Every finding on record at Cheviot Hills Post Acute

Based on observation, interview and record review, the facility failed to implement its' policy and procedures (P&P) titled, Transfer or Discharge, reviewed 10/20/2025 by failing to ensure that orientation was provided to the Responsible Party (RP 1) for one of the three sampled residents (Resident 1) who had a history of falls and a high fall risk when she (Resident 1) was discharged to her home under the care of RP 1. This deficient practice placed Resident 1 at risk for falls.During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (HTN-high blood pressure), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment tool) dated 4/6/2026, the MDS indicated Resident 1 had moderate cognitive impairment (a stage between normal aging and dementia, where a person has noticeable memory or thinking problems that are clear to others, but they can still handle everyday tasks). The MDS indicated Resident 1 required substantial/maximal assistance from staff for most of his Activities of Daily Living (ADLs such as, toileting hygiene, shower/bathe self, upper and lower body dressing, and putting on/taking off footwear). During a review of Resident 1's physician's order dated 4/21/2026, the order indicated LCD [last covered day - the final day that an insurance plan, such as Medicare, will pay for all or part of a beneficiary's services like a hospital stay or skilled nursing care] 4/23/2026. Discharge to home on 4/24/2026. During a review of the Occupational Therapy (OT) notes with a completion date of 4/21/2026 indicated, fall; poor safety awareness, precautions. During a review of the Physical Therapy (PT) notes with a completion date of 4/22/2026 indicated, fall; poor safety awareness, precautions. During an interview with the Certified Occupational Therapist Assistance (COTA) 1on 4/29/2026 at 1:01 pm, COTA 1 stated that Resident 1 required minimal to moderate staff assist for walking to provide safety and positioning. COTA 1 stated that Resident 1 could fall if she (Resident 1) was not provided with the assistance level she (Resident 1) required. COTA 1 confirmed that there was no care giver training or orientation provided to Resident 1's RP. During an interview with the Physical Therapy Assistance (PTA) 1 on 4/29/2026 at 1:16 pm, PTA 1 stated that Resident 1 was impulsive, confused, and required cueing (both verbal and tactile) which made her (Resident 1) transfer levels vary from minimal to moderate staff assistance. PTA 1 stated that Resident 1 would require the same level of assistance in house otherwise she could suffer a fall. PTA 1 confirmed that he had not provided caregiver training and that he was not asked to do so. During an interview with the Assistant Director of Nursing (ADON) on 4/29/2026 at 2:47 pm, the ADON stated that a proper and safe discharge included physician orders as well as caregiver education. The ADON stated that caregiver training was important in ensuring the safety of the discharge. The ADON confirmed that there was no documented evidence of caregiver training and that the training should have been provided as a smooth transition to home for Resident 1. During a review of the facility's policy and procedures (P&P) titled, Transfer or Discharge, reviewed 10/20/2026, the P&P indicated, Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record. The same P&P defined discharge as, the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.

Based on observation, interview, and record review, the facility staff failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of Quetiapine (Seroquel - a prescription medication used to treat mental health conditions by balancing certain natural substances - neurotransmitters in the brain) for one of three sampled residents (Resident 1). This deficient practice violated the residents' right to make an informed decision regarding the use of Seroquel.During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (HTN-high blood pressure), and major depressive disorder (MDD - a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's physician's order dated 3/11/2026, the order indicated Quetiapine Fumarate Oral Tablet (Quetiapine Fumarate) Give 100 mg by mouth one time a day for MDD with Psychotic [a mental state characterized by a severe loss of contact with reality] features. During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/6/2026, the MDS indicated Resident 1 was severe cognitive impairment (a significant decline in mental abilities-such as memory, thinking, and judgment-that prevents a person from living independently and managing daily tasks). The MDS indicated Resident 1 required substantial/maximal assistance from staff for most of his Activities of Daily Living (ADLs such as, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, lower/upper body dressing). During a concurrent interview and record review of Resident 1's consents with the Assistant Director of Nursing (ADON) on 4/27/2026 at 11:06 am, the ADON stated consents for antipsychotics are completed upon admission and when there is a new order. The ADON stated that a consent must include the name of the medication, dosage, route, and frequency of the administration. The ADON confirmed that there was no consent for Seroquel 100mg. The ADON stated that the importance of having a consent ensures that the resident would be getting that medication and that the resident/RP (Resident 1's mom) understood the risks and benefits of the ordered antipsychotic. During a review of a policy and procedures (P&P) titled, Informed Consent for Psychotropic Drugs, reviewed 2/2026 indicated, This policy outlines responsibilities for obtaining, verifying, and documenting informed consent to protect resident rights, promote safety, and facilitate appropriate use of these medications for residents with behavioral or psychotic symptoms, such as those associated with dementia. The same P&P defined informed consent as, Disclosure of material information (e.g., reasons for use, benefits, risks including black box warnings, alternatives including nonpharmacological approaches) to the residents or their representative allowing them to accept, refuse, or revoke consent.

Based on observation, interview, and record review the facility to develop and implement and individualized and comprehensive care plan for one out of three sampled residents (Resident 1), who was on Quetiapine (Seroquel - a prescription medication used to treat mental health conditions by balancing certain natural substances - neurotransmitters in the brain) and monitoring for psychotic behaviors manifested by inconsolable screaming. This deficient resulted in Resident 1's behaviors being unmonitored as well as unmonitored adverse drug reactions (undesired and harmful effects that occur because of a medication, treatment, or procedure).During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), hypertension (HTN-high blood pressure), and major depressive disorder (MDD - a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's physician's order dated 3/11/2026, the order indicated Quetiapine Fumarate Oral Tablet (Quetiapine Fumarate) Give 100 mg by mouth one time a day for MDD with Psychotic [a mental state characterized by a severe loss of contact with reality] features. During a review of Resident 1's physician's order dated 3/18/2026, the order indicated Quetiapine Fumarate Oral Tablet (Quetiapine Fumarate) Give 150 mg by mouth at bedtime for MDD with Psychotic [a mental state characterized by a severe loss of contact with reality] features M/B inconsolable screaming. During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/6/2026, the MDS indicated Resident 1 was severe cognitive impairment (a significant decline in mental abilities-such as memory, thinking, and judgment-that prevents a person from living independently and managing daily tasks). The MDS indicated Resident 1 required substantial/maximal assistance from staff for most of his Activities of Daily Living (ADLs such as, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, lower/upper body dressing). During a review of Resident 1's care plans, there was no care plan for Seroquel and no care plan for Resident 1's monitoring for his (Resident 1), psychotic behavior. During a concurrent interview and record review of Resident 1's care plans with the Assistant Director of Nursing (ADON) on 4/27/2026 at 11:06 am, the ADON stated that care plans must be developed for residents being monitored for behavioral issues such as aggressive behaviors and yelling. The ADON stated that care plans must be developed for medications to ensure that the care team is aware about what interventions to carry out for the resident. The ADON confirmed that there was neither a care plan for Resident1's behavior monitoring nor Seroquel. During a review of the policy and procedure (P&P) titled, CARE PLAN COMPREHENSIVE) reviewed 10/20/2025, the P&P indicated An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, physical, mental and psychosocial needs shall be developed for each resident. During a review of a P&P titled, Behavior Management, reviewed 10/20/2025, the P&P indicated, Residents exhibiting behavioral symptoms will be individually evaluated to determine the behavior. The interdisciplinary team identifies underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to changes in the residents' behavior. The P&P indicated, Staff will use non-pharmacological interventions as the first line of approach to managing challenging behaviors. behaviors and interventions will be addressed in the care plan.1. The facility will monitor identified residents who:a. Exhibit behavioral symptoms (e.g., verbally or physical abusive, socially inappropriate/disruptive, resist care, wandering, etc.).b. Implement non-pharmacologic interventions as initial interventions.c. Obtain informed consent.d. Refer to mental health services, if necessary.

Based on interview and record review, the facility failed to ensure that annual performance review was completed for that one of two Certified Nursing Assistant (CNA) 7 according to facility's policy and procedures (P&P) titled Performance Evaluations, reviewed 10/20/2025.This deficient practice had the potential to result in facility staff to not meet standards of practice, duties and responsibilities and possibly cause harm to the residents. Findings: During a concurrent interview and record review, on 2/20/2026, at 8:35 A.M., with Director of Staff Development (DSD), CNA 7's employee file and facility's performance evaluation policy were reviewed. CNA 7 employee file indicated that the facility hired CNA 7 on 6/12/2023. DSD stated that CNA 7 did not have an annual performance evaluation done and there was no documented evidence that annual performance evaluation was completed for CNA 7 in the past year. DSD stated that CNA 7's annual performance evaluation was not done because DSD thought that competency and the annual performance evaluation were one and the same thing. DSD stated that the facility's policy indicated that a performance evaluation needs to be completed 90 days after probation and annually. During an interview on 2/19/2026, at 12:15 P.M., with the Director of Nursing (DON), the DON stated that, the facility process is that employee performance evaluations are done 90 days after employment, then annually and placed in the employee files. The DON stated that performance evaluations are done to see if the employees are meeting the standards of the job descriptions, duties and responsibilities. The DON stated if the performance evaluations are not done, the facility may not know if the employee is suitable to take care of the residents and possibly cause harm to the residents. A review of the facility's P&P tiled Performance Evaluations, reviewed 10/20/2025 indicated that: Policy StatementThe job performance of each employee shall be reviewed and evaluated at least annually.Policy Interpretation and Implementation1. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually thereafter. The performance evaluation meeting will occur at the same time as the employee's compensation review.

Based on observation, interview, and record review, the facility failed to observe its written standards, policies and procedures for infection control measures by failing to adhere to infection prevention standards for two out of five sampled residents Resident 71 and Resident 94) when: A. Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 5 did not wear a gown while providing catheter care to one of five sampled residents (Resident 71) who was on enhanced barrier precautions (EBP- infection control measures in nursing homes requiring staff to wear gowns and gloves during high contact care for residents with specific risk factors such as wounds, indwelling devices, or known MDRO colonization [Multidrug Resistant Organisms - a person carrying organisms on or in the body without being sick or showing symptoms) according to the facility's policy and procedures (P&P) titled, Enhanced Standard/Barrier Precautions, revised 2/21/2025. This deficient practice had the potential to transmit infectious microorganisms to the other residents in the facility. B. The facility failed to change the Resident 94's Peripherally Inserted Central Catheter (PICC-a long, thin, flexible tube inserted into a peripheral vein in the arm and advanced to the heart used to deliver medication intravenously (IV-into a vein) access for weeks or months) dressing within 7 days according to the the facility's P&P titled, Peripheral and Midline IV Dressing Changes. This deficient practice placed the Resident 94 at risk for infection had the potential to result in blood stream infections through contamination of the Resident 94's PICC. A. A review of the admission record indicated the facility re-admitted Resident 71 on 6/5/2020 and re-admitted the resident to the facility on 1/21/2026, with diagnoses including obstructive and reflux uropathy (condition in which urine cannot drain properly, causing urine to back up and potentially damage the kidneys), benign prostatic hyperplasia (BPH- prostate gland enlargement) and heart failure (condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 71's Physician Order, dated 1/21/2026, indicated facility staff were to observe EBP due to the presence of a urinary catheter (a flexible tube inserted into the blabber to drain urine). A review of Resident 71 's Indwelling Catheter Care Plan initiated on 6/15/2025, indicated that the resident had a catheter due to obstructive uropathy. The care plan interventions included to cleanse external catheter. A review of Resident 71 's Minimum Data Set (MDS - a resident assessment tool) dated 11/14/2025, indicated Resident 71 's cognition (ability to think, understand, and reason) was severely impaired. The MDS further indicated Resident 71 was totally dependent upon staff foe activities of daily living (ADL-for toileting hygiene, bathing, lower body dressing and personal hygiene). The MDS also indicated Resident 71 had an indwelling urinary catheter. During an observation on 2/17/2026 at 8:17 AM, outside the door next to Resident 71 's nameplate there was signage that indicated staff were to observe EBP and to wear gloves and gown when assisting/attending to Resident 71 with toileting and changing incontinence briefs, performing ADL activities, caring for devices and giving medical treatment, cleaning and disinfecting the environment, wound care and mobility assistance and preparing to leave the room. During a concurrent observation and interview on 12/2/2024 at 10:49 AM, CNA 1 was observed performing morning care for Resident 71. CNA 1 was observed not wearing a gown while providing care. When asked should CNA 1 wear a gown while providing care, CNA 1 stated that CNA 1 should have been wearing a gown while providing care to Resident 71. CNA 1 stated that CNA 1 was not aware Resident 71 was under EBP. CNA 1 further stated wearing a gown prevents the spread of infection amongst other residents and staff. During a concurrent observation and interview on 2/19/2026 at 8:54 AM, LVN 5 was observed providing catheter care to Resident 71. During the catheter care, LVN 5 did not wear a gown. When asked about wearing a gown, LVN 5 stated he should have worn a gown in order to prevent spreading of infectious organisms to other residents and staff. During an interview on 02/20/2026 at 12:50 PM, the Director of Nursing (DON) stated the facility uses Enhanced Barrier Precautions for residents with multidrug-resistant organisms (MDROs), chronic wounds, and catheters. The DON also stated staff are required to use gown during catheter care. The DON further stated enhanced barrier precaution prevents the spread of any infection in the facility. A review of the facility's policy and procedures (P&P) titled, Enhanced Standard/Barrier Precautions, revised 2/21/2025, indicated, the facility implemented enhanced barrier precautions to prevent the transmission of multi-drug resistant organisms. The P&P also indicated personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for enhanced barrier precautions is only necessary when performing high-contact care activities. The P&P further indicated High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, mid line catheters h. Wound care: any skin opening requiring a dressing. B. A review of Resident 94's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included infection following a procedure, sternotomy (surgical procedure involving a vertical incision through the breastbone (sternum) to access the heart, lungs, and surrounding structures) surgical site, surgical site aftercare following surgery on the circulatory system, anemia (low levels of healthy red blood cells), hypertension (HTN-high blood pressure), muscle weakness, difficulty walking and gastro-esophageal reflux disease (GERD- condition where stomach contents (acid, bile, food) flow backward into the esophagus (throat), causing irritation and, esophageal damage). During a facility tour on 2/16/2026 at 8:17 am, Resident 94 was observed to have a PICC line dressing on the left upper arm that was dated changed on 2/8/2026. A review of Resident 94's order summary report dated 2/19/2026 indicated a physician order for Daptomycin (antibiotic used to treat severe infections)-Sodium Chloride intravenous solution 500mg-0.9mg/50ml to be administered intravenously for Sternotomy infection and IV Central lines dressing change every 7 days and as needed (PRN). During an interview on 2/18/2026 at 2:45 p.m. Registered Nurse (RN2) stated PICC lines are changed once a week and as needed if soiled. RN2 stated the importance of changing PICC lines is to ensure the Resident does not acquire an infection to assess the skin and ensure Resident is not allergic to the dressing. RN2 stated she was unaware Resident94's PICC line had not been changed for 8 days. During an interview on 2/20/2026 at 12:57 p.m. the Director of Nursing (DON) stated PICC line changes are done every 7 days and as needed if soiled to prevent infection at the catheter site. DON stated the Resident can acquire infection that could result in sickness causing unnecessary hospitalization and extended antibiotic therapy. A review of the facility's policy and procedures (P&P) titled, Peripheral and Midline IV Dressing Changes indicated, the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. Guidelines: .Change the dressing .at list every 7 days for Transparent semi-permeable Membrane (TSM) dressing for all peripheral catheter sites. A review of the facility's P&P titled Infection Prevention and Control Program dated 9/10/2024, subtitled Prevention of infection indicated, important facets of infection prevention include: Identifying possible infections or potential complications of existing infections Instituting measures to avoid complications or dissemination Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).

Based on observation, interview, and record review, the facility failed to accommodate the needs of one of five sampled residents (Resident 37) by failing to provide the resident a call device that the resident is able to use. This deficient practice had the potential for Resident 37 to be unable to call the facility staff for help when needed.Findings: A review of Resident 37's admission Record indicated the facility re-admitted the resident on 12/26/2023, with diagnoses including but not limited to encephalopathy (brain damage that causes severe confusion and forgetfulness), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (mild or partial weakness or loss of strength on one side of the body) and muscle contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) of multiple sites. A review of Resident 37's Minimum Data Set (MDS - a resident assessment tool) dated 12/26/2025, indicated the resident's cognition (the mental ability to make decisions of daily living) was severely impaired. The MDS also indicated the resident was totally dependent upon staff for Activities of Daily Living (ADL- activities such as bathing, dressing and toileting a person performs daily)oral hygiene, toileting hygiene, showering lower body dressing and personal hygiene). The MDS further indicated the resident was incontinent of bowel and bladder. A review of Resident 37's at Risk for Fall care plan (CP) initiated 12/3/2024, indicated Resident 37 was at risk for falls due to severe impaired cognition, poor safety awareness and the diagnosis of hemiplegia and hemiparesis. The CP interventions included to ensure the resident's call light was within reach or close proximity to the bed. A review of Resident 37's at Risk for Decreased Ability to Perform ADLs CP initiated 8/19/2024, indicated the CP goal is to anticipate and meet the resident's ADL care needs. The CP interventions included to keep the call light within the resident's easy reach and to assist the resident in turning and/or repositioning. A review of Resident 37's Joint Mobility Screen, dated 1/2/2026, indicated Resident 37's left hand passive range of motion (PROM-is the maximum distance a joint can move) was moderately impaired (approximately 50% of full range of motion). The Joint Mobility Screen indicated Resident 37's right hand PROM was severely impaired (approximately 25% or less of full range of motion). During a concurrent observation and interview on 2/19/2026 at 9:13 AM with Licensed Vocational Nurse (LVN) 5 and Certified Nursing Assistant (CNA) 1 at Resident 37's bedside, Resident 37 and Resident 37's call bell was observed. The call bell had a red button to activate the device. Resident 37 was lying in bed with a hand roll in each hand and a brace on each arm. CNA 1 stated Resident 37 was not able to use her hands. LVN 5 stated Resident 37 would not be able to use the call bell located in the bed. CNA 5 further stated the call light is for assistance and it's for the resident's safety. During an interview on 2/20/2026 at 12:52 PM, the Director of Nursing (DON) stated the facility can give Resident 37 a sensitive call bell used for residents unable to use the usual call bell. The DON further stated the call ball is important because it is how the resident calls for assistance. A review of the facility's policy and procedures (P&P) titled, Answering the Call Light revised 10/20/2025, indicated Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. The P&P also indicated if the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

Based on observation, interview, and record review, the facility dietary staff failed to protect resident's right to privacy by tossing a meal ticket with a resident's name and room number dietary in the kitchen trash can for one of one resident (Resident 96). This deficient practice of failing to discard dietary document containing patient information in designated and secured location violate resident's right to privacy. Findings: During a concurrent interview and observation on 2/17/2026 at 7:38 AM with the acting dietary supervisor (ADS - manages daily food service operations, ensuring safe, nutritious, and appealing meals while supervising staff, controlling budgets, and upholding health regulations), a meal ticket containing a resident's dietary information was observed sitting on top of a pile of trash inside the step-on trash can located at the handwashing station. ADS stated that according to facility's policy, we do not toss any documents in the trash due to Health Insurance Portability and Accountability Act (HIPAA - privacy rule which establishes national standards to protect individuals' medical records and other individually identifiable health information) regulations. ADS further stated that all dietary documents are kept/placed inside a shredder box and are discarded when no longer needed. During an interview on 2/20/2026 at 12:38 PM with the registered dietitian (RD - a food and nutrition expert who can translate the science of nutrition into practical solutions for healthy living), the RD stated that all dietary documents containing patient information are put in the shredder and some in a wash bin where we put water and bleach to destroy the document; if they are not soiled they go in the shredder. RD further stated that all trash are discarded by dietary aides in the dumpster located outside in the back of the building. During a record review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Patients'/Residents' Rights with a revision date of 4/2025 indicated, patient/resident medical records must not be left where others can see or have access to them.keep residents'/patients' records locked away and out of public areas. The P&P also indicated paper records must be treated as though they contain Personal Health Information and are confidential.

Based on observation, interview and record review, the facility failed to provide a homelike environment one of four sampled residents (Resident 60) when Resident 60's dignity curtain (bed side curtain) had multiple scattered round/smeared brown spots and the dignity curtain was changed during room deep cleaning on 2/7/2026 according to the facility's policy and procedures (P&P) titled , titled Quality of Life _Home like Environment, reviewed 10/20/2025.This deficient practice resulted in an environment that was unclean, not homelike and had the potential for infection.Findings: A review of Resident 60's admission Record indicated the facility admitted Resident 60 on 2/20/2024 with diagnoses including hypertension (HTN-high blood pressure), hyperlipidemia (high fats levels in the blood), and hypothyroidism (low thyroid hormone [the body's metabolic thermostat]). A review of Resident 60's Minimum Data Set (MDS - a resident assessment tool) dated 11/21/2025, indicated Resident 60 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 60 independent to dependency on staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. During a concurrent observation and interview on 2/19/2026, at 8:40 A.M., with Resident 60, in Resident 60's room, Resident 60's dignity curtain was seen with multiple scattered round/smeared brown spots. Resident 60 stated that the dignity curtain was dirty and that she has not seen the facility staff change the dignity curtain. During a concurrent observation and interview on 2/19/2026, at 8:50 A.M., with Certified Nursing Assistant (CNA) 5, in Resident 60's room, Resident 60's dignity curtain was seen with multiple scattered round/smeared brown spots. CNA 5 stated that Resident 60's dignity curtain has some brown stuff on it, it was dirty. During an interview on 2/19/2026, at 9:14 A.M., with House Keeping Account Manager (HKAM), HKAM stated that the facility process is that Residents rooms are deep cleaned once a month, per the monthly deep cleaning schedule, during that time, the resident's dignity curtains are changed and more frequently for dirty curtains. HKDM stated that dignity curtains integrity is checked daily by the housekeeping during regular daily cleaning and as needed. The HKDM stated once housekeeping has deep cleaned a resident's room, the House Keeping Manager or Supervisor validates that the deep cleaning was done correctly using the facility's Quality Control Inspection (QCI) form. HKDM stated that the QCI form indicated that Resident 60's room was deep cleaned on 2/7/2026, however, there is no documented evidence on the form that Resident 60's dignity curtain was changed. HKDM stated that dignity curtains were not on QCI form and that they should be on it. HKDM stated that the dignity curtains should be on the form to ensure that they were changed/washed during room deep cleaning. HKDM stated that residents' dignity curtains need to be washed/changed for sanitary purposes, for residents' dignity, have a clan environment and to prevent germs. A review of the Facility's policy and procedures (P&P), titled Quality of Life _Home like Environment, reviewed 10/20/2025, indicated that: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.2. The facility staff and management maximizes, to the extent possible, the characteristics of thefacility that reflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment

Based on interview and record review, the facility failed to ensure that the resident or their representative was notified timely in writing the facility's bed hold policy for one of four sampled residents (Resident 72).This deficient practice resulted in resident 72 and/or their representative not being aware of the facility's bed hold and reserve payment policy upon transfer to the hospital from the facility.Findings: A review of Resident 72's admission Record indicated the facility admitted Resident 72 on 8/7/2025 with diagnoses including COPD, hypertension (HTN-high blood pressure), and diabetes (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 72's Minimum Data Set (MDS - resident assessment tool) dated 2/12/2026, indicated Resident 72 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 72 required substantial/maximal assistance from staff with Activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care. A review of Resident 72's physician order dated 11/5/2025, at 2:11 P.M., indicated . Resident 72 was transferred to a general acute care hospital (GACH) . A review of resident 72's Behold Policy and Notification indicated for Resident 72, admit date [DATE] .To be completed upon transfer: Resident 72 has been transferred to GACH on 11/5/2025. The resident or resident representative has been notified of their right to hold a bed for the above-named person.Form of notification: Telephone . During a concurrent interview and record review, on 2/20/2026, at 8:02 A.M., with the Assistant Director of Nursing (ADON), Resident 72's Behold Policy and Notification, dated 8/7/2025 ND 11/5/2025, was reviewed. The Behold Policy and Notification indicated person notified was resident 72'S family member (FM) via telephone. The ADON stated that the Behold policy and Notification is given at the time of transfer and it is to notify the resident and their representatives that the resident will still have a bed in the facility, which is their primary home for 7 days on hold when they return. The ADON stated for resident 72's transfer to GACH on 11/5/2025, the bed hold notification was done with resident 72's FM because resident 72 at the time could not go through the process of the bed hold in the current health state she was in. The DON stated the bed hold notification was done via telephone with resident 72's FM. During an interview, on 2/20/2026, at 10:10 A.M., with the Director of Nursing (DON), the DON stated upon admission, the facility's 7 (seven) days bed hold policy is discussed with the resident and the resident's representative. The DON stated that the resident or the resident's representative signs the Behold Policy and Notification during admission that they have understood that Behold Policy and Notification information. The DON stated upon a resident's transfer to GACH, a written 7 day bed hold notification is provided to the residents in the facility or their representatives via mail. The DON stated that the resident and/or their representatives are aware that the resident can return to the facility and to the same bed with in 7 seven of discharge from GACH because the facility is the resident's home. A review of the facility's Policy &Procedures (P&P) titled Bed-Holds, Returns, Admissions, Discharges and Transfers with revision date 10/20/2025, indicated,Policy StatementResidents and/or representatives are informed (in writing) of the facility and state (ifapplicable) bed-hold policies.Policy Interpretation and Implementation1. All residents/representatives are provided written information regarding the facilityand state bed-hold policies, which address holding or reserving a resident's bedduring periods of absence (hospitalization or therapeutic leave). Residents,regardless of payer source, are provided written notice about these policies at leasttwice:a. notice 1: well in advance of any transfer (e.g., in the admission packet); andb. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24hours).

Based on observation and interview, the facility staff failed to provide an environment that is free from accidents and hazards by failing to ensure that staff did not pour and leave orange liquid bathing soap in cups that the residents use to drink fluids unattended inside residents bathroom for one of one resident (Resident 94) according to facility's policy and procedures titled Quality of care: Safety of Residents dated 10/20/2025.This deficient practice had the potential for the Resident 94 and residents who are confused and/or have wandering behavior to accidentally ingest the orange liquid bathing soap. Findings: During record review, Resident 94's admission Record indicated that the resident was admitted to the facility on [DATE], with diagnoses that included infection following a procedure, sternotomy (surgical procedure involving a vertical incision through the breastbone (sternum) to access the heart, lungs, and surrounding structures) surgical site, surgical site aftercare following surgery on the circulatory system, anemia (low levels of healthy red blood cells), hypertension (HTN-high blood pressure), muscle weakness, difficulty walking and gastro-esophageal reflux disease (GERD- condition where stomach contents (acid, bile, food) flow backward into the esophagus (throat), causing irritation and, esophageal damage) During record review, Resident 94's general acute care hospital (GACH) Acute Care Assessment Plan dated 2/8/2026, indicated that Resident 94 was an independent historian. During record review, Resident 94's GACH Acute Care Physical Therapy Evaluation document dated 2/9/2026, indicated that Resident could ambulate (walk) without assistive device at bedside, required minimum contact guard assistance for sit to stand to sit and sit to stand and is able to ambulate up to 150 feet (ft-unit to measure distance) with standby assistance. During a facility tour on 2/16/2026 at 8:40 a.m., 2 ounces (oz-unit of measurement) of orange liquid was observed inside a clear 8 oz drinking cup used by residents to drink fluids (water and juice) on top of the bathroom sink counter in Resident 94's bathroom. During an interview on 2/16/2026 at 8:50 a.m., Certified Nurse Assistant (CNA) 6 stated the orange liquid in the Residents 8oz drinking cup was soap used to bathe residents. CNA6 stated he was unaware that bathing liquid soap had been poured into a cup that is used to provide drinks to residents and was left inside the Residents bathroom. CNA6 stated it is unsafe to pour soap inside a cup used by residents to drink fluids and to place it on top of the Resident bathroom sink where it can be easily reached and consumed by a resident. During an interview on 2/20/2026 at 1:01 pm, the Director of Nursing (DON) stated pouring liquid bath soap inside residents drinking cup, placing the cup on top of the Resident bathroom sink counter, and leaving the cup unattended places the residents at risk of ingesting the liquid soap which can cause irritation of gastrointestinal (GI) lining, nausea, vomiting, diarrhea, cramps, abdominal pain, unnecessary hospitalization and even poor outcomes for the resident. During record review, the facility's policy and procedures (P&P) titled Quality of care: Safety of Residents dated 10/20/2025, indicated Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Safety risks and environmental hazards are identified through employee training, employee monitoring and reporting and facility wide commitment to safety at all levels of the organization.

Based on observation, and interview, the facility failed to observe and maintain their infection control measures for one of four sampled residents (Resident 72) when Resident 70's nebulizer (a small electric machine that turns liquid medication into fine mist) tubing and mask was on Resident 72's night stand not stored in a plastic bag or labelled with a the residents name/date according to facility's policies and procedures (P&P), titled Infection Prevention and Control Program, reviewed 10/20/2025, and Administering Medication through a small Volume (Handheld) Nebulizer reviewed 10/2025. This deficient practice had the potential to cause infection and/or hospitalization for Resident 72.Findings: A review of Resident 72's admission Record indicated the facility admitted Resident 72 on 8/7/2025 with diagnoses including COPD, hypertension (HTN-high blood pressure), and diabetes (DM -a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 72's Minimum Data Set (MDS - resident assessment tool) dated 2/12/2026, indicated Resident 72 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 72 required substantial/maximal assistance from staff with Activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily) care. During a concurrent observation and interview on 2/17/2026, at 9:19 A.M., with Resident 72, in Resident 72's room, a nebulizer machine was on Resident 72's nightstand and was connected to a tubing which was attached to an undated mask. The mask was not stored in a bag. Resident 72 stated that she had chronic obstructive pulmonary disease (COPD - on going lung disease causing difficulty in breathing), uses the nebulizer as needed (PRN) and that the last time she used the nebulizer machine was yesterday, 2/16/2026. During a concurrent observation and interview on 2/17/2026, at 9:33 A.M., with Licensed Vocations Nurse (LVN) 2, in Resident 72's room, a nebulizer machine was on Resident 72's nightstand, connected to a tubing and a mask attached to it without with no date and was not in a bag. LVN 2 stated that nebulizer tubing and mask need to be in a bag, covered with the resident's name on it and the date the tubing/mask was first opened. LVN 2 stated that the tubing and mask need to be bagged/dated to prevent infection control, to prevent the resident from getting respiratory viruses and getting sick. LVN 2 stated she will go ahead, disinfect the nebulizer machine, get a new tubing and mask for the nebulizer, put them in a bag and put a date on it. During an interview with on 2/19/2026, at 10:01 A.M., with the Director of Nursing (DON), the DON stated that nebulizer tubing and mask needs to be stored in a bag with the resident's name and date on it. The DON stated nebulizer tubing/masks need to be changed weekly and as needed. The DON sated that, having a date on the tubing/mask is so that staff know when the tubing/mask needs to be changed. The DON stated that having the nebulizer tubing and mask in the bag with the date is done so that germs may be prevented which may lead to an infection. A review of the facility's P&P titled Infection Prevention and Control Program, reviewed 10/20/2025, indicated that:PurposeAn infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.PolicyThe infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.11. Prevention of Infection.(3) educating staff and ensuring that they adhere to proper techniques and procedures. A review of the facility's P&P titled Administering Medication through a small Volume (Handheld) Nebulizer, reviewed 10/2025, indicated that:PurposeThe purpose of this procedure is to safely and aseptically administer aerosolized particles ofmedication into the resident's airway.Steps in the Procedure26. Rinse and disinfect the nebulizer equipment according to facility protocol.28. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it.29. Change equipment and tubing every seven days, or according to facility protocol.

Based on interview and record review, the facility failed to ensure a resident's clinical record was maintained in accordance with accepted professional standards and practice that are accurate, by failing to document rehabilitative care (a set of medical and therapeutic interventions designed to help individuals regain, maintain, or improve physical, mental or cognitive abilities lost due to injury, illness, surgery or disability) in the Restorative Administrative Record for one out of two sampled residents (Resident 9) according to facility's policy and procedures (P&P) titled Charting and Documentation dated, 10/20/2025. This deficient practice had the potential to result in a lack and/or a delay in communication between the staff and cause an interruption in the provision of Restorative care/intervention for Resident 9.Findings: A review of Resident 9's admission record indicated the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (high blood pressure), transient ischemic attack (TIA- is a mini-stroke caused by a temporary blockage of blood flow to the brain, lasting from a few minutes to 24 hours), cerebral infarction (is the death of brain tissue caused by lack of oxygen due to blocked blood flow to the brain), dysphagia (difficulty swallowing) following cerebral infarction muscle weakness, contracture of right elbow, contracture of left elbow and, contracture of right hand,. A review of the Resident 9's Minimum Data Set (MDS - a resident assessment tool) dated 1/23/2026, indicated Resident 9 cognitive skills (mental ability to make decisions of daily living) were severely impaired. Resident 9 was totally dependent on staff for activities of daily living (ADL-oral hygiene, shower/bathing, bed mobility, dressing, toilet use and hygiene upper and lower dressing). A review of Resident 9's Order Summary Report dated 2/20/2026, indicated Restorative Nurse Assistant (RNA) to apply hand roll splint (is a medical device used to iummobilize, support, or position the hand and fingers in a functional or neutral posyure) to RUE 5X/WEEK(five times a week), 4-8 hours as tolerated with skin check every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday. A review of Resident 9's Restorative Administration Record for the period of 2/1/2026-2/28/2026 printed on 1/30/2026 indicated no documentation for Restorative Nursing care from 2/1/2026 to 2//20/2026. During an interview on 2/20/2026 at 8:50 am, Restorative Nurse Assistant (RNA) 1, stated that she (RNA1)has consistently carried out the orders by apply hand roll splint to RUE 5X/WEEK, 4-8 hours as tolerated with skin check every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday. RNA1 stated she did not realize that there was a 2nd page to the Restorative Administration Record as her reason for failing to document. During an interview on 2/20/2026 at 1:47 pm, the Director of Nursing (DON) stated documentation is a primary communication tool among the healthcare team and provides legal protections for practitioners. DON stated that, if a service is provided and not documented, it was not done. A review of facility's policy and procedures (P&P) titled Restorative Nursing Services dated 10/20/2025 indicated, Residents will receive restorative nursing services as needed to help promote optimal safety and independence. A review of facility's P&P titled Charting and Documentation dated, 10/20/2025 indicated, Services provided to the residents . shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team.

Based on observation, interview, and record review, the facility failed to ensure that a call button was within reach for one of five sampled residents (Resident 38) according to the facility's policy and procedures (P&P) titled, Call System Resident dated reviewed 10/20/2025. This deficient practice had the potential to result in delay of necessary care including emergency response for Resident 38.Findings: A review of Resident 38's admission Record indicated Resident 38 was admitted to the facility on [DATE], with medical diagnoses that included: Muscle weakness (a lack of physical or muscle strength, throughout the body), anemia (lower than normal amount of red blood cells in the body), and Type 2 diabetes (a disease characterized by elevated levels of blood sugar). A review of Resident 38's Minimum Data Set (MDS - resident assessment tool), dated 12/26/2025, indicated Resident 38's cognition (the mental ability to make decisions of daily living) was moderately impaired. The MDS indicated Resident 38 required moderate to maximal assistance from staff for activities of daily living (ADL-toileting, hygiene, bathing, upper and lower body dressing, and personal hygiene). During observation and concurrent interview on 02/17/2026 at 7:53 AM, Resident 38 was lying in bed, and the resident's the call light cord was hanging off the bed, the call light button was on the floor on the left side of the bed, and out of Resident 38's reach. Resident 38 stated he did not know where the call light was, it has to be here somewhere. During an interview on 02/17/2026 at 07:54 AM, with Certified Nurse Assistant (CNA) 3. CNA 3 stated she had checked on Resident 38 when she got report from the night shift CNA at change of shift. CNA 3 stated she was not sure how the call light got on the floor. During an interview on 02/18/2026 at 3:24 PM Director of Nursing (DON) stated it is important for the residents to have the call lights available for them to call for assistance when they need help. During a review of the facility's policy and procedures (P&P) titled, Call System Resident dated reviewed 10/20/2025, the P&P indicated, Policy Statement: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.Policy Interpretation and ImplementationEach resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities.

Based on interview, and record review, the facility failed to develop and implement an individualized person-centered care plan for one of the three sampled residents (Resident 2) who was assessed to have dry skin to the face and Bilateral Lower Extremeties (BLE- both legs) upon admission. This deficient practice had the potential to result is further dryness, skin break, and infection.During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including sequelae of cerebral infarction are the long-term problems or lasting effects that occur after a stroke (brain tissue death from blocked blood flow), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs). During a review of Resident 2's initial admission assessment dated [DATE] at 8:47 pm, the assessment indicated under the body check section that Resident 2 had excessive dry skin noted to the face and BLE (Bilateral Lower Extremities - both legs). During a review of Resident 2's care plans indicated Resident 1 did not have a care plan for dry skin. During an interview with the Assistant Director of Nursing (ADON) on 1/14/2026 at 1:26 pm, ADON stated that dry skin is considered a skin abnormality and must be care planned. ADON confirmed that Resident 2 was admitted to the facility with dry skin on the face and BLE but that there was no care plan. The DON stated that the potential of not accurately assessing Resident 2's dry skin could have resulted in broken skin or infection. During a review of the facility policy and procedures (P&P) titled, CARE PLAN COMPREHENSIVE, with a review date of 10/20/2025, indicated, The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical physical, and mental and psychosocial needs that arc identified in the comprehensive assessment. The same P&P indicated under procedure the following:Each resident' s comprehensive care plan is designed to: Incorporate identified problem areas.Incorporate risk and contributing factors associated with identified problems.Aid in preventing or reducing declines in the resident's functional status and/or functional levels.The same P&P indicated assessments are ongoing and care plans are reviewed and revised as information about the resident.

Based on interviews and record review, the facility failed to ensure that one out of three sampled residents (Resident 2) who had dry skin to the face and both legs was assessed by a licensed nurse with a specific skill set within their scope. This deficient practice had the potential to result in skin breakdown and infection.During a review of the admission record for Resident 2 indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including sequelae of cerebral infarction are the long-term problems or lasting effects that occur after a stroke (brain tissue death from blocked blood flow), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs). During a review of Resident 2's initial admission assessment dated [DATE] at 8:47 pm, the assessment indicated under the body check section that Resident 2 had excessive dry skin noted to the face and BLE (Bilateral Lower Extremities - both legs). During a review of Resident 2's physician orders between 3/21/2025-to-12/17/2025 indicated there were no orders skin ointments/protectants for dry skin. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 12/26/2025, indicated Resident 2 had mild cognitive impairments (poor decision-making requiring cues and supervision). The same MDS indicated Resident 2 required between setup or clean-up and substantial/maximum assistance for his Activities of Daily Living such as: (ADLs- routine tasks/activities such as oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear).During a review of Resident 2's care plans indicated Resident 1 did not have a care plan for dry skin. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/14/2026 at 11:11 am, LVN 1 stated that orders for A + D ointment (grease-based ointment used to soothe, protect, and heal irritated skin. Its primary function is acting as a barrier to lock in moisture and keep out irritants) are ordered for residents who experience dry skin. LVN 1 stated that the Charge Nurses (CNs- LVNs) complete residents' assessments on residents after Certified Nursing Assistants report abnormalities in resident's skin. LVN 1 stated that CNs constantly assess residents with every interaction such as blood sugar checks and medication administration and changes in conditions are reported to the Registered Nurse Supervisor (RNS) for additional assessment. During an interview with the RNS on 1/14/2026 at 12:38 pm, RNS stated that her roles included among other assessments. RNS stated that full body assessments are completed upon admission, readmission, or change of condition. During a review of the job description titled, Licensed Practical (Vocational) Nurse (LPN)/(LVN), revised 5/2022 indicated, The primary purpose of this position is to provide nursing care to residents under the supervision of a physician and/or registered nurse and within the scope of nursing practice for the state. During an interview with the Assistant Director of Nursing (ADON) on 1/14/2026 at 1:26 pm, ADON stated that dry skin is considered a skin abnormality and must be care planned. ADON confirmed that Resident 2 was admitted to the facility with dry skin on the face and BLE but that there was no care plan. The ADON stated that residents are assessed upon admission, readmission, and change of condition. The ADON stated that the night shift CNs complete a weekly head-to-to-toe assessment (a thorough, systematic physical check of a person's entire body, from their head down to their toes, to get a complete picture of their overall health, identify any existing or potential problems, and establish a health baseline). The ADON confirmed that none of the weekly summary documentation with the following assessment dates: 4/4/2025, 4/11/2025, 5/3/2025, 5/31/2025, 6/7/2025, 6/14/2025, 6/21/2025, 7/12/2025, 7/19/2025, and 9/2/2025 indicted that Resident 2 had dry skin which she admitted was inaccurate. The DON stated that the potential of not accurately assessing Resident 2's dry skin could have resulted in broken skin or infection. During a review of the job description titled, Registered Nurse (RN), indicated a primary purpose of the position, The primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents' attending physician and within the scope of nursing practice for the state. The same job description indicated, Ensure initial baseline and periodic comprehensive assessments and care plans are completed within required timeframes. During a review of the facility policy and procedures (P&P) titled, CARE PLAN COMPREHENSIVE, with a review date of 10/20/2025, indicated, The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical physical, and mental and psychosocial needs that arc identified in the comprehensive assessment. The same P&P indicated under procedure the following:Each resident' s comprehensive care plan is designed to: Incorporate identified problem areas.Incorporate risk and contributing factors associated with identified problems.Aid in preventing or reducing declines in the resident's functional status and/or functional levels.The same P&P indicated assessments are ongoing and care plans are reviewed and revised as information about the resident. During a review of the Board of Vocation Nursing and Psychiatric Technicians (BVNTP) site indicated that LVNs CANNOT perform the following which included: Assessment or evaluation of observed and gathered data from chest auscultation, palpation, and percussion. https://www.bvnpt.ca.gov/

Based on observations, interviews, and record reviews, the facility failed to provide necessary services to maintain good personal hygiene and grooming to one out of three sampled residents (Resident 1), by failing to ensure Resident 1 did not have excessive dry skin to the face and overgrown toenails. This deficient practice placed Residents 1 at risk for skin infections, skin breakdown, and poor self-perception.Findings: During a review of Resident 1's admission record, the admission record indicated the facility admitted the resident on 3/21/2025 with diagnoses that included Type 2 Diabetes Mellitus (a disease in which your body does not produce enough insulin needed to control sugar levels in the blood), other sequelae of cerebral infarction (the long-term health problems or disabilities that remain after someone has a stroke), and dysphagia (difficulty swallowing). During a review of Resident 1's Body Check dated 3/21/2025 at 8:47 pm, the body check indicated Skin intact upon assessment. Excessive dry skin noted to the face and BLE [both lower legs]. During a review of Resident 1's minimum data set (MDS - standardized resident assessment) dated 9/26/2025, the MDS indicated the resident required substantial/maximal (Helper does more than half the effort. Helper lifts or holds trunks or limbs and provides more than half the effort) with showers and baths. During a review of Resident 1's care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) titled The resident has an ADL Self Care Performance Deficit r/t Impaired balance, Limited Mobility. Stroke dated 3/24/2025, the care plan did not indicate any interventions for Resident 1's Excessive dry skin noted to the face and BLE. During an observation in Resident 1's room on 12/18/2025 at 8:39 am, Resident 1 was observed lying down in bed, eyes closed. Resident 1 was observed to have dry white/gray flakes of skin on the face. During a concurrent observation in Resident 1's room and interview on 12/18/2025 at 10:31 am, Licensed Vocational Nurse 1 (LVN 1) observed Resident 1 and confirmed by stating Resident 1 had white/grayish skin flakes to the eyebrows, forehead, jaw and right cheek. LVN 1 also observed and stated Resident 1 had overgrown toenails on both feet. LVN 1 stated that the resident having white/grayish skin flakes on the eyebrows, forehead, jaw and right cheek and overgrown toenails was unacceptable and the resident was scheduled for a shower that day (12/18/2025). During an interview on 12/18/2025 at 11:11 am, Certified Nursing Assistant 2 (CNA2) was familiar with Resident 1 and stated she had showered the resident earlier that morning (12/18/2025) around 9am. CNA2 stated was alert, incontinent (loss of control of urine and/or bowel movements), and seldom refused showers. CNA2 stated Resident 1's skin was clear and confirmed by stating she say Resident 1's toenails were overgrown and should have reported the overgown toenails to the charge nurse. When asked what CNA2 would think of she observed the surveyor with white/grayish skin flakes on the eyebrows, forehead, jaw and right cheek, CNA2 stated she (CNA2) would think the surveyor had poor hygiene. During a follow up interview on 12/18/2025 at 11:28 am, LVN 1 stated she was made aware of Resident 1's overgrown toenails a week and a half prior to the date of interview and had spoken to the case manager but did not hear back. During an interview on 12/18/2025 at 3:15 pm, the Assistant Director of Nursing (ADON) stated facility staff had just been instructed to check all residents' hygiene. The ADON was not aware of Resident 1's overgrown toenails and stated a podiatrist was going to be called. During a review of the facility's policy ad procedure titled Activities of Daily Living (ADLs), Supporting dated 10/20/2025, the policy indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy indicated 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care);

Based on observation, interview and record review, the facility failed to ensure an accurate assessment in the Minimum Data Set (MDS- a federally mandated resident assessment tool) was done for one of three sampled residents (Resident 1). This deficient practice had the potential to affect the resident's plan of care and delivery of services. Cross reference with F656 Findings: During a review of Resident 1's Admission Record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including: heart failure (a condition where the heart weakened and cannot pump enough blood to meet the body's needs , cellulitis, muscle weakness, morbid (severe) obesity (excessive amount of body fat), hypertension (high blood pressure), obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage of the upper airway). During a review of Resident 1's History and Physical (H&P) dated 5/2/25, the H&P indicated the resident during her hospital course patient was found to have hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome ([NAME]- a condition where individuals who are obese experience hypoventilation [reduced breathing]) /OSA (Obstructive Sleep Apnea. It is a sleep disorder where the airway repeatedly collapses during sleep, causing breathing to stop or become shallow) treated with BiPAP (a breathing therapy that uses a small machine to deliver pressurized air through a mask worn over the nose or nose and mouth) with improvement and resolution of her metabolic (complex set of chemical reactions that occur within living organisms to maintain life)/hypercapnic (a condition where there is an abnormally high level of carbon dioxide [CO2- exhaled gas] in the blood) encephalopathy (condition affecting the brain). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's had intact cognition (the mental processes involved with knowing, learning, reasoning, understanding). The MDS further indicated Resident 1 was dependent on staff for bed mobility, bathing, dressing and personal hygiene and required supervision to partial moderate assistance for eating and oral hygiene respectively. During a concurrent interview and record review on 5/28/25 at 4:23 pm with Assistant Director of Nursing (ADON), the Resident 1's MDS Section I - Active Diagnoses dated 5/7/25 was reviewed. The ADON verified there was no diagnosis of OSA indicated on the assessment and stated it was missed. During the same interview and record review of the MDS, Section O - Special Treatments, Procedures, and Programs was reviewed. The ADON verified BiPAP was not indicated as a special treatment on the assessment and stated it should have been entered and it was missed. During a review of the facility's Policy and Procedures (P&P) titled Resident Assessment reviewed 10/21/24, the P&P indicated A comprehensive assessment of each resident is completed . Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Based on interview and record review the facility failed to develop a care plan for OSA (Obstructive Sleep Apnea. It is a sleep disorder where the airway repeatedly collapses during sleep, causing breathing to stop or become shallow) for one of three sampled residents (Resident 1). This failure resulted in no plan of care for Resident 1's OSA and had the potential to affect continuity and delivery of care. Cross reference with F641 Findings: During a review of Resident 1's Admission Record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including; heart failure (a condition where the heart weakened and cannot pump enough blood to meet the body's needs , cellulitis, muscle weakness, morbid (severe) obesity (excessive amount of body fat), hypertension (high blood pressure), obstructive sleep apnea (a sleep disorder where breathing repeatedly stops and starts during sleep due to a blockage of the upper airway). During a review of Resident 1's History and Physical (H&P) dated 5/2/25, the H&P indicated the resident during her hospital course patient was found to have hypercapnic respiratory failure secondary to Obesity Hypoventilation Syndrome ([NAME]- a condition where individuals who are obese experience hypoventilation [reduced breathing]) /OSA treated with BiPAP (a breathing therapy that uses a small machine to deliver pressurized air through a mask worn over the nose or nose and mouth) with improvement and resolution of her metabolic (complex set of chemical reactions that occur within living organisms to maintain life)/hypercapnic (a condition where there is an abnormally high level of carbon dioxide [CO2- exhaled gas] in the blood) encephalopathy (condition affecting the brain). During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/7/25, the MDS indicated Resident 1's had intact cognition (the mental processes involved with knowing, learning, reasoning, understanding). The MDS further indicated Resident 1 was dependent on staff for bed mobility, bathing, dressing and personal hygiene and required supervision to partial moderate assistance for eating and oral hygiene respectively. During a concurrent interview and record review with ADON on 5/28/25 at 4:23 pm, Resident 1's care plans were reviewed. The ADON verified there was no care plan developed for OSA or BiPAP and stated it could affect the resident's overall health. During a review of the facility's Policy and Procedures (P&P) titled Care Plan Comprehensive reviewed 10/21/24, the P&P indicated The facility's Interdisciplinary Team, in coordination with the resident and/or his/her family or representative, must developed and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment . Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk and contributing factors associated with identified problems . g. Identify professional services that are responsible for each element of care.

Based on interview and record review for one of three sampled residents (Resident 2), the facility failed to develop a care plan for the left foot treatments. This deficient practice had the potential to led to the development of redness to the left heel. Findings: A review of Resident 2's admission record indicated the facility admitted this [AGE] year-old male on 2/3/2025 with diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), atherosclerosis (chronic disease where sticky substances build up in the inner lining of the arteries) of right leg with gangrene (dead tissue caused by infection or lack of blood flow), atherosclerosis of aorta (largest blood vessel in the body), atherosclerotic heart disease, hypertensive heart disease (heart issues related to high blood pressure), presence of coronary angioplasty implant and graft (procedure where balloon is inserted into heart arteries to widen and improve blood flow), specified disorder, chronic obstructive pulmonary disorder (COPD-a chronic lung disease causing difficulty in breathing), hyperlipidemia (high fat in the blood), scoliosis (curvature in the spine), unilateral (on one side) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) left hip. A review of Resident 2's Minimum Data Set (MDS-a resident assessment) dated 2/7/2025 indicated Resident 2's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 2 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. Lastly, Resident 2 was identified at risk for developing a pressure injury and did not currently have any pressure injuries. During a concurrent interview and record review on 4/3/2025 at 2:51 p.m. with the DON. Resident 2's physician order dated 2/4/2025 was reviewed. Resident 2's physician order indicated to apply A&D ointment (skin moisturizer) to left foot/toes excessive dryness, leave open to air and monitor for skin breakdown every dayshift. The DON stated, This is considered a treatment order so we should have care planned some interventions for the left foot. The DON stated Resident 2 was at risk for developing a pressure injury due to his medical condition. The DON stated some interventions to prevent pressure ulcers included providing heel protector boots (boots used to reduce the risk of bed sores by keeping the heel floated, reliving pressure), low air loss (LAL- mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) mattress if appropriate and monitoring the skin daily. Lastly, the DON confirmed no care plan was developed for the care of Resident 2 ' s left foot. During a review of the facility's policy and procedure (P&P) titled,Skin Integrity Management, reviewed 10/2024, the P&P indicated, .Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments as indicated. Implement pressure ulcer prevention for identified risk factors. 4.2 Determine the need for support surface for bed and chair. 4.3 Determine the need for offloading devices. 4.4 Turning and repositioning based on resident care needs 4.5 For surgical wounds (e.g., flaps, grafts, donors, incisions, etc.), follow specific orders from the surgeon. 4.6 Implement Special Wound Care treatments/techniques, as indicated and ordered. A review of the facility policy and procedure titled, Care plans, comprehensive, person-centered reviewed 10/2024 indicated, [ .] Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview and record review for one of three sampled residents (Resident 2), the facility failed to monitor skin and report redness on Resident 2's left heel to the attending physician (AP). This deficient practice placed Resident 2 at risk of developing a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) to the left heel. Findings: A review of Resident 2's admission record indicated the facility admitted this [AGE] year-old male on 2/3/2025 with diagnoses including peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), Type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), atherosclerosis (chronic disease where sticky substances build up in the inner lining of the arteries) of right leg with gangrene (dead tissue caused by infection or lack of blood flow), atherosclerosis of aorta (largest blood vessel in the body), atherosclerotic heart disease, hypertensive heart disease (heart issues related to high blood pressure), presence of coronary angioplasty implant and graft (procedure where balloon is inserted into heart arteries to widen and improve blood flow), specified disorder, chronic obstructive pulmonary disorder (COPD-a chronic lung disease causing difficulty in breathing), hyperlipidemia (high fat in the blood), scoliosis (curvature in the spine), unilateral (on one side) osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) left hip. A review of Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 2/7/2025 indicated Resident 2's cognition (mental ability to make decisions for daily living) was intact. The MDS indicated Resident 2 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. Lastly, Resident 2 was identified at risk for developing a pressure injury and did not currently have any pressure injuries. On 4/1/2025 The California Department of Public Health (CDPH) received a complaint alleging a resident developed pressure ulcer while in the facility. During an interview on 4/3/2025 at 12:03 p.m. with the Ombudsman (OMBUDS-an advocate for residents of nursing homes, board and care centers, and assisted living facilities). The OMBUDS visited Resident 2 a week prior because Resident 2 informed the facility there was a possible pressure ulcer developing on Resident 2's heels and Resident 2 did not feel as if the facility addressed this concern. During a concurrent observation and interview on 4/3/2025 at 12:12 p.m. with Resident 2. in Resident 2's room, Resident 2 was lying in a regular mattress, two heel protector boots (boots used to reduce the risk of bed sores by keeping the heel floated, reliving pressure) were observed in the chair next to the bed, Resident 2 ' s right foot was wrapped in a clean gauze dressing and Resident 2's left foot was covered with a non-skid sock. Resident 2 stated, I feel like I was getting a bed sore or my right butt and, on my heels, I asked them to check while they are giving me a bath and they just say no you don ' t have one. I told them this about two weeks ago and I told the doctor during a video call. The doctor just said I needed to get out of bed and sit in a chair. I had a partial amputation on my right foot, and they change the dressing every day. They did not put any lotion or cream on my left foot today but that is normal; sometimes they do sometimes they don ' t. They did not put those boots on today nor last night, its hurts when I wear them on the right foot, but I haven ' t tried wearing them on just the left foot because they don ' t put them on. I overheard one of the unnamed staff nurses telling them to put the boots on me for two hours and then take them off for one hour, but no one has done that. During an interview on 4/3/2025 at 12:33 p.m. with the certified nursing assistant (CNA). The CNA stated the skin on Resident 2's left foot was very dry and needed A&D ointment. The CNA stated, I can't do it so I told the treatment nurse, I did not put anything on the left foot today after the bed bath. Lastly, the CNA stated, I did not notice any redness of Resident 2's skin today. During an interview on 4/3/2025 at 12:50p.m. the licensed Vocational Nurse (LVN) treatment nurse stated, Resident 2 has gangrene on the right foot, and I see him everyday and change the dressing. Resident 2 does not have any wounds on the left foot just dry skin. I believe we are doing A&D ointment for the dry skin. I usually apply it because it is considered a medication. No, it was not done this morning when I did the treatment on the right foot. During a concurrent observation and interview on 4/3/2025 at 1:27 p.m. with the LVN in Resident 2's room, Resident 2's sock was removed from left foot and the left foot was observed. A large amount of skin flakes feel from sock as sock was removed and the heel appeared reddened with a an approximate quarter sized area black area at the base of the heel. The LVN pushed on the reddened area and Resident 2 jumped in response. The LVN stated, I see some redness and a scab, usually the CNA is good about reporting any redness, but no one told me about any redness on the left heel today, I will have to call the doctor and do a COC. During a concurrent interview and record review on 4/3/2025 at 2:38 p.m. with the director of nursing (DON). Resident 2's change of condition (COC-document used to report a change in resident ' s health status that requires action) form dated 3/18/2025 was reviewed. Resident 2's COC form indicated Resident 2 developed a deep tissue injury (DTI- a serious form of pressure injury where damage occurs to the underlying tissue and appears as a purple or maroon discoloration on the intact skin). On the right heel. The DON stated Resident 2 was at risk for pressure ulcer due to Resident 2 ' s medical diagnoses. The DON stated the prevention measure in place were the heel protector boots. The DON stated a low air loss (LAL- mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) mattress would not have been appropriate because Resident 2 did not have and wounds on the back. Lastly, the DON stated the CNA ' s are also a second set of eyes to monitor the skin and report and changes. During a concurrent interview and record review on 4/3/2025 at 2:51 p.m. with the DON. Resident 2's physician order dated 2/4/2025 was reviewed. Resident 2's physician order indicated to apply A&D ointment (skin moisturizer) to left foot/toes excessive dryness, leave open to air and monitor for skin breakdown every dayshift. The DON stated, This should be done every shift by the treatment nurse. If the treatment nurse noticed and redness or skin changes to the left foot the doctor should be notified because the treatment orders may need to be changed. During an interview on 4/4/2025 at 11:56 a.m. The AP stated Resident 2 refused to wear the boots and that may have contributed to the development of the DTI on the right heel along with Resident 2's history of PVD. The AP stated the facility informed the AP of the redness to Resident 2's left foot on 4/3/2025 and instructed them to follow their protocol which would include encouragement to wear the protective heel boots. During a review of the facility's policy and procedure (P&P) titled, Change in Condition, reviewed 10/2024, the P&P indicated: I.PURPOSE To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition. II.POLICY A Facility must immediately inform the resident, consult with the Resident's physician and/or NP, and notify, consistent with his/her authority, Resident Representative where there is: An accident involving the Resident. A significant change in the Resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or A decision to transfer or discharge the Resident from the Center. A review of the facility policy and procedure titled, Skin integrity management reviewed 10/2024 indicated the implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Notify Medical Director, Director of Nursing (DON), Administrator, and or Designee if deviation from protocol is requested by physician/advanced practice provider (APP), managed care companies, or others. [ .] Nursing staff will observe for any sign of potential or active pressure injury daily while providing nursing care.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls, and identified to have fall risk indicators was not left unattended sitting on bed by the Certified Nursing Assistant (CNA) 1 on 11/5/2024. This failure resulted in Resident 1 had a fall on 11/5/2024 at 12:12 am and was sent to General Acute Care Hospital (GACH) on 11/5/2024. Resident 1sustained a mildly displaced right 10th through 12th rib fracture and right 10th rib fracture is segmental (happen when one of your bones is broken in at least two places, leaving a segment of your bone totally separated by the breaks). Findings: During a review of Resident 1 ' s admission record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including history of falling, unsteadiness on feet, and need for assistance with personal care. During a review of Resident 1 ' s History and physical (H&P, a term used to describe a physician's examination of a patient. In an H&P, the physician obtains a thorough medical history from the patient, performs a physical examination, and then documents their findings) dated 10/4/2024 it indicated Resident 1 did not have the capacity for medical decision making due to cognitive decline (the mental processes that allow people to think, understand, and complete tasks). During a review of Resident 1 ' s Nursing documentation evaluation dated 10/2/2024 at 4:55 pm, the nursing documentation evaluation indicated under the fall risk factor Fall Risk Indicators Identified. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/7/2024, indicated Resident 1 had moderate cognitive impairments (a stage of cognitive decline where a person has significant difficulty with complex tasks and may become confused about their surroundings). The same MDS indicated Resident 1 was required substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs) for most of her Activities of Daily Living such as: (ADLs - ADLs- routine tasks/activities such as bathing, dressing, toileting hygiene) and partial/moderate assistance for oral hygiene, personal hygiene. During a review of a Change of Condition (COC) dated 11/5/2024 at 12:12 am, it indicated Resident 1 had a fall on 11/5/2024. Resident 1 was seen sitting on the floor next to the foot of the bed in her room and had pain 10/10 (10 being the worst) to the back after the fall. The same COC indicated Resident 1 was transferred to the hospital per her request and MD (Medical Doctor) was made aware. During a review of a physician ' s order dated 11/5/2024 indicated Transfer to Acute hospital via 911 (a three-digit number that people in the United States can call to request emergency assistance) for further eval (evaluation) s/p (status post-after) fall. During a review of Resident 1 ' s care plan initiated 10/4/2024 indicated Resident 1 was at risk for falls: impaired mobility. The interventions included to monitor for and assist with toileting needs. During a review of the computed tomography scan (CT scan - a noninvasive medical imaging procedure that uses X-rays (a type of electromagnetic radiation that can pass through most objects, including the human body, to create images of internal structures) and a computer to create detailed pictures of the inside of the body) dated 11/5/2024 at 4:57 am indicated Recent appearing mildly displaced right 10th through 12th rib fractures. Right 10th rib fracture is segmental. During an interview with Family Member (FM) 1 on 11/6/24 at 10:54 am, FM 1 stated she spoke with the Licensed Vocational Nurse (LVN) 1 who informed her that Resident 1 had a fall earlier that morning and had requested to be sent to GACH because was experiencing severe pain which had not resolved after taking some pain medication. FM 1 stated that she (FM 1) called GACH where Resident 1 was admitted and was informed that Resident 1 had a right hip and several rib fractures which she did not have before. During an interview with LVN 1 on 11/6/2024 at 1:45 pm, LVN 1 stated that Resident 1 was incontinent (the inability to control the flow of urine or stool) of bowel and bladder but did not get up overnight (on 11/5/2024). LVN 1 stated she changed the Resident 1 incontinence briefs in bed. LVN 1 stated that she heard a scream coming from Resident 1 ' s room around midnight and when she got there, she found Resident 1 on the floor. LVN 1 stated CNA 1 who was assigned to her (Resident 1) reported that Resident 1 asked to go be taken to the bathroom. CNA 1 sat Resident 1 on the side of her bed with her feet on the floor and went to the bathroom to get it prepared. While in the bathroom, she (CNA) heard Resident 1 scream, ran back to the room, and found her (Resident 1) on the floor. She stated that Resident 1 was a fall risk should not have been taken out of bed and left unsupervised. During an interview with the Assistant Director of Nursing (ADON), on 11/6/24 at 2:15 pm, the ADON stated that Resident 1 was a fall risk because she had a history of falls, had some cognitive impairments, and had a (history of) humerus (shoulder bone) fracture. ADON stated that Resident 1 should not have been left sitting at the bedside unsupervised to prevent falls. During a review of the facility ' s policy and procedure (P&P) titled Fall Management, with an effective date 5/26/2021, the P&P indicated, To reduce risk for falls and minimize the actual occurrence of falls. The same P&P indicated; Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury.

Based on observation, interview, and record review the facility failed to ensure a resident with dysphagia (inability to chew or difficulty swallowing) and at risk for choking received a diet in the correct form for one of 11 sampled residents (Residents 1). On 9/3/2023 at 5:24 p.m. Resident 1 was given a regular consistency diet (no food consistency/texture restrictions) instead of a prescribed puree diet (diet used in the dietary management of dysphagia with the food prepared moist, smooth, cohesive [sticking together] with no water separation and with consistency of a pudding). This failure had a potential to cause life threatening conditions such as choking, aspiration (inhaling small particles into the lungs), and death. Findings: During a review of Resident 1's Admission Record, indicated the facility admitted Resident 1 on 8/14/2023, with diagnoses including acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), malnutrition (lack of sufficient nutrients in the body) and dysphagia. During a review of Resident 1's Physician's Order (PO), dated 8/16/2023, PO indicated an order for speech therapy (ST) evaluation and treatment of dysphagia for plan of care including oral motor exercises, safe swallow strategies, ongoing diet texture analysis with trial by mouth, and caregiver education and training daily five times per week for four weeks. During a review of Resident 1's Speech Therapy (ST - is the assessment and treatment of communication problems and speech disorders) Care Plan dated 8/16/2023, indicated Resident 1 required speech therapy related to dysphagia to reduce risk of aspiration. During a review of Resident 1's History and Physical (H&P), dated 8/17/2023, the H&P indicated Resident 1 does not have the capacity to make decisions. During a review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care-screening tool), dated 8/18/2023, indicated Resident 1 required one-person physical assist from staff for activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). MDS also indicated Resident 1 had signs and symptoms of swallowing disorder due to coughing or choking during meals or when swallowing medications. The nutritional approach indicated Resident 1 to have a mechanically altered (require change in texture of food/liquids such as puree food and thickened liquids) diet. During a review of Resident 1's Nutrition Risk Care Plan dated 8/21/2023, indicated Resident 1 was at risk for nutrition deficit (lack of sufficient nutrients in the body) secondary to swallowing deficit. The goal indicated Resident 1 to be able to tolerate diet without chewing and difficulty swallowing. The care plan further indicated to assist Resident 1 with meals and to provide diet as ordered. During a review of Resident 1's Nutritional Assessment document, dated 8/21/2023, indicated Resident 1 was on a puree diet with nectar thickened (easily pourable fluid designed for people with difficulty swallowing) liquid and no ST evaluation changes to the plan of care for Resident 1. During a review of Resident 1's Physician's Order, dated 8/23/2023, indicated a diet order of fortified (food to which extra nutrients have been added), puree texture, nectar thick consistency and with no added salt (NAS) diet. During a concurrent observation and interview on 9/3/2023 at 5:24 p.m., inside Resident 1's room, Resident 1 was observed chewing (food). A dinner tray was observed on Resident 1's bedside table with regular consistency diet of chicken salad, sliced peaches, green beans and slightly touched (consumed/ eaten) baked beans. Surveyor requested Resident 1 to stop eating until a facility staff comes in. During a concurrent observation and interview with LVN 2 on 9/3/2023 at 5:25 p.m., surveyor requested LVN 2 to check on Resident 1's tray. LVN 2 verified Resident 1's current tray was a regular and stated, Resident 1 should not have a regular diet if the diet order is puree. During a concurrent interview and record review with Registered Nurse 1 (RN 1), on 9/3/2023 at 5:26 p.m., physician's order for Residents 1, dated 8/23/2023, was reviewed. The physician's order indicated Resident 1 to have puree diet. RN 1 verified the physician's orders and stated that Resident 1 had received wrong dinner meal. RN 1 also stated it is important to check a resident's meal tray ticket and to make sure the meal was for right resident, right diet order and right meal consistency prior to serving the meal tray to a resident. During an interview with Dietary Director (DD) on 9/3/2023 at 6:36 p.m., DD stated and verified that on 9/3/2023, all residents' meals were checked during dinner and that all meals were prepared using residents' meal tray tickets to make sure the right diet order was served to the right resident. DD also stated nurses need to check the meals prior to serving to the resident. During an interview with CNA 1 on 9/3/2023 at 6:39 p.m., CNA 1 stated she served the meal tray to Resident 1. CNA 1 stated she was assigned to Resident 1 and that it was her first time to provide care to Resident 1. CNA 1 confirmed and stated resident meal tray ticket are placed on top of the meal container. CNA 1 stated and verified that she did not need to check in with the LN prior to serving the dinner meal for Resident 1. During an interview with the DON on 9/3/2023 at 6:51 p.m., the DON stated upon finding out what happened to Resident 1, she checked on Resident 1's meal tray ticket in Resident 1's bathroom trash can. The DON stated CNA 1 must have accidentally switched Resident 1's meal tray with Resident 8's meal tray. The DON stated, it was important that facility staff gives the right diet order to the residents due to Resident 1's high risk for aspiration and possibly choking when eating a regular diet meal. During an interview with the Speech Therapist 1 (ST 1), on 9/5/2023 at 1:14 p.m., ST 1 stated and verified ST treatment for Resident 1. ST 1 also stated and confirmed Resident 1 was at risk for aspiration. During a review of the facility's P&P titled, Diet Tray Card, reviewed on 7/18/2023, P&P indicated, The diet card's primary purpose is to provide caregivers with mealtime information. During a review of the facility's P&P titled, Tray Identification, reviewed on 7/18/2023, P&P indicated, Nursing staff shall check each food tray for the correct diet before serving the residents. During a review of the facility's P&P titled, Dysphagia Diet: Puree, reviewed on 7/18/2023, indicated, Puree food is more easily swallowed and prevents aspiration. During a review of the facility's P&P titled, Nutritional Considerations for Dysphagia Management, reviewed 7/18/2023, P&P indicated, The goal of the dysphagia diet is to maintain optimal nutritional status while providing foods and beverages that reduce the risks of choking and aspiration.

Based on observation, interview, and record review, the facility failed to have a system to ensure all 15 of 15 heating, ventilation, and air conditioning (HVAC) units were operational and provided heat to maintain comfortable and appropriate room temperature according to the facility's policy and procedures, titled Room Temperature Policy & Procedure, for 80 of 80 residents. This deficient practice had the potential to cause serious harm for the residents and risk for pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness), and death related to hypothermia (a significant and potentially dangerous drop in body temperature). On 3/16/2023, at 10:05 p.m., 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 of a resident) was called in the presence of the Administrator (ADM), Maintenance Supervisor (MS), Environmental Consultant (EC), [NAME] President of Operations (VPO), and Director of Physical Plant (DPP) because of the seriousness related to the facility's failure to maintain all 15 of 15 HVAC units operational and provide heat to maintain comfortable and appropriate room temperature according to the facility's policy and procedures, titled Room Temperature Policy & Procedure, for all residents. On 3/17/2023, at 2:05 p.m., the ADM provided an acceptable IJ removal plan that included the following summarized actions/items: a) In-services performed to staff regarding how to provide residents with clean, safe, comfortable, and home-like environment with emphasis on room temperatures. b) Hourly temperature log of the entire resident rooms. c) Quality Assurance & Performance Improvement meeting records. d) A summary of additional blankets and linens brought from outside. e) Quality circle rounds records. f) Confirmation page from Department of Health Care Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development - OSHPD) for applying for the emergency electrical panel repair/replacement, and HCAI forms completed by the facility indicating a project team included a design professional, an Inspector of Record (IOR), and a contractor for the electrical panel repair. g) A contract between the facility and the contractor for the electrical panel repair. On 3/17/2023, at 5:42 p.m., the contractor provided a timeline for the electrical panel repair. On 3/17/2023, at 6:12 p.m., after verifying satisfactory implementation of the facility's immediate corrective actions noted in the IJ Removal Plan (interventions to correct the deficient practice), the Immediate Jeopardy was removed onsite in the presence of the ADM, VPO, EC, and DPP. Findings: During an interview with the MS, on 3/16/2023, at 4:12 p.m., the MS stated that the facility contacted the Fire Department on 3/16/2023 because a staff smelled something burning in the basement level. The MS further stated he found a burnt panel on 3/16/2023 in the electrical room and the ADM was informed of the incident same day. During an interview with the MS on 3/16/2023, at 5:15 p.m., the MS stated the electrical panel repair progress depended on the availability of the necessary parts of the electrical panel. During a concurrent observation and interview with the MS on 3/16/2023, at 5:56p.m., the digital thermostats were observed not displaying numbers (blank) and the HVAC units were observed nonoperational. The MS confirmed the findings and stated all HVAC units became nonoperational due to the issue with the electrical panel. During an interview with the DPP on 3/16/2023, at 8:06 p.m., the DPP confirmed and stated the electrical panel was faulty and it would be difficult to precisely estimate when the electrical panel could be repaired at this point. A review of the National Weather Service's weather forecast indicated the lowest temperature for the night of 3/16/2023 was 51 degrees Fahrenheit [scale for measuring temperature] for the facility's zip code. During an observation on 3/16/2023, at 8:33 p.m., in room [ROOM NUMBER], the MS measured the room temperature, and it was measured at 70.7 degrees Fahrenheit. During an observation on 3/16/2023, at 8:34 p.m., in room [ROOM NUMBER], the MS measured the room temperature, and it was measured at 68.7 degrees Fahrenheit. During an observation on 3/16/2023, at 8:37 p.m., in room [ROOM NUMBER], the MS measured the room temperature, and it was measured at 70.1 degrees Fahrenheit. During an observation on 3/16/2023, at 8:38 p.m., in room [ROOM NUMBER], the MS measured the room temperature, and it was measured at 65.6 degrees Fahrenheit. During an observation on 3/16/2023, at 8:39 p.m., in room [ROOM NUMBER], the MS measured the room temperature, and it was measured at 70.7 degrees Fahrenheit. During an interview with the Infection Preventionist (IP), on 3/16/2023, at 9:26 p.m., the IP stated, if residents were exposed to cold temperatures, it may cause hypothermia and respiratory (the organs that are involved in breathing) illnesses. A review of the facility's hourly temperature log from 11:00 p.m. of 3/16/2023 to 11:00 a.m. of 3/17/2023 indicated that all resident rooms except room [ROOM NUMBER] were measured below 71 degrees Fahrenheit at least once. A review of the facility's policy and procedures titled, Room Temperature Policy & Procedure, dated 11/2012, indicated, The temperature should range between 71 degrees Fahrenheit and 81 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents, (Residents 1, 2, 3, and 4), who needed assistance with transfers, toilet use, bathing and personal hygiene, received assistance with personal and oral hygiene and toileting needs within five minutes, and soiled bed linen change. This deficient practice resulted in: 1. Residents 1 remained wet in urine and / or bowel movements for extended periods of time, became upset, was crying due to the lack of care and left the facility against medical advice (AMA) 22 days from admission. 2. Resident 2 had to urinate on the incontinent brief despite being able to control because staff did not assist him to use the toilet, which caused Resident 2 to be upset, helpless, and frustrated. 3. Resident 3 waiting for hours to be assisted to go to bed because the bed linen was not changed after his shower. Resident 3 stated he felt nasty and unclean, and did not want to sit on the bed. 4. Resident 4 waiting for approximately three hours to brush her teeth after breakfast and verbalized feeling gross. Findings: 1. A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 4/1/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical (H&P) exam completed by the attending physician on 4/2/2021, indicated the resident was able to understand and make decisions. A review of the Resident 1's Progress Nursing Notes dated 4/23/2021 at 3:25 p.m. indicated Resident 1 wanted to leave the facility and unidentified facility staff encouraged Resident 2 to stay but were unsuccessful. A review of Resident 1's Progress Nursing Notes dated 4/23/2021, timed at 3:35 p.m. indicated Resident 1 was yelling, screaming, and crying when Resident 1 was leaving the facility. At 10:53 p.m., a nurse documented Resident 1 left the facility at about 4:30 p.m. against medical advice (AMA). On 5/21/2021 at 10:00 a.m., during an interview, Resident 1's Family Member 1 (FM 1) stated Resident 1 was upset and mad because staff did not respond to her calls for assistance to use the toilet or change the incontinent briefs and that was the reason for Resident 1 to leave the facility. On 6/18/2021 at 9:10 a.m., during a telephone interview, Resident 1 stated she was incontinent, was unable to clean herself, could not walk without assistance, and needed a wheelchair and a walker for mobility. Resident 1 further stated she left the facility because she had waited for two hours for staff to clean and change her incontinent brief. Staff did not assist her to eat, go the restroom, or assist with anything. Resident 1 stated the staff took too long to answer the call lights when she needed help and her stay at the facility (22 days) was terrible and my feelings were hurt because they didn't want to help me. Resident 1 stated her significant other picked her up from the facility when she left AMA. On 6/24/2021 at 4:43 p.m., during an interview, Certified Nursing Assistant 8 (CNA 8) stated Resident 1 wore pull up briefs and used the call light when she needed to be changed. 2. A review of Resident 2's Admission Record indicated the facility admitted Resident 2, a [AGE] year-old male, on 11/6/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review Resident 2's Bowel and Bladder Program Screener form, dated 11/6/2020, indicated Resident 2 was continent of bowel and bladder and voided appropriately without incontinence. A review of Resident 2's H&P exam completed by the attending physician on 11/10/2021, indicated the resident was able to understand and make decisions. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/12/2020 and 3/10/2021, indicated Resident 2 could make decisions and required one-person extensive assist to walk and was always continent of bowel and bladder (B&B). The MDS further indicated Resident 2 required one person physical assist with personal hygiene and toileting. On 5/18/2021 at 9:52 a.m., during an observation outside Resident 2's room, a call light was on. In a concurrent interview, Resident 2 stated he pressed the call light for assistance. The facility's Marketing Assistant (MA) responded to the call light at 9:55 a.m. and informed Resident 2 that CNA 1 was on break. On 5/18/2021 at 9:55 a.m., during an interview, Resident 2 stated he was very upset and had not seen his attendant (CNA 1) since breakfast (between 7:30 a.m. and 8:00 a.m.). Resident 2 stated he was wet with urine for about one hour and needed his incontinent brief changed. Resident 2 further stated CNA 1 was horrible and always took a long time to help him. Resident 2 continued to state he did not want CNA 1 to care for him because CNA 1 did not do a good job. On 5/18/2021 at 10:10 a.m., during an interview, CNA 1 stated he went to his break and did not inform the charge nurse to have another staff cover for him. CNA 1 stated he had planned to change Resident 2's incontinent brief after his break. 3. A review of Resident 3's Admission Record, indicated the facility admitted Resident 3 on 2/26/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's H&P exam by the attending physician dated 2/27/2021, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's MDS dated [DATE], indicated Resident 3 had no problems with memory and required one to two-person physical assist with transfers, walking, toilet use, and personal hygiene. Resident 3 was continent of bowel and bladder. On 5/18/2021 at 10:00 a.m., during an interview and concurrent observation, Resident 3 was sitting in his wheelchair by his bed. Resident 3 stated he had asked CNA 1 to change the bed earlier after his shower, because the sheets were dirty pointing at two quarter size dark grey colored stains on the bed sheet. Resident 3 stated he wanted to go to bed but could not because he did not want to lay on the dirty bed which made him feel nasty and unclean. On 5/18/2021 at 10:25 a.m., during an interview, the Assistant Administrator (AA) stated staff breaks were rotated to ensure that a staff monitored the residents always. The AA stated CNAs should report to the nursing supervisor before going on break. On 6/15/2021 at 11:57 a.m., during an interview, Director of Staff Development (DSD) stated incontinent care should be provided within five or less minutes upon residents' request. A review of the facility's policy and procedures titled, Resident Care, Routine revised 11/2012, indicated provide incontinent care to each resident after each incontinent episode . assist residents requiring help with toileting, intervals shall be set per the resident's care plan. On 6/22/2021 at 11:57 a.m., during an interview, the Administrator stated policy reviews are conducted by the corporate office on as needed basis, and that the policy and procedure titled incontinence care dated 11/2012, was the most recent. 4. A review of Resident 4's Admission Record indicated the facility admitted the resident on 4/21/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's MDS dated [DATE], indicated Resident 4 had the ability to understand and make decisions, required extensive assistance with one-person assist with bed mobility, dressing, toilet use, and personal hygiene. Resident 4 required two-person assist with transfer to and from bed, chair, wheelchair and standing position. On 5/10/2021 at 10:05 a.m., during an observation, CNA 1 was in the hallway, outside the resident's room leaning on the wall looking at his cellphone. During an interview, Resident 4 stated she wanted to brush her teeth after breakfast (7:30 a.m. to 8 a.m.) but need assistance to go to the restroom and set up to brush her teeth. Resident 4 stated two hour had passed but nobody had assisted her. Resident 4 stated she felt a little gross honestly. On 5/10/2021 at 10:08 a.m., during an interview, CNA 1 stated he was assigned to Resident 4. CNA 4 entered Resident 4's room and the resident said he had not returned since he brought her breakfast. CNA 1 explained he went to break after the residents' breakfast time. On 5/18/2021 at 9:41 a.m., during an interview, CNA 3 stated they must inform the supervisor when going to breakfast for coverage. On 5/18/2021 at 10:25 a.m., during an interview, the Assistant Administrator (AA) stated staff have rotating breaks to ensure a staff was always present to monitor the resident while another staff is on break. The AA further stated staff must hand off and communicate with each other and or the nursing supervisor before they go on break. On 6/1/2021 at 9:41 a.m., during an interview, CNA 2 stated she was usually assigned to care for Resident 4 and the resident likes to brush her teeth before and after meals and needs assistance with it. On 6/22/2021, at 9:30 a.m., during an interview with the Assistant MDS nurse and concurrent review of Resident 4's undated Care Plan for selfcare performance deficit with activities of daily living (ADLs, such as grooming and personal hygiene) indicated Resident 4 required extensive staff participation with personal hygiene and oral care. Assistant MDS (AMDS) nurse explained extensive assistance means the resident is involved in the oral care activity and staff provides weight bearing support. A review of the facility's policy and procedures titled, Resident Care, routine, revised 11/2021, indicated provide oral care to each resident at least twice daily . Oral care should be given to residents as part of morning and bedtime care. A review of the facility's policy and procedures titled Communication section Personal Communication Devices dated 7/2019, indicated employees should conduct personal business during breaks and other rest periods. This includes the use of personal communication conversation devices including cell phones. A review of the facility's policy and procedures titled, Call Light, Answering revised 4/1/19, indicated each resident call light will be answered in a reasonable and timely manner . listen to resident request, if request cannot be addressed immediately agree on a return time acceptable to the resident. A review of the facility's policy and procedures titled, Resident Care, Routine indicated provide oral care to each resident at least twice daily . Oral care should be given to residents as part of morning and bedtime care.

Based on observation, interview and record review, the facility failed to provide incontinence (inability to feel and control urination and bowel movements) care for two of four sampled residets (Residents 1 and 2) who used briefs and were assessed to be incontinent of bowel and bladder (B&B). This deficient practice resulted in Residents 1 and 2 remaining wet and or soiled for extended periods of time, becoming upset, and was compelled to leave the facility against medical advice (AMA, when a person chooses to leave an institution before the treating physician recommends discharge), and had the potential had to place Residents 1 and 2 at risk for skin breakdown and urinary tract infections. Findings: 1. A review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 4/1/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's B&B Program Screener (B&B assessment for continence) form dated 4/1/2021, indicated Resident 1 was always continent of urine, never incontinent of stool (bowel), and always aware of need to use the toilet. A review of Resident 1's History and Physical (H&P) Examination completed by the attending physician on 4/2/2021, indicated Resident 1 was able to understand and make needs known. A review of Resident 1's initial Baseline Care Plan developed on 4/2/2021, indicated Resident 1 was continent of B&B, was able to go to the bathroom, transfer to toilet with one-person assist, and had treatable and under control predisposing (risk) factors, medications and conditions that impacted continence. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 4/7/2021 and 4/23/2021, indicated Resident 1 was frequently incontinent of B&B and had difficulty walking. A review of Resident 1's Progress Notes on Health Status Note dated 4/23/2021, timed at 3:25 p.m. indicated Resident 1 was yelling, screaming, and crying, when Resident 1 was leaving the facility. At 10:53 p.m., a nurse documented Resident 1 left the facility at about 4:30 p.m. against medical advice (AMA), did not want to stay at the facility, and was alert and cognitively intact. On 5/21/2021 at 10:00 a.m., during an interview, Resident 1's Family Member 1 (FM 1) stated Resident 1 was upset and mad because staff did not respond to her calls for assistance to use the toilet or change the incontinent briefs, and that was the reason for Resident 1 left the facility. On 6/18/2021 at 9:10 a.m., during a telephone interview, Resident 1 stated she was incontinent of B&B prior to admission at the facility, was unable to clean herself, walk without assistance, and needed a wheelchair and a walker for mobility. Resident 1 further stated she left the facility because she had waited for two hours for staff to clean and change her incontinent brief (a piece of absorbent material worn by a person to absorb and retain urine and feces). Resident 1 stated the facility staff did not assist her to eat, go the restroom, or assist with anything. Resident 1 stated the staff took too long to answer the call lights when she needed help and her stay at the facility (22 days) was terrible and my feelings were hurt because they didn't want to help me. Resident 1 stated her significant other picked her up from the facility when she left AMA. On 6/22/2021 at 9:30 a.m., during an interview and record review with the Assistant MDS nurse, Resident 1's B&B Program Screener form dated 4/1/2021 indicated Resident was always continent of urine and stool (bowel), and always aware of need to use the toilet. However, a review of Resident 1's MDS dated [DATE] and 4/23/2021, indicated Resident 1 was frequently incontinent of B&B and had difficulty walking. The Assistant MDS Nurse could not explain the inconsistency between the B&B Program assessment and the MDS. On 6/24/2021 at 4:43 p.m., during an interview, Certified Nurse Assistant 8 (CNA 8) stated Resident 1 would call when she needed incontinent brief changed. 2. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 11/6/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review Resident 2's B&B Program Screener form, dated 11/6/2020, indicated Resident 2 was incontinent of B&B, and voided appropriately without incontinence. A review of Resident 2's Care Plan on B&B dated 11/7/2020, indicated the resident was incontinent and used disposable briefs. The interventions included changing (the incontinent brief) every two hours and as needed. A review of Resident 2's H&P examination completed by the attending physician on 11/10/2021, indicated the resident was able to understand and make decisions. A review of Resident 2's MDS dated [DATE] and 3/10/2021, indicated Resident 2 could make decisions and required one-person extensive assist to walk and was always incontinent of B&B. A review of Resident 2's Patient Results collected on 4/29/2021 at 4:30 p.m., indicated Resident 2 tested positive (reference range-negative) for COVID-19 (A highly contagious respiratory disease thought to spread from person to person through droplets released when an infected person coughs, sneezes, or talks). On 5/18/2021 at 9:52 a.m., during an observation and interview, Resident 2 pressed the call light and requested and the facility's Marketing Assistant (MA) responded to the call light at 9:55 a.m. Resident 2 stated he had asked CNA 1 to change his wet incontinent brief before breakfast and was calling again to be changed. MA informed Resident 2 that CNA 1 was on break. On 5/18/2021 at 9:55 a.m., during an interview, Resident 2 stated he was very upset and had not seen his attendant (CNA 1) since breakfast (between 7:30 a.m. and 8:00 a.m.). Resident 2 stated he was wet with urine for about one hour and needed his incontinent brief changed. Resident 2 further stated CNA 1 was horrible and always took a long time to help him. Resident 2 continued to state he did not want CNA 1 to care for him because CNA 1 did not do a good job. On 5/18/2021 at 10:10 a.m., during an interview, CNA 1 stated he went to his break and did not inform the charge nurse to have another staff cover for him. CNA 1 stated he had planned to change Resident 2's incontinent brief after his break. On 5/20/2021 at 1:55 p.m., during an observation and interview, Resident 2 was wearing incontinent brief. Resident 2 stated he developed COVID-19 and became weak. Resident 2 stated he had the urge to pass urine and was not incontinent, however, the facility staff put incontinent briefs on him. On 6/22/2021 at 9:30 a.m., during an interview and record review with the Assistant MDS nurse, Resident 2's B&B Program Screener form dated 11/6/2020 indicated Resident 2 was continent of B&B and voided appropriately without incontinence. However, Resident 2's MDS dated [DATE] and 3/10/2021, indicated Resident 2 was always incontinent of B&B. The Assistant MDS Nurse could not explain the inconsistency between the B&B Program assessment and the MDS. On 6/22/2021 at 11:32 a.m., during an interview, CNA 4 stated Resident 2 would call for incontinent brief to be changed. A review of the facility's policy and procedures titled Bowel and Bladder Management revised 11/2012, indicated the facility is committed to ensuring that residents the facility continent will remain continent, unless their clinical condition changes such that incontinence is demonstrated to be unavoidable . Check the resident at regular intervals (usually every two hours (2) . If the resident is wet, provide thorough skin care and change absorbent pads or briefs.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident1) received sufficient fluid intake to maintain proper hydration and health. Resident 1, who was diagnosed with dysphagia (difficulty swallowing) and dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), did not receive the amount of fluids needed daily for over three months. As a result, on [DATE], Resident 1 had a low blood pressure 80 /50 millimeters of mercury (mmHg [normal ,d+[DATE]]), was transferred to the General Acute Care Hospital (GACH), where she was diagnosed with dehydration, (a condition caused by the loss of too much fluid from the body, when you are losing more fluids than you are taking in, and your body does not have enough fluids for normal function). Resident 1 died on [DATE]. Findings: A review of Resident 1's Facesheet indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a review of Resident 1's care plan for Nutritional Risk, dated [DATE], the goal indicated to maintain pertinent diet-related laboratory tests at acceptable parameters. The BUN was not indicated. The care plan interventions included to maintain GT at this time, provide GT care as ordered, water flush as ordered and offer nectar thickened water or juice every two hours while awake. A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's quarterly Minimum Data Set (MDS- a comprehensive, standardized assessment and care screening tool), dated [DATE], indicated Resident 1's cognitive skills and mental status were severely impaired. The MDS indicated Resident 1 required extensive assistance / one-person physical assist when eating or drinking and was on a mechanically altered therapeutic diet. A review of Resident 1's average daily fluid intake record for: -,d+[DATE] was 604 ml. -,d+[DATE] was 694 ml. -,d+[DATE] was 656 ml. A review of Resident 1's Physician Orders, dated [DATE], indicated to monitor and assess resident for abnormal signs and symptoms every shift. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If one of the following, altered mental status from baseline, systolic blood pressure below 100 (top number), oxygen saturation below 92%, bluish lips or face: increase monitoring to every four hours. Report change to Medical Doctor (MD) immediately. If two or more of above, call MD for potential for basic life support (BLS) transfer, every shift. A review of Resident 1's oral fluid intake record indicated the following: - [DATE], Resident 1 consumed 710 mL of fluid. - [DATE] Resident 1 consumed 480 mL of fluid. - [DATE], Resident 1 consumed 680 mL of fluid. - [DATE], Resident 1 consumed 50 mL of fluid. -[DATE], Resident 1 consumed 870 mL of fluid. - [DATE], no fluid consumption was documented. - [DATE], Resident 1 consumed 290 mL of fluid. -[DATE], Resident 1 consumed 510 mL of fluid. A review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's MAR for [DATE] at 4 PM, indicated the blood pressure was ,d+[DATE] mmHg the heart rate was 40 beats per minute, and the respiratory rate was 12 breaths per minute. A review of Resident 1's progress notes, dated [DATE] timed at 6:40 PM indicated Resident 1 had poor oral intake, had altered level of consciousness, arousable but continued to close eyes, and moaning. A review of Resident 1's Health Status Note, dated [DATE], at 6:40 PM, indicated the physician was notified and ordered emergency transfer to GACH 1 for further evaluation. A review of Resident 1's Order Summary Report, dated on [DATE] indicated, a transfer to emergency room (ER) via 911. A review of GACH 1 Emergency Department (ED) Provider Notes, dated [DATE], indicated Resident 1 was diagnosed with [CONDITION(S)] (low blood pressure), dehydration, and acute Urinary Tract Infection. A review of Resident 1's GACH 1 ED laboratory test results on the day of transfer, [DATE] at 8 PM, indicated Resident 1's BUN (blood urea [MEDICATION(S)], a measure of how much waste product is in blood and can indicate dehydration) was elevated at 30 milligrams per deciliter (mg/dL, the normal range is 9 to 20). A review of Resident 1's GACH 1 ED MAR, dated [DATE], indicated Resident 1 received 0.5 milligrams (mg) of [MEDICATION(S)] (medication used to increase heart rate) intravenous (IV) push at 7:40 PM and 1,000 mL of normal saline (medication used to replenish fluids) at 7:50 PM. A review of Resident 1's Certificate of Death dated [DATE] indicated Resident 1 expired at GACH 1 at 2:43 AM, due to heart attack and cardiac arrythmia. On [DATE] at 4:05 PM, during an interview with Licensed Vocational Nurse 4 (LVN 4), stated she was assigned to Resident 1 on [DATE] and Resident 1 was usually verbal and had a good appetite. On [DATE], at 2:38 PM, during an interview, the Dietary Manager (DM) stated fluids provided with a meal tray included water and may include milk, juices, coffee, or tea. On [DATE] at 11:40 AM, during an interview with Registered Dietician (RD) and a concurrent review of Resident 1's Nutrition Assessment, dated [DATE], the RD stated the required daily fluid intake was 1,060 ml to 1,325 ml a day. The RD stated Resident 1 was receiving 1,320 ml from her meal trays, 600 ml on her breakfast tray, 360 ml on her lunch tray, and 360 ml on her dinner tray. The RD stated Resident 1 also had a bedside pitcher of nectar thick liquids. She stated a bedside pitcher might hold a quart of fluids. The RD was unable to confirm Resident 1 was in fact consuming all the liquids in the meal trays and from the bedside water pitcher. The RD stated she was not aware the GT water flush was discontinued on [DATE]. The RD further stated Resident 1 was at risk for dehydration. A review of the facility's policy and procedure titled, Hydration, undated, indicated risk factors for dehydration include functional impairments that make it difficult to drink, reach fluids, or communicate fluid needs. The policy indicated the clinical signs of possible insufficient fluid intake are assessed through continual nursing assessment such as confusion or change in mental status, lethargy, and laboratory values such as blood urea [MEDICATION(S)] (BUN), The registered dietitian (RD) or designee should assess IV or tube feeding/flush orders and reevaluate per facility policy as needed. A review of the facility's Job Description titled, Dietitian, dated ,d+[DATE], indicated the duties and responsibilities of the dietitian included reviews the dietary requirements of each resident when admitted to the facility and as may be required, and assists the attending physician in planning resident's prescribed diet plan. The dietician job description indicated visits residents routinely to evaluate quality of meals served, likes and dislikes, etc. and maintains liaison with families as appropriate. A review of facility's policy and procedure titled, Diet Changes and Reports, dated ,d+[DATE], indicated nursing services (i.e., Director of Nursing Services, nurse supervisor, charge nurse) was responsible for notifying the Food Services Director when a nutritional problem was identified (i.e., weight loss, pressure ulcer, eating problem, dehydration, etc.). The policy and procedure indicated to notify the Nutritional Services Director through hand-written or electronic communication. Oral communication was permitted, however, follow up all oral communication with written/electronic communication.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to provide a safe environment to help prevent the development and transmission of communicable disease and infections; did not ensure that facility staff conducting Covid-19 testing used appropriate personal protective equipment (PPE), and that testing was conducted in a private room with the door closed and where room surfaces could easily be disinfected. The failure could potentially result in staff exposure to Covid-19 from coughing and sneezing induced during the procedure and transmitted to other facility staff and residents already at high risk for contracting the infection with serious consequences including death. Finding includes: During Covid-19 testing at 10:30 a.m. on 12/03/20, the infection control practitioner (Staff 5) was observed performing Covid-19 testing of staff. Staff 5 was noted wearing only a pair of gloves and an N95 mask. When interviewed about the use of PPEs appropriate for the testing she was doing, Staff 5 stated, This is how we do it here. Staff 5 added that she had been employed at the facility since August 2020. The test was also conducted by Staff 5 in a large multi-purpose room with the door to one of the main hallways wide open. The room, according to an administrative staff member (Staff 1) was used as a conference room where facility meetings were held, and was used as a work station by representatives from outside agencies who were in the facility. The day prior, at 2:00 p.m. on 12/02/20 during the entrance conference, a facility staff was observed eating his meal in the room. Following an off-site request to review documentation of training or in-service provided to licensed staff who were responsible for conducting Covid-19 testing, Staff 1 responded in an email at 5:20 p.m. on 12/03/20 that .In regards to (ICP) and others being (inserviced) or trained prior to providing the COVID-19 test and, other than being trained to become a (licensed) nurse on how to properly perform these swabs, there has not been. In another interview at 9:55 a.m. on 12/04/20, Staff 5 stated that the only training she had on conducting COVID-19 testing was when she watched a video with the California Fire Department with her previous employer. Staff 5 added that There is no PPE required for the nasopharyngeal swab, and that Guidelines change every day. During a follow-up interview with 3 other licensed staff at 10:17 a.m. on 12/04/20, Staff 3 and Staff 4 stated that both conducted COVID-19 testing for the facility. Staff 3 explained that the required PPE for COVID-19 testing was an N95 mask, gloves, and a gown. Staff 4, on the other hand, stated that the proper PPE for conducting COVID-19 testing was full PPE which includes a gown, gloves, N95 mask and a face shield. Neither staff were familiar with a policy or procedure guide for the facility's expectations on how to conduct the COVID-19 testing. Offsite Review of the facility's Covid-19 Mitigation Plan on 12/03/20 at 2:30 p.m. revealed that for collecting diagnostic respiratory specimens (e.g. nasopharyngeal swab) from a patient with possible Covid-19, the following should be observed: Specimen collection should be performed in a normal examination room with the door closed; and HCP (health care providers) in the room should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown. The CDC guidelines on conducting Covid-19 testing revealed that PPEs needed included an N95 equivalent or higher-level respirator (or facemask if respirators are not available), facemasks, gloves, gowns, eye protection (goggles or disposable face shields that cover the front and sides of the face). The guidelines also noted avoiding collecting specimens in open-style housing spaces with current residents or in multi-use areas where other activities are occurring. In another interview at about 10:35 a.m. on 12/04/20, a regional infection control practitioner (Staff 6) verified that the facility's policy for testing included use of an N95 facemask, a face shield, a gown and a pair of gloves. Staff 6 added that testing was also to be conducted in a small room with the door closed. Following a determination that the findings noted above constituted an immediate threat to the life and safety of facility residents (and staff) that can potentially lead to the spread of the Covid-19 infection, the survey team declared Immediate Jeopardy which was communicated to Staff 1 and Staff 6 at 10:35 a.m. on 12/04/20. Immediate Jeopardy was removed at 12:45 p.m. on 12/04/20 following immediate actions taken by the facility to mitigate the threat including providing Staff 3 with immediate in-service training, as well as training for all designated testers outlined in a training schedule provided by the facility. The facility also revised its policy and procedure to clarify PPEs required, and identified a temporary location exclusively for the purpose of testing.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was diagnosed with [REDACTED]. [REDACTED]. Findings: A review of the Admission Record indicated Resident 1 was readmitted to the facility, on [DATE], with [DIAGNOSES REDACTED]. A review of the Fall Risk Assessment form, dated [DATE], indicated Resident 1 was confined to chair and disoriented, unable to independently come to standing position, and required hands on assistance to move from place to place. The fall risk assessment indicated Resident 1 was a high risk for falls. A review of Resident 1's Minimum Data Set (MDS- standardized resident assessment and care screening tool), dated [DATE], indicated the resident was totally dependent on staff when moving between locations on the unit and required extensive assistance from staff for dressing, eating, and personal hygiene. According to a review of the Change in Condition Evaluation form, dated [DATE], at 2:15 p.m., Resident 1 was sitting on a pillow, in a wheelchair in the patio with a family member, then the resident slid out of the wheelchair with the pillow. The Registered Nurse Supervisor (RN 1) assessed the resident and documented no head injury, no complaints of pain or discomfort, no skin tear, and no discoloration. A review of the Progress Notes, dated [DATE], at 3:10 p.m., indicated Resident 1's physician was notified of the fall. The resident's vital signs included a low blood pressure ,[DATE] (normal ,[DATE]), and a low temperature of 97.2, oxygen at 95% on room air. The Progress Note timed at 3:18 p.m., indicated the physician ordered to monitor Resident 1 for 72 hours. A review of Resident 1's Progress Note, dated [DATE], at 10:21 a.m., indicated at 7:10 a.m., the resident was in bed sleeping, no acute distress. At 8:30 a.m., the certified nursing assistant informed the charge nurse (licensed vocational nurse 1 - LVN 1) the resident refused breakfast. At 9:20 a.m., the charge nurse (LVN 1) was in Resident 1's room to give 9 a.m. medications. Resident 1 was not responsive, unable to get vital signs. The progress note indicated the RN supervisor and staff were in room to perform cardiopulmonary resuscitation (CPR- is an emergency procedure that combines chest compressions and breathing in a person who is having a [MEDICAL CONDITION]) and provide oxygen. At 9:23 a.m., the charge nurse called 911 and the paramedics arrived in the facility. The paramedics declared Resident 1 dead. At 9:49 a.m. the physician was notified. At 9:57 a.m. the resident's responsible person was informed. A review of the clinical record indicated there was no documented evidence to indicate Resident 1 was being monitored for 72 hours per the physician's orders [REDACTED]. A review of Resident 1's Certificate of Death indicated the date of death was on [DATE] at 9:29 a.m., with the primary cause of death as cardiopulmonary arrest. During an interview, on [DATE], at 2:15 p.m., LVN 1 stated the change of condition, neuro check sheet and nursing notes were started and documented on [DATE]. LVN 1 stated a verbal report and the change of condition form were endorsed to the next shift. LVN 1 further stated if Resident 1 was being monitored and assessed per physician's orders [REDACTED]. LVN 1 also stated if neurological checks were done, staff would know if the resident was more drowsy. During an interview, on [DATE], at 12:10 p.m., the Director of Nursing (DON) stated LVN 1 endorsed the change of condition to the on-coming charge nurse on the following shift and the on-coming charge nurse forgot to follow up, and document the neuro checks and assessments of Resident 1 after the fall. The DON stated if Resident 1 was not assessed then the resident's health may decline. The DON confirmed after she reviewed Resident 1's record and stated, If not documented, not done. During a phone interview with the DON, on [DATE], at 3:11 p.m., she stated Resident 1 did not have a fall care plan before the fall. The DON stated the care plan was important for Resident 1 so staff could identify safety interventions to prevent falls. The DON stated Resident 1 had a fall assessment and there should have been a fall care plan initiated and updated quarterly. A review of the facility's policy titled, Falls Management, revised ,[DATE], indicated the facility defined an actual fall as any occurrence where the resident was found on the floor; slides to the floor unassisted; trips or slips to the floor. The policy indicated continued monitoring by a licensed nurse was necessary, as symptoms may present at any time, even days following the actual event. This would include assessing for injury and monitoring of vital signs every shift for a minimum of 72 hours and documented in nurse's notes. Residents with actual or suspected head injury, neuro checks conducted for un-witnessed fall for residents who were deemed to be an unreliable historian and nurse was unable to determine if a head injury occurred would have neurological checks implemented and documented per the Neurological Assessment policy. A review of the facility's policy titled, Neurological Assessment (Neuro-Checks), revised (MONTH) 2012, indicated Neuro checks would be completed by a licensed nurse after a fall involving a blow or injury to the head, and any un-witnessed fall. The policy indicated the neuro-check procedure consist of assessing residents responsiveness, motor ability, pupil signs and vital signs. The policy further indicated to collect neurological signs every 15 minutes for the first hour, every 30 minutes for the next 4 hours, every hour for the next two hours, then every shift for a total of 72 hours. The policy indicated to record findings on the Neurological Signs form. A review of the facility's policy titled, Change of Condition, Resident, revised ,[DATE], indicated the facility would identify and intervene to provide medical or nursing care for a resident experiencing an acute medical change of condition in a timely and effective manner. Nursing would document assessments and interventions on the clinical record. Continue to monitor and document resident's condition at a minimum of every shift for 72 hours and as needed, until the acute episode had subsided and the resident was stable.

Based on observation, interview, and record review, the facility failed to ensure the residents have the right to be free from neglect, physical, verbal, and mental abuse for three of 18 sampled residents (Residents 74, 180, and 71). There were 74 residents who potentially subjected to Certified Nursing Assistant 5 (CNA 5)'s aggressive behavior, CNA 3 and 8's neglectful and abusive behavior. During the survey, there were 40 residents, who were dependent on staff with activities of daily living and might require a use of shower gurney/bed. Resident 74 was left by CNA 3 lying on his back over his sore; was neglected by the facility when he could not receive showers because the facility did not have shower gurney/bed; and was neglected by leaving him wet with urine. Resident 180 was verbally mistreated by CNA 5 and was neglected when he was not given timely pain medication upon admission. Resident 71 was hurt when transferred by CNA 8. These deficient practices resulted in residents being subject to neglect, verbal, mental and physical abuse. An Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a resident)) was called on 5/5/18 at 2:40 p.m., for F600 in the presence of the facility Administrator and Director of Nursing (DON). The facility provided an acceptable immediate plan of correction (P[NAME]) on 5/5/18, at 6:40 p.m. The IJ abatement remedy included: 1. In-service staff on the importance of answering call lights and attending to resident's needs, and that all staff are responsible to answer call lights. Answer call lights and not to turn off until resident's needs are meet. 2. In-service staff on neglect, intimidation, and abuse prevention. Department managers to interview alert and oriented residents, and responsible parties. Observe staff resident interactions. Administrator or designee to monitor compliance. 3. Purchase shower gurney, in-service all nursing staff on importance of residents activities of daily living, follow residents shower schedule and resident preferences. 4. ln-service licensed staff on pain management specifically on pain medication administration. Assess and re-assess residents for pain. Update pain plan of care. On 5/5/18 at 6:40 p.m., after the survey team validated the immediate plan of action the IJ was abated, the Administrator, DON, Assistant Director of Nurses (ADON) were notified. Findings: During an interview on 5/4/18, at 7:46 p.m., the Evaluator requested Licensed Vocational Nurse 6 (LVN 6) to contact the Director of Staff Development (DSD). At that time, Certified Nursing Assistant 5 (CNA 5) abruptly and with an aggressive demeanor interrupted indicating the DSD was not available. The Evaluator asked for CNA 5's name and position. CNA 5 again without saying her name, aggressively stated, l am just a CNA. When CNA 5 was interviewed if she approached the residents the same way, CNA 5 close to the face of the Evaluator and with a loud voice, I am sorry. l said l am sorry. The Director of Nursing (DON) was present at the Nurses' Station at the time of the incident. a. A review of the Admission Record indicated Resident 74 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 5/1/18, Resident 74 had no memory loss, was able to make needs known, was dependent on staff for toilet use and transfers, was not able to walk, needed extensive assistance from staff with bed mobility, personal hygiene, and dressing. The MDS indicated Resident 74 had limited movement of one arm and both legs. During an interview on 5/4/18, at 7:59 p.m., Resident 74 stated the nursing staff were mean, terrible, and did not answer the call lights for assistance. Resident 74 stated, l cannot do anything for myself, l have not showered since I was admitted here, and staff make me feel unimportant. On 5/5/18, at 6:06 p.m., the Administrator, LVN 6, Maintenance Supervisor (MS), and Maintenance Assistant (MA), confirmed the facility did not shower residents that could not sit in a shower chairs because the facility did not have shower gurneys/beds. During an interview on 5/6/18, at 8:07 a.m., CNA 1 stated she was working in the facility since the middle of (MONTH) (YEAR). CNA 1 stated she provided only bed baths because she was afraid residents would fall off shower chairs and there were not shower gurneys. During an interview on 5/6/18, at 8:36 a.m., CNA 4 stated Resident 74 refused to shower because the facility did not have shower gurneys. CNA 4 stated since Resident 74 could not sit in a shower chair due to weak muscles, the resident only received bed baths. During an interview on 5/6/18, at 10:52 a.m., Staff 2 stated, Resident 74 complained CNA 3 did not want to change his wet incontinent brief and another CNA changed Resident 74's wet brief. During an interview on 5/6/18, at 11:40 a.m., Resident 74 stated, CNA 3 twice changed his wet incontinent brief and left him lying on the back, over his pressure sore, which caused excruciating pain (10/10 in a rating pain scale from zero to 10, zero indicating no pain and 10 indicating the worst pain possible). Resident 74 stated when requesting CNA 3 not to leave him lying on his back, CNA 3 ignored his request. Resident 74 stated, l know she heard me but she ignored me. l felt mad and angry. Resident 74 stated he informed the Assistant Director of Nursing (ADON) of CNA 3's neglectful behavior and CNA 3, no longer assigned to care for him. During an interview on 5/6/18, at 11:50 a.m., the ADON stated when a resident complains about abusive or neglectful staff, the alleged perpetrator is remove from care area or suspended, and the allegations are investigated. The ADON stated, the staff is counsel depending on the allegation, written up, and the write up is placed in the staff personnel file. The staff will no longer assigned to the resident, until the resident is okay with that staff member. The ADON stated, Resident 74 informed ADON about CNA 3's behavior; however, on a concurrent employee file review, the ADON confirmed there was no write up or counseling on CNA 3's personnel file. The ADON stated CNA 3 still worked at the facility. A review of the facility's Resident Census and Condition indicated there were 77 residents in house, and 40 resident were dependent on staff with bathing. b. A review of the Admission Record indicated Resident 180 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the History and Physical (H&P) dated 5/8/18, indicated Resident 180 was able to make decisions. The same H&P indicated the resident to have dietary consult, increase oral (PO) fluids, eat yogurt, and brat diet. During an interview on 5/4/18, at 5:42 p.m., Resident 180 stated that upon admission, the first night, he had hiccups that caused abdominal pain. Resident 180 pressed the call light for pain medication, and to inform the nurse his abdominal wound was bleeding, but no staff responded to the call light for 45 minutes. Resident 180 stated his abdominal pain level was 8/10 and when a nursing staff finally answered the call light, the nurse told him she would be back. Resident 180 stated the nurse did not return to check on him until 1 a.m. and told him the facility did not have his ordered medications and instead gave him two Tylenol (pain medication) at 4 a.m. Resident 180 stated the facility was, A torture chamber; They are torturing me; What about those people who can't speak up? Resident 180 added he did not see any nurses providing care at night and stated, l wanted to call the police to come help me. During an interview on 5/5/18, at 8:34 a.m., LVN 5 stated, CNA 5 talks tough, very loud, very impulsive, and liked to intrude and interrupt conversations. LVN 5 stated, CNA 5 was disrespectful, argumentative, and rude to staff, and the residents have complained that CNA 5 was disrespectful and would say to them, What do you want? LVN 5 stated she witnessed CNA 5 interrupt and be rude to the Evaluator. During an interview on 5/5/18, at 4:35 p.m., Staff 1 stated CNA 5 was mean, rough, tough, and disrespectful to residents. On 5/8/18, at 10:58 a.m., during interview and review of CNAs 3 and 5's employee files with the DON, the DON was unable to find any disciplinary actions against CNA 3. CNA 5's employee record indicated a criminal search conducted on 2/1/18, which disclosed CNA 5 had criminal record. CNA 5's employee file also contained an email dated 2/22/18, from the prior administrator, the email indicated a response to a complaint about CNA 5's physical abuse (hitting with a closed fist a resident's arm) to a resident on 2/1/18. The email indicated that CNA 5 denied any wrongdoing, and was suspended. However, a review of CNA 5's time card indicated CNA 5 continued to work after 2/1/17 the day of the alleged abuse. A review of the facility's Abuse Prohibition, Prevention, and Reporting Reasonable Suspicion of Crime in the Facility policies and procedures revised 3/2018, indicated: 1. If a potential employee had previous disciplinary action against them and those have resolved, the facility would make hiring determination based on specific nature and circumstances of previous disciplinary action. 2. Supervisors on all shifts to identify inappropriate staff behaviors, such as, use of derogatory language, rough handling, and ignoring residents while giving care. 3. The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse. 4. The facility will ensure all residents are protected from physical and psychological harm during abuse investigation. The employee is removed immediately from care or vicinity of residents, and suspended until investigation is complete and findings been reviewed by Administrator. CNA 5, was not removed from residents' care areas during an alleged abuse investigation. 5. The facility has a strict non-retaliation for good faith reporting. The facility will not impede or inhibit an individual (s) reporting duties, nor will the individual (s) be reprimanded or disciplined for reporting abuse. Failure to report suspected abuse may result in legal action against the individual (s) withholding information. During survey Cooperate RN took Staff 1 and 2's abuse, neglect declaration statements, and handed them to the Administrator. 6. The facility will report to facility Administrator, State Agency, Law Enforcement, and Ombudsman, all allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown source even if no reasonable suspicion immediately and no later than two (2) hours actual, alleged, or potential abuse or results in serious bodily injury. The facility will conduct no later than 24 hours all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of property, and injuries of unknown source and did not result in serious bodily injury. The Administrator was not able to provide documents to support State Agency, and Ombudsman office were informed of CNA 5's alleged physical abuse on a resident, and CNA 3 ignoring Resident 74's request for diaper change and repositioning. c. During an interview on 5/6/18, at 10 a.m., Resident 71 stated he wanted to press charges on CNA 8 for abuse. Resident 71 stated CNA 8 was getting him out of bed a few weeks ago (no specific date provided) using the mechanical lift (Hoyer lift, a sling lift/assistive device (electric or hydraulic power) use to transfer resident between bed and a chair or other similar resting places), and the sling started digging in his leg. Resident 71 stated he told her to stop and CNA 8 yelled, Do it! While she was digging her fingers in his leg. Resident 71 stated Staff 2 came and took CNA 8 out of the room; however, nothing was done with CNA 8. Resident 71 added that since then he has knee pain. Resident 71 stated that he was always left in a wet incontinent brief and had to sit in it for over 12 hours. A review of the Admission Record indicated Resident 71 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - standardized assessment and care-planning tool) dated 4/24/18, indicated resident 71 had no memory problem, was able to communicate needs and needed extensive assistance with all his activities of daily living (ADLs). During an interview on 5/8/18, at 9:45 a.m., Resident 44 stated the CNAs leave Resident 71 wet all the time. Resident 44 stated he was the roommate of Resident 71 and witnessed when CNA 8 hurt Resident 71 using the mechanical lift and did not stop after Resident 71 told her he was hurting. Resident 44 stated CNA 8 yelled at Resident 71, when he complained. Resident 44 indicated he was the one who called Staff 2 to assist. A review of the Admission Record indicated Resident 44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], indicated Resident 44 was alert, oriented, able to make needs known and required extensive assistance from staff with activities of daily living. During an interview on 5/8/18, at 10:28 a.m., Staff 2 stated Resident 44 informed him about CNA 8's mistreatment of [REDACTED]. During an interview on 5/8/18, at 10:35 a.m., CNA 8 acknowledged Resident 71 was complaining of leg pain the day she transferred him to bed. CNA 8 stated she had no help to put Resident 71 in bed.

Based on observation, interview,and record review, the facility failed to ensure that licensed nurses and certified nursing assistants have the specific competencies and skill sets necessary to care for four of 18 sampled residents (Resident 23, 42, and 180) by: 1. Failing to check the blood sugar level and administering insulin before breakfast as the physician ordered for Resident 23. 2. Failing to ensure Resident 42's heart rate was checked before the resident swallowed Carvedilol. 3. Failing to ensure Junivia (Sitagliptin) a medication used for diabetes (DM) was available for administration to Resident 42. 4. Failing to administer Junivia (Sitagliptin) as per physician's orders [REDACTED]. 5. Failing to ensure Resident 180, who was newly admitted to the facility, and complained of pain, received pain management, until 11 hours after the resident was admitted to the facility. 6. Failing to implement corrective actions when a resident complained CNA 5 bonged (bonked-knocked or hit) her on the arm, to prevent future occurrences. The deficient practices resulted in lack of control of blood sugar levels and adverse reactions for Resident 23 and 42, including blood sugar levels that are too high or too low and can lead to complications including nerve damage, eye disease, kidney disease, heart and blood vessel disease, coma, [DIAGNOSES REDACTED] (low blood sugar), and foot problems, had the potential to result in adverse reactions to Resident 42 for Carvedilol (blood pressure medication) by administering the medication before checking the resident's heart rate, resulted in Resident 180 experiencing unnecessary pain, and had the potential to result in mistreatment of [REDACTED]. Findings: a. Resident 23's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 23's History and Physical signed by attending physician, indicated the resident was able to make decisions. During medication administration on 5/05/18, at 8:08 AM., Certified Nurse Assistant (CNA 2) was observed to remove the breakfast tray from Resident 23's bedside table. In a concurrent interview, with the observation, CNA 2 stated the resident ate breakfast at 8:00 AM., and ate 100 percent (%) of her meal. Licensed Vocational Nurse (LVN 8) was observed to check Resident 23's blood sugar after breakfast, but the blood sugar check was ordered to be done at 6:30 AM. The resident's blood sugar test result was 452 (Target blood sugar for diabetics before meals 70 to 130) https://www.webmd.com/diabetes/guide/normal-blood-sugar-levels-chart-adults. LVN 8 was observed to administer Insulin [MEDICATION NAME] (to control high blood sugar) Solution 15 units to the resident's abdomen. In a concurrent interview, with the observation, LVN 8 stated the Assistant Director of Nurses (ADON) was aware, and LVN 8 had requested for LVNs on 11:00 PM to 7:00 AM. shift to do the residents morning blood sugars to prevent medication delays. LVN 8 stated the resident's Medication Administration Record [REDACTED]. During an interview on 5/06/18, at 8:22 AM., the Director of Nurses (DON), stated LVNs on 7:00 AM-3 PM shift, perform Resident 23's AC (before) breakfast blood sugar check. The DON stated the residents breakfast was served at 7:30 AM. The DON stated it would take the LVNs 45 minutes from 7:00 AM before starting the medication pass. The DON stated not following physician's orders [REDACTED]. The DON stated the physician adjusted insulin dosage according to documented resident's blood sugar. Resident 23's Physician order [REDACTED]., indicated to administer Insulin [MEDICATION NAME] Solution as per sliding scale (insulin therapy, the dose is based on your blood sugar level), subcutaneously (applied under the skin) before meals and at bedtime for DM. b. Resident 42's Admission Record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident's 42 Minimum Data Set (MDS, a standardized comprehensive assessment tool and care screening tool) dated 3/17/18, indicated resident had moderate cognitive (ability to learn, think, make decisions, and remember) impairment. During medication administration on 5/05/18, at 7:52 AM., LVN 8 was observed to check and record Resident 42's blood pressure (BP) at 119/60 milliliters of mercury (mm Hg). LVN 8 was observed administer to the resident, Carvedilol (medication to treat heart failure) 12.5 mg one tablet by mouth (PO). LVN 8 was observed check the resident's heart rate (HR) after the resident swallowed Carvedilol 12.5 mg one tablet PO (by mouth). LVN 8 recorded the resident's HR at 76 per minute. During interview on 5/05/18, at 11:13 AM., LVN 8 stated it was important to check Resident 42's HR before the resident swallowed the Carvedilol 12.5 mg one tablet PO. LVN 8 stated a side effect for Carvedilol was [MEDICAL CONDITION] (low BP), dizziness, low or slow HR. During an interview on 5/08/18, at 7:47 AM., Resident 42 stated, he missed a blood sugar tablet on 5/718, in the evening. The resident stated, he had missed the blood sugar medication five times. The resident stated, the evening medication nurse showed him a bubble pack that was empty. The resident stated, it was important to continue taking Junivia and he could ask his responsible party to bring Junivia from the resident's home. During an accompanied medication cart inspection on 5/08/18, at 9:12 AM., the Assistant Director of Nurses (ADON) found an empty Junivia (medication to control blood sugar) bubble pack for the resident. The ADON stated the last pharmacy delivery date for Resident 42's Junivia was on 4/22/18. During an interview on 5/08/18, at 9:15 AM., the ADON stated licensed nurses are supposed to reorder medications when there are five doses left, before the medication runs out. The ADON stated l did not see Junivia refill request in the pharmacy refill binder. The ADON stated, the resident's medication indicated the resident received Junivia on 5/7/18, but the last dose per bubble count was administered on 5/6/18. The ADON stated the licensed nurses must follow up medication reorder with the pharmacy daily until medications were delivered at the facility. During an interview on 5/14/18, at 10:44 AM., LVN 3 stated, the resident was alert and capable of making decisions. LVN 3 stated she did not administer Junivia to Resident 42 on 5/7/18, and showed the resident the empty Junivia bubble pack. LVN 3 stated later on 5/7/18, LVN 3 found an old Junivia bubble pack and administered one tablet of Junivia to the resident at 9:00 PM. (4 hours after the medication was due). LVN 3 stated, the resident has diabetes and Junivia was to ordered to be administered at 5:00 PM with dinner. LVN 3 stated, she did not obtain an order to administer Junivia at 9:00 PM. LVN 3 stated Junivia administered after 5:00 PM., could lower the resident's blood sugar. LVN 3 stated the resident insisted LVN 3 to administer the 5:00 PM., Junivia. Resident 42's Medication Administration Record [REDACTED] 1. Administer Junivia (Sitagliptin) 25 mg one (1) tablet PO by mouth one time a day for diabetes (DM) with food at 5:00 PM. 2. Hold Carvedilol tablet 12.5 mg one tablet PO if Systolic Blood Pressure (SBP, top BP number) is less than 110 mm Hg, and heart rate (HR, pulse) less than 60 beats per minute. The resident's average BP was 132/70 mmHg, HR was 68 beats per minute. The facility Individual Education document dated 4/27/18, indicated LVN 3 was counseled on medication administration, signing of medications, and medication reorder when the fifth to last pill was punched (used). The facility's policy titled Medication Ordering and Receiving from Pharmacy dated 4/2008, indicated to reorder medications five days in advance to assure an adequate supply is on hand. The facility's policy titled Medication Administration dated 10/2017, indicated: 1. Medications are administered in accordance with written orders of the attending physician, and administered within 60 minutes of scheduled time. 2. Medications supplied for one resident are never administered to another resident. 3. The resident is always observed after administration to ensure the medication was completely ingested (swallowed). c. Resident 180's Admission Record indicated the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Resident 180's History and Physical (H&P) document dated 5/8/18, indicated resident was able to make decisions. The same H&P indicated the resident to have dietary consult, increase oral (PO) fluids, eat yogurt, and brat (bananas, rice, apple sauce, and toast) diet. During an interview on 5/04/18, at 5:42 PM., Resident 180 stated he was discharged from a General Acute Care Hospital (GACH) Intensive care Unit (ICU, for very ill people) after abdominal surgery. The resident stated the facility's staff lacked supervision. The resident stated the first night in the facility on 5/3/18, the resident hiccups caused abdominal pain. He pushed the call light for pain medication, and to inform the nurse his abdominal wound was bleeding. The resident stated no staff responded to his call light for 45 minutes. The resident stated the abdominal pain level was 8 out of 10 (on a pain rating scale of zero being no pain, and 10 being the worst pain possible). The resident stated a nurse answered the call light and stated she would be back. The resident stated the nurse did not return to check on him until 1:00 AM. The resident stated, the nurse stated they did not have the resident's medication orders. The resident stated the nurse gave him two Tylenol (pain medication for mild pain) at 4:00 AM. (over 11 hours after the resident was admitted to the facility). The resident stated the facility was a torture chamber, They are torturing me. What about those people who can't speak up? The resident stated he did not see any nurses at night. The resident stated he did not mind the nurses checking on him at night. The resident stated l wanted to call the police to come help me. d. During an interview on 5/05/18, at 8:34 AM., LVN 5 stated, CNA 5 talks tough, very loud, very impulsive, and liked to intrude and interrupt conversations. LVN 5 stated, the residents complained CNA 5 was disrespectful and asked the residents What do you want? LVN 5 stated she wondered how CNA 5 treated residents who could not defend themselves. During an interview on 5/05/18, at 04:35 PM., Staff 1 stated CNA 5 was mean, rough, tough, and disrespectful to residents. During interview and employee record review on 5/08/18, 10:58 AM., the DON stated l can't find CNAs 3 and 5 write ups in their employee files. During an interview on 5/9/18, at 9:23 AM., Staff 1 stated the facility's Cooperate RN took Staff 1 and 2's declaration statement, and handed them to the Administrator. A review of the employment record on 5/9/18, for the County Criminal Records Search dated 10/24/17, indicated CNA 3 had no reportable records found. A review of employment record on 5/9/18, for the County Criminal Records Search dated 2/1/18, indicated CNA 5 had 2 reportable records found. The former facility's Administrator emailed a complainant to the Department of Public Health on (MONTH) 7, (YEAR), in response to a resident's physical abuse allegation. The complaint indicated on 2/1/18, a resident complained, CNA 5 bonged (bonked-knocked or hit) the resident's left arm. The resident demonstrated a fist striking motion on upper left arm. The facility Investigation indicated CNA 5 denied any wrong doing and was suspended. There was no document in the CNAs employment file to support CNA 5 was suspended. The CNAs facility Time Card dated 7/26/17, to 5/8/18, indicated CNA 5 worked from 2/3/18, to 2/13/18, and 2/14/18, to 2/22/18. The Time Card indicated CNA 5 took Paid Time Off (PTO) from 2/23/18, to 2/26/18. The Facility's document titled In-service Meeting Minutes dated 2/17/18, indicated CNA 5 received one on one (1:1) in-service, on customer service and abuse prevention. During an interview 5/08/18, at 7:55 AM, the Director of Nurses (DON) stated CNA 3 was terminated on 5/7/18. The DON stated CNA 5 was suspended and will be terminated. During a interview and employee record review on 5/08/18, at 10:58 AM., the DON stated l can't find CNAs 3 and 5's write up in their employee files. The facility's policy titled Abuse Prohibition and Prevention Policy and Procedure, and Reporting Reasonable Suspicion of Crime revised 3/2018, indicated: 1. If a potential employee had previous disciplinary action against them and those have resolved, the facility would make hiring determination based on specific nature and circumstances of previous disciplinary action. 2. Supervisors on all shifts to identify inappropriate staff behaviors, such as, use of derogatory language, rough handling, and ignoring residents while giving care. 3. The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse. 4. The facility will ensure all residents are protected from physical and psychological harm during abuse investigation. The employee is removed immediately from care or vicinity of residents, and suspended until investigation is complete and findings been reviewed by Administrator. CNA 5 was not suspended during an alleged abuse investigation. 5. The facility has a strict non-retaliation for good faith reporting. The facility will not impede or inhibit an individual (s) reporting duties, nor will the individual (s) be reprimanded or disciplined for reporting abuse. Failure to report suspected abuse may result in legal action against the individual (s) withholding information. During survey Cooperate RN took Staff 1 and 2's abuse and neglect declaration statements and handed them to the Administrator. 6. The facility will report to facility Administrator, State Agency, Law Enforcement, and Ombudsman, all allegations of abuse, neglect, exploitation, mistreatment, including injuries of unknown source even if no reasonable suspicion immediately and no later than two (2) hours actual, alleged, or potential abuse or results in serious bodily injury. The facility will conduct no later than 24 hours all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of property, and injuries of unknown source and did not result in serious bodily injury. The Administrator was not able to provide documents to support State Agency, and Ombudsman, were informed of CNA 5's alleged physical abuse on a resident, and CNA 3 ignoring Resident 74's request for diaper change and repositioning.

Based on observation, interview and record review the facility failed to ensure pain was managed for one of 19 sampled residents (11) by failing to: 1. Ensure Resident 11 was able to use the call light to communicate to the nursing staff about being in pain and would not have pain (rated ten out of ten on a zero to ten pain scale, where a zero was no pain and ten the worse possible pain), for an extended period of time without relief. 2. Ensure the licensed nurses ruled out pain as a possible trigger for Resident 11's anxiety and inability to fall asleep and/or to stay asleep. Failure to provide the necessary care and services resulted in prolonged, severe pain, discomfort and anxiety for Resident 11. Findings: On April 18, 2016, at 2:25 pm, Resident 11 was observed sitting up in her wheelchair with facial grimacing. When asked how she was doing Resident 11 stated mucho dolor. When asked if she could explain in English Resident 11 stated she had much pain and pointed to her back. On a scale from zero to ten, where a zero is no pain and ten being the worst pain, Resident 11 stated her pain was a ten. Resident 11 indicated [MEDICATION NAME] (pain reliever) was the medication given to her when she was in pain. When asked how she calls for help Resident 11 pointed to her call light. However, Resident 11 stated the call light not working. Resident 11 picked up the call light and pushed the red button, the call light did not sound or activate the light above her door. Resident 11 was observed attempting to use the call light at least four times by pushing the red button; however neither the sound nor the light was activated. On April 19, 2016, at 8:30 am, Resident 11 was observed sitting in the bed, leaning towards the left side. Resident 11 stated she was in pain, and rated her pain as ten out of ten on a scale from zero to ten, where a zero was no pain and ten was the worst pain. Resident 11 was observed attempting to call for assistance by using her call light, neither the sound or light was activated. The maintenance supervisor spoke to Resident 11 and she told him the call light did not work. He asked Resident 11 to demonstrate how she used the call light. Resident 11 pushed the button two to three times and neither sound nor light was activated. The maintenance supervisor was observed using Resident 11 ' s call light and it worked. He stated the pad type call light may work better for the resident and he replaced the regular push button call light with a pad call light. Resident 11 was observed immediately able to activate the call light using the pad instead of the push button. A review of the medical record indicated Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Pain assessment dated [DATE], Resident 11 had experienced pain within the last five days. A review of Pain Assessment indicated Resident 11 had pain frequently and limited her day to day activities because of the pain. The assessment also indicated Resident 11 had difficulty sleeping at night because of her pain. On a scale of one to ten, ten being the worst, Resident 11 rated her pain as seven. A review of the pain assessment 2/6/16, indicated Resident 11 expressed her pain verbally and was receiving [MEDICATION NAME] 10/325 milligrams ((mg) a narcotic [MEDICATION NAME]) as needed for pain relief. There was a physician's order [REDACTED]. Resident 11 also had a physician's order [REDACTED]. There was Resident 11 ' s care plan for pain due to the [DIAGNOSES REDACTED]. One of the goals for Resident 11 was not to have an interruption in normal activities due to pain. The interventions included to anticipate the resident's need for pain medication, to monitor/report the resident's non-verbal signs of pain, to observe and report changes in sleep patterns/resistance to care and to evaluate the effectiveness of pain interventions. A review of the readmission assessment dated [DATE], indicated Resident 11 had trouble falling and staying asleep at night. On March 22, 2016, there was a physician's order [REDACTED]. A review of the Medication Administration Record [REDACTED]. However, medication [MEDICATION NAME] 10/325 mg for severe pain was given to the resident less often (seven days) even though it was indicated the pain medication was effective once given. A review of Resident 11 ' s clinical record indicated there was no documented evidence the licensed nurses or interdisciplinary team (IDT) attempted to rule out the possible cause of Resident 11's anxiety m/b restlessness. There was no documented evidence Resident ' s frequent pain was ruled out as a possible trigger for anxiety. On April 19, 2016, at 9:10 am, during an interview, Resident 11 stated she was aware of receiving medication for being anxious. However, the resident stated she was anxious because she was in a lot of pain and could not sleep. Resident 11 stated she does need help repositioning, but usually does not like staff to turn her because of the pain in her back. Resident 11 stated she always has pain in her back and it is usually a ten out of ten on a scale of one to ten, where a zero is no pain and ten is the worst pain. A review of Resident 11 ' s clinical record indicated there was no documented evidence the licensed nurses attempted non-pharmacological interventions prior to medication administration. There was no evidence the licensed nurses or interdisciplinary (IDT) team assessed Resident 11 for a more effective pain management program to deal with pain due to the lumbar fracture. According to the MAR for April 2016, Resident 11 was not administered pain medication on April 18 or 19, 2016, when the resident verbalized her pain was a ten. According to the licensed nurses progress notes there was no documented evidence Resident 11 had pain. In addition, the licensed nurses documented Resident 11 did not experience any pain on 11 other days in the month of March. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool dated April 3, 2016, indicated Resident 11 could make herself understood and understood others. Resident 11 was able to correctly report the year, month and day of the week during the assessment as well as remember and repeat words asked of her. According to the licensed nurses progress notes dated April 18 and 19, 2016, there was no documented evidence Resident 11 experienced pain on either day. However, the notes did include documentation of Resident 11 receiving anti-anxiety medication for restlessness at bedtime on April 18 and 19, 2016, as ordered. On April 19, 2016, at 4:25 pm, the registered nurse (RN 6) stated sometimes Resident 11's daughter would call the facility and tell the staff her mom doesn't seem quite right. She would tell them she thinks her mom needs pain medication. RN 6 stated there have been times they would then check on the resident and give pain medication. On April 21, 2016, at 2:20 pm, the licensed vocational nurse (LVN 12) stated a certified nursing assistant (CNA) always let the licensed nurses know when the resident has pain. However, LVN 12 was not aware Resident 11 had pain on April 18 and 19, 2016. LVN 12 stated he was not aware Resident 11 had difficulty using the call light or that the resident was experiencing pain so often. At the same time RN 18 stated she did not think Resident 11 had difficulty using her call light and was not aware there was a problem. RN 18 stated she was not aware of the severity and frequency of Resident 11's pain even thought it was documented on multiple pain assessments. RN 18 stated the pain assessment documentation indicated Resident 11's pain interfered with her activities of daily living and sleeping at night. However, she could not explain why a more effective pain management program had not been discussed with the IDT team. On April 25, 2016, at 11:15 am, during an interview, CNA 3 stated she did not ask Resident 11 if she was having any pain on April 19, 2016. CNA 3 stated she usually would look if the resident was having any facial grimacing as an indicator she was in pain. CNA 3 stated if the resident would show any signs of pain she would report it to the charge nurse. CNA 3 confirmed Resident 11 needed assistance with turning and repositioning, however the resident would usually refuse to be turned. CNA 3 stated she was not aware the resident was refusing repositioning because she was in pain.