the ADON, the ADON indicated she was informed by the GACH that Resident 15 had a right shoulder fracture on 7/31/2025. The ADON stated she only informed the Director of Nursing (DON) of Resident 15's fracture but did not report to the California Department of Health (CDPH), law enforcement, or the Ombudsman. The ADON stated not reporting Resident 15's fracture of unknown origin had the potential to result in placing Resident 15 for continued harm.During an interview on 8/1/2025 at 3:03 p.m., with the DON, the DON stated she was just made aware of Resident 15's fracture on 7/31/2025 afternoon by ADON. The DON stated she was unaware of how Resident 15 got a fracture and it should have been reported by the ADON to CDPH, law enforcement and the Ombudsman. The DON stated it was important to report and investigate immediately to ensure there was no abuse because it could happen to another resident.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting, dated 12/2007, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors.During a review of the facility's P&P titled, Abuse Reporting and Investigation, dated 1/10/2024, the P&P indicated, All allegations of abuse, neglect, mistreatment, exploitation or injury of unknown cause/origin shall be reported to the Abuse Prevention Coordinator (APC) immediately. When the APC receives a report of an incident or suspected incident of abuse, mistreatment, neglect, exploitation or injuries of unknown source, the APC shall initiate an investigation immediately. During a review of the facility's P&P titled, Abuse Prevention Program, dated 12/1/2022, the P&P indicated, Injury of unknown source, an injury that meets both the following conditions: the source of the injury was not observed by any person or the source of the injury is suspicious because of the extent of the injury, the location of the injury. 2,During an interview on 8/1/2025 at 9:26 a.m., with the DSD, the DSD stated she did not have her annual competency evaluation. The DSD stated the AD and CNA 5 do not have their annual competency evaluation completed either. The DSD stated the importance of competency evaluations was to improve staff training, to make sure residents are safe, and to meet compliance.During an interview on 8/01/2025 at 3:31 p.m., with the Director of Nursing (DON), The DON stated every staff needs updated training. The DON stated residents will have a negative outcome when receiving care if the staff do not know the right procedures. During a review of the facility's policy and procedure (P&P), titled Competency of Nursing Staff, date revised 10/2027, the P&P indicated All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.

Based on observation, interview, and record review the facility failed to ensure:1. Uncovered bowl of dry cereal dated 7/21/2025 to 7/25/2025 was not stored in the dry storage room uncovered passed the use by date.2. Emergency food supply of six cans of corned beef hash with an expiration date of 12/2023 and a box of canned pulled chicken with an expiration date of 6/1/2025 were thrown away.These failures had the potential to result in the residents developing food borne illnesses ( illnesses caused by consuming contaminated foods or beverages) that could lead to other serious medical complications and hospitalizations.Findings:During an observation on 7/28/2025 at 9:15 a.m., in the dry food storage room, observed an uncovered bowl of dry cereal was on a tray labeled Cereal 7/21/2025 to 7/25/2025. The Dietary Manager (DM) quickly threw the cereal in the trash. During an observation on 7/30/2025 at 11:01 a.m., with DM, in the facility basement, observed six cans of corned beef hash cans that expired on 12/2023 and a box of canned pulled chicken that expired on 6/1/2025. There were no labels on the cans. During an interview on 8/01/2025 at 12:14 p.m., with DM, DM stated he threw the cereal because it was passed the use by date. DM stated the cans need to be labeled because they could end up being in the circulating food for the residents. DM stated the expired food in the emergency food supply were slowly getting discarded. DM stated the residents could get food borne illnesses or sickness-like diarrhea (loose stool) from eating expired foods.During an interview on 8/1/2025 at 3:29 p.m., with the Director of Nursing (DON), the DON stated residents can get stomach pain, diarrhea, nausea and vomiting from eating expired foods. The DON stated resident can be exposed to botulism (rare and potentially fatal illness caused by botulinum toxin) in the expired cans.During a review of the facility's policy and procedure (P&P) titled Storage of Food and Supplies, dated 2023, the P&P indicated, Food and supplies will be stored properly and in a safe manner.Dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled and dated.

Based on observation, interview, and record review, the facility failed to maintain accurate records for two out of 10 sampled residents (Resident 21 and Resident 52) by failing to:1. Indicate how long Resident 21 could wear a left elbow extension (straightening the elbow) splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and left resting hand splint during Restorative Nursing Aide program (RNA, nursing aide program that helps residents to maintain their function and joint mobility) treatment. 2. Accurately indicate how long Resident 52 could wear a left knee splint during RNA treatment. These deficient practices had the potential to cause injury to Residents 21 and 52 due to wearing splints for too long (skin integrity and pain) or for too little time (decline in ROM). Findings:1. During a review of Resident 21's admission Record (AR), the AR indicated Resident 21 initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following unspecified cerebrovascular disease (disease of the blood vessels, especially blood vessels to the brain) affecting left dominant side, aphasia (a disorder that makes it difficult to speak), stiffness of left wrist, stiffness of left hand, and pain in left elbow. During a review of Resident 21's Minimum Data Set (MDS, resident assessment tool) dated 4/22/2025, the MDS indicated Resident 21 had functional ROM limitations on one side of the upper extremity (UE, shoulder, elbow, wrist, hands) and on both sides of the lower extremity (LE, hip, knee, ankle/foot). The MDS also indicated Resident 21 required dependent assistance from staff for oral hygiene, bathing, dressing, and bed to chair transfers. The MDS indicated Resident 21 rarely understood others.During a review of Resident 21's History and Physical Examination (H&P) dated 7/18/2025, the H&P indicated Resident 21 did not have the capacity to understand and make decisions. During a review of Resident 21's medical records, the medical records indicated a previous order dated 6/17/2025 for RNA to see resident for BUE PROM and application of LUE elbow extension splint and resting hand orthotic (an external device to support, align, or correct a movable part of the body) five times a week or as tolerated. During a review of Resident 21's June 2025 Documentation Survey Report (DSR), the RNA intervention/task indicated RNA to see [resident] for BUE PROM and application of LUE elbow extension and resting hand orthotic five times a week or as tolerated. The DSR did not indicate how long Resident 21 could wear the LUE elbow extension and resting hand orthotic. During a review of Resident 21's Occupational Therapy Discharge Summary (OT DC) dated 6/17/2025, the OT DC indicated discharge recommendations for Resident 21 to wear an elbow extension splint and a resting hand splint on LUE for up to six hours. During a concurrent interview and record review on 7/30/2025 at 11:15 a.m. with the Rehab Director (RHB), Resident 21's June 2025 RNA records were reviewed. The RHB stated the RNA order dated 6/17/2025 indicated for RNA treatment for BUE PROM and application of LUE elbow extension splint and resting hand orthotic five times a week or as tolerated. The RHB stated the RNA order did not indicate the wear time and schedule for how long the RNAs should put on the left elbow extension splint or for the left resting hand splint. The RHB stated therapy needed to indicate in the RNA order how long to wear splints because it was the time therapy established Resident 21 could safely tolerate the splint. The RHB stated RNAs needed to know how long to put on the splint, because if RNA put on the splint for too long, the splint could cause skin problems and if the RNAs put on the splint for too little time, the resident would not maximize the tolerance and benefit of the splint. During an interview on 7/30/2025 at 3:36 p.m. with the Director of Nursing (DON), the DON stated RNA orders needed to include the type of splint and the splint wear time. The DON stated the RNA orders needed to be accurate because the time to wear the splint was how long the resident could tolerate the splint to prevent injury to the resident. During a review of the facility's policies and procedures (P&P) revised 1/1/2017, titled Splinting, the P&P indicated there must be a physician's order for splinting and to provide splint guidelines for application, wear, and care. 2. During a review of Resident 52's AR, the AR indicated Resident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including spina bifida (birth disorder in which the spine does not fully develop) and primary generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 52's MDS, dated [DATE], the MDS indicated Resident 52 had severe cognitive impairments (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS indicated Resident 52 did not have any functional range of motion (ROM, full movement potential of a joint) limitations in both upper extremities (BUE, shoulder, elbow, wrist/hand) and had functional ROM limitations on both sides of the lower extremities (BLE, hip, knee, ankle/foot). The MDS indicated Resident 52 was able to eat with setup assistance and required substantial assistance from staff for oral hygiene, bathing, upper body dressing. The MDS indicated Resident 52 required dependent assistance for lower body dressing, rolling left and right and shower transfers. During a review of Resident 52's Care Plan (CP) dated 6/26/2024, the CP indicated Resident 52 was at high risk for further decline in ROM related to impaired mobility and decreased strength for both lower extremities and spina bifida. The CP goal indicated Resident 52 will maintain ROM to BLE through the next review date. The CP interventions indicated left knee extension splint two hours as tolerated with RNA once a day five days a week. During a review of Resident 52's Order Summary Report (OSR) dated 7/30/2025, the OSR indicated an order dated 8/26/2024 for RNA for gentle passive ROM to BLE followed by application of left knee splint for four hours once a day five times a week or as tolerated. During a concurrent observation and interview on 7/28/2025 at 1:05 p.m., Resident 52 was lying in bed on the right side with head of bed up and the left knee was observed bent halfway. Resident 52 stated she was able to eat using her left arm with the lunch tray set on a bedside table in front of the resident. During a concurrent interview and record review on 7/30/2025 at 11:15 a.m., Resident 52's orders were reviewed. The RHB stated the order for RNA for gentle passive ROM to BLE followed by application of left knee splint for four hours once a day five times a week or as tolerated was not accurate and the RNA order for application of the left knee splint should be for two hours and not four hours. The RHB stated Resident 52's RNA care plan was accurate, and the RNA order and the RNA care plan should be the same. The RHB stated PT established Resident 52 could safely tolerate the left knee splint for two hours and two hours was how long RNA staff should put on the left knee splint. The RHB stated it was important for the RNA order to be accurate, because if Resident 52 wore the left knee splint for more than the resident could tolerate, it could cause pain. During an interview on 7/30/2025 at 3:36 p.m. with the DON, the DON stated the RNA orders should be accurate, because the RNA program was a nursing program to prevent residents from declining in ROM and contractures. The DON stated the RNA orders needed to be accurate because the time to wear the splint was how long the resident could tolerate the splint to prevent injury to the resident. During a review of the facility's policies and procedures (P&P) revised 1/1/2017, titled, Splinting, the P&P indicated there must be a physician's order for splinting and to provide splint guidelines for application, wear, and care.

Based on observation, interview, and record review, the facility failed to maintain three of three electrical rehabilitation therapy (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) equipment for resident use. This deficient practice had the potential for injury to any resident using the therapy equipment. Findings:During an observation and interview on 7/28/2025 at 1:21 p.m., with the Rehabilitation Director (RHB), the RHB stated the rehabilitation gym was downstairs on the first floor. The RHB stated the therapy department had three electrical therapy equipment including an ultrasound (equipment used to produce high-frequency sound waves that travel deep into tissue and create therapeutic heat), transcutaneous electrical nerve stimulation (TENS, a machine that uses electrical currents through a device to stimulate the nerves for therapeutic purposes) combination unit, Therapy Equipment (TE 1), an adjustable therapy mat (TE 2), and a bicycle (TE 3). The RHB provided a tour of the therapy gym on the first floor and located inside the therapy were TE 1, TE 2, and TE 3. The RHB stated she was not sure when the last maintenance check or calibration was for the three electrical therapy equipment. During an interview on 7/30/2025 at 11:15 a.m., with the RHB, the RHB stated TE 1 was purchased last year. The RHB stated no therapy staff or maintenance staff have checked or maintained TE 1, TE 2 and TE 3 and there were no records of any maintenance of the therapy equipment. The RHB stated it was important to maintain therapy equipment because the therapy equipment could cause injury to residents using the equipment if the equipment was not working correctly. During an interview on 7/30/2025 at 2:54 p.m. with the Maintenance Director (MND), the MND stated the maintenance staff did not check the therapy equipment or have a process for frequent preventive maintenance checks. The MND stated if the equipment was broken, then therapy staff could create a work order for the maintenance staff to fix the equipment, but maintenance staff did not perform general maintenance on the therapy equipment. During an interview on 7/30/2025 at 3:36 p.m. with the Director of Nursing (DON), the DON stated it was important to perform general preventive maintenance on therapy equipment, because it was to provide safe equipment for the residents using the therapy equipment during therapy. During a review of the facility's policy and procedure revised 12/2009, titled Maintenance Service, indicated the Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure the equipment are maintained in a safe and operable manner at all times. During a review of the facility's policy and procedure revised 1/1/2017, titled, Equipment Servicing and Maintenance, indicated inspection shall include functioning, general condition of equipment and a record will be kept in the department for each piece of equipment that is inspected.

The facility failed to ensure one of two residents (Resident 99) foley catheter ( a medical device that helps drain urine from your bladder [drainage bag]- the bag attached to the end of the catheter that collects the urine) was covered with a dignity bag ( a cover or pouch designed to hide the urine collection bag) in accordance with professional standards and the residents' right to dignity.This failure resulted in potential embarrassment, compromised privacy, and a lack of respect for Resident 99's dignity.Findings:During a concurrent observation and interview on 7/29/2025 at 3:57 p.m. with Certified Nurse Assistant (CNA) 4 in room [ROOM NUMBER]A, it was observed that Resident 99's foley catheter drainage bag was not covered by a dignity bag. CNA 4 stated the dignity bag was not in place on the drainage bag. CNA 4 stated that it is all staff's responsibility to maintain the foley catheters and ensure all residents have a dignity bag. CNA 4 stated that she usually places a dignity bag to cover the residents' drainage bag. CNA 4 stated that she does not know why she did not place a dignity bag on Resident 99's drainage bag. CNA 4 stated that she believed that having an uncovered drainage bag would be considered disrespectful for Resident 99. During a concurrent observation and interview on 7/29/2025 at 4:15 p.m. with Treatment Nurse (TN) 1, TN 1 stated she was unaware of Resident 99's drainage bag not being covered with a dignity bag. TN 1 stated that it is the facility's policy and procedure that all drainage bags be always covered with a dignity bag. TN 1 stated that she understands residents' drainage bags should be covered with a dignity bag to ensure that their privacy and dignity is protected. TN 1 stated that she is responsible for ensuring dignity cover is in place for the residents. TN 1 acknowledged the absence of Resident 99's dignity bag and confirmed understanding of the facility's policy on maintaining resident dignity and privacy.During an interview on 7/31/2025 at 11:03 a.m. with the Director of Staff Development (DSD), the DSD stated it is the facility's policy and procedure to apply a dignity bag on all residents' foley catheter drainage bags. The DSD stated it is the responsibility of all staff to ensure that all the drainage bags are covered with a dignity bag. The DSD stated that staff receives in services and huddles on how to maintain foley catheters and maintaining residents' dignity. The DSD stated that she was unaware of the incident regarding Resident 99 not having a dignity bag. The DSD stated that when residents' foley catheters are uncovered it is a violation of their dignity. During an interview on 8/01/2025 at 3:00 p.m. with the Director of Nursing (DON), the DON stated residents have the right to have privacy and their foley catheter drainage bags should be always covered with a dignity bag. The DON stated that it is the facility's practice that all residents that have a foley catheter have a dignity bag. The DON stated that the facility has policies and procedures in place to ensure that all foley catheter bags are stored and positioned in a manner that maintains resident dignity and reduces infection. The DON stated that staff receive in-services upon hire and through ongoing education to ensure that the staff are trained properly and understand the importance of keeping the residents' drainage bags covered. During a review of the facility's policy and procedures (P&P) dated 2021, the P&P indicated demeaning practices and standards of care that compromise dignity are prohibited. The P&P indicated staff are expected to promote dignity and assist resident; for example: a. helping the resident to keep urinary catheter bags covered.

Based on interview and record review, the facility failed to report an abuse allegation to the California Department of Health, the Ombudsman, and the law enforcement agency for one of three sampled residents (Resident 74), when Resident 74 reported to the Assistant Director of Nursing (ADON) that Certified Nurse Assistant (CNA) 1 physically abused her while providing her with personal care. This deficient practice had the potential to place other residents at risk for physical abuse. Findings:During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) and rheumatoid arthritis (a chronic-progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment and required maximal (helper does more than half the effort) assistant with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During an interview on 7/29/2025 at 1:03 p.m., with Resident 74's family member, Resident 74's family member stated there was a CNA (unknown) that was rough with Resident 74 while changing her diaper (incontinent pad). At this time, Resident 74 took out her personal cell phone and showed me a picture she took of the CNA involved. Resident 74's family member stated they informed the staff of what had happened. During an interview on 7/30/2025 at 10:20 a.m., with the Assistant Director of Nursing (ADON), ADON stated Resident 74 told her a CNA on the night shift was rough with her when changing her. ADON stated depends on the situation when asked if she considers being rough with a resident a form of abuse. The ADON stated she did not report the allegation because Resident 74 told her she was fine. During an interview on 7/30/2025 at 10:50 a.m., with CNA 3, CNA 3 stated being rough with a resident was considered a form of abuse. During a phone interview on 7/30/2025 at 11:23 a.m., with CNA 1, CNA 1 stated she made aware that Resident 74 accused her of being rough with her while changing her and was going to be suspended by the facility. During an interview on 7/30/2025 at 11:39 a.m., with the Director of Staff Development (DSD), the DSD stated if a resident stated a staff member was rough with them, it is considered a form of abuse and should be reported to CDPH and investigated immediately. The DSD stated it was important to report and investigate the allegation of abuse to ensure it does not happen to another resident. During an interview on 8/1/2025 at 3:03 p.m., with the Director of Nursing (DON), the DON stated she was told Resident 74 was refusing to be changed but CNA 1 changed her anyways. The DON stated the allegation should have been reported and investigated but at the time they did not consider it a form of abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse Reporting and Investigation, dated 1/10/2024, the P&P indicated, To promptly report all allegations of abuse as required by law and regulations to the appropriate agencies within the required time frames. To keep residents safe and prevent from future or recurrent potential abuse. All allegations of abuse, will be reported by the facility Administrator to the following agencies: The State licensing/certification agency responsible for surveying/licensing the facility, the local/State Ombudsman, and local law enforcement. Cross reference F607 and F610

Based on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled Abuse Prevention Program, dated 12/1/2022 by failing to investigate an abuse allegation for one of three sampled Residents (Resident 74).This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.Findings:During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) and rheumatoid arthritis (a chronic-progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment and required maximal (helper does more than half the effort) assistant with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During an interview on 7/29/2025 at 1:03 p.m., with Resident 74's family member, Resident 74's family member stated there was a CNA (unknown) that was rough with Resident 74 while changing her diaper (incontinent pad). At this time, Resident 74 took out her personal cell phone and showed me a picture she took of the CNA involved. Resident 74's family member stated they informed the staff of what had happened. During an interview on 7/30/2025 at 10:20 a.m., with the Assistant Director of Nursing (ADON), ADON stated Resident 74 told her a CNA on the night shift was rough with her when changing her. ADON stated depends on the situation when asked if she considers being rough with a resident a form of abuse. The ADON stated she did not report the allegation because Resident 74 told her she was fine. During an interview on 7/30/2025 at 10:50 a.m., with CNA 3, CNA 3 stated being rough with a resident was considered a form of abuse. During a phone interview on 7/30/2025 at 11:23 a.m., with CNA 1, CNA 1 stated she made aware that Resident 74 accused her of being rough with her while changing her and was going to be suspended by the facility. During an interview on 7/30/2025 at 11:39 a.m., with the Director of Staff Development (DSD), the DSD stated if a resident stated a staff member was rough with them, it is considered a form of abuse and should be reported to CDPH and investigated immediately. The DSD stated it was important to report and investigate the allegation of abuse to ensure it does not happen to another resident. During an interview on 8/1/2025 at 3:03 p.m., with the Director of Nursing (DON), the DON stated she was told Resident 74 was refusing to be changed but CNA 1 changed her anyways. The DON stated the allegation should have been reported and investigated but at the time they did not consider it a form of abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 12/1/2022, the P&P indicated, To promote an environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. The facility shall thoroughly investigate allegation of abuse by identifying and interviewing all involved, including the alleged victim, alleged perpetrator, witness(es) and others who might have seen, heard or have knowledge of the allegations, and with documented evidences that support the investigation.During a review of the facility's P&P titled, Abuse Reporting and Investigation, dated 1/10/2024, the P&P indicated, To thoroughly investigate ALL allegations of abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of unknown source when appropriate. To keep residents safe and prevent from future or recurrent potential abuse. Cross reference F607 and F609

Based on interview and record review the facility failed to ensure Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) was resubmitted and documented correctly for two of two sampled residents (Resident 9 and Resident 52).This failure had the potential to result in Resident 9 and Resident 52 not receiving the necessary care and services they need.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including depression (serious mood disorder that affects how a person feels, thinks, and behaves, schizoaffective (a mental illness that can affect thoughts, mood, and behavior), anxiety (a feeling of worry, nervousness, or unease) , psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and insomnia (difficulty sleeping).During a review of Resident 9's Physician Progress Notes, dated 1/8/2025, the Physician Progress Notes indicated that Resident 9 was able to make healthcare decisions.During a review of Resident 9's Minimum Dat Set (MDS-a resident assessment tool), dated 5/28/2025, the MDS indicated, Resident 9 needed nursing staff supervision with oral hygiene, toileting, showering, dressing, transferring and walking.During a review of Resident 9's Notice of Exempted Hospital Discharge, dated 2/12/2025, the Notice of Exempted Hospital Discharge indicated, the facility must resubmit a new Level I Screening as a Resident Review on the 31st day.During a review of Resident 52's admission Record, the admission Record indicated Resident 52 was originally admitted to the facility on [DATE] and readmitted to the facility with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought).During a review of Resident 52's MDS dated [DATE], the MDS indicated, Resident 52 had the ability to express ideas and wants. The MDS indicated Resident 52 had the ability to understand others. The MDS indicated Resident 52 was dependent on nursing staff for toileting, lower body dressing, putting on and taking off footwear, and transferring. The MDS indicated Resident 52 needed substantial to maximal assistance from nursing staff with oral hygiene, showering, upper body dressing and personal hygiene. During a review of Resident 52's Notice of PASRR Level I Screening Results, dated 2/8/2025, the Notice of PASRR Level I Screening Results indicated Resident 52 did not have schizophrenia.During an interview on 7/31/2025 at 9:00 a.m., with Medical Records Director (MRD), MRD stated she was responsible for reviewing the PASARR. MRD stated Resident 9 did not have a new Level I Screening done. MRD stated Resident 9 needs a new Level I Screening resubmitted to determine the services needed for the resident's care. MRD stated Resident 52 PASARR was documented incorrectly and will have to resubmit another Level I Screening. MRD stated the residents' care and services can be affected if the Level I Screening was not done. During an interview on 8/1/2025 at 3:26 p.m., with the Director of Nursing(DON), the DON stated the residents need Level I Screening so they will get the proper treatment and be provided with the necessary care.During a review of the facility's policy and procedure (P&P), titled Preadmission Screening & Resident Review (PASARR), dated 11/20/2023, the P&P indicated, Facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort to include incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. Referring all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II resident review upon a significant change in status assessment. Notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review.

Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of three sampled residents (Resident 74) when Resident 74 reported to the Assistant Director of Nursing (ADON) that Certified Nurse Assistant (CNA) 1 physically abused her while providing her with personal care. This deficient practice resulted in failure in the delivery of necessary care and services. Findings:During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was admitted to the facility on [DATE] with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) and rheumatoid arthritis (a chronic-progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 74's MDS dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment and required maximal (helper does more than half the effort) assistant with activities of daily living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). During a concurrent interview and record review on 7/30/2025 at 4:09 p.m., with the Registered Nurse Supervisor (RNS) 1, RNS 1 validated there was no care plan for the abuse allegation made by Resident 74. RNS 1 stated facility should develop and implement a plan of care for an abuse allegation, so the facility staff were aware of what occurred and what interventions should be put in place to care for Resident 74. During an interview on 8/1/2025 at 12:34 p.m., with RNS 2, RNS 2 stated following an abuse allegation, a care plan should be developed and implemented because it represents the goals and interventions for the staff to follow for Resident 74's care. RNS 1 stated the care plan was important to ensure it does not happen again and for the safety of the residents. During an interview on 8/1/2025 at 3:03 p.m., with the Director of Nursing (DON), the DON stated a care plan should have been developed and implemented for Resident 74's abuse allegation because it served as an outline of care provided based on the resident's needs. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Persons-Centered, dated 12/2016, the P&P indicated, Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition).

Based on interview, and record review, the facility (SNF B) failed to ensure residents were free from sexual abuse (non-consensual sexual contact of any type) for one of three sampled residents (Resident 2). The facility (SNF B) failed to: 1.Ensure Resident 1 did not sexually assault Resident 2. 2. Ensure Certified Nursing Assistant (CNA) 1 and CNA 2 did not leave Resident 1 and Resident 2 alone in the room after Resident 1 sexually assaulted Resident 2 once, thus allowing Resident 1 to sexually assault Resident 2 second time. 3. Ensure CNA 1 and CNA 2 followed the facility (SNF B)'s policy and procedure (P/P) titled, Abuse Reporting and investigation, dated 1/10/2024, which indicated if the suspected perpetrator is the resident, the residents will be separated so they do not interact with each other or with another resident. These failures resulted in Resident 1 on 10/8/2024, sexually assaulting Resident 2 twice, and placed other residents in SNF B at risk for sexual assault and aggressive behavior from Resident 1. On 10/11/2024 at 6:20 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy ([IJ] a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Director of Nursing (DON) and the Administrator (ADM), due to the facility (SNF B)'s failure to prevent Resident 1 from sexually abusing Resident 2 twice. On 10/13/2024 the facility (SNF B) provided CDPH with an acceptable Immediate Jeopardy Removal Plan (IJRP) containing the following summarized immediate corrective actions: 1. Ensure all residents are free from abuse through training addressing the critical elements of identifying all categories of abuse and the procedures for reporting abuse. 2. Immediate action taken: a. Resident 1 was discharged from the facility (SNF B) and sent to a General Acute Care Hospital (GACH 3) on 10/09/2024 for psychiatric evaluation and treatment. As of 10/13/2024 Resident 1 remains in GACH 3. b. Resident 2 was transferred to GACH 2 for evaluation on 10/9/2024 and returned to the facility (SNF B) on 10/9/2024. c. Upon Resident 2's return to the SNF B the Social Services Director (SSD) began Resident 2's monitoring for emotional distress. Resident 2 was seen by a Psychologist (a health practitioner that specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) and Psychiatrist (a health practitioner that specializes in the diagnosis and treatment of mental illness) on 10/9/2024. d. On 10/9/2024, the SSD interviewed all cognitively (ability to think, understand, learn, and remember) aware residents and inquired if the residents have experienced abuse in the facility (SNF B) or know of any abuse in the facility (SNF B). On 10/12/2024 the SSD interviewed staff regarding residents who were not able to be interviewed to see if the facility (SNF B) staff had witnessed any signs of abuse or changes in residents' behaviors. Any issues identified from the interviews will be investigated by the Abuse Coordinator/ADM. e. All 87 residents have the potential to be affected by alleged abuse incidents. All residents with psychiatric diagnoses admitted since 8/31/2024 (the date Resident 1 was admitted to the facility [SNF B]) will be reviewed by the interdisciplinary team ([IDT] group of health care professionals with various areas of expertise who work together toward the goals of the resident) for their psychiatric and behavioral needs, including their medication regimen and/or need for psychiatric consultation by 10/13/2024. A referral for psychological / psychiatric services for evaluation and treatment when indicated will be done. Any issues identified will be addressed by the IDT team members. The facility (SNF B)'s contracted psychiatrist was notified on 10/11/2024 to assist with any needed psychiatric consultations. f. Any residents admitted from 10/11/2024 will be assessed by the IDT for their medical, physical, and psychological needs and care planned accordingly. 3.Training and education to prevent abuse: a. Staff training on abuse prohibition will consist of abuse prevention, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. Symptoms may include aggressive behavior, wandering, resistance to care, yelling or difficulty adjusting to new routines or staff. These trainings will continue upon hire, annually and as needed. 4.Training provided specific to the allegation of abuse: a. The DON, the Director of Staff Development (DSD), and/or Clinical Resources (CR) will in-service (staff education) and educate licensed nurses: 39 staff (23 Licensed Vocational Nurses [LVN]'s and 14 Registered Nurses [RN]'s) to Review admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned. Upon identification of abuse to separate residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision (a staff member assigned to monitor only that resident) to keep a resident safe from any further alleged abuse. In-services initiated on 10/11/2024 and will be completed by 10/16/2024. These trainings will continue upon hire, annually and as needed. b. The ADM, the DON, the DSD or CRs will in-service and educate facility (SNF B) staff: 134 staff (including housekeeping, activities, rehabilitation, social services and maintenance departments, licensed and unlicensed nursing staff and all department heads) on the immediate action required during an alleged abuse situation to include : immediate need to separate residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision to keep a resident safe from any further alleged abuse. In-services initiated on 10/11/2024 and will be completed by 10/16/2024. These trainings will continue upon hire, annually and as needed. c. Education and training for staff on leave, vacation, per diem or registry status will be completed prior to the start of their working shift by the Administrator, the DON, the DSD and/or CRs. 5.The facility (SNF B) Medical Director was notified by the ADM and the DON on 10/11/2024 of the Immediate Jeopardy. The Medical Director will continue to assist the facility (SNF B) to meet the needs of the Residents. 6. Prior to the Quality Assurance Performance Improvement ([QAPI] data driven approach to improve the quality of care and safety in nursing homes) meeting all training and education which includes abuse, review of admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned, separating residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision to keep a resident safe from any further alleged abuse, and all resident interviews regarding any alleged abuse, will be completed. These trainings will continue upon hire, annually and as needed. Policy and procedures relating to the admission process and abuse will be reviewed and revised if necessary, during the QAPI meeting. 7. This Immediate Jeopardy Removal Plan will be reviewed at the next scheduled QAPI Committee Meeting on 10/16/2024. On 10/13/2024 at 2:02 p.m., while onsite the facility (SNF B) informed the surveyors' team there were no additional instances of sexual abuse identified through their interviews of the facility (SNF B) residents and staff. After verification of the facility (SNF B)'s implementation of the IJ removal plan corrective actions, and through observations, interviews, and record review, the Department accepted the IJ removal plan and removed the IJ, in the presence of the ADM and the DON. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to SNF B on 8/31/2024 with diagnoses including schizophrenia (a mental disorder that causes a break with reality and affects how people think, perceive, and interact with others, malignant neuroleptic syndrome (life-threatening condition that can occur as a side effect of certain antipsychotic[medication that affects the brain] medications) and diabetes mellitus type 2 (condition when the body cannot regulate blood sugar). During a review of Resident 1's History and Physical (H&P), dated 9/3/2024, the H&P indicated Resident 1 did not have awareness of place, location, and time. During a review of Resident 1's Minimum Data Set [(MDS), a federally mandated screening tool], dated 7/7/2024, the MDS indicated Resident 1 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 did not have any limitation in functional range of motion (range of motion required for a person to be as independent as possible). During a review of Resident 1's Change of Condition document ([COC] significant change in resident's status that requires intervention) dated 10/8/2024, the COC indicated Resident 1 had 'inappropriately touched' Resident 2. During a review of Resident 1's physician orders, dated 10/9/2024, the physician orders indicated, to transfer Resident 1 to GACH 3 for psychiatric evaluation. During a review of Resident 1's Nurses Notes, dated 10/9/2024, the Nurses Notes indicated Resident 1 was transferred to GACH 3 on 10/9/2024 at 7:50 a.m., for psychiatric evaluation due to inappropriately touching Resident 2. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to SNF B on 7/23/2024 with diagnoses including metabolic encephalopathy (disease affecting how s brain works), muscle weakness and adult failure to thrive (a state of decline caused by chronic diseases and functional impairments, manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 2's H&P, dated 7/24/2024, the H&P indicated Resident 2 had decreased mental status. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 2 had limitations in functional range of motion (ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident is at risk of injury) affecting his bilateral (both) upper and lower extremities. The MDS indicated Resident 2 was dependent (helper does all the effort, resident does none of the effect to complete activity) on staff for eating, hygiene, showering/bathing, dressing, toilet hygiene (ability to maintain perineal hygiene, adjust clothes before or after voiding, or having a bowel movement). The MDS indicated Resident 2 was dependent on staff to roll left to right while in bed. During a review of Resident 2's COC, dated 10/8/2024 the COC indicated Resident 1 was found in Resident 2's bed touching Resident 2 inappropriately. During a review of Resident 2's physician's orders, dated 10/9/2024, the physician's orders indicated to transfer Resident 2 to GACH 2 for further evaluation and treatment. During a review of Resident 2's Nurses Notes, dated 10/9/2024, the Nurses Notes indicated Resident 2 was transferred to GACH 2 on 10/9/2024 at 12:20 a.m., for further evaluation and treatment due to being touched inappropriately by another resident. During a record review of CNA 1's documented witness statement, dated 10/8/2024, the statement indicated the following: on 10/8/2024 at 6:30 p.m., CNA 1 entered Resident 1 and Resident 2's room and noticed the privacy curtain was pulled around Resident 2's bed. Behind the curtains CNA 1 observed Resident 1 and Resident 2 laying together on their left side facing away from the door. CNA 1's witness statement indicated Resident 1, and Resident 2 were naked from the waist down. Resident 1 was observed to be grinding his hips and rubbing his penis on the buttocks of Resident 2. Resident 1 had his right hand on Resident 2's right hip moving Resident 2 back and forth while he was grinding on Resident 2. CNA 1's witness statement indicated CNA 1 shouted, hey that's not okay and you can't do that!. Resident 1 stated, ok, sorry! got up, pulled down his gown and went back to sit on his bed (Bed B). CNA 1 called CNA 2 to the room and informed CNA 2 of the incident, and they together left Resident 1 and Resident 2 in the room to report the incident to Licensed Vocational Nurse 2 (LVN 2). During a record review of CNA 2's documented witness statement, dated 10/8/2024, the statement indicated CNA 1 notified CNA 2 that she (CNA 1) witnessed Resident 1 grinding on Resident 2, while in Resident 2's bed. CNA 2's witness statement indicated CNA 2 stated she walked with CNA 1 (to go inform LVN2 of the incident), then stopped (on the way) to inform CNA 3 of the situation. CNA 2 stated she and CNA 3 returned (from the hallway) to Resident 1 and Resident 2's room and heard someone yelling, help me, help me repeatedly. CNA 2 stated she witnessed Resident 1 sitting on Resident 2's bed, rubbing Resident 2's leg. During a record review of CNA 3's documented witness statement, dated 10/8/2024, the statement indicated when CNA 2 and CNA 3 came to Resident 1 and Resident 2's room they heard someone yelling, help me, help me. CNA 3's statement indicated she observed Resident 1 sitting on Resident 2's bed and rubbing Resident 2's leg up and down, Resident 2 did not have his adult briefs (a disposable undergarment designed to provide absorbency for people that cannot control their bladder and/or bowel movements) on. CNA 3's statement indicated Resident 1 got up and walked back to his bed. CNA 3's statement indicated CNA 3 asked Resident 2 if he was okay, Resident 2 responded, No. CNA 3's statement indicated Resident 2 reported to her that Resident 1 touched his penis. CNA 3's statement indicated she and CNA 1 changed Resident 2's adult briefs. During a record review of LVN 2's documented witness statement, dated 10/8/2024, the statement indicated the following: LVN 2 was notified by CNA 1 that Resident 1 was inappropriately touching Resident 2 in Resident 2's bed. LVN 2's witness statement indicated LVN 2 walked into the room with LVN 1 and RN 1 and questioned Resident 1 and Resident 2. Resident 2 appeared scared and said he wanted to leave; Resident 1 stated I put it in him just once. LVN 2's witness statement indicated Resident 1 and Resident 2 would be sent to the hospital for evaluations. During an interview on 10/11/2024, at 1:40 p.m., CNA 1 stated her documented witness statement was an accurate account of the incident on 10/8/2024 involving Resident 1 and Resident 2. CNA 1 stated she left Resident 1 and Resident 2 in the room unattended while she notified LVN 2 of the incident. CNA 1 stated, it was important to separate residents after an incident of alleged abuse to ensure residents' safety. CNA 1 stated residents must be monitored with 1:1 supervision (a single staff member is dedicated to constantly monitor one resident) to ensure the incident does not happen again. During an interview on 10/11/2024, at 1:00 p.m., DON-P at psychiatric SNF A (where Resident 1 resided before being transferred to GACH 1) stated at SNF A Resident 1 was receiving Clozapine (medication to treat schizophrenia, usually a last resort drug after all other medications have failed due to many side effects) and Depakote (medication to treat mood disorders) daily due to paranoid delusions (false beliefs that someone is being threatened or mistreated) and poor impulse (tendency to act without thinking) control. The DON stated when a medication dose reduction (an attempted decrease in medication dosage to manage behavior and decrease adverse side effects of the medication) was attempted (date unknown) , Resident 1 required close monitoring due to increased hypersexual (a condition where a person is unable to control their sexual urges, and arousal) behaviors. The DON stated, Resident 1 cannot be without antipsychotic (medication that affects the brain) medications as he will have inappropriate aggressive sexual behaviors towards vulnerable, dependent residents. During an interview on 10/11/2024, at 3:20 p.m., the DON stated Resident 1's impulsive behaviors were not managed, and it resulted in Resident 1 sexually assaulting Resident 2. The DON stated they (SNF B) failed to maintain Resident 2's safety from Resident 1 when SNF B staff left Resident 1 and Resident 2 unattended and unsupervised after CNA 1 witnessed the first inappropriate sexual act performed by Resident 1 toward Resident 2. During a review of SNF B's policy and procedure (P/P) titled, Abuse Reporting and investigation, dated 1/10/2024, if the suspected perpetrator is another resident, the residents will be separated so they do not interact with each other or with another resident. During a review of SNF B's P/P titled, Residents Rights, dated 8/2022, indicated federal and state laws guarantee certain basic rights to residents of this facility. These rights include the resident's right to a dignified existence, to be treated with respect, kindness, and dignity, to be free from abuse, neglect, misappropriation of property and exploitation.

Based on interview and record review, the facility (SNF B) failed to ensure a resident, who had a history of schizophrenia (chronic mental illness that affects how a person thinks, feels, and behaves) with disorganized (jumbled, or do not make sense can cause problems with communication) thoughts, aggressive and inappropriate sexual behaviors, had behaviors under control for one of three sampled residents (Resident 1) to prevent Resident 1 from sexually assaulting Resident 2 two times on 10/8/2024. The facility failed to: 1. Ensure Resident 1was evaluated by a psychiatrist (a health practitioner that specializes in the diagnosis and treatment of mental illness) upon admission and as needed during the time he was a resident in the current Skilled Nursing Facility (SNF B). 2. Ensure Resident 1's prior history of medication regimen therapy with a total of 350 milligrams ([mg] unit of measurement of mass) daily dose of Clozapine (medication to treat schizophrenia, usually a last resort drug after all other medications have failed due to many side effects) for disorganized thoughts and to control aggressive behavior and sexually inappropriate behavior, was reviewed to evaluate if Resident 1 needed to continue Clozapine medication therapy to treat Resident 1's behaviors. 3. Ensure Resident 1's physician was notified of the resident's history of receiving a medication called Clozapine to treat aggressive behavior and to consider restarting this medication therapy. 4. Ensure Resident 1 was assessed for psychiatric needs and psychiatric medications since admission to SNF B on 8/31/2024 based on the resident's diagnosis and history of aggressive behavior. These failures resulted in Resident 1, who had not received any treatment or medications for his diagnosis of schizophrenia since 8/31/2024, sexually assaulting Resident 2 who was his roommate, twice on 10/8/2024 and placed other residents in the facility (SNF B) at risk for sexual assault and aggressive behaviors from Resident 1. On 10/8/2024, Certified Nursing Assistant (CNA) 1 witnessed Resident 1 sexually assaulting Resident 2 and separated Resident 1 from Resident 2 but failed to maintain supervision of Resident 1. A few minutes later CNA 2 witnessed Resident 1 sexually assaulting Resident 2 a second time. On 10/09/2024 Resident 1 was sent to a general acute care hospital (GACH 3) for evaluation and treatment. On 10/11/2024 at 6:20 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy ([IJ] a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Director of Nursing (DON) and the Administrator (ADM) due to the facility's (SNF B) failure to protect Resident 2 from being sexually abused twice by Resident 1. On 10/13/2024 the facility (SNF B) provided CDPH with an acceptable Immediate Jeopardy Removal Plan (IJRP) containing the following summarized immediate corrective actions: 1. Ensure all residents are free from abuse through training addressing the critical elements of identifying all categories of abuse and the procedures for reporting abuse. 2. Immediate action taken: a. Resident 1 was discharged from the facility (SNF B) and sent to a General Acute Care Hospital (GACH 3) on 10/09/2024 for psychiatric evaluation and treatment. As of 10/13/2024 Resident 1 remains in GACH 3. b. Resident 2 was transferred to GACH 2 for evaluation on 10/9/2024 and returned to the facility (SNF B) on 10/9/2024. c. Upon Resident 2's return to SNF B the Social Services Director (SSD) began monitoring Resident 2 for emotional distress. Resident 2 was seen by a psychologist (a health practitioner that specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) and Psychiatrist (a health practitioner that specializes in the diagnosis and treatment of mental illness) on 10/9/2024. d. On 10/9/2024, the SSD interviewed all cognitively (ability to think, understand, learn, and remember) aware residents and inquired if the residents have experienced abuse in the facility (SNF B) or know of any abuse in the facility (SNF B). On 10/12/2024 the SSD interviewed staff regarding residents who were not able to be interviewed to see if the facility (SNF B) staff had witnessed any signs of abuse or changes in residents' behaviors. Any issues identified from the interviews will be investigated by the Abuse Coordinator/ADM. e. All 87 residents have the potential to be affected by alleged abuse incidents. All residents with psychiatric diagnoses admitted since 8/31/2024 (the date Resident 1 was admitted to the facility [SNF B]) will be reviewed by the interdisciplinary team ([IDT] group of health care professionals with various areas of expertise who work together toward the goals of the resident) for their psychiatric and behavioral needs, including their medication regimen and/or need for psychiatric consultation by 10/13/2024. A referral for psychological / psychiatric services for evaluation and treatment when indicated will be done. Any issues identified will be addressed by the IDT team members. The facility (SNF B)'s contracted psychiatrist was notified on 10/11/2024 to assist with any needed psychiatric consultations. f. Any residents admitted from 10/11/2024 will be assessed by the IDT for their medical, physical, and psychological needs and care planned accordingly. 3.Training and education to prevent abuse: a. Staff training on abuse prohibition will consist of abuse prevention, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. Symptoms may include aggressive behavior, wandering, resistance to care, yelling or difficulty adjusting to new routines or staff. These trainings will continue upon hire, annually and as needed. 4.Training provided specific to the allegation of abuse: a. The DON, the Director of Staff Development (DSD), and/or Clinical Resources (CR) will in-service (staff education) and educate licensed nurses: 39 staff (23 Licensed Vocational Nurses [LVN]'s and 14 Registered Nurses [RN]'s) to Review admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned. Upon identification of abuse to separate residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision (a staff member assigned to monitor only that resident) to keep a resident safe from any further alleged abuse. In-services initiated on 10/11/2024 and will be completed by 10/16/2024. These trainings will continue upon hire, annually and as needed. b. The ADM, the DON, the DSD or CRs will in-service and educate facility (SNF B) staff: 134 staff (including housekeeping, activities, rehabilitation, social services and maintenance departments, licensed and unlicensed nursing staff and all department heads) on the immediate action required during an alleged abuse situation to include : immediate need to separate residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision (a single staff member is dedicated to constantly monitor one resident) to keep a resident safe from any further alleged abuse. In-services initiated on 10/11/2024 and will be completed by 10/16/2024. These trainings will continue upon hire, annually and as needed. c. Education and training for staff on leave, vacation, per diem or registry status will be completed prior to the start of their working shift by the Administrator, the DON, the DSD and/or CRs. 5.The facility (SNF B) Medical Director was notified by the ADM and the DON on 10/11/2024 of the Immediate Jeopardy. The Medical Director will continue to assist the facility (SNF B) to meet the needs of the Residents. 6. Prior to the Quality Assurance Performance Improvement ([QAPI] data driven approach to improve the quality of care and safety in nursing homes) meeting all training and education which includes abuse, review of admission documents thoroughly to ensure that the resident's medical, physical, and psychological needs are assessed, and care planned, separating residents, immediately remove perpetrator from victim when indicated and provide immediate 1:1 supervision to keep a resident safe from any further alleged abuse, and all resident interviews regarding any alleged abuse, will be completed. These trainings will continue upon hire, annually and as needed. Policy and procedures relating to the admission process and abuse will be reviewed and revised if necessary, during the QAPI meeting. 7. This Immediate Jeopardy Removal Plan will be reviewed at the next scheduled QAPI Committee Meeting on 10/16/2024. On 10/13/2024 at 2:02 p.m., while onsite the facility (SNF B) informed the surveyors' team there were no additional instances of sexual abuse identified through their interviews of the facility (SNF B) residents and staff. After verification of the facility (SNF B)'s implementation of the IJ removal plan corrective actions, and through observations, interviews, and record review, the Department accepted the IJ removal plan and removed the IJ, in the presence of the ADM and the DON. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was admitted to SNF B on 8/31/2024 with diagnoses including schizophrenia, malignant neuroleptic syndrome (life-threatening condition that can occur as a side effect of certain antipsychotic [a medication used to treat symptoms of psychosis [collection of symptoms that cause a person to lose touch with reality] medications) and diabetes mellitus type 2 (condition when the body cannot regulate blood sugar). During a review of Resident 1's History and Physical (H&P), dated 9/3/2024, the H&P indicated Resident 1 did not have awareness of place, location, and time. During a review of Resident 1's Minimum Data Set [(MDS), a federally mandated screening tool], dated 7/7/2024, the MDS indicated Resident 1 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 1 did not have any limitation in functional range of motion (range of motion required for a person to be as independent as possible). During a review of Resident 1's GACH 1 Records, dated 7/19/2024 through 8/31/2024, the GACH 1 records indicated Resident 1 was admitted to GACH 1 from a psychiatric skilled nursing facility (SNF A) where he was receiving a total of 350 mg of Clozapine daily. During a review of Resident 1's physician's orders from SNF A, dated 3/7/2024, the physician's orders indicated the following orders: 1.Clozapine 200 mg tablet by mouth at bedtime for disorganized thoughts and aggressive behaviors. 2. Clozapine 150 mg tablet by mouth in the morning for disorganized thoughts. 3. Depakote (medication to treat mood disorders) 150 mg tablet by mouth two times a day for mood swings. The physician's orders indicated Resident 1's medication orders were active until his transfer to GACH 1 on 7/19/2024. During a review of Resident 1's Change of Condition document ([COC] significant change in resident's status that requires intervention) dated 10/8/2024 from SNF B, the COC indicated Resident 1 had 'inappropriately touched' Resident 2. During a review of Resident 1's physician's orders, dated 10/9/2024, the physician's orders indicated to transfer Resident 1 to GACH 3 for psychiatric evaluation. During a review of Resident 1's Nurses Notes, dated 10/9/2024, the Nurses' Notes indicated Resident 1 was transferred to GACH 3 on 10/9/2024 at 7:50 a.m., for psychiatric evaluation due to inappropriately touching another resident. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (disease affecting how a brain works), muscle weakness and adult failure to thrive (a state of decline caused by chronic diseases and functional impairments, manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 2's H&P, dated 7/24/2024, the H&P indicated Resident 2 had a decreased mental status. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 2 had limitations in functional range of motion (ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) affecting his bilateral (both) upper and lower extremities. The MDS indicated Resident 2 was dependent (helper does all the effort, resident does none of the effect to complete activity) on staff for eating, hygiene, showering/bathing, dressing, toilet hygiene (ability to maintain perineal hygiene, adjust clothes before or after voiding, or having bowel movement). The MDS indicated Resident 2 was dependent on staff to roll left to right while in bed. During a review of Resident 2's COC, dated 10/8/2024 the COC indicated Resident 1 was found in Resident 2's bed touching Resident 2 inappropriately. During a record review of CNA 1's documented witness statement, dated 10/8/2024, the statement indicated the following: on 10/8/2024 at 6:30 p.m., CNA 1 entered Resident 1 and Resident 2's room and noticed the privacy curtain was pulled around Resident 2's bed. Behind the curtains CNA 1 observed Resident 1 and Resident 2 laying together on their left side facing away from the door. CNA 1's documented witness statement indicated Resident 1, and Resident 2 were naked from the waist down. Resident 1 was observed to be grinding his hips and rubbing his penis on the buttocks of Resident 2. Resident 1 had his right hand on Resident 2's right hip moving Resident 2 back and forth while he was grinding on Resident 2. CNA 1's documented witness statement indicated CNA 1 shouted, hey that's not okay and you can't do that!. Resident 1 stated, ok, sorry! got up, pulled down his gown and went back to sit on his bed (Bed B). CNA 1 called CNA 2 to the room and informed CNA 2 of the incident, and they together left Resident 1 and Resident 2 in the room to report the incident to Licensed Vocational Nurse 2 (LVN 2). During a record review of CNA 2's documented witness statement, dated 10/8/2024, the statement indicated CNA 1 notified CNA 2 that she (CNA 1) witnessed Resident 1 grinding on Resident 2, while in Resident 2's bed. CNA 2's witness statement indicated CNA 2 stated she walked with CNA 1 (to go inform LVN 2 of the incident), then stopped (on the way) to inform CNA 3 of the situation. CNA 2 stated she and CNA 3 returned (from the hallway) to Resident 1 and Resident 2's room and heard someone yelling, help me, help me repeatedly. CNA 2 stated she witnessed Resident 1 sitting on Resident 2's bed, rubbing Resident 2's leg. During a record review of CNA 3's documented witness statement, dated 10/8/2024, the statement indicated when CNA 2 and CNA 3 came to Resident 1 and Resident 2's room they heard someone yelling, help me, help me. CNA 3's statement indicated she observed Resident 1 sitting on Resident 2's bed and rubbing Resident 2's leg up and down, Resident 2 did not have his adult briefs (a disposable undergarment designed to provide absorbency for people that cannot control their bladder and/or bowel movements) on. CNA 3's statement indicated Resident 1 got up and walked back to his bed. CNA 3's statement indicated CNA 3 asked Resident 2 if he was okay, Resident 2 responded, No. CNA 3's statement indicated Resident 2 reported to her that Resident 1 touched his penis. CNA 3's statement indicated she and CNA 1 changed Resident 2's adult briefs. During a review of Resident 2's Physician's Orders, dated 10/9/2024, the Physician's Orders indicated, to transfer Resident 2 to GACH 2 for further evaluation and treatment. During a review of Resident 2's Nurses Notes, dated 10/9/2024, the Nurses Notes indicated Resident 2 was transferred to GACH 2 on 10/9/2024 at 12:20 a.m., for further evaluation and treatment due to being touched inappropriately by another resident. During an interview on 10/11/2024, at 1:00 p.m., the Director of Nursing (DON-P) from SNF A stated Resident 1 had been a resident of SNF A since 2019 until he was transferred to GACH 1 in July 2024. DON-P stated Resident 1 was transferred to GACH 1 because he required a higher level of care due to generalized weakness and because his oxygen saturation was below normal levels (the percentage of oxygen [O2] in person's blood: reference range is 95% to 100% without the use of supplemental oxygen]). DON-P stated, Resident 1 was receiving Clozapine and Depakote daily at their facility (SNF A) due to paranoid (false beliefs that someone is being threatened or mistreated) delusions (a false belief or judgment about external reality) and poor impulse (tendency to act without thinking) control. DON-P stated when a medication dose reduction (an attempted decrease in medication dosage to manage behavior and decrease adverse side effects of the medication) was attempted (date unknown), Resident 1 required close monitoring due to increased hypersexual (a condition where a person is unable to control their sexual urges, and arousal) behaviors. DON-P stated, Resident 1 cannot be without antipsychotic medications as he will attempt inappropriate sexual behaviors and aggression towards vulnerable, dependent residents. During an interview on 10/11/2024, at 2:18 p.m., SNF B's pharmacist (PharmD) stated upon her review of Resident 1's medication regimen on 9/6/2024, Resident 1 was noted to have a diagnosis of schizophrenia and the SNF B physician did not prescribe antipsychotic medication for Resident 1. PharmD stated if a resident was receiving an antipsychotic medication prior to admission to the current facility (SNF B), it was important for the nursing staff to inquire why Resident 1 did not continue to have a prescription for antipsychotic medications, since the resident has diagnoses and history of sexual behaviors and aggression toward other residents. During an interview on 10/11/2024 at 2:25 p.m., PharmD stated she was not aware Resident 1 was previously a resident at SNF A and was receiving antipsychotic medications. PharmD stated Clozapine is an antipsychotic medicine used to treat schizophrenia after other treatments have failed. PharmD stated the nursing staff should have notified Resident 1's medical doctor (MD) and provided the information pertaining to Resident 1's previous Clozapine orders and psychiatric history. PharmD stated the MD would determine if psychiatric follow up is necessary, which it likely would be. During a concurrent interview and record review, on 10/11/2024, at 3:00 p.m., with the MDS nurse (MDSN), Resident 1's GACH 1 records, dated 7/19/2024 through 8/31/2024 were reviewed. The MDSN stated she along with the DON, Assistant Director of Nursing (ADON), and Medical Records Director (MDR) failed to review the chart thoroughly and missed the portion addressing Resident 1's psychiatric history. The MDSN stated the nursing staff failed to ensure Resident 1 was receiving the proper behavioral care and services which placed Resident 1 at a higher risk for displaying sexually inappropriate behaviors toward Resident 2. During an interview on 10/11/2024, at 3:12 p.m., the DON stated when a resident is newly admitted to the facility, she together with the MDSN Infection preventionist, ADON, and MDR will review all documents from the discharging facility to ensure all orders and medications were carried out. The DON stated she overlooked the information in Resident 1's hospital records that indicated Resident 1 was previously a resident at a psychiatric facility, SNF A. The DON stated she failed to note that Resident 1 was receiving Clozapine. During an interview on 10/11/2024, at 3:20 p.m., the DON stated had she taken note of Resident 1's history, she would have reached out to DON-P and likely would not have admitted Resident 1 to the facility. The DON stated she should have called Resident 1's physician to notify him about Resident 1's psychiatric history to ensure Resident 1 received the necessary assessment, treatments, and services to meet his behavioral needs. The DON stated, Resident 1 did not receive the appropriate behavior care and services due to our failure of looking over his psychiatric history. The DON stated Resident 1's impulsive behaviors were not managed and resulted in Resident 1 sexually assaulting Resident 2. During a review of the Facility Assessment (foundation for the facility to assess its resident population and determine the direct care staffing and other resources to provide the required care to their residents) updated 6/19/2024, the Facility Assessment indicated the following: Residents will be admitted to this facility as long as their nursing and medical needs can be met by the facility. The DON or designee reviews perspective inquiry documentation to determine if the facility can meet the needs and the care perspective of the residents. Residents who are admitted to the facility will have an admission assessment and patient center care plan developed. When a resident has been admitted to the facility and who's care needs cannot be met, the resident's physician will be immediately notified in effort to receive an order for the resident to be transferred to a facility that can meet the needs, care and services required. The Facility Assessment indicated that a comprehensive care plan be developed for each resident to provide specific information to include resident's strengths, goals, life history and preferences, discharge planning and will be completed within seven days of the Care Area Assessment ([CAA] tool to identify and address potential problems for residents) completion.

Based on interview, and record review, the facility's nursing staff failed to monitor and assess urine output and urinary retention for a resident, who was at risk for urinary retention (difficulty completely emptying the bladder) due to a diagnosis of benign prostatic hypertrophy ([BPH] a condition that causes the prostate gland to enlarge making it harder for the bladder to push out urine and can lead to urinary retention and a urinary tract infection ([UTI] an infection in any part of the urinary system such as kidneys, bladder, ureters, and urethra) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA 2) and CNA 3 reported to licensed nursing staff when Resident 1 had a dry diaper (no urine output) during their eight hour shift. 2. Ensure licensed nurses conducted a physical assessment of Resident 1 to determine if he was in pain, had abdominal distension (a condition where the bladder stretches and becomes inflamed due to pressure when the bladder does not empty properly), a decrease in urine output and/or the inability to urinate, and did not rely on CNAs to report signs and symptoms (s/s) of urinary retention, including a dry diaper that they were not trained to detect, and it was not the CNA's scope of practice. 3. Ensure nursing staff followed the facility's policy and procedure titled, Resident Hydration and Prevention of Dehydration which indicated the fluids intake and output monitoring will be initiated for those residents with the potential of inadequate intake or output and incorporated into the care plan, and nursing staff will assess factors that may be contributing to inadequate fluid intake and output, monitor and document fluid intake and output. These deficient practices resulted in licensed nurses not recognizing that Resident 1 had no documented urine output for over 24 hours. Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment after suffering a seizure (uncontrolled electrical activity in the brain, which may produce a physical convulsion, thought disturbances, or a combination of symptoms) on 8/6/2024. At the GACH Resident 1 was diagnosed with a UTI, severe sepsis (a life-threatening condition that occurs when sepsis [an inflammatory response to an infection] causes one of more of the body's organs to malfunction because of a low blood pressure (B/P) resulting from inflammation throughout the body), and urine retention with 1900 milliliters ([ml] a unit of liquid measurement) of urine in Resident 1's bladder. Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including secondary malignant neoplasm of the brain (cancer that spread to the brain), BPH, and acute kidney failure (when kidneys suddenly lose their ability to function). During a review of Resident 1's Care Plan dated 8/2/2024, the Care Plan indicated Resident 1 had an impaired nutrition and hydration status. One of the Care Plan's interventions included to observe and report if the resident had a decreased urine output, dark urine, and increased confusion. During a review of Resident 1's Fluids Flow Sheet dated 8/3/2024 through 8/6/2024, the Fluids Flow Sheet indicated Resident 1 ingested of 300 ml of fluid on 8/3/2024, 620 ml of fluid on 8/4/2024, 420 ml of fluid on 8/5/2024, and 120 ml of fluid on 8/6/2024, a total of 1460 ml. The Fluids Flow Sheet indicated there was no documentation of Resident 1's fluid output (urine quantity). During a review of Resident 1's Documentation Survey Report dated 8/2024, the Documentation Survey Report indicated Resident 1 was incontinent (involuntary voiding of urine and/or stool) of urine on 8/1/2024, 8/3/2024, 8/4/2024, 8/5/2024, and 8/6/2024. Continued review of the Documentation Survey Report indicated there was no documentation if Resident 1 had urine output. During a review of Resident 1's Situation Background Assessment Recommendation ([SBAR] a form of communication between members of a health care team) dated 8/6/2024 and timed at 8:10 a.m., the SBAR indicated Resident 1 was to be transferred to a GACH via 911 due to uncontrolled seizures. During a review of Resident 1's Emergency Medical Services record dated 8/6/2024 and timed at 8:19 a.m., the Emergency Medical Services record indicated paramedics responded to a 911 call at the facility and upon arrival Resident 1 was noted with shortness of breath (SOB). The Emergency Medical Services Record indicated Resident 1 had an Oxygen saturation ([O2 Sat] a measurement of how much oxygen is in the blood, reference, range is 95% to 100%) level of 81% on room air (without administration of O2), was hypotensive (below normal B/P) with a B/P of 87/65 millimeters of mercury ([mmHg] a unit of B/P measurement. B/P reference range is 120/80) and tachycardic (when the heart rate (HR) is too fast) with a HR of 135 beats per minute ([bpm] HR reference range is 60-100 bpm). During a review of the GACH's Encounter Information dated 8/6/2024, the GACH's Encounter Information indicated Resident 1 arrived at the GACH's emergency room (ER) on 8/6/2024 at 8:49 a.m. During a review of the GACH's Nephrology Consult Note dated 8/6/2024 and timed at 3:02 p.m., the Nephrology Consult Note indicated Resident 1 was admitted to the Intensive Care Unit ([ICU] a unit in a hospital that manages patients who are critically ill) for acute kidney injury related to urinary retention, a UTI, severe sepsis, and hypoxic respiratory failure (occurs when the lungs are not able to get not enough oxygen in the blood and deprives the body's organs and tissues of oxygen). The Nephrology Consult Note indicated Resident 1's kidney function normalized after a urinary indwelling catheter (a flexible tube inserted into the bladder to collect and drain urine) was placed in Resident 1's bladder. During a review of the GACH's Shift Outcome Evaluation record dated 8/6/2024 and timed at 7:21 p.m., the Shift Outcome Evaluation record indicated Resident 1's urinary bladder scan (a procedure that measures the volume of urine in the bladder) indicated Resident 1's bladder had 1900 ml of urine. During an interview on 8/13/2024 at 1:47 p.m., CNA 2 stated she cared for Resident 1 on 8/5/2024 from 7 a.m. to 3 p.m. and on 8/6/2024 from 7 a.m. until Resident 1 was transferred to the hospital around 8:30 a.m. CNA 2 stated on 8/5/2024 Resident 1's diaper was dry until he went to radiation therapy (a cancer treatment that uses high doses of radiation to kill cancer cells and shrink tumors) at 1:30 p.m. CNA 2 stated Resident 1 did not return during her shift on 8/5/2024. CNA 2 stated on 8/6/2024 in the morning Resident 1 was lethargic (a state of weariness that involves diminished energy, mental capacity, and motivation) and confused, he could not remember how to put a spoon in his mouth during breakfast. CNA 2 stated sometime between 7:45 a.m., and 8:15 a.m., on 8/6/2024 Resident 1 had a seizure and was transferred to the GACH. During an interview on 8/13/2024 at 2:12 p.m., Licensed Vocational Nurse (LVN 1) stated if a resident had a dry diaper without any urine output halfway through the shift (four hours or more), she would assess the resident for bladder distention and she would inform the physician because the resident could be retaining urine. During an interview on 8/14/2024 at 9:40 a.m. Registered Nurse 1 (RN 1) stated, the registered nurses perform head to toe assessments ([comprehensive assessment] a physical exam that nurses perform to evaluate a resident's health status and identify potential issues) when admitting residents to the facility and when there is a change of condition ([COC] a sudden and significant change in a resident's physical, cognitive, behavioral, or functional state indicative of acute illnesses). RN 1 stated comprehensive assessments were not performed on residents daily but were prompted by concerns identified by CNAs and LVNs. During a concurrent interview and record review on 8/14/2024 at 10:22 a.m., with RN 1, Resident 1's Physician's Order dated 8/1/2024 was reviewed. The Physician's Order indicated Resident 1 was to receive Tamsulosin (used to treat men with symptoms of an enlarged prostate (benign prostate enlargement) for BPH. RN 1 stated residents who have a history of BPH should be monitored for urine output and urinary retention. During an interview on 8/15/2024 at 8:34 a.m., CNA 3 stated on 8/4/2024 during the 7 a.m. to 3 p.m., shift Resident 1's diaper was dry and without urine all shift. CNA 3 stated he did not report Resident 1's diaper was dry (without urine) for 8 hours because he did not realize it was unusual and needed to be reported. During an interview on 8/15/2024 at 10:52 a.m., LVN 2 stated she was Resident 1's assigned nurse on 8/5/2024 from 7 a.m. to 3 p.m., and during that time Resident 1 was awake but did not respond to questions. LVN 2 stated she was not aware that this was a change in Resident 1's condition because this was her first time caring for Resident 1. LVN 2 stated she should have reviewed Resident 1's clinical record to determine if this was Resident 1's normal behavior or not. LVN 2 stated she was not aware that she should monitor Resident 1 for urinary retention, and no one informed her that Resident 1's diaper had been dry, without urine on 8/5/2024 during the day shift. During an interview on 8/15/2024 at 12:20 p.m., the Director of Staff Development (DSD) stated CNAs cannot perform assessments and are not taught the s/s of urinary retention or dehydration, but they are instructed to report to a licensed nurse about dry diapers, refusal of care, and refusal to eat. The DSD stated licensed nurses should look at the resident's care plan and they are responsible for communicating care needs and what CNAs should look out for while caring for a resident. During an interview on 8/15/2024 at 1:48 p.m., LVN 2 stated she was Resident 1's assigned nurse on 8/5/2024 from 7 a.m. to 3 p.m. and was not aware of Resident 1's hydration care plan because during morning report, only Resident 1's increased confusion was mentioned. LVN 2 stated licensed nurses were responsible for assessing residents for dehydration and they should have been monitoring Resident 1 for urinary retention every shift as ordered by the physician for administration of Seroquel. During an interview on 8/15/2024 at 2:13 p.m., the Assistant Director of Nursing (ADON) stated licensed nurses were responsible for reviewing resident's care plans to implement interventions, especially when working with a resident for the first time. The ADON stated CNAs do not have access to care plans so licensed nurses were responsible for communicating the plan of care to the CNAs. The ADON stated when a care plan's interventions indicated to observe and report s/s of dehydration it was not appropriate to rely on CNAs to assess and report information to the licensed nurse, because assessment required a licensed nurse to lay their eyes on the resident to determine the resident's status. During a review of facility's Policy and Procedure (P&P), titled Resident Hydration and Prevention of Dehydration, dated 10/2017, the P&P indicated the fluids intake and output monitoring will be initiated for those residents with the potential of inadequate intake or output and incorporated into the care plan. The P&P indicated nursing staff will assess factors that may be contributing to inadequate fluid intake and output, monitor and document fluid intake and output.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received respiratory care of Continuous Positive Airway Pressure ([CPAP] a machine that uses mild air pressure to keep breathing airways open while you sleep) device mode every night shift as ordered by Resident 1's physician and: 1. Follow Resident 1's Physician's order dated 11/15/2023 which indicated oxygen (O2) at five (5) liters(l) per minute ([min] unit of measurement) via nasal cannula ([NC]a device that delivers oxygen through two thin plastic tubes inserted into the nose) continuously every shift for Chronic Obstructive Pulmonary Disease ([COPD] a group of lung diseases that block airflow and make it difficult to breathe) exacerbation. Follow Resident 1's Physician's order dated 12/7/2023 which indicated oxygen at five (5) L/min via NC to keep oxygen saturation ([O2 sat] how much oxygen is in a person's blood more than 92 percent ([%] unit of measurement) every shift. 2. Follow Resident 1's Physician's order dated 11/15/2023 and 12/7/23 which indicated Continuous Positive Airway Pressure ([CPAP] a machine that uses mild air pressure to keep breathing airways open while you sleep) order device mode every night shift. 3.Notify Resident 1's Physician when Resident 1's oxygen saturation (O2 sat) amount of O2 in the blood) was 87% on 11/17/23, 82% on 11/18/23, 81% on 11/22/23 and 85 % on 12/8/23. 4. Ensure licensed nurses did not remove Resident 1's CPAP machine and did not administer only two (2) L/min of O2 via NC when Resident 1's O2 Sat was less than 92% on 11/21/23. These deficient practices resulted in Resident 1 being transferred to a general acute care hospital (GACH) on 11/22/2023 for evaluation and treatment in the intensive care unit (ICU) from 11/22/2023-12/7/2023 (a total of 15 days). Findings: During a review of Resident 1's Admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including obstructive sleep apnea (a sleep-related breathing disorder which occurs when the throat muscles relax and blocks the airway), chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems). During a review of Resident 1's Minimum Data Sheet (MDS- a comprehensive assessment and care screening tool) dated 11/18/2023, the MDS indicated Resident 1 had no cognitive impairment (ability to learn, understand, and make decisions). The MDS indicated Resident 1 required maximum assistance on toilet hygiene, shower, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 1 was on continuous oxygen therapy and non-invasive mechanical ventilator- CPAP. During a review of Resident 1's care plan titled Needs Special Care related to CPAP machine use dated 11/16/2023, the care plan interventions included to monitor the resident for episodes of shortness of breath, monitor CPAP for use/function at nighttime and hour of sleep. During a review of Resident 1's care plan titled At risk for altered respiratory status/difficulty breathing related to pneumonia (lung infection), COPD and obstructive sleep dated 11/16/2023, the care plan interventions included observe/document changes in orientation, increased resoluteness, anxiety and air hunger (a sensation of a strong urge to breathe or a feeling of severe breathlessness), observe for signs and symptoms of respiratory distress and report to medical doctor (MD) for increased respirations, decreased pulse oximetry (oxygen saturation), administer oxygen as ordered, CPAP with preset settings as ordered by medical doctor (MD). During a record review of Resident 1's Physician order dated 11/15/2023, the Physician order indicated oxygen at five (5) L/min via NC continuously every shift for COPD exacerbation. During a record review of Resident 1's Physician order dated 11/15/2023, the Physician order indicated CPAP order device mode at bedtime. During a concurrent interview and record review on 12/26/2023 at 1:20 p.m., with the Director of Nursing (DON), Resident 1's Progress Notes dated 11/17/2023 timed at 11:32 p.m. was reviewed. The DON stated the Progress Notes dated 11/17/2023 timed at 11:32 p.m., indicated Resident 1 was administered 4L/min of O2 via NC without a Physician's order. DON stated the Progress Notes indicated Resident 1's Physician ordered 5L/min not 4L. The DON stated Resident 1's Physician was not informed of Resident 1's desaturation (low O2 sat) between 87-90 % and using accessory muscles to breath (indicates increased work of breathing), the CPAP was not used. The DON also stated licensed staff removed the CPAP and administer oxygen via nasal cannula at four liters per minute. During a concurrent interview and record review on 12/26/2023 at 1:29 p.m., with the DON, the Progress Notes dated 11/18/2023 timed at 1:08 p.m., and 7:12 p.m. were reviewed. The DON stated the Progress Notes indicated Registered Nurse (RN) 3 administered O2 via NC to Resident 1 at 3L/min without a Physician's order. During a concurrent interview and record review on 12/26/2023 at 1:37 p.m., with the DON, the Progress Notes dated 11/18/2023 timed at 10:53 p.m., and 11:06 p.m. were reviewed. The DON stated the Progress Notes indicated Licensed Vocational Nurse (LVN) 3 did not inform Resident 1's Physician of Resident 1's desaturation of 82 % on 11/18/23 at 10:53 p.m. and CPAP machine was not used. The DON stated the Progress Notes indicated LVN 3 attempted to have Resident 1 use the CPAP machine, but Resident 1's O2 sat was 82% (normal O2 sat is 95 %-100%). The DON stated the Progress Notes did not indicate any documentation for change of condition and notification of Resident 1's physician. During a concurrent interview and record review on 12/26/2023 at 1:49 p.m., with the DON the Progress Notes dated 11/19/2023 timed at 6:43 a.m. was reviewed. The DON stated the Progress Notes indicated LVN 9 administered 5L/min of O2 continuously via NC to Resident 1 and Resident 1 was not on the CPAP machine. The DON stated the Progress Notes indicated LVN 9 did not notify Resident 1's Physician that Resident 1 was not using the CPAP machine. During a review of Resident 1's Progress Notes dated 11/19/23, at 1:41 p.m., the Progress Notes indicated RN 3 administered O2 at 3L/min via NC to Resident 1. During a review of Resident 1's Progress Notes dated 11/20/23, at 8:34 a.m., the Progress Notes indicated LVN 7 administered O2 at 3L/min via NC to Resident 1. During a review of Resident 1's Progress Notes dated 11/20/23, at 1:04 p.m., the Nursing Progress Notes indicated RN 3 administered O2 at 3L/min via NC to Resident 1. During a concurrent interview and record review on 12/26/2023 at 1:49 p.m. with the DON, Resident 1's Progress Notes dated 11/21/23, at 2:10 a.m., and 8:23 p.m., were reviewed. The DON stated the Progress Notes indicated LVN 6 administered 2L/min of O2 to Resident 1 via NC at 2:10a.m., and 5L/min of O2 at 8:23p.m. The DON stated there was no documentation to indicate Resident 1 was placed on the CPAP machine. The DON stated there was also no documentation to indicate Resident 1's physician was notified Resident 1 was on O2 at 2L/min or that the resident was not placed on a CPAP machine during the nightshift (11 p.m-7 a.m.). During a review of Resident 1's Progress Notes dated 11/22/23, at 6:17 p.m. The Nursing Progress Notes indicated Resident 1 was not able to breath, and Resident 1's O2 sat was 80 % at five liters nasal cannula. The Progress Notes indicated the non-rebreather mask (special medical device that helps provide with higher concentration of oxygen in emergencies) was applied at 5L/min. The Progress Notes indicated Resident 1's O2 sat was 89%. The Progress Notes indicated Resident 1's O2 sat was 81 %-87%. Resident 1 was transferred to GACH on 11/22/23 at 7:46 p.m. During a review of Resident 1's Progress Notes dated 12/8/23, timed at 5:17 a.m., the Progress Notes indicated Resident 1's O2 sat was 85% after one hour CPAP was removed. The notes indicated Resident 1 was on 5 L/min of O2 via nasal cannula, and had a heart rate of 130 beats/min. The Progress Notes also indicated Resident 1 was transferred to GACH on 12/8/2023 (no time indicated). During a telephone interview on 12/26/2023 at 1:56 p.m., with RN 3, RN 3 stated licensed staff should follow Resident 1's physician orders on the amount of oxygen to administer to Resident 1. RN 3 stated if licensed nurse will administer less or more oxygen level as ordered, Resident 1's physician should be notified or obtain an order when the licensed staff adjusts the oxygen setting being administered to Resident 1. RN 3 stated giving higher oxygen setting had the potential for oxygen toxicity (harmful effects that can occur when a resident was exposed to high levels of oxygen), and less oxygen setting had the potential for desaturation. During a telephone interview on 12/26/2023 at 2:15 p.m., with Resident 1's Physician, the Physician stated a resident with a diagnosis of COPD can receive5L/min of O2 via NC to keep the O2 level at of 92%. The Physician stated he was not informed when Resident 1's O2 level dropped below 90% (87 % on 11/17/23, 82% on 11/18/23, 81% on 11/22/23 and 85% on 12/8/23). Resident 1's Physician stated he was not informed on Resident 1 was not placed on the CPAP machine on 11/17-19/23,11/21-22/23 and 12/7/23. During a telephone interview on 12/26/2023 at 2:40 p.m., with LVN 8, LVN 8 stated when Resident 1 was placed on the non-rebreather mask on 11/21/23, a higher dosage of O2 (10L/min) should have been applied and a licensed nurse must get an order from Resident 1's Physician and document on Resident 1's Progress Note. LVN 8 stated if it was not documented it was not done. During an interview on 12/26/2023 at 4:10 p.m., with the DON, the DON stated when Resident 1's O2 sat was below 92% and the CPAP was not administered on 11/17-19/23, 11/21-22/23 and 12/7/23, the licensed staff should have notified Resident 1's Physician, monitored Resident 1's O2 sat, and respiratory status continuously. During a telephone interview on 12/26/2023 at 4:15 p.m., with LVN 3, LVN 3 stated on 11/17/2023 at 11:32 p.m. she removed Resident 1's CPAP machine and administered 4L/min of O2 via NC. LVN 3 stated she did not notify Resident 1's Physician. LVN 3 stated she checked CPAP mask seal and setting, monitored Resident 1's O2 Sat, but did not document her findings. LVN 3 stated she should have left Resident 1 on the CPAP machine per Physician's order. During a telephone interview on 12/27/2023 at 8:55 a.m., with Resident 1, Resident 1 stated he did not want to return to the facility because the facility's licensed nurses were not competent and lacked training on how to use a CPAP machine. During a telephone interview on 12/27/2023 at 1:03 p.m., with the GACH Social Worker (SW), the SW stated she filed the complaint on behalf of the GACH Emergency Department (ED) Physician. The SW stated the Physician felt the reason for Resident 1's transfer to the GACH was because Resident 1 was not placed on the CPAP machine while in the facility. During a telephone interview on 12/27/2023 at 2:31 p.m., with RN 1, RN 1 stated the initial order for O2 was 5L/min. RN 1 stated 5L/min of O2 should not be given to a resident with COPD because it could lead to O2 toxicity and respiratory arrest. RN 1 stated if Resident 1's O2 sat was still low after O2 administration, Resident 1's Physician should have been notified and a change of condition should be documented. RN 1 stated the staff should not have changed Resident 1's O2 setting without a Physician's order. During a telephone interview on 1/3/2024 at 1:45 p.m., with Resident 1's Physician, the Physician stated if Resident 1 was not placed on the CPAP machine as ordered, the resident could retain carbon dioxide ([CO2] colorless, odorless gas found in our atmosphere in the blood), and it could lead to respiratory distress. During a record review of Resident 1's Progress Notes dated 11/17/2023,11/18/2023, 11/19/20232, and 11/20/2023, the Progress Notes indicated Resident 1's Physician was not informed of Resident 1's desaturation (low O2 levels) and that the CPAP was removed at nighttime. During a review of Resident 1's Emergency Department (ED) Consult Notes indicated Resident 1 was admitted to the ICU on 11/22/2023 and discharged on [DATE] (a total of 15 days ) for acute hypoxemic (when O2 levels in the blood are lower than normal) and hypercapnic (too much CO2, respiratory failure (a serious condition that makes it difficult to breathe because the lungs cannot get enough oxygen into the blood), and pneumonia (lung infection). Resident 1 was started on Bilevel positive airway pressure ([ BIPAP] a machine that normalizes breathing by delivering pressurized air.), inhalers and treated with antibiotics (medicines that fight bacterial infections). During a review of the facility's policy and procedure (P&P) titled Oxygen Administration revised 2010, the P&P indicated, staff will verify that there was a physician's order for this procedure (oxygen administration). The P&P indicated staff will review the Physician's orders or facility's protocol for oxygen administration. During a review of facility's P&P titled CPAP/BiPAP Support revised 3/2015, the P&P indicated, the purpose of the P&P was To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. To improve arterial oxygenation (Pa02- the volume of oxygen taken up across the lungs per minute) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. To promote resident comfort and safety. During a review of facility's P&P titled Change in a Resident's Condition or Status revised 5/2017 indicated, the P&P indicated the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status such as changes in level of care, billing/payments, and resident rights. The P&P indicated prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact Situation, Background, Assessment, Recommendation' (SBAR) Communication Form. During a review of facility's P&P titled Charting and Documentation revised 7/2017, the P&P indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The P&P indicated the medical record will facilitate communication between the interdisciplinary (IDT-a group of health care professionals with various areas of expertise who work together toward the goals of their residents) team regarding the resident's condition and response to care.

Based on interview and record review, the facility's staff failed to ensure a resident received all the necessary care and services to prevent pressure ulcer ([PU] injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) development for one of two sampled residents (Resident 1). The deficient practices included: 1.Failure to adhere to Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Failure to ensure Resident 1 was turned and repositioned every two hours, as per the resident's plan of care and the facility's policy and procedure (P/P), titled Pressure Ulcer Prevention and Management. 3. Failure to ensure Resident 1 was receiving adequate (acceptable; more than 50%) food and fluid intake to prevent dehydration (excessive loss of body water/not enough water taken in) and weight loss, which put the resident at risk for pressure ulcer development. Resident 1 developed a large Stage III (full thickness skin loss involving damage or necrosis [death] of subcutaneous tissue [under the skin] that may extend down to, but not through, underlying fascia [flat band of tissue below the skin that covers underlying tissues and separates different layers of tissue]) pressure ulcer of the right ischial (lower or back part of the hip bone) tuberosity (a round bone attached to the muscle) that required a wound consultation (a specialist in the care of wounds) and extensive wound care treatment (cross referenced to F692). This deficient practice resulted in Resident 1 developing a large 6.4 centimeter ([cm] a unit of measurement) in length ([L] measurement of something from end to end) x 2.5 cm in width ([W] measurement of something from side to side) x 0.2 cm in depth (D) of the right ischial tuberosity requiring several wound debridement (removal of damaged, dead or infected skin tissue from a wound) to promote wound healing and had the potential to result in further pressure ulcer development and secondary infections. Findings: During a review of Resident 1's Admission Record (face sheet), the face sheet indicated the resident was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Admission Assessment, dated 6/8/2019, the assessment indicated Resident 1 did not have any pressure ulcer/pressure injury (PU/PI). The Admission Assessment indicated for the staff to describe any existing pressure ulcers or skin conditions, such as abrasions (scraped area where a part of the skin is rubbed off), bruise (bleeding under the skin), incision (a surgical opening), pressure ulcer, skin inflammation (a localized physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection), lacerations (deep cut), and rashes (skin bumps or patches). The Admission Assessment indicated Resident 1 did not have any opened skin areas or concerns. During a review of Resident 1's history and physical (H/P), dated 5/6/2020, the H/P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Braden Scale (an assessment tool for predicting pressure sore risk) Pressure Sore Risk Assessment (PSRA), dated 11/18/2020, the PSRA indicated Resident 1 was assessed as having a score of 14. According to the Braden Scale Risk Assessment, a total score of 12 or less represented a high risk. During a review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 11/30/2020, the MDS indicated Resident 1's cognition (ability to reason and think) was severely impaired, required moderate to extensive assistance with a one to two-person physical assist with transfers, toileting and personal hygiene. The MDS indicated Resident 1 utilized a walker and a wheelchair for mobility. The MDS indicated Resident 1 was at risk for developing PU and skin injuries. According to the MDS, Resident 1 did not have any ulcers, wounds, and/or any skin problems. During a review of Resident 1's revised care plan, revised on 11/2020 and titled, Risk for moderate skin breakdown related to limited bed mobility, use of diuretic (medication used to increase urine output) therapy, being chairfast, on anticoagulant therapy (medications used to thin blood) and complicated by dementia/Alzheimer's (a chronic or persistent disorder of memory loss), cerebral vascular accident ([CVA] decreased blood flow to the brain that results in minor or major deficits) and [CONDITION(S)]. The staff's interventions indicated for the staff to assess Resident 1's skin weekly and as needed, which included assess and observe skin condition including color, turgor (skin flexibility), temperature, sensation moisture and texture. Resident 1's care plan indicated for the staff to provide incontinent care daily, keep the resident clean, dry, and odor free. Resident 1's care plan indicated for the staff to limit the resident time in the wheelchair and encourage the resident to turn and reposition every two hours. During a review of Resident 1's recapitulated (summary) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Treatment Administration Record (TAR), for the month of 12/2020, the TAR indicated Calazinc Body Shield was applied to Resident 1's sacrococcyx area from 12/1/2020 through 12/31/2020. During a review of Resident 1's Weekly Summary, dated 12/15/2020 and 12/22/2020, the Weekly Summary indicated Resident 1 had no signs or symptoms of dehydration, skin intact and clear. The Weekly Summary indicated Resident 1 was incontinent of bowel and bladder and was kept clean and dry. There was no documented evidence on the weekly summaries Resident 1 had any pressure ulcers. During a review of Resident 1's recapitulated (summary) physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Nurse's Progress Note (NPN), dated 1/8/2021 and timed at 4 p.m., the NPN indicated Resident 1 was positive for COVID-19 and was transferred from the green zone (non-isolation) room on the facility's second floor to a room in the red zone (isolation) room on the third floor. During a review of Resident 1's TAR, dated for the month of 1/2021, the TAR indicated there was no documented evidence Resident 1 received Calazinc Body Shield to the sacrococcyx area from 1/9/2021 through 1/18/2021 as a preventive measure as prescribed by the physician. There was also no documented evidence on the NPNs from 1/9/2021 to 1/18/2021, Resident 1 was being turned every two, as per the resident's plan of care and if there were skin changes. During a review of Resident 1's NPN, dated 1/19/2021 and timed at 2:50 p.m., the NPN indicated Resident 1 was transferred from the COVID-19 unit on the third floor back to a non-isolation room on the second floor. During a review of Resident 1's NPN, dated 1/19/2021 and timed at 3 p.m., the NPN indicated Resident 1 had ongoing skin care and incontinent treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . over ideal body weight [overweight]). During a review of a Situation Background, Appearance and Review ([SBAR] an internal communication tool), dated 1/19/2021, the SBAR indicated Resident 1 had excoriation to the left ischial tuberosity with tissue splitting between the buttocks. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Cleanse left ischial tuberosity excoriation with normal saline (salt water), pat dry, apply hydrogel (a liquid dressing used to soothe and heal the skin) and cover with dressing daily for 14 days. 2. Cleanse tissue split on the internatal area, pat dry, apply hydrogel and cover with dressing, daily for 14 days. 3. May provide a low air loss mattress (tiny laser made air holes in its top surface which continually blow out air causing the patient to float; reduces skin interface pressure at the mattress surface) with a bolster (long narrow pillow or cushion filled with cotton) for comfort and prevention of further skin breakdown. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's NPN, dated 1/20/2021, the NPN indicated Resident 1's laboratory blood work were as follow: blood urea [MEDICATION(S)] ([BUN] a test to see how well the kidneys are working) was elevated at 54 (normal reference range [NRR is 7-23mg/dl]), which could be indicative of dehydration (a harmful reduction in the amount of water in the body) and with a weight loss of 24 pounds ([lbs]) since 1/6/2021. Resident 1's laboratory report also indicated Resident 1 had an elevated sodium level of 160 mEq/L (milliequivalent/liter [unit of measurement] NRR is 135-145 mEq/L), elevated sodium levels in the blood can be indicative of dehydration due to Resident 1's poor food and fluid intake. The NPN also indicated the resident was seen by the physician with new orders to start intravenous ([IV] into the vein) fluids due to Resident 1's abnormal laboratory results of being dehydrated. The NPN indicated Resident 1 was assisted with meals on 1/20/2021. During a review of Resident 1's laboratory Report, dated 1/20/2021, the report indicated Resident 1 had low pre-[MEDICATION(S)] levels (a blood test indicator to know if someone is getting enough nutrition/food intake) of 12 milligram (mg)/deciliter ([dL] unit of measurement) with NRR being 18-38 mg/dL. According to the National Pressure Ulcer Advisory Panel (NPUAP), low serum [MEDICATION(S)] and protein levels puts a person at a higher risk for developing pressure ulcers and affects the wound healing process www.npuap.org During a review of an online article titled, Pressure Ulcer and Nutrition, the article indicated hydration (to supply with ample fluid or moisture; hydrates [to absorb water] and softens the skin) plays a vital role in the preservation and repair of skin integrity. According to the article, dehydration disturbs cell metabolism and wound healing and adequate fluid intake was necessary to support the blood flow to wounded tissues and to prevent additional breakdown of the skin. https://www.ncbi.nlm.nih.gov/pmc/articles/ During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders indicated for Resident 1 to receive [MEDICATION(S)] cream (medicated cream used to treat wounds and burns) to her Stage II wound for 14 days. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Wound Consultation note, dated 1/24/2021, the consultation note indicated Resident 1 had a Stage III pressure ulcer to the left ischium, measuring 6.4 cm in L x 2.5 cm in W x 0.2 cm in D, with 30 percentage (%) slough (shedding of the outer layer of skin) and 70% granulation (the development of new skin tissue). The consultation note indicated Resident 1 had an excisional subcutaneous debridement. The consultation note indicated for Resident 1 to receive aggressive offloading (minimizing or removing weight from particular body part to help prevent and heal ulcers), a low air loss mattress (a pressure relieving mattress for skin management), including turning every two hours, and providing a high protein caloric (a meal plan with extra calories and protein) diet. During a review of Resident 1's Wound Consultation note, dated 1/29/2021, the consultation note indicated Resident 1 developed a wound overlying her left ischial tuberosity after a recent episode of COVID-19. Resident 1 was immobile, required assistance with activities of daily living ([ADLs] daily routine activities such as eating, bathing, dressing, toileting, transferring and walking), unable to turn herself or walk without assistance and received intravenous fluids due to being dehydrated. The consultation note indicated Resident 1 had a left medial gluteal chronic skin ulcer with the fat layer (layer of skin beneath the dermis (top layer of skin) sometimes called the subcutaneous fat; provides insulation keeping the person warm) exposed. The wound consultation note indicated Resident 1's wound measured 3.9 cm in L x 3.2 cm in W x 0.2 cm in D, with 20% of slough, 80% granulation and indicated multiple debridement may be required to accelerate endogenous (internal) healing. During interviews on 2/17/2021 at 1:41 p.m. and 3/11/2021 at 1:10 p.m., the Treatment Nurse 1 (TN 1) stated Resident 1 never had any skin issues within the past four years while in the facility. TN 1 stated Resident 1 did not have any skin issue prior to being transferred to the COVID-19 floor. TN 1 stated once Resident 1 was transferred back to the second floor on 1/19/2021, wound care and treatment was initiated. During an interview on 3/23/2021 at 2:10 p.m., the Registered Nurse Supervisor (RNS) stated Resident 1 never had any wounds or a PU prior to being on the COVID-19 floor. The RNS stated Resident 1 was in bed a lot and currently is ambulating to the commode with assistance. During an interview on 5/5/2021 at 10:55 a.m., TN 1 stated Resident 1 had an abrasion noted under her left buttocks in 1/2021, that had the appearance of skin that rubbed off. TN 1 stated she was notified of Resident 1's abrasion by an unidentified certified nursing assistant (CNA). During an interview on 5/5/2021 at 1:28 p.m., CNA 1 stated she was assigned to Resident 1 before 12/29/2020 and after 1/18/2021. CNA 1 stated Resident 1 was able to assist with self-repositioning by grabbing the bed rails but needed to be reminded and encouraged. During a review of the facility's Staff Assignment Records ([CONDITION(S)]) for the Red Zone from 1/9/2021 through 1/18/2021, the [CONDITION(S)] indicated there was no staff assigned to provide care to Resident 1. The following days and times indicated Resident 1 had no documented assigned nurse: 1/9/2021 from 6:30 a.m. to 3 p.m. 1/10/2021 from 6:30 a.m. thru 3 p.m. 1/11/2021 from 6:30 a.m. thru 12 p.m. 1/12/2021 from 6:30 a.m. thru 11:30 p.m. 1/13/2021 from 12 a.m. thru 6:30 a.m. 1/14/2021 from 10:30 p.m. thru 7 a.m. 1/15/2021 from 10:30 p.m. thru 7 a.m. 1/18/2021 from 6:30 a.m. thru 3 p.m. During a concurrent interview and record review on 5/5/2021 at 2:15 p.m. with the Assistant Director of Nursing (ADON) and the DON, while reviewing the Red Zone staff's assignment sheets for the month of 1/2021, the ADON was asked if there were staff assigned to provide care to Resident 1. The ADON stated the staff provided care for Resident 1 while the resident was housed in the Red Zone from 1/9/2021 through 1/18/2021. The ADON was asked how she knew staff were assigned to and providing care to Resident 1, the ADON stated, By the CNAs documentation. The DON stated, after reviewing the [CONDITION(S)] for 1/9/2021 to 1/18/2021, the charge nurse must have forgotten to write down the staff who were assigned to care for Resident 1. During an interview on 5/5/2021 at 3:26 p.m., the DON was asked if the care provided by the CNAs were in the resident's clinical records, the DON stated the CNAs document on a kiosk (a small stand-alone device providing information and services on a computer screen). The DON stated, after checking for CNAs documentation, the facility was delinquent with CNA's documentation which included turning and repositioning residents and she was unsure if the CNAs documented on Resident 1's records. The DON was asked about the lack of documentation of the Calazinc Body Shield being applied to Resident 1 from 1/9/2021 to 1/18/2021, as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facility's undated P/P titled, Pressure Ulcer Prevention and Management, the P/P indicated for the staff to perform assessment or care needs for pressure prevention and/or management with emphasis on, but not limited to prevention, pressure reducing devices, general nutritional status (based on appearance and condition), and treatment. The P/P indicated for the staff to assess/examine all bony prominences (heels, lateral and medical aspects of the ankles, hips, sacrum, coccyx, ischial tuberosities, occiput (back of the head), ears, shoulders/scapula, elbows) in at-risk patients at least daily. The P/P indicated for the staff to assess for signs and symptoms of inadequate hydration and nutrition, reduce or eliminate pressure, shear, friction and moisture, prevent skin breakdown when skin is intact, or prevent further deterioration when skin integrity is impaired. The P/P indicated for the staff to change the resident's position at least every two hours while in bed, the CNAs would observe the resident's skin during periods of direct care and report any evidence of redness, excoriation, wounds, rashes, swelling or any other skin problems to the licensed nurse and the physician would be notified.

Based on observation, interview, and record review, the facility failed to ensure nutrition interventions were evaluated to prevent unplanned weight loss and to meet a resident's desirable body weight for one of three sampled residents (Resident 1) when: 1. Resident 1's nutrition status was not assessed from 1/8/2021 to 1/19/2021 to ensure the resident maintained acceptable parameters of nutritional status. 2. Resident 1 had no plan of care to address the weight loss and prevent further weight loss when the resident was refusing to eat. Resident 1, experienced a 24 pounds (lbs.) weight loss (9.9 percent [%]) of body weight within two (2) weeks from 1/6/2021-1/20/2021 and was not seen by a registered dietitian ([RD] a food and nutrition expert who has met academic and professional requirements), when the resident was not eating and was losing weight, as per the facility's policy and procedure (P/P) that indicated a resident would be referred to an RD once identified to be losing weight. This deficient practice resulted in Resident 1 experiencing an unplanned severe weight loss of 24 lbs. in two (2) weeks, which put the resident at risk for further decline in health and the potential for an increased risk for undesirable weight loss. Findings: During a review of Resident 1's Admission Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 10/1/2020, the MDS indicated Resident 1 had severely impaired cognition (thought process). The MDS indicated Resident 1 needs an extensive assistance with a two-persons physical assist for bed mobility, and a one-person physical assist for dressing, eating, toilet use and personal hygiene. The MDS indicated Resident 1 was not on a physician-prescribed weight loss regimen. During a review of Resident 1's physician orders, dated 5/10/2019, the orders indicated Resident 1 was receiving a regular texture CCD (carbohydrate-controlled diet for people with diabetes (disorder in which the body does not produce enough or respond normally to insulin [hormone that regulates the amount of glucose in the blood], causing blood sugar (glucose) levels to be abnormally high) to help stabilize blood glucose levels [sugar in the blood]) with NAS (no added salt) diet. Another physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's weight record, dated 12/1/2020 to 2/24/2021, indicated the resident's weights were as follows: 12/1/2020 = 248 lbs. 12/8/2020 = 245 lbs. 12/15/2020 = 245 lbs. 12/21/2020 = 246lbs. 12/29/2020 = 245 lbs. 1/6/2021 = 243 lbs. 1/20/2021 = 219 lbs. 1/27/2021 = 223 lbs. 2/3/2021 = 222 lbs. 2/10/2021 = 221lbs. 2/17/2021 = 223 lbs. 2/24/2021 = 226 lbs. Based on the weight history, Resident 1 had a severe decline in weight of 24 lbs. from 1/6/2021 to 1/20/2021. During a review of Resident 1's nurse's progress notes (NPN), indicated the following: On 1/12/2021, the resident ate 50 percent (%) of dinner and the resident's family (FM 1) was concerned about the resident's intake. On 1/14/2021, the resident was refusing to eat breakfast, lunch, and evening snacks. On 1/15/2021, the resident consumed 15% of the dinner. On 1/16/2021, the resident consumed 30% of lunch, only drank juice and a few bites of meal. On 1/17/2021, the resident consumed 30% of breakfast and lunch. The resident's family (FM 1) called facility concerned about the resident's intake. FM 1 requested for the resident to have daily weights. On 1/18/2021, resident put the food in mouth held it, unable to complete the swallowing process, and wanted to spit the food out. During a review of Resident 1's dietary notes and care plans revealed there was no documentation of the resident's poor intake and/or a nutritional assessment from 1/8/2021 to 1/19/2021 (11 days). During a review of Resident 1's NPNs and dietary notes, for the month of 1/2021, the notes indicated there were documentation of the resident's poor intake and/or the need for assistance to eat while on COVID-19 quarantine (isolation) from 1/8/2021 to 1/19/2021. There was a note, dated 1/12/2021 indicating the physician was left a message of the resident's poor intake, but there was no further follow-up to the physician. During a review of Resident 1's weight variance significant weight change records for 1/2021 indicated there were no documentation regarding the resident's poor intake. During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's NPN, dated 1/20/2021, the NPN indicated Resident 1's laboratory blood work were as follow: blood urea [MEDICATION(S)] ([BUN] a test to see how well the kidneys are working) was elevated at 54 (normal reference range [NRR is 7-23mg/dl]), which could be indicative of dehydration (a harmful reduction in the amount of water in the body) and with a weight loss of 24 pounds ([lbs]) since 1/6/2021. Resident 1's laboratory report also indicated Resident 1 had an elevated sodium level of 160 mEq/L (milliequivalent/liter [unit of measurement] NRR is 135-145 mEq/L), elevated sodium levels in the blood can be indicative of dehydration due to Resident 1's poor food and fluid intake. The NPN also indicated the resident was seen by the physician with new orders to start intravenous ([IV] into the vein) fluids due to Resident 1's abnormal laboratory results of being dehydrated. The NPN indicated Resident 1 was assisted with meals on 1/20/2021. Resident 1 had low pre-[MEDICATION(S)] levels (a blood test indicator to know if someone is getting enough nutrition/food intake) of 12 milligram (mg)/deciliter ([dL] unit of measurement) with NRR being 18-38 mg/dL. According to the National Pressure Ulcer Advisory Panel (NPUAP), low serum [MEDICATION(S)] and protein levels puts a person at a higher risk for developing pressure ulcers and affects the wound healing process www.npuap.org During a review of Resident 1's NPN, dated 1/20/2021, the NPN indicated Resident 1 was assisted with meals on 1/20/2021. During a review of Resident 1's Speech Therapy ([ST] a professional who assess, diagnose, and treats oral/feeding and swallowing skills) plan of care, dated 1/21/2021, the plan of care indicated the ST was requested by FM 1. According to the plan of care, Resident 1's diet was downgraded from regular to a mechanical soft diet with chopped meat with extra gravy at lunch and dinner. The care plan also indicated Resident 1 had oral dysphagia (difficulty in swallowing) and was at risk for weight loss. There was no ST consult for oral dysphagia diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a dining observation on 4/7/2021 at 12:43 p.m., Resident 1 was in a wheelchair in the main dining room eating her lunch. Resident 1's meal tray included Shrimp Puttanesca (6 breaded shrimp with capers and tomato sauce), sautéed spinach, cheddar cornbread, dessert and beverages. Resident 1 was eating her meal without assistance. Resident 1 was asked if she had lost weight recently, Resident 1 stated, They've (referring to staff) told me I have lost weight, but I don't know exactly how much I have lost. During an interview on 4/7/2021 at 2:30 p.m., CNA 1 stated she was responsible for weighing residents, depending on the orders. CNA 1 stated she was very familiar with Resident 1. CNA 1 stated Resident 1 was on weekly weights. CNA 1 stated she did not work in the COVID-19 area and stated the nurses in the COVID-19 area were responsible to weigh the residents while there. CNA 1 stated if there was no weight documented then it was not done. During an interview, on 4/7/2021 at 2:45 p.m., the director of nurses' (DON) stated there was no weights taken during the period Resident 1 was in the COVID-19 area from 1/8/2021-1/19/2021. The DON stated she worked in the COVID-19 unit for long hours and taking residents' weights were not a priority at that time. The DON stated we were taking care of the basic needs of the residents such as cleaning, turning, feeding, and providing medications to the residents. During the same interview, the DON stated she was taking care of Resident 1 during the time she was on the COVID-19 unit. The DON stated Resident 1 was not eating and was sick with COVID and had lost her appetite. The DON stated Resident 1 only wanted juice and ice cream but refused her meals. The DON stated they did not have a RD in the facility because she had just resigned. The DON stated there was no RD and/or speech therapy consults for resident's poor intake. The DON stated they had no time to sit down and have the weekly weight variance meetings (team discuss residents' weight loss and/or nutritional risk). During an interview on 4/7/2021 at 3 p.m., the registered nurse supervisor (RN 1) stated Resident 1 did not feel well on 1/19/2021, after she returned from the COVID-19 unit. RN 1 stated Resident 1's face was thin and that was when they started IV fluids, ordered Speech therapy, and a Dietitian consult. During a telephone interview on 4/13/2021 at 11 a.m., RD 1 stated she started working in the facility on 1/18/2021. RD 1 stated she initially received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RD 1 stated she completed her consultation for Resident 1 on 1/22/2021 and recommended to start the resident on a high calorie supplement with the medication pass. RD 1 stated on 1/25/2021 Resident 1 started receiving 2 Cal HN (high calorie nutrition supplement) 90 milliliter ([ml] unit of measurement) BID (twice a day) with the medication pass for extra calories and active liquid protein (liquid protein supplement syrup consistency) 30 ml providing 21grams (unit of measurement) of protein for wound healing of the Stage III pressure ulcer (full thickness skin loss involving damage or necrosis [death] of subcutaneous tissue [under the skin]) per the physician order. RD 1 stated if there had been an RD consult sooner Resident 1 would have been started on supplements earlier to prevent decline in nutrition status, especially for COVID-19 positive residents. RD 1 stated supplements would add additional calories for residents who have low food intake due to poor appetite. During a review of the facility's P/P, revised 4/2012 and titled, Weight Assessment and Intervention the P/P indicated care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the dietitian, the consultant pharmacist and the resident or resident's legal surrogate. The P/P indicated any change of weight of 5% or more weight loss will be retaken and the dietician notified immediately and should respond within 24 hours. According to the P/P, individualized care plans shall address the identified causes of weight loss, goals and benchmark for improvement and timeframes and parameters for monitoring and reassessment.