Every finding on record at Driftwood Healthcare Center

Based on interview and record review, the facility failed to ensure Resident 2's Responsible Party (RP) choices were upheld regarding medication consent and dosing for one of three sampled Residents (Resident 2) who was prescribed Trazodone (medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest] 50 milligrams ([mg] unit of measurement) at bedtime for insomnia. This deficient practice resulted in the Resident 2 receiving treatment inconsistent with the RPs directive. Resident 2 continued to receive Trazadone 50 mg on 7/2/2026, 7/3/2026, 7/4/2026 and 7/5/2026 despite the RP consenting to decrease the Trazodone to 25 mg. This failure resulted in Resident 2 experiencing increased lethargy on 7/2/2026 and had the potential to result in excessive sedation, increased fall risk, and cognitive impairment. Findings:During a review of Resident 2's Face Sheet (front page of the chart that contains the summary of basic information about the resident), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities), and anxiety (excessive worry) disorder.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 6/22/2026, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired.During a review of Resident 2's untitled Care Plan, initiated 3/31/2026, the Care Plan indicated Resident 2 had an episode of walking back and forth in the hall and had an angry outburst. The Care Plan's goal indicated Resident 2 will have improved sleep pattern by reporting adequate rest or fewer episodes of insomnia. The Care Plan's interventions included monitoring/recording Resident 2's mood, assessing whether any changes were related to external factors or current medications and treatments, and reporting any acute changes; particularly alterations in sleep patterns, to the physician as required.During a review of Resident 2's Psychiatric Evaluation Report, dated 6/19/2026, the report indicated Resident 2's plan of care included continued monitoring of mood, anxiety, cognition, and sleep. During a review of Resident 2's Order Summary Report (physician's orders), dated 6/29/2026, the Order Summary Report indicated an order was placed for Resident 2 to receive Trazadone Hydrochloride (HCL) 50 mg by mouth at bedtime for insomnia and the inability to sleep at nighttime.During a review of Resident 2's Psychotherapeutic Drug Informed Consent Form (voluntary agreement to accept treatment after receiving education regarding the risks, benefits and alternatives offered), dated 6/29/2026, the Consent Form indicated Resident 2 was to receive Trazadone 50 mg every night at bedtime due to Resident 2's inability to sleep due to insomnia and the RP was who would be the one consenting for treatment on Resident 2's behalf. The Consent Form indicated the area where did the prescribers' name, signature and date was blank. The Consent Form indicated that if the signature of the RP cannot be obtained, a licensed nurse must sign the form, by signing the form, the licensed nurse confirming that the RP gave their consent to the treatment with the psychotherapeutic drug on 6/29/2026. The Consent Form indicated Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 signed and dated the consent on 6/29/2026 and there was documentation indicating the RP refused to sign the consent on 7/2/2026.During a review of Resident 2's Psychotherapeutic Drug informed Consent Form, dated 7/2/2026, the Consent Form indicated Resident 2 was to receive Trazadone 25 mg at night due to Resident 2's inability to sleep due to insomnia and the RP was who would be the one consenting for treatment on Resident 2's behalf. The Consent Form indicated the area where the prescribers' name, signature and date was blank. The Consent Form indicated the RP signed the consent on 7/2/2026.During a review of Resident 2's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/1/2026 through 6/30/2026, the MAR indicated Resident 2 received Trazadone HCL Tablet 50 mg on 6/29/2026 and 6/30/2026.During a review of Resident 2's MAR, dated 7/1/2026 through 7/31/2026, the MAR indicated Resident 2 received Trazadone HCL Tablet 50 mg from 7/1/2026 to 7/5/2026.During a review of Resident 2's untitled Care Plan, initiated 7/7/2026, the Care Plan indicated Resident 2 has episodes of insomnia. The Care Plan's goal indicated Resident 2 will show positive response to medication, minimizing side effects with intervention.During a telephone interview on 7/8/2026 at 10:30 a.m., Resident 2's RP stated during the first week of June 2026, nursing staff informed her that Resident 2 was often awake at night, pacing the hallway or sitting at the nurses' station. The RP stated that after receiving this information, she requested that Resident 2 be assessed by the psychiatrist due to her disrupted sleep patterns. She stated she consistently asked nursing staff for a status update on the psychiatrist's visit. The RP stated staff did not discuss with her any interventions nursing staff would attempt to address Resident 2's insomnia. RP stated she wanted to know if Resident 2 was provided opportunities for increased daytime activity to promote improved nighttime sleep but was not given information. The RP stated she was never informed whether the psychiatrist evaluated Resident 2. The RP recalled that the nursing staff contacted her on 6/29/2026 via telephone to consent for Trazodone 25 mg to be administered at bedtime. The RP stated this occurred several weeks after her initial request for a psychiatric consultation. The RP stated she was not aware of any non pharmacological approaches attempted prior to initiating Trazodone. The RP stated she visited Resident 2 on 7/2/2026 sometime after lunch and observed Resident 2 to be very lethargic. The RP asked a licensed nurse how if Resident 2 was given any other medications in addition to the Trazadone. The RP stated she was surprised to learn that Resident 2 was being administered 50 mg of Trazadone. The RP stated she understood that she only agreed to Resident 2 receiving 25 mg once a day at bedtime. The RP stated she immediately asked for the Trazadone dosage to be decreased from 50 mg to 25 mg. RP stated she signed a new informed consent indicating she provided consent for Trazadone 25 mg at bedtime instead of 50 mg. RP state she was frustrated as she still had not received a call from the psychiatrist and the licensed nursing staff could not provide an answer on when the psychiatrist would see Resident 2. RP state she felt frustrated and distrustful of the facility not following her wishes for Resident 2's best interest.During an interview on 7/8/2026 at 12:44 p.m., RN 1 stated on 6/29/2026, the previous shift had endorsed to her indicating a telephone order was received from Resident 2's physician to initiate Trazadone. RN 1 stated she was not informed of the reason for initiating Trazadone aside for the indication of insomnia. RN 1 stated she did not review Resident 2's medical records to determine what interventions per attempted prior to Resident 2 being initiated on Trazadone. RN 1 stated she was following the physician's orders. RN 1 stated she called the RP to obtain informed consent for Trazadone 50 mg at bedtime. RN 1 stated she called LVN 1 as a witness to the telephone consent.During an interview on 7/8/2026 at 1 p.m., LVN 1 stated that on 6/29/2026, RN 1 asked her to serve as the second witness for obtaining informed telephone consent from Resident 2's RP. LVN 1 stated she verified that the RP agreed to administer Trazodone 50 mg at bedtime to Resident 2 and stated she confirmed the RP's agreement during the telephone call.During an interview on 7/8/2026 at 1:35 p.m., the Director of Nursing (DON) stated she is responsible for reviewing the residents' clinical documents to ensure all residents ' receive appropriate care and treatment. The DON stated that based on her review of Resident 2's clinical documents, the records indicated that on 7/2/2026, Resident 2's RP provided informed consent indicated Trazadone 25 mg. The DON stated the there was another consent, dated 6/29/2026, indicating informed consent for Trazadone 50 mg, witnessed by two licensed nurses. The DON stated the physician's order indicated Trazadone 50 mg at bedside, with a start date of 6/29/2026. The DON stated Resident 2's MARs indicated Resident 2 received Trazadone on 7/2/2026, 7/3/2026, 7/4/2026 and 7/5/2026 despite the RP revising the consent on 7/2/2026 for Trazadone 25 mg. The DON stated there was no documentation indicating the nursing staff called Resident 2's physician to inform the physician of RP's directive to change the Resident 2's Trazadone dose. The DON stated the nursing staff should have called the physician to discuss the medication regiment instead of continuing to administer Trazadone 50 mg to Resident 2.During a review of the facility's policy and procedure (P&P) titled, Resident's Rights, dated 01/01/2012, the P&P indicated residents have the freedom of choice, about how they wish to live their everyday life and receive care, subject to the facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety.During a review of the facility's P&P titled, Informed Consent, dated 01/03/2024, the P&P indicated the facility except in emergencies, informed consent must be obtained prior to the proposed treatment or procedure, where possible, consent should be obtained sufficiently in advance to allow the resident or their surrogate decision-maker time to consider and make an informed decision.During a review of the facility's P&P titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated the facility focuses on the resident as the center of control and supports each resident in making her own choices.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) whose Responsible Party (RP) verbalized quality of care concerns to facility staff, was informed of and helped in completing a Grievance/Complaint Investigation Report.This failure resulted in Resident 2 and RP 2 not receiving timely or formal communication regarding the outcome or resolution of the complaint, which led to distrust toward the facility. This failure had the potential to delay necessary care and services to Resident 2 and could negatively impact Resident 2's mental health and emotional well being.Findings:During a review of Resident 2's Face Sheet (front page of the chart that contains the summary of basic information about the resident), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnosis including schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (dementia (progressive state of decline in mental abilities) and anxiety (worry) disorder.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 6/22/2026, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired and required substantial to maximum assistance (helper does more than half the effort) from staff for her activities of daily living ([ADLs] activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 2's Social Service Notes, dated 6/23/2026, the Social Service Notes indicated Resident 2's RP was dissatisfied with the current room situation and stated she (RP) called the local Long-Term Care (LTC) Ombudsman department and the department of Social Services to report the Social Services Director (SSD). The Social Service Note indicated the SSD reminded RP that it is her right as the RP to contact the Department of Health and the Department of Social Services with any concerns. There was no documentation in the Social Service Note indicating that the SSD identified or addressed RPs concerns. During a telephone interview on 7/7/2026 at 12 p.m., Resident 2's RP stated that over the last couple of months, she had informed the SSD and nursing staff of her quality-of-care concerns and of her most recent concern involved an incident in which she requested that Resident 4's (Resident 2's roommate) bedside commode, which had a foul smelling odor, be moved to another area on Resident 4's side of the room instead of near Resident 2's bed. The RP stated she had asked multiple staff members to move the commode, but staff took no action. The RP stated due to her frustration waiting for staff to address the issue, she asked facility staff for permission to move the commode herself. She stated that when she moved the commode, Resident 4 became audibly upset. She stated staff heard the commotion, came to the room, and informed her not to move the commode. She stated the incident caused a misunderstanding between herself and Resident 4. She stated she felt reprimanded by the facility for moving the commode, even though she had permission to do so. The RP stated she brought her concerns to the social worker regarding Resident 2's right to have a homelike and safe environment free from foul odors from Resident 4's commode. She stated this was one example of the facility not following up on her concerns. The RP stated another issue occurred about a month prior, when she notified facility staff that Resident 2 had a physician's appointment the following day and requested that staff ensure Resident 2 was awake, prepared, and ready on time. She stated that when she arrived at the facility around 8 a.m. that day, Resident 2 was still asleep. She stated she asked CNA 2, Resident 2's assigned CNA, why Resident 2 was not awake and ready yet. She stated CNA 2 had not been notified of Resident 2's appointment. She stated she assisted in getting Resident 2 ready to avoid missing the appointment. She stated this delay in care caused Resident 2 to almost miss the physician's appointment. She stated she brought her concerns to the nursing staff that day but did not receive follow up. She stated she remained concerned that this could happen again. The RP stated she was not provided with education or the option to file an official grievance.During an interview on 7/8/2026 at 11 a.m. the SSD stated she is the facility's grievance officer and is responsible for ensuring all grievances are logged. The SSD stated she was not aware of any outstanding grievances from 5/2026 to 7/2026. The SSD stated all grievances have been entered into the grievance log and stated if there are any concerns regarding care, residents and family members can file a grievance and it can be initiated by any staff member.During a subsequent interview on 7/8/2026 at 11:30 a.m., the SSD stated she had initiated a grievance for Resident 4 (Resident 2's roommate) because Resident 2's RP moved Resident 4's commode and opened a window, causing Resident 4 to feel upset that her right rights were violated. The SSD stated Resident 2's RP also verbalized frustration and stated she moved the Resident 4's commode because it was too close to Resident 2's area of the room. The SSD stated she offered a room change to Resident 2 and Resident 2's RP, but the RP refused the room change. The SSD stated she did not further investigate why the RP moved the commode. The SSD stated she informed the RP that she could make a complaint to the office of the LTC Ombudsman or the Department of Health, but she did not think to create a grievance to address or investigate the underlying issue. The SSD stated both residents in the room had the right to equal treatment and to have their room concerns addressed. The SSD stated she was not aware that Resident 2 almost missed an appointment due to delayed ADL care. The SSD stated that when staff became aware of that concern, a grievance should be initiated to track the concern, ensure it is resolved, and provide updates to the complainant to ensure the instance doesn't happen again. The SSD stated failure to follow the policy increases the chances of delay in care and lead to feelings of distrust toward the facility from the resident or the RP.During an interview on 7/8/2026 at 12 p.m., CNA 2 stated she recalled an incident about a month prior when Resident 2's RP arrived at the facility at approximately 8 a.m. CNA 2 stated the RP planned to take Resident 2 to a doctor's appointment that morning. CNA 2 stated she did not know Resident 2 had an early appointment, and when the RP arrived, Resident 2 was still in bed, had not eaten, and was not prepared to leave for her appointment. CNA 2 stated Resident 2 experienced a delay in care, and she was not sure if the RP's concerns were noted or addressed.During an interview on 7/8/2026 at 4 p.m., The Director of Nursing (DON) stated facility policy require staff to investigate and resolve all grievances and clearly communicate outcomes to residents and their representatives. The DON stated failure to address grievances can delay care and cause frustration and distrust among residents and families.During a review of the facility's policy and procedure (P&P) titled, Grievances and Complaints, revised 11/14/2025 the P&P indicated when the facility staff member overhears or receives a grievance/complaint from a resident, a responsible representative, family member, the facility staff member encourages and offers to facilitate the completion of a Grievance/Complaint investigation report. Upon receiving the grievance/complaint report, the grievance officer or designee provides a copy of the report to the appropriate department manager to being the investigation and subsequent resolution. The Grievance Official will be provided with a completed Resident Grievance/Complaint Investigation Report withing five business days of the start of the investigation.the facility will inform the resident and his RP with a summary of findings and corrective action if applicable. the disposition of all written grievances and/or complaints is recorded on the Resident Grievance/complaint log.

Based on interview and record review, the facility failed to ensure a resident (Resident 2) who had insomnia (trouble falling asleep or staying asleep) staff implemented Care Plan interventions which included behavioral monitoring to determine changes in sleep patterns and received resident-directed care and treatment consistent with the residents Care Plan prior to the initiation of Trazadone (a medication used to treat prescription medication prescribed to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of three sampled residents (Resident 2). This deficient practice resulted in nursing staff failing to adequately assess and monitor Resident 2's sleep patterns per the Care Plan and resulted in nursing staff to be unaware of the clinical indications that lead to the physician's order for Trazodone. This deficient practice had the potential to delay in identifying and providing needed care and services to Resident 2. Findings:During a review of Resident 2's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 had diagnoses including with diagnoses schizophrenia (a mental illness that is characterized by disturbances in thought), dementia (a progressive state of decline in mental abilities) and anxiety (excessive worry) disorder.During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 6/22/2026, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. During a review of Resident 2's untitled Care Plan, initiated 3/31/2026, the Care Plan indicated Resident 2 had an episode of walking back and forth in the hall and had an angry outburst. The Care Plan's goal indicated Resident 2 will have improved sleep pattern by reporting adequate rest or fewer episodes of insomnia. The Care Plan's interventions included monitoring/recording Resident 2's mood, assessing whether any changes were related to external factors or current medications and treatments, and reporting any acute changes; particularly alterations in sleep patterns, to the physician as requiredDuring a review of Resident 2's Psychiatric Evaluation Report, dated 6/19/2026, the Psychiatric Evaluation Report indicated Resident 2's plan of care included continued monitoring of mood, anxiety, cognition, and sleep.During a review of Resident 2's Order Summary Report (physician's orders), dated 6/29/2026, the Order Summary Report indicated an order was placed for Resident 2 to receive Trazadone Hydrochloride (HCL) Tablet 50 milligrams ([mg] unit of measurement) by mouth at bedtime for insomnia and the inability to sleep at nighttime.During a telephone interview on 7/8/2026 at 10:30 a.m., Resident 2's RP stated that during the first week of June 2026, nursing staff informed her that Resident 2 was often awake at night, pacing the hallway or sitting at the nurses' station. The RP stated that after receiving this information, she requested that Resident 2 be assessed by the psychiatrist due to her disrupted sleep patterns. She stated she consistently asked nursing staff for a status update on the psychiatrist's visit. The RP stated staff did not discuss with her any interventions nursing staff would attempt to address Resident 2's insomnia. She stated she would have wanted to know if Resident 2 was provided opportunities for increased daytime activity to promote improved nighttime sleep. The RP stated she was never informed whether the psychiatrist evaluated Resident 2. She recalled that nursing staff contacted her on 6/29/2026 to sign a consent for Trazodone, several weeks after her initial request for a psychiatric consultation. She stated she was not aware of any non pharmacological approaches attempted prior to initiating Trazodone.During an interview on 7/8/2026 at 1:28 p.m., Registered Nurse (RN) 1 stated on June 29,2026, the previous shift had endorsed a telephone order from Resident 2's physician to initiate Trazadone. RN 1 stated she was not informed of the reason for initiating Trazadone aside for the indication of insomnia. RN 1 stated she did not review Resident 2's medical records to determine what interventions per attempted prior to Resident 2 being initiated on Trazadone. RN 1 stated she was following the physician's orders.During an interview on 7/8/2026 at 1:35 p.m., the Director of Nursing (DON) stated she is responsible for reviewing the residents' clinical documents to ensure all residents receive appropriate care and treatment. The DON stated based on review of Resident 2's Care Plan, Resident 2's Care Plan interventions included required monitoring and documentation sleep patterns and any signs of insomnia. The DON stated that her review of Resident 2's clinical documents showed no documentation indicating Resident 2's sleep related behaviors were monitored or assessed. The DON stated that the failure to monitor and document these behaviors prevented nursing staff from developing or revising the care plan which would include implementing non pharmacological interventions before initiating Trazodone. The DON further stated that, based on the available documentation, she could not determine the clinical indications that led to Resident 2 being prescribed Trazodone. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated the facility must develop and implement a comprehensive person- centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure the Responsible Party (RP), who was a Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation), appointed by the Los Angeles County Office of the Public Guardian, for one of four sampled residents (Resident 1) was informed of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) and allowed to give their consent for Resident 1 to continue use of the medication, versus providing this information to Resident 1's FM and allowing her to give consent for Resident 1's use of the medication. This deficient practice resulted in Resident 1's Conservator being unaware of medications Resident 1 was prescribed and the inability to make decisions regarding Resident 1's care. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/12/2025, the MDS indicated Resident 1's cognition was severely impaired, and Resident 1 was dependent (helper does all of the effort) on facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Letter of Conservatorship dated 6/27/2025, the Letter of Conservatorship indicated the Los Angeles County Office of the Public Guardian, appointed Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation) of the person and estate of the named Conservatee (a person who is deemed by a court to be unable to manage their own personal and/or financial affairs, and for whom a judge has appointed a conservator to make decisions on their behalf) , Resident 1, effective as of 6/11/2025. During a review of Resident 1's Physician Orders, the Physician's Orders indicated the following medication prescribed to Resident 1: 1. 9/5/2025 - Quetiapine Fumarate (antipsychotic medication used to treat schizophrenia) 25 mg one tablet by mouth every eight hours as needed for agitation. 2. 9/8/2025 - Aripiprazole (antipsychotic medication used to treat mental conditions such as schizophrenia) 20 milligrams ([mg] a unit of measurement) one tablet once a day for schizophrenia manifested by predominant negativity as evidenced by a blunted affect (reduced or diminished ability to show feelings)/lack of motivation to perform daily activities. During a review of Resident 1's Informed Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) dated 9/5/2025, the Informed Consent form indicated the signature allowing Resident 1 to use Quetiapine Fumarate was obtained from Resident 1's FM, not Resident 1's Conservator. During a review of Resident 1's Informed Consent dated 9/8/2025, the Informed Consent form indicated the signature allowing Resident 1 to use Aripiprazole was obtained from Resident 1's FM, not Resident 1's Conservator. During an interview on 11/25/2025 at 3:02 p.m., the Director of Nursing (DON) stated the informed consent for Quetiapine Fumarate Quetiapine Fumarate and Aripiprazole should have been obtained from Resident 1's Conservator, not Resident 1's FM. The DON stated the facility staff were not [NAME] that Resident 1 had a Conservator. During a review of the facility's Policy and Procedure (P/P) titled Surrogate Decision Maker- Informed Consent dated 11/14/2025, the P/P indicated the facility will identify a person (who is unaffiliated with the facility) to serves as a representative of the Resident, including public guardians.

Based on interview and record review, the facility failed to ensure the Responsible Party (RP), who was a Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation), appointed by the Los Angeles County Office of the Public Guardian, for one of four sampled residents (Resident 1) was involved in the development of Resident 1's a discharge plan to reflect Resident 1's discharge needs, goals, and treatment preferences. This deficient practice resulted in Resident 1 being inappropriately discharged from the facility with a Family Member (FM), who was not Resident 1's Conservator and placed Resident 1 at risk for decline in health and non-continuity of care. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 9/12/2025, the MDS indicated Resident 1's cognition was severely impaired, and Resident 1 was dependent (helper does all of the effort) on facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Letter of Conservatorship dated 6/27/2025, the Letter of Conservatorship indicated the Los Angeles County Office of the Public Guardian, appointed Conservator (a person appointed by a court to manage the financial or personal affairs of someone who is unable to do so themselves due to illness, disability, or other incapacitation) of the person and estate of the named Conservatee (a person who is deemed by a court to be unable to manage their own personal and/or financial affairs, and for whom a judge has appointed a conservator to make decisions on their behalf) , Resident 1, effective as of 6/11/2025. During a review of Resident 1's Physician Order dated 11/6/2025, the Physician Order indicated Resident 1 could be discharged on 11/7/2025, per Resident 1's FM's request. During a review of Resident 1's Discharge Planning Review Form dated 11/7/2025, the Discharge Planning Review Form indicated Resident 1's FM was contacted regarding Resident 1's discharge planning and Resident 1 was discharge to his FM's care, per the request of the FM. During an interview on 11/25/2025 at 12:06 p.m., the Social Services Director (SSD) stated she was not aware that Resident 1 had a Conservator. The SSD stated if she had known Resident 1 had a Conservator, she would have communicated with and included the Conservator in the discussion regarding discharge plans for Resident 1. During an interview on 11/25/2025 at 3:02 p.m., the Director of Nursing (DON) stated facility staff were unaware that Resident 1 had a Conservator because there was no information regarding a Conservatorship provided when Resident 1 was admitted to the facility. The DON stated Resident 1's discharge planning should not have been discussed with Resident 1's FM and Resident 1 should not have been allowed to discharge with his FM. During a review of the facility's Policy and Procedure (P/P) titled Discharge Planning dated 7/2020, the P/P indicated if the Interdisciplinary team ([IDT] a group of professionals from different fields who work together to achieve a common goal) and the Attending Physician determine that the resident may be appropriate for discharge, Social Services Staff will coordinate the discussion of discharge with the IDT, the resident, and the Responsible Party (RP).

Based on observation, interview, and record review, the facility failed to prevent the spread of infection for 91 of 91 residents in the facility by failing to: 1. Ensure the hot water temperature logs of the washing machines were accurate and monitored daily.2. Implement policies and procedures (P&P) of proper washing machine temperatures and accurate documentation logs. This deficient practice had the potential to spread infection to all 91 residents in the facility.Findings: During a concurrent interview and record review on 8/7/2025 at 4:15 p.m. with the Housekeeping Supervisor (HS), the HS stated the staff should record the temperatures of the washing machine daily on the Washer Water Temperature Log. The HS stated he did not actually take the temperatures of the hot water and stated the previous managers told him to write 160 degrees (unit of measurement) on the temperature log daily. During a concurrent interview and record review on 8/8/2025 at 9:00 a.m. with the Laundry Assistant (LA), the LA stated the correct temperature of the washing machines should be 160 degrees Fahrenheit ([F] temperature scale) for the laundry to be sanitized. The LA stated no one has taught the staff how to monitor the water temperature. The LA stated we were told by the previous supervisor to just fill in the temperature log sheet daily and write 160 degrees. During a concurrent interview and record review on 8/8/2025 at 10:00 a.m. with the Maintenance Supervisor, the MS produced records of the water temperature monitoring log. The MS stated the laundry hot water temperature was recorded Monday to Friday only and no one monitors the hot water temperature on the weekends when he is off. The Maintenance Director stated he does not have any policies on monitoring the temperature of the washing machines. The MS stated it is important to check the laundry hot water temperature to make sure the facility follow regulations to kill germs and prevent the spread of infection.

Based on observation, interview and record review, the facility failed to ensure proper medication storage according to requirements indicated on the pharmacy label and labelling medications when: 1.One vial of unopened Humulin R [type of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication)] was not stored inside the refrigerator. 2.One bottle of unopened latanoprost eye drops (medication used to manage elevated pressure in the eye) was not stored inside the refrigerator. 3.One bottle of artificial tears (lubricating eye drops used to help relieve dry and irritated eyes) was not labeled with resident's full name, bottle showed room number, had a broken seal, and no open date. 4. One bottle of omeprazole sodium liquid (medication used to reduce stomach acid) was not removed from use after the label discard date of 8/6/2025. 5. One bottle of AZO Cranberry (used to aid in maintaining urinary tract health) was not labeled with an open date.6. Voltaren External Gel 1% (Brand name for Diclofenac Sodium topical gel, used to relieve arthritic pain) was not labeled with an open date.These deficient practices had the potential to result in medication errors, reduced therapeutic effects, and adverse outcomes from administering the wrong or expired medications, including loss of medication efficacy. Findings: 1.During a review of Resident 38's admission Record, the admission Record indicated the facility admitted the resident on 6/2/2020, with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paraplegia (loss of movement and or sensation, to some degree, of the legs) and dementia (progressive state of decline in mental abilities). During a review of Resident 38's History and Physical (H&P) dated 6/2/2020, the H&P indicated the resident can make needs known but cannot make medical decisions. During a review of Resident 38's Minimum Data Set (MDS-a resident assessment tool) dated 5/212025, indicated the resident had severely impaired cognition (ability to think and understand). The MDS indicated the resident was dependent on staff for bed mobility, locomotion, dressing and personal hygiene. During a review of Resident 38's Order Summary Report, a physician's order dated 2/8/2022, indicated to administer Humulin R insulin subcutaneously two times a day for DM. During a review of Resident 38's Medication Administration Record (MAR), the MAR indicated Humulin R insulin was administered to the resident on 8/7/2025, during the 6:30 a.m. medication administration. During a concurrent observation and interview on 8/7/2025 at 10:36 a.m., with Licensed Vocational Nurse 1 (LVN) 1, Resident 38's Humulin R insulin vial was unopened with yellow top seal (cap) and label indicated Refrigerate was found inside medication cart 3. LVN 1 stated medications need to be at certain temperature to work and if improperly stored, residents may get adverse reactions. During an interview on 8/7/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated medications are refrigerated to maintain stability and potency and may have reactions if not kept at a certain temperature. During a review of facility's policies and procedures (P&P) titled Medication Storage in the Facility updated on 8/2019, indicated medications requiring refrigeration or temperatures between 2 C (36F) and 8C (46F) are kept in a refrigerator with a thermometer to allow temperature monitoring. The P&P also indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication, and reordered from the pharmacy, if a current order exists. During a review of facility's P&P titled Medication Ordering and Receiving from Pharmacy updated on 2/2020, indicated each prescription medication label includes resident name, medication name, strength of medication, date dispensed, specific directions for use, prescriber name, quantity of medication, prescription number, dispensing pharmacy name, address, telephone number and beyond use or expiration date of medication. 2. During a review of Resident 100's admission Record, the admission Record indicated the facility admitted the resident on 11/10/2023, and was readmitted on [DATE], with diagnoses including glaucoma (a group of eye diseases that damage the optic nerve, which is crucial for sending visual information to the brain), paraplegia (loss of movement and or sensation, to some degree, of the legs) and generalized muscle weakness. During a review of Resident 100's Minimum Data Set (MDS- a resident assessment tool) dated 7/13/2025, the MDS indicated the resident had moderately impaired cognition (ability to think and understand). The MDS indicated the resident was dependent on staff for toileting hygiene, bathing and lower body dressing. The MDS indicated total dependence on staff for bed to chair transfers. During a review of Resident 100's Order Summary Report, a physician ‘s order dated 8/6/2025, indicated to instill latanoprost 0.005% solution 1 drop in both eyes at bedtime for glaucoma. During a review of Resident 100's Medication Administration Record (MAR), the MAR indicated latanoprost was administered to the resident on 8/7/2025. During a concurrent observation and interview on 8/7/2025 at 10:36 a.m., with Licensed Vocational Nurse 1 (LVN) 1, Resident 100's latanoprost eye drops was unopened, the seal not broken and label indicated Refrigerate was found inside medication cart 3. LVN 1 stated medications need to be at certain temperature to work and if improperly stored, residents may get adverse reactions. During an interview on 8/7/2025, at 3:38 p.m., with Director of Nursing (DON), the DON stated medications are refrigerated to maintain stability and potency and may have reactions if not kept at a certain temperature. During a review of facility's policies and procedures (P&P) titled Medication Storage in the Facility updated on 8/2019, indicated medications requiring refrigeration or temperatures between 2 C (36F) and 8C (46F) are kept in a refrigerator with a thermometer to allow temperature monitoring. The P&P also indicated outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication, and reordered from the pharmacy, if a current order exists. During a review of facility's P&P titled Medication Ordering and Receiving from Pharmacy updated on 2/2020, indicated each prescription medication label includes resident name, medication name, strength of medication, date dispensed, specific directions for use, prescriber name, quantity of medication, prescription number, dispensing pharmacy name, address, telephone number and beyond use or expiration date of medication. 3. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 3/16/2024, and was readmitted on [DATE], with diagnoses including type 2 diabetes mellitus, contracture of muscle (stiffening/shortening at any joint, that reduces the joint's range of motion) and sepsis (a life-threatening blood infection). During a review of Resident 1's History and Physical (H&P) dated 6/22/2025, H&P indicated that resident had a capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 6/29/2025, the MDS indicated resident had intact cognition (ability to think and understand). The MDS indicated the resident was dependent on staff for bed mobility, locomotion, dressing and personal hygiene. During a review of Resident 1's Order Summary Report dated 4/22/2025, indicated a physician's order of artificial tears ophthalmic solution, to instill 1 drop in both eyes every eight hours as needed for dry eyes and artificial tears ophthalmic solution 0.2-0.2-1%, instill 1 drop in both eyes three times a day for dry eyes. During a review of Resident 1's Medication Administration Record (MAR), MAR indicated artificial tears was last administered on 6/18/2025. During a concurrent observation and interview on 8/7/2025 at 10:36 a.m., with Licensed Vocational Nurse 1 (LVN) 1, artificial tears seal was broken, with no open date label, a room number was written on box was found inside medication cart 3. LVN 1 stated the artificial tears belonged to Resident 1. LVN 1 stated medication must be labeled with the date opened, as some medications are only effective for 30 days. LVN 1 stated without proper labeling, expired medications may be administered to a resident, reducing effectiveness. LVN 1 stated medication should have identifiers such as last name and first initial of resident, to ensure medication was given to the correct resident, and if only room number was used, the medication may be administered to the wrong resident due to room changes, posing a safety risk. During an interview on 8/7/2025 at 3:38 p.m., with the Director of Nursing (DON), the DON stated medications need to have identifier with a labelled date and time, to know if medication was still usable or need to be discarded. The DON stated using only room number as an identifier creates a risk of giving medication to the wrong resident, as residents may be moved to different rooms. During a review of facility's P&P titled Medication Ordering and Receiving from Pharmacy updated on 2/2020, indicated each prescription medication label includes resident name, medication name, strength of medication, date dispensed, specific directions for use, prescriber name, quantity of medication, prescription number, dispensing pharmacy name, address, telephone number and beyond use or expiration date of medication. 4. During a review of Resident 63's admission Record, the admission Record indicated the facility admitted the resident on 4/19/2023, and was readmitted on [DATE], with diagnoses including dementia (progressive state of decline in mental abilities), paraplegia (loss of movement and or sensation, to some degree, of the legs) and gastro esophageal reflux disease (GERD-a condition where stomach contents flow back into the esophagus, irritating the lining and causing various symptoms). During a review of Resident 63's History and Physical (H&P) dated 1/19/2025, H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 63's Minimum Data Set (MDS) dated [DATE], the MDS indicated the resident had moderately impaired cognitive (ability to think and understand) skills for daily decision making. The MDS indicated the resident was dependent on staff for bed mobility, locomotion, dressing and personal hygiene. During a review of Resident 63's Order Summary Report dated 7/7/2025, indicated a physician's order for omeprazole oral suspension (medication used to reduce stomach acid) 2 milligram per milliliter (mg/ml, unit of weight), to give 10 ml via PEG tube (percutaneous endoscopic gastrostomy, surgical procedure for inserting a tube through the abdomen wall and into the stomach used for nutrition and medication administration) one time a day for GERD. During a review of Resident 63's Medication Administration Record (MAR) indicated omeprazole oral suspension was administered on 8/7/2025 during the 6:30 a.m. medication administration. During a concurrent observation and interview on 8/7/2025 at 10:36 a.m., with Licensed Vocational Nurse 1 (LVN) 1, Resident 63's omeprazole sodium liquid label indicated Discard after 8/6/2025 was found inside medication cart 3. LVN 1 stated the importance of checking the medication's expiration date, was because it may no longer be effective after the expiration date or discard date. During an interview on 8/7/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated failure to follow medication's discard date may result in reduced potency and could affect interactions when the medication was administered. During a review of facility's policies and procedures (P&P) titled Medication Ordering and Receiving from Pharmacy updated on 2/2020, P&P indicated date open procedure: using professional judgement, the pharmacist may label medications with different expiration dates that the manufacturers' labeling on the original container. The pharmacy label supersedes other information on the medication container and all other labeling recommendations. During a review of facility's policies and procedures (P&P) titled Disposal of Medication and Medication-Related Supplies updated on 8/2019, the P&P indicated if a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose. 5. During a review of Resident 28's admission Record, the admission Record indicated the facility admitted the resident on 11/19/2022 and readmitted [DATE], with diagnosis including urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 28's Minimum Data Set (MDS- resident assessment tool) dated 10/1/2024, indicated the resident had intact cognition and required substantial assistance from staff with bed mobility and was totally dependent for toileting and bathing. During a review of Resident 28's Order Summary Report a physician's order dated 7/29/2025 indicated to administer one cranberry oral tablet (supplement used to aid in maintaining urinary tract health) by mouth daily in the morning. During an observation of Medication Cart 1 and concurrent interview with Licensed Nurse (LVN) 2 on 8/7/2025 at 3:14 pm, an opened AZO Cranberry (used to aid in maintaining urinary tract health) medication container was stored inside the medication cart. The AZO cranberry medication bottle did not indicate the date opened. LVN 2 stated licensed nurses should write the date all medications were opened to identify when the medications will expire. LVN 2 stated certain medications are only good for a certain number of days after opening and if used after the date medications might lose efficacy. During an interview with the Director of Nursing (DON) on 8/7/2025 at 3:39 p.m., the DON stated licensed nurses should indicate the opened date on all medication containers. The date opened was needed to determine when to discard medications. The DON stated administering medications past their expiration date can result in decreased efficacy of treatment. During a review of the facility's policy and procedure (P&P) titled Medication Labels updated August 2020, indicated each prescription medication label includes Beyond use (or expiration) date of medication. 6. During a review of Resident 69's admission Record, the admission Record indicated the facility admitted the resident on 9/17/2024 and readmitted on [DATE], with a diagnosis including inflammatory spondylopathy lumbar region (inflammation of the vertebrae in the lower back). During a review of Resident 69's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 10/1/2024 indicated the resident had moderate cognitive impairment. The MDS indicated the resident required moderate assistance from staff with toileting, tub transfer, bathing and walking. During a review of Resident 69's Order Summary Report a physician's order dated 7/8/2025 indicated to apply Voltaren External Gel 1% [Diclofenac Sodium (Topical)] to affective area topically every 6 hours as needed for pain management. During an observation of Medication Cart 1 and concurrent interview with Licensed Nurse (LVN) 2 on 8/7/2025 at 3:14 p.m., an opened Voltaren External Gel 1% (used to relieve arthritic pain) was observed to have no open date. LVN 2 stated licensed nurses should write the date all medications were opened to identify when the medications will expire. LVN 2 stated certain medications were only good for a certain number of days after opening and if used after the date medications might lose efficacy. During an interview with the Director of Nursing (DON) on 8/7/2025 at 3:39 p.m., the DDON stated licensed nurses should indicate the opened date on all medication containers. The date opened was needed to determine when to discard medications. The DON stated administering medications past their expiration date can result in decreased efficacy of treatment. During a review of the facility's policy and procedure (P&P) titled Medication Labels updated August 2020, indicated each prescription medication label includes Beyond use (or expiration) date of medication.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 85 out of 91 total residents in the facility by failing to:A. Ensure food items were labelled, dated, and sealed properly.B. Discard expired thickened water and kiwi strawberry flavored syrup for juice dispenser.C. Follow a meal ticket/tray card during tray line (Resident's trays are assembled and check for accuracy before food is delivered to them).D. Ensure [NAME] (CK) 2 did not wear jewelry while serving food during tray line.E. Ensure Dietary Aid (DA)1 performed hand hygiene and wear gloves while placing residents' utensils on tray during tray line.These failures had the potential to affect residents and to result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, and can lead to other serious medical complications including hospitalization.Findings:A. During a concurrent observation and interview on 8/5/2025, at 8:28 a.m., with CK 1, in the dry storage area, there were food items that were not dated and sealed properly as follows:a. Opened, used and unsealed breadcrumbs in a plastic bin (lid was not close tightly) with Receiving Date (RD- the day of delivery) of 3/3/2025, Open Date (OD) of 4/5/2025, and Use By (UB) of 9/5/2025. b. Opened, used and unsealed cracker crumbs in a plastic bin (lid was not sealed) with no RD, OD of 3/3/2025, and UB of 3/3/2026.c. Opened and used shredded coconut in a plastic bin (lid was not sealed) with RD of 5/24/2025, OD of 5/24/2025, and UB of 11/24/2025. CK 1 stated, all food items should have been labeled with receiving date when the facility got delivery from vendors. CK 1stated, all food items should have an open date and used by date (expiration date). CK 1 stated, it was all the dietary staff responsibility to check all food items for labels, dates, properly stored and sealed. CK 1 stated these practices were important to make sure all food items were in good condition because the residents consumed these food items. CK 1 stated that all opened food items should be closed tightly to prevent contamination. CK 1stated, once the food items were opened, there should be different shelf life. CK 1 stated, all staff should refer to Dry Goods Storage Guidelines for shelf life (the length of time for which an item remains usable, fit for consumption) after opening and labeled UB date on food items.During a review of the facility's Policy and Procedure (P&P) titled, Dry Goods Storage Guidelines, dated 2023, the P&P indicated, breadcrumbs and shredded coconuts had shelf life of six months after opening.During a concurrent observation and interview on 8/5/2025, at 8:44 a.m., with CK1, in Refrigerator #1 near the sink area, there were food items that were not labeled, dated, and sealed properly as follows:a. opened, used, and unsealed tortillas in a plastic bag with no RD, OD of 8/3/2025, and UB 8/6/2025.CK 1 stated, all food items should be dated, and dietary staff should follow the Refrigerator Storage Guide to ensure safety of perishable items that required refrigeration. Ck 1 stated, all opened items should be sealed properly to prevent contamination.During a review of the facility's Policy and Procedure (P&P) titled, Dry Goods Storage Guidelines, dated 2023, the P&P indicated, opened tortillas should be refrigerated and had shelf life of two months after opening.During a concurrent observation and interview on 8/5/2025, at 8:55 a.m., with CK1, in Freezer #1 near the sink area, there were food items that were not sealed properly as follows: a. opened, used, and unsealed kernel corns in a box with RD of 7/28/2025, OD of 7/31/2025, and UB of 9/31/2025.CK1 stated, all food items should be sealed tightly, and dietary staff should follow Freezer Storage guideline to ensure safety of perishable items.During a review of the facility's Policy and Procedure (P&P) titled, Produce Storage Guidelines, dated 2023, the P&P indicated, frozen vegetable in freezer had shelf life of ten months after opening.During a review of the facility's Policy and Procedure(P&P) titled, Food Storage and Handling, revised 2/29/2024, the P&P indicated, 9. Frozen Vegetable Storage: Label and date all food items, use within 6 months.13. Dry Storage Area: place opened products in storage containers with tight fitting lids, label and date all storage products.B. During a concurrent observation and interview on 8/5/2025, at 9:02 a.m., with DA 1, there were two boxes of juice mixer that were expired, but connected to juice dispenser as follows: a. Box of thicken Water for juice dispenser with RD of 7/14/2025, OD of 7/22/2025, and UB of 7/28/2025 (expired). b. Kiwi Strawberry flavored syrup in a box with RD of 7/7/2025, OD of 7/27/2025, and UB of 8/3/2025 (expired).DA 1 stated, she should have called and let the vendor know about expired boxes to be changed, because expired drink could cause sickness to residents. C. During a concurrent observation and interview on 8/5/2025, at 12:05 p.m., with DA 2 during the tray line, DA 2 read out the meal ticket #1 that indicated mechanical soft diet (a texture-modified diet focused on making food easier to chew and swallow). The meal ticket #1 indicated the resident had either allergies or disliked broccoli and cucumbers, but DA 2 did not read out about it. There were chopped mixed vegetables which included broccoli on the tray. DA 2 stated, she forgot to read out for CK1 and Ck 2 regarding no broccoli.During a concurrent observation and interview on 8/5/2025, at 12:10 p.m., with DK 2 during the tray line, DA 2 read out the meal ticket #2 that indicated mechanical soft diet. The meal ticket #2 indicated, the resident preferred gravy, but DA 2 did not read out regarding gravy. The tray did not have gravy on any of the food items. DA 2 stated, following meal tickets were important to ensure that the residents received meals as ordered and to prevent accidental ingestion of food items that could cause allergic reactions. During a review of the facility's Policy and Procedure (P&P) titled, Dining Program, revised 1/1/2012, the P&P indicated, Dietary Staff: Check tray cards against the meal served at the tray line and correct any discrepancies.D. During a concurrent observation and interview on 8/5/2025, at 12:15 p.m., with CK 2 during the tray line, CK 2 was wearing a gold cross necklace and a gold chain bracelet which was not covered with gloves. CK2 was serving the food items to assist CK 1. CK 2 stated, he was wearing them many times and no one said anything. During an interview on 8/5/2025, at 12:18 p.m., with the Dietary Director (DD) during the tray line, the DD stated, CK 2 should not wear any jewelry while he is serving food to prevent cross contamination (the transfer of bacteria or other microorganisms from one substance to another). During a review of the facility's Policy and Procedure (P&P) titled, Dietary Department-Infection Control, Revised 2/29/2024, the P&P indicated, 1. Personal cleanliness is required in sanitary food preparation: e. Rings, bracelets, and watches are not permitted to be worn while working in the food service area or while preparing food.E. During a concurrent observation and interview on 8/5/2025, at 12:21p.m., with DA 1 during the tray line, DA 1 was placing the utensils, napkins, and drinks for the trays for tray line. DA 1 did not perform hand hygiene between the trays and did not wear the gloves. DA 1 touched the plastic bin behind her with one hand and grabbed drink cups from the bin to place them on the trays without performing hand hygiene. DA 1 grabbed the tip of forks and spoons with bare hands without hand hygiene and placed them on the trays. DA 1 stated, she did not realize she was contaminating the resident trays.During an interview on 8/5/2025, at 12:26 p.m., with the DD during the tray line, the DD stated, hand hygiene should be performed between the tasks. The DD stated, DA 1 should have worn the gloves after hand hygiene to prevent contamination during the tray line. During an interview on 8/8/2025, at 2:56 p.m., with the Director of Nursing (DON), the DON stated, dietary staff should be performed hand hygiene to prevent food borne illness. The DON stated, all food items should be dated, labeled, and sealed to prevent contamination and food borne illness. The DON stated that the dietary staff should follow diet order and meal ticket/tray card to accommodate resident's needs and prevent ingesting food items that could cause allergic reactions accidentally. During a review of the facility's Policy and Procedure (P&P) titled, Dietary Department-Infection Control, Revised 2/29/2024, the P&P indicated, 2. Proper Hand Washing: b. immediately before engaging in food preparation, including working with non-prepackaged food, clean equipment and utensils, and unwrapped single-use food containers and utensils.g. During food preparation, as often as necessary to remove soil and contamination, and to prevent cross-contamination when changing tasks.handling clean table ware and serving utensils in the food service area.

Based on observation, interview and record review, the facility failed to ensure accurate documentation for two of 16 sampled residents (Resident 6 and Resident 15) by failing to:a. Ensure Resident 6, who had a diagnosis of depression (a serious mood disorder that affects how you think, feel, and handle daily activities) and taking an antidepressant medication (medications used to treat depression and other conditions) was documented on the medical diagnosis list.b. Ensure Resident 15's Medication Administration Record for the month of August 2025 was accurate when it indicated Resident 15 received Naloxone (a medicine that rapidly reverses an opioid [strong pain medication] overdose) on 8/1/2025, when Resident 15 did not receive Naloxone.These deficient practices resulted in Resident 15 having a documented medication error in the MAR, had the potential to negatively impact the provision of necessary care and services and portray an inaccurate reflection of Resident 6 diagnosis list in the facility. Findings: a. During a review of Resident 6’s admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder ([PTSD], a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it), anxiety (a mental health condition that cause fear, dread and other symptoms that are out of proportion to the situation), opioid (a class of drugs that are used to reduce moderate to severe pain) use disorder (a mental health condition where a pattern of opioid use affects your health and daily life), and rhabdomyolysis (a serious condition where damaged muscle tissue breaks down, releasing its contents into the bloodstream that can lead to kidney damage). During a review of Resident 6’s Minimum Data Set ([MDS], a resident assessment tool) dated 6/5/2025, the MDS indicated Resident 6 had intact cognitive (thought process) function and was set up assistance (helper sets up while resident completes the activity) with self-care abilities such as eating, oral hygiene, personal hygiene and upper body dressing. The MDS indicated a mood total severity score (indicates the overall severity of a person's depression or mood disturbance) of 13 (5-9 indicating mild, 10-14 indicating moderate, involves a greater number of symptoms and a more significant impact on daily functioning). During a review of Resident 6’s Order Summary Report dated, the Order Summary Report indicated to give sertraline (a prescription medication used to treat depression and other mental health conditions) tablet (pill) 100 milligram ([mg], a unit of measurement) give one tablet by mouth one time a day for depression manifested by excessive worries of life situation ordered on 8/6/2025, and alprazolam (a prescription medication used to treat anxiety disorder, and panic disorder) oral Tablet 0.5 mg give one tablet by mouth every morning and at bedtime for anxiety manifested by irritability (a state of increased sensitivity and a tendency to react with anger, frustration, or annoyance to stimuli, often triggered by small things) or restlessness ordered on 7/31/2025. During a review of Resident 6’s primary doctor progress note dated 7/17/2025, the primary doctor progress note indicated Resident 6 had a past medical history of chronic opioid use, anorexia (an eating disorder that causes people to weigh less than is considered healthy for their age and height, usually by excessive weight loss), and depression. Resident 6 note indicated depression, anxiety and to continue a psychology (the study of the human mind and its functions)/psychiatry (the branch of medicine of study, diagnosis, and treatment of mental illness) consultation and continue medication of alprazolam 0.5 mg every 12 hours and sertraline 50 mg daily. During a review of Resident 6’s psychiatry doctor progress note dated 8/6/2025, the psychiatry doctor progress note indicated Resident 6 was currently on sertraline 50 mg by mouth daily and alprazolam 0.5 mg by mouth twice a day for anxiety disorder and depressive disorder. During a concurrent observation and interview on 8/5/2025 at 10: 06 a.m. with Resident 6 in their room, Resident 6 was lying in bed watching from their electronic device. Resident 6 stated he takes medication for mood but does not remember the names of the medications at this time. During a concurrent interview with record review on 8/8/2025 at 11:41 a.m. with the Director of Nursing (DON), the admission record, the primary doctor progress note, and psychiatry doctor progress note were reviewed. The DON stated Resident 6’s medical diagnosis list should have listed that Resident 6 had some type of depressive mood disorder. The DON stated the importance of having accurate documentation of medical diagnosis was so the facility staff would know current condition of resident and accurate assessment of the resident to know what's going on and to provide appropriate care. The DON stated the two doctor’s progress notes indicated Resident 6 had depression, the medical diagnosis list should have indicated some type of depressive mood disorder since Resident 6 was taking anti-depression medication. During a review of the facility’s policy and procedures (P&P) titled, “Completion and Correction” revised 1/1/2012, indicated, the purpose was to ensure that medical records are complete and accurate, the facility will work to complete and correct medical records in a standardized manner to provide the highest quality and accuracy in documentation, entries will be complete, legible, descriptive and accurate. b. During a review of Resident 15’s admission Record (Face Sheet), the admission Record indicated Resident 15 was admitted to the facility 2/12/2025 with diagnoses including fibromyalgia (a chronic condition that causes pain in muscles and soft tissues all over the body) and falls. During a review of Resident 15’s minimum data set (MDS, a resident assessment tool) dated 7/17/2025, the MDS indicated Resident 15 had moderate cognitive (the broad set of mental processes that relate to acquiring knowledge and understanding through thought, experience, and senses) impairment. During a review of Resident 15’s Order Summary Report, the Order Summary Report indicated an order was placed on 5/25/2025 for Naloxone HCl Nasal Liquid 4 milligrams (mg, a unit of measurement)/ 0.25 milliliters (ml, a unit of measurement): 1 spray in nostril as needed for opioid overdose. During a review of Resident 15’s MAR for 8/2025, the MAR indicated Resident 15 received a dose of Naloxone on 8/1/2025 at 6:18 a.m. During an interview on 8/7/2025 at 11:55 a.m., with Registered Nurse (RN) 3, RN 3 stated he was working on 8/1/2025 and Resident 15 was okay and never received Naloxone. RN 3 stated it was a “mistake” that Naloxone was marked as given on the MAR for 8/1/2025. During an interview on 8/8/2025 at 3:25 p.m., with the director of nursing (DON), the DON stated the Naloxone was not given to Resident 15 and it was a medication error due to documentation. The DON stated it was important to ensure documentation was correct for medication administration because it could lead to errors in giving care or responding to changes of condition. During a review of the facility’s policy and procedure (P&P) titled Completion and Correction, Medical Records Manual- General dated 1/1/2012, the P&P indicated the purpose of the policy was to ensure medical records were complete and accurate.

Based on observation, interview, and record review, the nursing staff failed to ensure the call light device was in reach for one out of three residents (Resident 1). This deficient practice had the potential to result in a delay of care and the Resident 1 needs not being met. Findings: During a concurrent observation and interview on 8/6/2025 at 4:00 p.m. with Resident 1, Resident 1 was in bed with the call light next to his lower right hip. Resident 1 stated he would like to call for help but is not able to call his nurse. Resident 1 stated when he needs help, he usually yells to his roommate to call a nurse when he needs assistance. During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses including functional quadriplegic ( a complete inability to move due to severe physical disability or frailty without any physical injury), hypotension (low blood pressure) and contracture of muscles multiple sites (multiple muscles have become permanently shortened and stiff where the cannot move).During a review of Resident 1's History and Physical (H&P), dated 6/22/2025, the H&P indicated, Resident 1 has the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 6/29/2025, the MDS indicated Resident 1 is dependent (helper does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on eating , oral hygiene, toilet hygiene, shower/bathe self, upper and lower body dressing. During a review of Resident 1's the Care Plan (CP) dated 6/24/2025, the CP, interventions indicated to monitor and anticipate needs assisting with turning and repositioning, keep call light in reach and answer promptly. During an interview on 8/6/2025 at 4:15 p.m., with Resident 1's roommate (Resident 41), Resident 41 stated he usually helps to call a nurse for Resident 1 by calling a nurse on his cell phone. During a concurrent observation and interview on 8/6/2025 at 4:30 p.m. with Certified Nurse Assistant (CNA) 1 at Resident 1's bedside, CNA 1 stated Resident 1 could not reach his call light. CNA 1 stated that because Resident 1 could not reach the call light, his needs could not be addressed. During an interview on 8/8/20205 at 10:00 a.m., with Registered Nurse 2 (RN) 2, RN 2 stated the call light should have been placed near Resident 1's chest so he could reach it. RN 2 stated it was important to have the call light in reach so Resident 1's needs can be met immediately. During an interview on 8/8/2025 at 3:38 p.m. with the Director of Nursing (DON), the DON stated the call light should be within reach of Resident 1 preferably next to his head. The DON stated that when Resident 1 cannot reach his call light, his needs cannot be met. During a review of the facility's P&P titled Communication- Call System dated 10/9/2024, the P&P indicated: Upon admission, each resident will be instructed how to use the call alert system. The P&P indicated, the call alert device will be placed within the resident's reach. The P&P indicated an adaptive call alert system will be provided to the residents who are unable to utilize the general alert call system.

Based on interview and record review, the facility failed to investigate a claim of missing belongings for one of eight sampled residents (Resident 8).This deficient practice resulted in Resident 8 missing her blanket for three months.Findings:During a review of Resident 8's admission Record (face sheet), the admission Record indicated Resident 8 was admitted to the facility 10/26/2018 with diagnoses including muscle weakness and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool) dated 5/19/2025, the MDS indicated Resident 8 had severe cognitive impairment (inability to plan and carry out regular tasks and apply judgment).During a review of Resident 8's Inventory of Personal Effects dated 4/24/2024 and updated on 7/28/2025, the Inventory of Personal Effects section under lost, and stolen was updated to include four blankets missing per family member (FM) 1.During a review of Resident 8's Theft/ Loss Report dated 8/7/2025, the report indicated Resident 8's family member (FM) 1 stated 1 pink and red blanket with hearts was missing for three months.During an interview on 8/6/2025 at 10:37 a.m., with FM 1, FM 1 stated the facility does Resident 8's laundry and three months ago she informed the nursing staff (unknown) Resident 8's Valentine blanket with hearts was missing and still not found.During an interview on 8/7/2025 at 2:33 p.m., with the social services director (SSD), the SSD stated she had not been informed by nursing staff when FM 1 reported the missing blanket. The SSD stated if she had been informed, she would have tried to find the missing blanket and replaced the blanket if appropriate. The SSD stated she spoke with FM 1 who verified the blanket had been missing for three months (unknown actual date) and FM 1sent the SSD a photo of Resident 8 using the missing blanket while in the facility. The SSD stated FM 1 informed her that FM 1 had reported the missing blanket to multiple certified nursing assistants (CNAs) and charge nurses (unidentified) when the blanket first went missing. The SSD stated that although the blanket had not been logged into the inventory list, the photo verified Resident 8 had the blanket while in the facility so if the facility was unable to locate the item, the facility would replace the blanket. The SSD stated the nurses are supposed to report missing items to her in a timely manner (within a day or two) so the missing item could be investigated. The SSD stated it was important to investigate missing items in a timely manner, so the residents and their family know the facility cares about their grievances and acts upon them. The SSD stated if she was aware, she could have tried to locate the item or replace it sooner. The SSD stated not knowing caused a delay in action.During an interview on 8/8/2025 at 3:33 p.m., with the director of nursing (DON), the DON stated missing items needed to be reported to the SSD right away (within a day or two). The DON stated it was important to investigate the missing item quickly because if the missing item was wanted or needed by the resident it could affect the way the resident feels, and the item might be important to them.During a review of the facility's policy and procedure (P&P) Theft and loss dated 7/11/2017, the P&P indicated all inquiries regarding lost or stolen items are reported to the administrator and/or designee (SSD). The P&P indicated when personal property was reported missing, the staff will immediately begin a search for the missing property.

Based on interview and record review, the facility failed to ensure psychotropic medications (medications that affect brain activities associated with mental processes and behavior) were not used unnecessarily for one of five sampled residents (Resident 66) by failing to define and monitor resident specific, measurable target behaviors related to the use of Seroquel [an atypical antipsychotic used to improve mood, thoughts, and behaviors] for people with schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs)] for Resident 66.These deficient practices increased the risk of Resident 66 experiencing adverse effects (unwanted or dangerous medication-related side effects) such as drowsiness, dizziness, constipation, or increased risk of fall, and possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 66's admission Record, the admission Record indicated, Resident 66 was admitted to the facility on [DATE] with diagnoses including Lewy Bodies dementia (a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain), delusional disorder (a mental health condition characterized by persistent, false beliefs that are not based on reality), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).During a review of Resident 66's History and Physical (H&P), dated 7/1/2025, the H&P indicated, Resident 66 had no capacity (ability) to understand and make decisions.During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 7/7/2025, the MDS indicated Resident 66 required maximal assistance (Helper does more than half the effort) from one staff for transfer, dressing, moderate assistance (Helper does less than half the effort) from one staff for hygiene, supervision or touching assistance (Helper provides verbal cues and /or touching/steadying and /or contact guard assistance as resident completes activity) from one staff for bed mobility, and set up or touching assistance (Helper sets up or cleans up) for eating. The MDS section E (behavior) indicated, Resident 66 did not have physical and verbal behavioral symptoms directed toward others. The MDS section E indicated Resident 66 did not have hallucination (an experience involving the apparent perception of something not present) and delusions (something that is believed to be true or real but that is false or unreal). The MDS section E indicated Resident 66 did not have behavior related to rejection of care.During a review of Resident 66's Care Plan (CP), revised on 7/10/2025, the CP Focus indicated, Resident 66 uses psychotropic medication for psychosis. The CP Goal indicated, Resident 66 will be free from psychotropic drug related complications. The CP Interventions indicated, give one tablet of Seroquel by mouth 50 mg once a day and at bedtime for psychosis manifested by delusional thoughts and sexually inappropriate thoughts.During a review of Resident 66's Psychiatric Assessment/Evaluation/ Consultation, dated on 7/16/2025, the Psychiatric Assessment/Evaluation/ Consultation indicated, Resident 66 did not hallucinate, delusions, or behavioral issues.During a concurrent interview and record review on 8/7/2025, at 4:16 p.m., with Registered Nurse (RN) 4, Resident 66's Order Summary Report (OSR), dated 8/7/2025 was reviewed. The OSR indicated, to monitor target behaviors for use of Seroquel due to psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) manifested by psychomotor agitation (a state of restlessness and anxiety that results in repetitive and unintentional movements) and indicate the number of behavior occurrences ordered on 7/7/2025. The OSR indicated to give Seroquel 50 milligram (mg [unit of measurement]) one tablet by mouth once a day and 50 mg at bedtime (total of 100 mg per day) for psychosis. RN 4 stated, she was not sure what psychomotor agitations to monitor for Seroquel. RN 4 stated, target behavior should be specific and measurable, so a psychiatrist ( a medical practitioner specializing in the diagnosis and treatment of mental illness) could refer to and consider Gradual Dose Reduction (GDR- a systematic approach to stepwise tapering of medication dosage to assess if a lower dose can effectively manage symptoms, conditions, or risks, or if the medication can be discontinued entirely). RN 4 stated, the staff should monitor specific target behaviors. During a concurrent interview and record review on 8/8/2025, at 9:45 a.m., with RN 1, Resident 66's Medication Administration Record (MAR), dated from 7/7/2025 to 8/6/2025 was reviewed. The MAR indicated there was no psychomotor agitation. RN 1 stated, she did not witness any agitation since Resident 66 was admitted from the General Acute Care Hospital (GACH). RN 1 stated that monitoring psychomotor agitations should be clarified with psychiatrist because they are too general as a target behavior. RN 1 stated, if the target behavior was not specific and measurable for the residents, this could lead to inaccurate assessment and delay in GDR.During a telephone interview on 8/8/2025, at 12:12 p.m., with the Psychiatric Nurse Practitioner (PNP) 1, the PNP 1 stated, Resident 66 was on Seroquel from the hospital prior to admission. The PNP 1stated, Resident 66 did not have any behaviors including hallucinations and delusions according to his assessment. The PNP 1 stated, he wanted to taper it down with GDR since Resident 66 was on Seroquel from the GACH. The PNP 1 stated nurses should monitor specific target behaviors because psychomotor agitation could be anything such as fidgeting, restlessness, or burst of anger. The PNP 1stated, Seroquel could be an unnecessary medication, and it should be tapered down as soon as possible to avoid adverse reaction (an undesired or harmful effect of a drug) and a chemical restraint (the use of medications to restrict a person's movement or freedom of action, or to control behavior, when the medication is not part of a standard treatment for their condition). During an interview on 8/8/2025, at 2:56 p.m., with the Director of Nursing (DON), the DON stated, target behavior should be specific and measurable to the resident's diagnosis. The DON stated, psychomotor agitations could be many things, and this should be clarified with PNP 1. The DON stated that monitoring specific target behavior was important, because a GDR would be performed based on the data. The DON stated that inaccurate data would lead to delays on treatment, and the residents continuing to receive unnecessary medication. The DON stated that the resident might suffer from unnecessary side effects/adverse reactions. The DON stated that unnecessary medication could be used as chemical restraint as well.During a review of the facility's Policy and Procedure(P&P) titled, Behavior/Psychoactive Medication Management, revised 4/24/2025, the P&P indicated, Psychoactive Medication Considerations: vi. Any order for psychoactive medications must Include a specific behavior manifestation.viii. Residents have the right to be free from chemical restraints. 4. Parameters for use of Anti-psychotic Medications: a. Antipsychotic medications may be used to treat the following conditions: i. Schizophrenia, ii. Schizoaffective disorder, iii. Schizophreniform disorder, iv. Tourette's disorder, v. Huntington's disease, vi. Nausea, hiccups, itching, vii. A physical behavior problem which causes the residents to 1. Present a danger to self or others or interferes with resident's ability to participate iothers or of care. viii. Psychotic symptoms such as hallucinations or delusions which impair the resident's functional capacity (eating, sleeping, toileting, etc.). b. Anti-psychotic medications SHOULD NOT BE USED if one or more of the following conditions is the only manifestation: i. Restlessness, ii. Wandering, iii. Poor self-care, iv. Nervousness, v. Uncooperativeness, vi. Impaired memory, vii. Sleep disturbance, viii. Unsociability, ix. Fidgeting.

Based on interview, and record review, the facility failed to ensure one out of two sampled residents (Resident 6) had their Level 1 Preadmission Screening and Resident Review ([PASRR], a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) completed accurately.This deficient practice had the potential to delay care for Resident 6 and had the potential of not receiving the proper level of care or services required.Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance or illness elsewhere in the body that disrupts the brain's normal functioning, leading to various brain symptoms), rhabdomyolysis (a serious condition where damaged muscle tissue breaks down, releasing its contents into the bloodstream that can lead to kidney damage), post-traumatic stress disorder ([PTSD], a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it), and anxiety (a mental health condition that cause fear, dread and other symptoms that are out of proportion to the situation). During a review of Resident 6's Minimum Data Set ([MDS], a resident assessment tool) dated 6/5/2025, the MDS indicated Resident 6 had intact cognitive (thought process) function and was set up assistance (helper sets up while resident completes the activity) with self-care abilities such as eating, oral hygiene, personal hygiene and upper body dressing. The MDS indicated a mood total severity score (indicates the overall severity of a person's depression or mood disturbance) of 13 (5-9 indicating mild, 10-14 indicating moderate, involves a greater number of symptoms and a more significant impact on daily functioning).During a review of Resident 6's Order Summary Report DATED 7/31/2025, the Order Summary Report indicated Sertraline (a prescription medication used to treat depression and other mental health conditions) Tablet (pill) 100 milligram ([mg], a unit of measurement) give one tablet by mouth one time a day for depression manifested by excessive worries of life situation ordered on 8/6/2025, alprazolam (a prescription medication used to treat anxiety disorder, and panic disorder) oral tablet 0.5 mg give one tablet by mouth every morning and at bedtime for anxiety manifested by irritability (a state of increased sensitivity and a tendency to react with anger, frustration, or annoyance to stimuli, often triggered by small things)/restlessness ordered on 7/31/2025. During a review of Resident 6's PASRR Level 1 screening dated 5/29/2025, the PASRR Level 1 screening was negative, and a Level 2 screening was not required. The reason noted for Resident 6's negative PASRR Level 1 screening was no serious mental illness. The PASRR Level 1 indicated NO was checked on question number nine, does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance. There was no other screening done for Resident 6 after this screening was completed.During a concurrent interview and record review on 8/8/2025 at 11:16 a.m. with the Director of Nursing (DON), the PASRR Level 1 screening dated 5/29/2025 was reviewed. The DON stated the PASRR Level 1 screening, on question number nine, should have been answered YES to trigger a Level 2 screening to be done. The DON stated Resident 6 started on new psychotropic medications after the first screening was done and that a resident review status change screening should have been done. The DON stated the importance of an accurate PASRR screening assessment was if a resident was positive for mental illness, the facility can provide appropriate care and treatment services for the resident. The DON stated residents who are positive for mental illness, a psychology/psychiatry consultation would be ordered, and care plan would be updated accordingly. During a review of the facility's policy and procedure (P&P), titled admission Screening Resident Review (PASRR), revised 4/24/2024, The P&P indicated the Facility MDS Coordinator will be responsible for accessing and ensure updates to the PASRR are completed by MDS guidelines such as significant change of statues MDS.

Based on observation, interview, and record review, the facility failed to implement a care plan for two of the three sampled residents (Resident 52 and Resident 6) by failing to:A. Ensure Resident 52 had a care plan for impaired hearing. B. Ensure Resident 6 who had a diagnosis of post-traumatic stress disorder ([PTSD], a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it), had a care plan and included the use of psychotropic medications for mood disorders. These deficient practices had the potential to negatively affect the quality of life and wellbeing for Resident 6 and Resident 52 and could result in preventing them from achieving their highest practical well-being or needs not being met. Findings: A. During a review of Resident 52’s admission Record, the admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses including muscle weakness, type 2 diabetes mellitus (high blood sugar) and major depressive disorder (a mental illness that negatively affects how you feel, think and act). During a review of Resident 52’s Minimum Data Set ([MDS], a resident assessment tool) dated 6/12/2025, the MDS indicated Resident 52’s cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 52 was dependent on toilet hygiene, substantial /maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on shower/bathe self, upper and lower body dressing and partial/moderate assistance (helper does more than half the effort) with oral hygiene personal hygiene and upper body dressing. During a concurrent interview and record review on 8/8/2025 at a.m., with the Social Service Director (SSD), the SSD stated Resident 52 has signs of hearing loss. The SSD stated it is important that the resident has a care plan to address her hearing loss so that everyone is aware and knows how to care for the resident. During an interview on 8/8/2025 at 3:38 p.m., with the Director of Nursing (DON), the DON stated that because Resident 52 is hard of hearing there should have been a care plan initiated. The DON stated that when you are talking to Resident 52 her needs may not be met because she is hard of hearing. A review of the facility's policy and procedure (P&P) titled Person- Centered Care Planning, with a revised date of 4/24/2025, indicated the baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. The P&P indicated it should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision and behavioral interventions, and assistance with activities of daily living. B. During a review of Resident 6’s admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including PTSD, anxiety (a mental health condition that cause fear, dread and other symptoms that are out of proportion to the situation), opioid (a class of drugs that are used to reduce moderate to severe pain) use disorder (a mental health condition where a pattern of opioid use affects your health and daily life), and muscle weakness. During a review of Resident 6’s MDS dated [DATE], the MDS indicated Resident 6 had intact cognitive (thought process) functioning and was set up assistance (helper sets up while resident completes the activity) with self-care abilities such as eating, oral hygiene, personal hygiene and upper body dressing. During a review of Resident 6’s Order Summary Report, the Order Summary Report indicated Sertraline HCl (a prescription medication used to treat depression and other mental health conditions) tablet (pill) 100 milligram ([mg], a unit of measurement) give one tablet by mouth one time a day for depression manifested by excessive worries of life situation ordered on 8/6/2025, and alprazolam (a prescription medication used to treat anxiety disorder, and panic disorder) oral tablet 0.5 mg give one tablet by mouth every morning and at bedtime for anxiety manifested by irritability (a state of increased sensitivity and a tendency to react with anger, frustration, or annoyance to stimuli, often triggered by small things) or restlessness ordered on 7/31/2025. During a review of Resident 6’s untitled care plan dated 5/30/2025, the care plan did not indicate a goals or interventions for PTSD, or the use of psychotropic medications. There was no care plan in place for the focus, goals, and interventions for Resident 6’s diagnosis of PTSD or psychotropic medications used for mood disorders. During a concurrent observation and interview on 8/5/2025 at 10: 06 a.m. with Resident 6 in their room, Resident 6 stated she went through trauma in the past and has PTSD but did not want to discuss it any further. Resident 6 stated the facility staff are aware of the past trauma. During a concurrent interview and record review on 8/8/2025 at 10:52 a.m., with the Social Service Director (SSD), the untitled care plan dated 5/30/2025 was reviewed. The SSD stated there should be a care plan for Resident 6’s PTSD diagnosis. The SSD stated the importance of having a care plan for PTSD was so the facility staff that care for the residents can care for them with caution. During a concurrent interview and record review on 8/8/2025 at 2:58 p.m. with the Director of Nursing (DON), the untitled care plan dated 5/30/2025 was reviewed. The DON stated there should be a care plan in place for Resident 6’s PTSD diagnosis and the psychotropic medications Resident 6 was taking for mood disorders. The DON stated having a care plan for PTSD was important so facility staff can be aware of resident’s triggers and how to care for the residents appropriately. The DON stated if there was no care plan for PTSD, facility staff may retrigger the trauma and it may affect the resident’s mood, and affect the resident’s activities of daily living, and everyday life. The DON stated the importance of a care plan for the psychotropic medication Resident 6 was taking was the medication may alter the resident’s moods and behaviors and that the care plan lets facility staff know how to monitor for side effects of the medication, if the medication was targeting behaviors it was ordered for and if the medication was effective at targeting the behaviors. The DON stated the importance of having a comprehensive person-centered care plan was, so the facility staff are providing appropriate care for the residents, addressing any issues medically, and emotionally. During a review of the facility’s policy and procedures (P&P) titled Person Centered Care Planning revised 4/24/2025, indicated, trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. The P&P indicated the facility must develop and implement comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well­being, the services provided or arranged by the facility, as outlined by the comprehensive care plan, must be culturally competent and trauma informed. The P&P indicated comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments.

Based on observation, interview, and record review, the facility failed to ensure a medication listed on the oral medications' Emergency kit (Ekit) index (list) matched the medication found inside the Ekit.This failure had the potential to result in a delay in the administration of emergency medication and medication error.Findings: During an observation and concurrent interview with Registered Nurse (RN) 1 at Nurses' Station 1 of the Ekit on 8/7/2025 at 11:27 a.m., the medication listed on slot number 25 in the Ekit medication list indicated potassium chloride 20 milliequivalents (mEq, unit of weight). The medication observed in slot 25 was four tablets of nitrofurantoin 50 milligrams (mg, unit of weight). Registered Nurse (RN ) 1 stated the pharmacist verifies the Ekit contents when delivered to the facility. RN 1 stated if a medication was not in the Ekit, there was a risk for medication error, or delay in administration of the needed medication.During a telephone interview on 8/7/2025 at 11:47 a.m., the dispensing pharmacist (Pharmacist) stated Ekits were re-filled when a licensed nurse makes a request. The Pharmacist stated the on-duty pharmacist was responsible for verifying Ekit contents with the medication list on the front of Ekit. The Pharmacist stated if there was a discrepancy between Ekit contents and list then the Ekit should be returned to the pharmacy to be fixed. During a review of the facility's policy titled Emergency Pharmacy Service and Emergency Kits updated February 2020, the policy indicated Emergency kits are monitored/inventoried by the consultant pharmacist at least every 30 days for completeness and expiration dating of the contents.

Based on observation, interview, and record review, the nursing staff failed to document monitoring on the medication administration record (MAR) for signs and symptoms of bleeding for one out of three residents (Resident 63) who is on Apixaban (a medication that thins the blood, prevents clots). This deficient practice had the potential to result in Resident 63 having blood in the stool or urine, bruising or severe headaches. Findings:During a review of Resident 63's admission Record (face sheet) dated 8/8/2025, the admission record indicated Resident 63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypotension (low blood pressure), hyperlipidemia (high cholesterol) and atrial flutter (a heart rhythm disorder where the upper chambers of the heart beat very rapidly, typically between 250 and 350 times per minute).During a review of Resident 63's MDS dated [DATE], the MDS indicated Resident 63 was dependent (resident does none of the effort to complete the activity or the assistance of two or more helpers is required to for the resident to complete the activity) on toilet transfer, chair/bed to chair transfer, toilet hygiene, shower/bathing self, oral hygiene and lower and upper body dressing. During a review of Resident 63's Order Summary Report dated 1/19/2025, the report indicated Resident 63 had an active order for Apixaban oral tablet 2.5 mg (unit of measure) 1 tablet two times a day. During a review of Resident 63's Care Plan (CP) initiated 1/28/2025, the CP indicated to monitor and document every shift for signs and symptoms of bleeding related to Apixaban. During a concurrent interview and record review on 8/8/2025 at 09:31 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 63's MAR. LVN 1 stated Resident 63 has not been monitored for the use of the Apixaban. LVN 1 stated the monitoring should have been documented and recorded on Resident 63' s MAR. LVN 1 stated the licensed nurses are not documenting monitoring for episodes of bleeding and bruising, which is important so we can notify the doctor. During an interview on 8/8/2025 at 10:00 a.m., with Registered Nurse 2 (RN 2), RN 2 stated Resident 63 is on an Apixaban, and it should be monitored and documented for bleeding every shift. During an interview on 8/8/2025 at 3:38 p.m., with the Director of Nursing (DON), the DON stated Apixaban is an anticoagulant, and we must monitor bleeding and bruising. The DON stated monitoring should be on the MAR and because it is not documented on the MAR this means we are not monitoring episodes of bleeding.During a review of the facility's Policy and Procedure (P&P) titled, Medication- Black Box Warning, revised July 2018, the P&P indicated:1. The Licensed Nurse will review the Black Box Warning (the most serious type of warning required by the U.S. Food and Drug Administration (FDA) on the labeling of prescription drugs) for signs and symptoms of those high risks medication(s) for health risks and monitor.2. The Licensed Nurse will document signs and symptoms related to parameters and document any adverse consequences in nursing progress notes or on the MAR.3. The Licensed Nurse will inform the Attending Physician of any signs and symptoms related to monitoring parameters and /or any adverse consequences.

Based on interview and record review, the facility failed to protect the health, welfare, and rights for 94 of 94 residents by failing to implement the facility's written abuse policy and procedure (P&P) to suspend Certified Nurse Assistant (CNA) 1 and CNA 2 who were involved in the alleged abuse allegation. This deficient practice placed all residents at risk of abuse and had the potential for Resident 1 to feel unprotected and unsafe in the facility. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and cerebral infarction (when part of your brain dies its blood supply is cut off). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/26/2025, the MDS indicated Resident 1's cognition (ability to think, understand, learn, and remember) was intact and was dependent (helper does all the effort) on showering, bathing, toileting, dressing. During an interview on 7/7/2025 at 12:49 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated when there is an abuse allegation, the staff involved should not be allowed to work until the investigation is complete to ensure other residents are not at risk for abuse. During a concurrent interview and record review on 7/7/2025 at 1:29 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Abuse Prevention and Management, dated 6/12/2024, was reviewed. The DON stated, the P&P indicated, If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with facility policies. The DON stated she did not suspend the Certified Nurse Assistant (CNA) 1 and CNA 2 but based on the policy, the DON stated they should have been suspended. The DON stated not suspending the CNA 1 and CNA 2 could have resulted in abuse potentially happening to other residents and putting the safety of the residents at risk. During a review of the facility's P&P titled, Abuse Prevention and Management, dated 6/12/2024, the P&P indicated, The facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with facility policies.

Based on interview and record review, the facility failed to ensure the personal belongs for one of two sampled resident's (Resident 1), who was discharged from the facility on 1/17/2025, were made available to Resident 1 and/or Resident 1's Responsible Party (RP) and/or Family Member (FM). This deficient practice resulted in Resident 1's being discharged to a Board and Care ([B&C] a type of small, residential facility that provides housing and personal care services to individuals who need assistance with ADLs) facility without her personal belongings and had the potential for Resident 1 to feel detached in her new environment. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 12/13/2024, the MDS indicated Resident 1 was unable to make decisions that were consistent and reasonable. During a review of Resident 1's History and Physical (H&P) dated 10/2/2023, the H&P indicated Resident 1 does not have the capacity to understand and make decisions because of dementia and her family member is the surrogate (a substitute) decision maker for her care needs and medical decisions. During a review of Resident 1's Inventory of Personal Effects dated 9/29/2023, the Inventory of Personal Effects indicated a blank/unsigned receipt on discharge by Resident 1 and/or Resident 1's RP/FM. The Inventory of Personal Effects indicated Resident 1 had the following items at the facility: a. four blouses (no description) b. one underpants (no description) c. one coat (no description) d. two short pants (no description) e. four pairs of slippers (no description) f. two sweaters (no description) g. six undershirts (no description) h. six pairs of socks (no description) i. two pillows (no description) j. two blankets (no description) k. two pairs of glasses (no description) l. two perfume bottles (no description) m. one black cellular phone During a telephone interview on 6/5/2025 at 10:48 a.m., Resident 1's FM stated she was called by the facility's Social Services Worker Director (SSD) on 1/17/2025 (time unspecified) informing her that Resident 1 would be discharged from the facility later that day. The FM stated on 5/27/2025, she received a call from the County Public Administrator's Office notifying her that Resident 1 passed away at an ([ECF] a healthcare institution that provides ongoing medical care, rehabilitation services, and assistance with ADLs to individuals who require prolonged or specialized attention) and when she contacted the owner of ECF she was told that Resident 1 arrived there (2/2025) with the clothes she had on, a top and bottom, a list of medication and an insurance card. The FM stated Resident 1 was subjected to an undignified situation at the ECP and lived the rest of her life without her personal belongings that were necessary for a comfortable life. During a telephone interview on 6/6/2025 at 2:28 p.m., Resident 1's RP stated he did not know about and had not been involved in any discharge plans for Resident 1 until 1/17/2025 when the facility's SSD called to inform him that Resident 1 would be discharged to a B&C facility that day. The RP stated the facility did not call him when Resident 1 was discharged from the facility nor was not told anything about Resident 1's personal belongings. During a telephone interview on 6/9/2025 at 8:27 a.m., the Extended Care Owner (ECO) stated she was contacted by a person from a B&C facility (information unknown) and asked if she had an available female room. The ECO stated the first week of 2/2025 Resident 1 came to her facility in a car and was dropped off, she (Resident 1) had no personal belongings, only the clothes she wore, a list of medications and an insurance card. During an interview and record review on 6/9/2025 at 9:49 a.m., the Social Service Director (SSD) stated Resident 1's Inventory of Personal Effects did not indicate disposal of personal belongings upon discharge. During an interview and record review on 6/9/2025 at 1:11 p.m., the Director of Nursing Services (DON) stated it was the responsibility of the facility's registered nurse supervisor (RNS) on duty and the SSD to ensure Resident 1's RP and/or FM are notified regarding the disposition of the resident's belongings on discharge from the facility. During a review of the facility's Policy and Procedure (P/P) titled, Discharge and Transfer of Residents revised 2/2018, the P/P indicated the facility must ensure the facility staff will prepare the resident's inventory at the time of discharge and the facility will provide the resident and their representative a copy of the Resident's Inventory and have the recipient sign. During a review of the facility's P/P titled, Personal Property revised 7/14/2017, the P/P indicated the facility shall take reasonable steps to protect the residents' personal property by returning inventories personal items to the residents or their representatives upon discharge in a timely manner and take reasonable steps to safeguard the belongings of the resident in the interim.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was diagnosed with dementia (a progressive state of decline in mental abilities), and who lacked the capacity to understand and make decisions was discharged appropriately from the facility. This deficient practice resulted in Resident 1 being discharged to a Board and Care ([B&C] (a type of small, residential facility that provides housing and personal care services to individuals who need assistance with ADLs) facility on [DATE] without an Interdisciplinary Team (IDT] a team comprised of healthcare professionals from different discipline collaborating to develop and coordinate the residents' care plans such as a discharge plan with a goal to optimize the resident outcomes) discharge meeting, prior discharge planning, Resident 1's Responsible Party (RP) and/or Family Member (FM) provided with a Notice of Proposed Discharge/Transfer 30 days prior to the resident's transfer, assessment of the resident on transfer to the B&C, confirmation that the resident's contact information was received at the B&C, a list of the resident's medication or an inventory list with Resident 1's personal affects sent with her. Resident 1 was transferred from the B&C to an Extended Care facility ([ECF] a healthcare institution that provides ongoing medical care, rehabilitation services, and assistance with ADLs to individuals who require prolonged or specialized attention) sometime in 2/2025 and expired at the Extended Care facility on [DATE] without the RP and/or FM's knowledge. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia, and depression (a mood disorder that causes persistent feelings of sadness and loss of interest in activities). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated [DATE], the MDS indicated Resident 1 was unable to make decisions that were consistent and reasonable, and required a one person assist to complete her activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's History and Physical (H&P) dated [DATE], the H&P indicated Resident 1 did not have the capacity to understand and make decisions because of dementia. The H&P indicated her family member was the surrogate (a substitute) decision maker for her care needs and medical decisions. During a review of Resident 1's untitled Care Plan dated [DATE], the Care Plan indicated Resident 1 had impaired cognitive function (having difficulty with thinking, learning and remembering) and impaired thought processes related to dementia. The Care Plan's goals was for Resident 1 to maintain her current level of cognitive function and to develop skills to cope with cognitive decline and maintain safety, with interventions that included communicating with Resident 1 and her family and/or caregivers regarding Resident 1's needs and capabilities. During a review of Resident 1's Physician's Progress Notes dated [DATE], the Physician's Progress Notes indicated Resident 1's physician communicated with the nursing staff and the case management/discharge planner that Resident 1's discharge plans and procedures be discussed/notified/permitted by Resident 1 and her family to ensure Resident 1's safe discharge from the facility. During a review of Resident 1's Medical Record, the Medical Record indicated there was no documented evidence the facility conducted a discharge planning IDT that involved Resident 1 and her RP/FM. During a review of the Social Service Progress Notes dated [DATE] (the corrected date was [DATE]), the Social Service Progress Notes indicated Resident 1 was to be discharged to a B&C facility on that same day ([DATE]) and Resident 1's RP was informed via a telephone call. During a review of Resident 1's Medical Record, the Medical Record indicated there was no documented evidence that a Notice of Proposed Transfer and Discharge was completed 30 days prior to Resident 1's discharge to the B&C facility on [DATE]. During a review of Resident 1's Discharge Planning Review Form dated [DATE] and timed at 4:38 p.m., the Discharge Planning Review Form indicated the following: No reason for Resident 1's discharge A Post discharge medication list was discussed with the resident/family then contradicted the previous documentation to say the reconciled medication list was not provided to the resident family and/or care giver. A walker (front wheel walker [FWW] a mobility aid with two wheels a the front and two legs with glides or rubber tips at the back) was provided to Resident 1 Medications were sent with Resident 1 Contact information to include the name, relation and phone numbers of Resident 1's RP were provided Continued review of the Discharge Planning Review Form indicated there were no signatures of Resident 1 and/or the RP to indicate that either one of them understood the discharge instructions. During a review of Resident 1's Medical Records, the Medical Records indicated there was no documented evidence that Resident 1's status on discharge form the facility ([DATE]) was assessed. During a review of Resident 1's Inventory of Personal Effects dated [DATE], the Inventory of Personal Effects indicated a blank/unsigned receipt on discharge by Resident 1 and/or Resident 1's RP/FM. The Inventory of Personal Effects indicated Resident 1 had the following items at the facility: a. four blouses (no description) b. one underpants (no description) c. one coat (no description) d. two short pants (no description) e. four pairs of slippers (no description) f. two sweaters (no description) g. six undershirts (no description) h. six pairs of socks (no description) i. two pillows (no description) j. two blankets (no description) k. two pairs of glasses (no description) l. two perfume bottles (no description) m. one black cellular phone During a telephone interview on [DATE] at 10:48 a.m., Resident 1's FM stated she was called by the facility's Social Services Worker Director (SSD) on [DATE] (time unspecified) informing her that Resident 1 would be discharged from the facility later that day. The FM stated the SSD did not provide her with information where Resident 1 would be going because she (FM) was not the RP. The FM stated she contacted the RP a few days after Resident 1 was discharged from the facility ([DATE]) to ask him about Resident 1's discharge location but the RP had no information about Resident 1's location. The FM stated on [DATE], she received a call from the County Public Administrator's Office notifying her that Resident 1 passed away at an ECF. The FM stated she was devastated that the facility discharged Resident 1 from the facility without providing her location to the RP and no one knew where in the community she (Resident 1) was. The FM stated Resident 1's condition was unknown, and she (Resident 1) died alone without the presence of her family and was not given the proper respect/compassion during her last days. During a telephone interview on [DATE] at 2:28 p.m., Resident 1's RP stated he did not know about and had not been involved in any discharge plans for Resident 1 until [DATE] when the facility's SSD called to inform him that Resident 1 would be discharged to a B&C facility that day. The RP stated he told the SSD to notify Resident 1's FM of Resident 1's discharge information. The RP stated the facility did not call him when Resident 1 was being discharged from the facility. The RP stated the end of 5/2025 he received a letter form the County Public Administrator's Office, when he called the County Public Administrator's Office, he was informed that Resident 1 passed away at an ECF. The RP stated he was dismayed that Resident 1 was alone after her discharge from the facility up until the time she took her last breath. The RP stated this could have been avoided if the facility had notified him (RP) and Resident 1's FM where Resident 1 was discharged to. During a telephone interview on [DATE] at 8:27 a.m., the Extended Care Owner (ECO) stated she was contacted by a person from a B&C facility (information unknown) and asked if she had an available female room. The ECO stated the first week of 2/2025 Resident 1 came to her facility in a car and was dropped off, she (Resident 1) had no personal belongings, only the clothes she wore, a list of medications and an insurance card. The ECO stated the contact person from the B&C told her Resident 1 had no family. The ECO stated Resident 1 expired on [DATE] in her sleep and she (ECO) called a local funeral home to pick up Resident 1's body. During an interview on [DATE] at 9:49 a.m., the SSD stated there was no Notice of Proposed Transfer and Discharge completed by the facility for Resident 1 prior to being discharged to a lower level of care. During a subsequent interview on [DATE] at 2:50 p.m., the SSD stated the facility had not conducted a discharge planning IDT meeting with Resident 1 and/or her RP before Resident 1 was discharged from the facility on [DATE] and Resident 1's inventory list was not signed for receipt by Resident 1 and/or her RP on discharge from the facility. The SSD stated she faxed Resident 1's information to the B&C facility prior to her discharge on [DATE] but there was no confirmation receipt that the B&C facility received the documents. The SSD stated she should have confirmed with the B&C facility that Resident 1's information was received prior to her discharge from the facility and documented her communication with the B&C in Resident 1's medical record. During a telephone interview on [DATE] at 11:02 a.m., Registered Nurse Supervisor (RNS) 2 stated on [DATE] during the 7 a.m. to 3 p.m. shift, she prepared and signed Resident 1's discharge planning review form (discharge instructions) in preparation for Resident 1's discharge to a B&C facility. RNS 2 stated Resident 1 was not transferred to the B&C during her shift, and she did not call Resident 1's RP or FM regarding Resident 1's discharge information/instructions. RNS 2 stated she did not prepare and complete Resident 1's Notice of Transfer and Discharge Form because that was SSD's responsibility to complete the form. During a telephone interview on [DATE] at 3:36 p.m., the Funeral Director (FD) of a cremation company stated Resident 1 arrived at the funeral home with a top and bottom on, and two metal rings on her fingers. The FD stated he called the County Public Administrator's (CPA) office because Resident 1 did not have family to take charge of Resident 1's remains, per the ECO. During a telephone interview on [DATE] at 11 a.m., the CPA stated the cremation company referred Resident 1's remains to their office to locate Resident 1's family. The CPA stated Resident 1's RP and FM were not estranged from Resident 1. During an interview and record review on [DATE] at 1:11 p.m., the Director of Nursing Services (DON) stated Resident 1 was not able to make medical decisions for herself and there was no Notice of Proposed Transfer and Discharge Form signed by Resident 1's RP on file. The DON stated it was the responsibility of the facility's and SSD to ensure Resident 1's RP and/or FM were involved in the actual discharge process to ensure Resident 1's safe transition to the community. During an interview on [DATE] at 12:30 p.m., the Administrator (ADM) stated the residents' discharge plan, discharge instructions and discharge process should involve not only the resident but also the resident's RP and/or FM to ensure the resident's safe discharge to the community. During a review of the facility's Policy and Procedure (P/P) titled, Discharge and Transfer of Residents revised 2/2018, the P/P indicated the facility must ensure: a. The resident's discharge planning is complete and appropriate, and the necessary information is communicated to the continuing care provider b. The resident/resident representative will be provided with a Notice of Proposed Transfer and Discharge 30 days prior to discharge or as soon as practicable. c. The IDT will complete a discharge summary/post discharge plan of care when a resident is near a planned discharge and a copy of the discharge plan of care and/or discharge summary be provided to the resident, resident representative or the receiving facility. d. The social services or the nursing department must provide the resident and their representative with the Notice of Proposed Transfer and Discharge document and the social service department will provide a copy of the same document to the resident and their representative and a copy shall be placed in the resident's medical record. e. The Discharge Summary/Post Discharge Plan should include the resident's discharge destination including the address and phone number and the resident's representative and/or family contact information f. The resident's actual discharge must be documented in the resident's medical record to indicate the following: g. The date, time, and condition of the resident upon discharge h. Condition and diagnoses of the resident upon discharge or final disposition i. Discharge planning notes; and j. The resident's medications shall be reconciled and the disposition of the resident's drugs during discharge should be prepared, labelled and endorsed to the resident and/or the responsible party and/or to the representative of the incoming facility, according to the orders of the resident's primary care physician. During a review of the facility's P/P titled, NP03 Discharge and Transfer of Residents revised [DATE], the P/P indicated the facility shall ensure the residents' discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider to prevent inappropriate, unnecessary and untimely transfer and discharges.

Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 1) who was observed with a discoloration on her forehead, black eye and eye swelling was reported to California Department of Public Health (CDPH). This failure resulted in CDPH being unable to investigate Resident 1's injury of unknown origin in a timely manner Findings: During a review of Resident 1's Admission Record, the Admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease (a long term condition where the kidneys gradually lose their ability to filter waste and extra fluid from the blood), abnormalities of gait and mobility, dementia (a progressive state of decline in mental abilities) hypertension (HTN-high blood pressure) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's History and Physical (H&P), dated 4/26/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set,(MDS - a resident assessment tool), dated 1/31/2025, the MDS indicated Resident 1 was dependent on nursing staff for oral hygiene, toileting, showering, and dressing. The MDS indicated Resident 1 needed substantial to maximal nursing assistance with eating and transferring to a chair. The MDS indicated Resident 1 needed partial to moderate nursing assistance with rolling from left to right, sitting, lying in bed and walking. During a review of Resident 1's Change in Condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) Evaluation, dated 3/20/2025, the COC indicated, on 3/20/2025 at 7:30 am Resident 1 was sitting on the bed with her side rails up, on and off agitation noted and the CNA observed that Resident 1 had skin discoloration to the forehead (color was not indicated). The COC indicated Resident 1's medical doctor and family member were notified. The COC indicated Resident 1's MD ordered a skull x-ray and skin monitoring. During a review of Resident 1's Physician Orders, dated 3/20/2025, the Physician Orders indicated, to monitor Resident 1's forehead for skin discoloration, and for skin management. The Physician Orders indicated a skull x-ray for Resident 1. During a review of Resident 1's Physician Orders, dated 3/21/2025, the Physician Orders indicated, neurological checks (examination of mental status, motor function, sensory) every two hours for 72 hours every shift for eye swelling. During a review of Resident 1's Physician Orders, dated 3/21/2025, the Physician Orders indicated, to instill Pataday Ophthalmic Solution, two drops in both eyes two times a day for eye irritation. During a review of Resident 1's Physician Progress Notes, dated 3/24/2025, the Physician Progress Notes indicated, Resident 1 had a bump on the forehead, with swelling and bruising over the left eye. During an observation on 4/29/2025 at 1:10 pm in Resident 1's room, observed Resident 1 lying in bed with a pillow covering her head mumbling. Observed Resident 1 bruising to the left forehead, a black eye and swelling to the forehead. Licensed Vocational Nurse (LVN) 1 came to assist Resident 1 with the help from other staff and pulled Resident 1 up in bed and elevated the head of the bed. During an interview on 4/29/2025 at 1:15 p.m., with Resident 2. Resident 2 stated she has been the roommate of Resident 1 for a year. Resident 2 stated one day (unknown date) in the morning before breakfast Resident 1 was sitting in the wheelchair outside of the room in front of the door and leaned forward and the whole wheelchair tipped forward. Resident 2 stated Resident 1 injured her eye. Resident 2 stated Resident 1's eye had redness and swelling. Resident 2 stated the nurses came to help Resident 1. Resident 2 stated Resident 1 fell while trying to stand. Resident 2 stated she heard the charge nurse tell Resident 1's family member she hit her head on the bed railing. During an interview on 4/30/2025 at 12:35 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she worked the night shift (11 p.m. to 7 a.m.) on 3/19/2025. CNA 1 stated she provided total care, diaper change and linen change for Resident 1. CNA 1 stated she did not observe any discoloration on Resident 1's forehead or left eye. During an interview on 4/30/2025 at 12:42 p.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated she works the 11 pm to 7 am shift. RNS 1 stated Resident 1 requires maximal assistance with activities of daily living such as feeding, bathing, and toileting. RNS 1 stated Resident 1 was being fed by the CNAs and probably (unwitnessed) hit her left forehead on the side rails. RNS 1 stated she assessed Resident 1 for pain. RNS 1 stated when she assessed Resident 1's forehead Resident 1 grimaced (a facial expression usually of disgust, disapproval, or pain) on 3/20/2025. RNS 1 stated Resident 1's forehead was tender to touch. RNS 1 stated Resident 1 was given icepacks for comfort. During an interview on 4/302025 at 1:02 p.m., with Certified Nursing Assistant (CNA) 2 , CNA 2 stated she saw Resident 1 at around 7 am on 3/20/2025. CNA 2 stated Resident 1 had bruising on the forehead. CNA 2 stated she asked CNA 3 what happened to Resident 1. CNA 2 stated CNA 3 stated she does not know, CNA 2 stated she reported to the charge nurse. During an interview on 4/30/2025 at 1:11 p.m., with CNA 3. CNA 3 stated he saw Resident 1 on 3/20/2025 at 7 a.m. CNA 3 stated he asked CNA 2 for help to pull Resident 1 up in bed. CNA 3 stated Resident 1 had swelling and discoloration on the left eye. CNA 3 stated he did not know how the injury to Resident 1's left eye happened. During an interview on 4/30/2025 at 1:29 p.m., with Registered Nurse Supervisor (RNS) 2. RNS 2 stated on 3/21/2025 she noticed Resident 1 had a swollen eye with discoloration. RNS 2 stated she informed the Nurse Practitioner. RNS 2 stated the Nurse Practitioner ordered cold compresses for 20 minutes for 3 days and eye drop for eye irritation. RNS 2 stated she did not know how the resident received the injury to the left head. RNS 2 stated she did not receive any report on how Resident 1 injured her head. RNS 2 stated there was no documentation of what happened to Resident 1 on 3/20/2025. RNS 2 stated that when a resident has an injury and no one knows what happened a Change of Condition should be done, the doctor and family member were informed. RNS 2 stated the injury was monitored to see if it was getting worse. RN 2 stated then the DON was notified. RNS stated that the injury should also be reported to the ombudsman, police and CDPH. RNS 2 stated that the injury was reportable because it could be abused. During an interview on 4/30/2025 at 2:35 pm with RNS 3, RNS 3 stated on 3/20/2025 at 7 am, RNS 1 told her Resident 1 had discoloration on the forehead. RNS 3 stated she asked RNS 1 what happened to Resident 1. RNS 1 stated RNS 3 said Resident 1 probably hit her head on the side rails (but no witness). RNS 3 stated an injury of unknown origin or unknown cause like Resident 1's discoloration on the forehead and swelling of eye, needs to be investigated and reported within one hour to the police, state agency, the Administrator and the Director of Nursing. RNS 3 stated the DON does the investigation of the incident. RNS 3 stated an investigation should be done to determine the cause of the injury and to prevent it from happening again. During a concurrent interview and record review on 4/30/2025 at 3:48 pm with the Director of Nursing (DON), reviewed the facility's Policy and Procedure (P&P) titled Abuse & Neglect, date revised 5/30/2024 which indicated Injury of unknown source is defined as an injury that meets both of the following conditions: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time, or the incidence of injuries over time. The DON stated she did not know she had to report this. The DON stated at the change of shift on 3/20/2025 CNA 1 noticed Resident 1's eye. The DON stated she was not clear what shift the injury happened on. The DON stated Resident 1 might have hit herself while in bed but was not witnessed by staff. The DON stated Resident 1 was observed with the discoloration on the left forehead and left eye. The DON stated an x-ray was done to make sure Resident 1 did not have a fracture. The DON stated Resident 1 had a black eye with discoloration. During a review of the facility's policy and procedure (P&P) titled, Abuse & Neglect, date revised 5/3/2024. The P&P indicated, Injury of Unknown source is defined as an injury that meets both the following conditions: The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury, the injury, the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time, or the incidence of injuries over time. During a review of the facility's P&P titled, Unusual Occurrence Reporting, date revised 5/30/2024. The P&P indicated, The facility reports the following events by phone and in writing to the appropriate State or Federal agencies; .major accidents, allegations of abuse . other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees, or visitors. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility conducts documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate. The investigation should include but not limited to interviews with residents, staff, and other witnesses.

Based on observation, interview, and record review, the facility failed to ensure residents, who were on dysphagia (difficulty chewing and swallowing) minced and moist (mechanical-soft texture modified diet for difficulty chewing and swallowing) diet received food consistent with diet order and according to the minced and moist diet menu recipe for seven of eight sampled resident (Resident 10, 11, 50, 53, 62, 81, and 83). The facility failed to: 1. Ensure the Dietary Supervisor (DS), who was overseeing meal preparation, [NAME] (CK 1) who was preparing the residents' meals, and Licensed Vocational Nurse (LVN 4), who was validating the meal on residents' trays for diet appropriateness and food texture before meal was served to the residents, ensured Resident 10, 11, 50, 53, 62, 81, and 83 received correct food consistency per their prescribed diet. 2. Ensure Resident 10, 11, 50, 53, 62, 81, and 83 did not receive a ground pimento cheese salad sandwich (sandwich included two slices of regular [not minced] white bread, including the crust, with a scoop of ground pimento cheese in between slices of bread, and sliced in half) on their lunch trays 8/14/2024, which was not in accordance with the residents' physician order. 3. Ensure the dietary department followed the facility's policy and procedure (P&P) titled, Dietary Department- General, which indicated the dietary department was to prepare and provide nutritionally adequate, well-balanced meals that were consistent with physician's diet order. These deficient practices resulted in Resident 10, 11, 50, 53, 62, 81, and 83 receiving a lunch tray on 8/14/2024 that contained a ground pimento cheese salad sandwich on a regular soft white bread which placed Resident 10, 11, 50, 53, 62, 81, and 83 at high risk for aspiration (condition when food, liquid, or other material enters a person's airway [passageway for air] and eventually the lungs), choking (life threatening condition where an object such as food lodges in the throat blocking the flow of air), and possible death. On 8/15/2024 at 4:56 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Director of Nursing (DON) and the Administrator (ADM) due to the facility's failure to ensure Residents 10, 11, 50, 53, 62, 81, and 83 received food consistent with their therapeutic diet ( diet that controls the intake of a certain foods) texture of dysphagia minced and moist diet. On 8/16/2024 at 4:20 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 8/16/2024 at 4:32 p.m., in the presence of the DON and ADM. The IJPR included the following immediate actions: On 8/14/24 and 8/15/24, Resident 10 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet (dysphagia minced and moist diet) texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 11 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 50 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 53 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 62 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 81 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, Resident 83 was assessed by a licensed nurse for any untoward effects from receiving food not consistent with mechanical soft diet texture. Resident remained in stable condition. The attending physician was notified. On 8/14/24 and 8/15/24, the Registered Dietician (RD) provided an in-service (education) to DS, CK 1, and licensed nurses regarding validation of the residents' diet for appropriate texture based on the prescriber order before meal trays were delivered to the residents to ensure correct food consistency was being served. On 8/15/2024, the facility's new dietary menu system, (web-based menu program) provided the missing recipes for Mechanical Soft Minced and Moist diet. On 8/15/2024, the RD provided a one to one (1:1) in-service to the DS regarding food preparation in accordance with the menu recipe for the prescribed diet. Findings: 1. During a review of Resident 10's Admission Record, the Admission Record indicated Resident 10 was admitted to the facility 9/13/2023 with diagnoses including dysphagia, unspecified dementia (loss of memory, language, problem-solving and other thinking abilities), and major depressive disorder (a mental disorder that causes a persistent low mood and loss of interest in activities that are normally enjoyable). During a review of Resident 10's care plan titled, Nutritional Problem initiated on 9/15/2023, the care plan indicated the goal for Resident 10 was to maintain adequate nutritional status as evidenced by maintaining the resident weight within five percent (%) of current weight and to have no signs or symptoms (s/s) of malnutrition (lack of proper nutrition, caused by not having enough to eat or not eating enough). The care plan interventions included monitoring, documenting, and reporting any s/s of dysphagia: food pocketing (a common term for when people with dementia keep food in their cheeks or the back of their mouth instead of swallowing it), choking, coughing, drooling, and several attempts at swallowing as well as providing and serving the resident's diet as ordered by the physician. During a review of Resident 10's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/21/2024, the MDS indicated Resident 10 had severe impairment in cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 10 required setup or clean-up assistance while eating but was able to eat by herself. During a review of Resident 10's Speech Therapist ([ ST] a licensed professional aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) Evaluation and Plan of Treatment dated 6/27/2024, the ST Evaluation and Plan of Treatment indicated ST has seen Resident 10 for a clinical swallowing evaluation (procedure used to assess how well a person swallows) due to increased concerns of aspiration after an event of low tolerance of regular texture solid food diet when the resident was coughing and required oral suctioning (remove food and/ or liquid from mouth and throat with a suction machine). The ST Evaluation and Plan of Treatment indicated a recommendation for puree (blended) diet and thin liquids with strict adherence to swallowing precautions such as sitting up while eating, small bites, eating slowly, and alternating solids and liquids. ST Evaluation and Plan of Treatment indicated the goal for Resident 10 was to increase the ability to safely swallow a minced and moist consistency to facilitate transition to a more complex food consistency. During a review of Resident 10's Physician's Order Summary Report, the Physician's Order Summary Report dated 7/17/2024 indicated an order for a dysphagia mechanical soft texture, regular/ thin consistency liquids, ground (finely chopped) food. During a review of Resident 10's ST Treatment Encounter Note dated 7/23/2024, the ST Treatment Encounter Note indicated Resident 10 was seen for dysphagia and to continue with the mechanical soft, ground texture foods. 2. During a review of Resident 11's Admission Record, the Admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including dementia and dysphagia., During a review of Resident 11's ST Evaluation and Plan of Treatment dated 10/17/2023, indicated Resident 11 was evaluated by ST to assess the resident's swallowing function and readiness to upgrade her diet from pureed foods. The ST Evaluation and Plan of Treatment indicated Resident 11 had a history of aspiration pneumonia (a lung infection that occurs when food, liquid, or other foreign objects are inhaled into the lungs instead of being swallowed). The ST recommendation was to continue with the pureed diet with goal for Resident 11 to safely swallow a minced and moist consistency diet. During a review of Resident 11's ST Treatment Encounter Note dated 11/21/2023, indicated Resident 11 was seen for dysphagia treatment and tolerated a mechanical soft ground texture (minced and moist) diet. During a review of Resident 11's care plan titled, At risk for aspiration- receiving a mechanical soft, ground food diet revised on 2/28/2024 indicated goal for Resident 11 not to have episodes of aspiration. The care plan interventions included for Resident 11 to receive therapeutic diet and diet texture modifications as ordered by the physician. During a review of Resident 11's MDS dated [DATE], the MDS indicated Resident 11 had severe impairment of cognitive skills for daily decision making. The MDS indicated Resident 11 required setup or clean-up assistance while eating but was able to eat by herself. The MDS indicated Resident 11 complained of difficulty or pain while swallowing. During a review of resident 11's Physician's Order Summary Report, the Physician's Order Summary Report dated 7/17/2024 indicated an order for dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food. On 7/18/2024 there was a physician's order to assist Resident 11 with feeding as needed. 3. During a review of Resident 50's Admission Record, the Admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (occurs when blood flow to the brain was blocked, causing brain tissue to die), dysphagia, type 2 diabetes (a condition in which the body fails to process glucose (sugar) correctly) and dementia. During a review of Resident 50's ST Evaluation and Plan of Treatment dated 11/20/2023, indicated the goal for Resident 50 was to reduce risk of choking or coughing events and to safely swallow a minced and moist consistency diet. The ST Evaluation and Plan of Treatment indicated ST recommended to continue with the pureed diet. During a review of Resident 50's care plan titled, At risk for Aspiration initiated on 11/24/2023, the care plan indicated the goal for the resident included to not have any s/s of aspiration and to maintain safe swallowing. The care plan interventions included to provide diet as ordered by the physician and if a difficulty swallowing occurred to notify ST. During a review of Resident 50's ST Treatment Encounter Note dated 12/14/2023, indicated Resident 50 was seen for dysphagia treatment and evaluation of the resident's diet. The ST Treatment Encounter Note indicated ST recommended for Resident 50 to tolerate the mechanical soft, ground diet (minced and moist). During a review of Resident 50's MDS dated [DATE], the MDS indicated Resident 50 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 50 required setup or clean-up assistance while eating but was able to eat by herself. The MDS indicated Resident 50 complained of difficulty or pain while swallowing and was on a mechanically altered diet. During a review of Resident 50's Physician's Order Summary Report, the Physician's the Order Summary Report indicated an order dated 7/17/2024 for a consistent carbohydrate diet ([CCHO], a restrictive eating plan that helps people with diabetes manage their blood sugar levels) dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food. 4. During a review of Resident 53's Admission Record, the Admission Record indicated Resident 53 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, dysphagia, cerebral infarction, and dementia. During a review of Resident 53's ST Evaluation and Plan of Treatment dated 5/1/2024, the ST Evaluation and Plan of Treatment indicated Resident 53 was evaluated for swallowing function with the goal to reduce risk of choking or coughing events and to tolerate safest and least restrictive diet without signs of aspiration. The ST Evaluation and Plan of Treatment indicated ST recommended to continue with the pureed diet. During a review of Resident 53's care plan titled, Altered nutrition: on a Mechanically Altered, Therapeutic Diet and At Risk of Aspiration initiated 5/11/2024, indicated the goal for Resident 53 included not to have any signs of aspiration and Resident 53 will demonstrate correct eating techniques to maximize safe swallowing. The care plan interventions included serving the resident's diet and diet texture modifications as needed as ordered by the physician. During a review of Resident 53's Physician's Order Summary Report dated 7/11/2024, the Physician's Order Summary Report indicated an order for a CCHO diet, dysphagia mechanical soft texture, nectar thick (can be sipped from a cup but require effort if taken via a straw) consistency liquids, and ground food. During a review of Resident 53's MDS dated [DATE], the MDS indicated Resident 53 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 53 required setup or clean-up assistance while eating but was able to eat by herself. The MDS indicated Resident 53 coughed or choked during meals and complained of difficulty or pain while swallowing. The MDS indicated Resident 53 was on a mechanically altered diet. During a review of Resident 53's ST Treatment Encounter Note dated 7/30/2024, the ST Treatment Encounter Note indicated Resident 53 was seen for dysphagia treatment and ST recommended to continue mechanical soft ground texture foods with mildly (nectar consistency) thick liquids. 5. During a review of Resident 62's Admission Record, the Admission Record indicated Resident 62 was admitted to the facility 5/10/2023 with diagnoses including dysphagia, acute kidney failure (a sudden and often reversible decline in kidney function), muscle weakness, and atrial fibrillation (a rapid and irregular heartbeat). During a review of Resident 62's ST Treatment Encounter Note dated 2/1/2024, the ST Treatment Encounter Note indicated Resident 62 presented with mild oral dysphagia (difficulty swallowing) and ST recommended minced and moist foods, mechanical soft ground diet with thin liquids. During a review of Resident 62's MDS dated ,d+[DATE]/ 2024, the MDS indicated Resident 62 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 62 required supervision or touching assistance (staff provides verbal cues/ and or steadying as the resident completes the activity) for eating. The MDS indicated Resident 62 was on a mechanically altered diet and complained of difficulty with swallowing. During a review of Resident 62's care plan titled, At risk for Aspiration initiated on 5/31/2023, the care plan indicated Resident 62's goal was not to have evidence of aspiration. The care plan interventions included to provide Resident 62 diet as and diet texture modifications per physician's order. During a review of Resident 62's Physician's Order Summary Report dated 7/17/2024, the Physician's Order Summary Report indicated an order for a regular diet, dysphagia mechanical soft texture, regular/ thin consistency liquids, ground food. During a review of Resident 62's Physician's Order Summary Report dated 8/23/2023 the Physician's Order Summary Report indicated to always assist Resident 62 with feeding. 6. During a review of Resident 81's Admission Record, the Admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, muscle weakness, depressive episodes, and cognitive communication deficit. During a review of Resident 81's care plan titled, Nutritional problem or potential nutritional problem related to poor appetite initiated 7/11/2024, the care plan indicated Resident 81's goal was to provide Resident 81's diet as ordered by the physician and monitoring for any signs of dysphagia. During a review of Resident 81's MDS dated [DATE], the MDS indicated Resident 81 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 81 needed substantial/ maximal assistance (staff does more than half the effort) for eating. During a review of Resident 81's ST Evaluation and Plan of Treatment dated 7/25/2024, the ST Evaluation and Plan of Treatment indicated Resident 81 was evaluated due to communication deficits and dysphagia with residue remaining in the oral cavity (mouth) while eating. The ST Evaluation and Plan of Treatment indicated ST recommended to downgrade the resident's diet to a minced and moist diet for dysphagia and swallow precautions (steps taken to ensure safe swallowing and prevent aspiration). During a review of Resident 81's Physician's Order Report, dated 8/2/2024, the Physician's Order Report, indicated and order for a mechanical soft texture, regular/ thin consistency liquids, for mechanical soft ground foods. During a review of Resident 81's ST Treatment Encounter Note dated 8/12/2024, the ST Treatment Encounter Note indicated Resident 81 was seen to address swallowing safety and swallowing dysfunction and ST recommended a minced moist diet. 7. During a review of Resident 83's Admission Record, the Admission Record indicated Resident 83 was admitted to the facility 7/17/2024 with diagnoses including dysphagia, autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). During a review of Resident 83's MDS dated [DATE], the MDS indicated Resident 83 was rarely or never understood. The MDS indicated eating was not attempted during the MDS review. The MDS indicated Resident 83 was dependent (staff does all the effort) on staff for eating. The MDS indicated Resident 83 was on a mechanically altered diet and complained of difficulty or pain with swallowing. During a review of Resident 83's care plan titled, At risk for Aspiration dated 7/30/2024 indicated the resident was started on a dysphagia mechanical soft texture, regular/ thin consistency liquids, ground texture. The care plan goal for Resident 83 included to demonstrate correct eating technique to maximize swallowing and Resident 83 would not show any signs of aspiration. The care plan interventions included to provide Resident 83 with the diet per physician's order and to monitor the resident for signs and symptoms of aspiration. During a review of Resident 83's Physician's Order Summary Report, the Physician's Order Summary Report indicated an order dated 7/30/2024 for a dysphagia mechanical soft texture, with regular/ thin consistency liquids, ground texture diet and observe the resident for alertness, food pocketing, coughing per swallowing protocol (guidelines or procedures used to assess and manage residents with swallowing difficulties). During a review of Resident 83's ST Treatment Encounter Note dated 8/1/2024, the ST Treatment Encounter Note indicated Resident 83 was seen for dysphagia treatment and ST recommended for Resident 83 to continue mechanical soft ground texture foods (minced and moist) and thin liquids. During a review of the facility's Diet Spreadsheet for Wednesday 8/14/2024, the Diet Spreadsheet indicated a grilled cheese sandwich was to be served for residents on a regular diet and a pimiento cheese sandwich to be served to residents on a therapeutic diet (a modification of a regular diet). The Diet Spreadsheet indicated a ground pimento cheese sandwich was to be served to residents on a dysphagia minced and moist diet ([MM5] the diet code for minced and moist diet). During a review of the facility's ground pimento cheese salad sandwich MM5 recipe, the MM5 recipe indicated bread was to be minced and assembled into a sandwich as follows: 1. For each sandwich: place two slices of bread into a washed and sanitized food processor and pulse grind for 4-6 seconds to create a minced, bread crumb consistency. 2. Placed minced bread into a bowl and spray with a vegetable pan spray or spritz with water or an appropriately prepared broth to moisten the bread (not soaked or wet). 3. Divide the moistened minced breadcrumbs in half or portion the minced and moistened bread on a plate or in a sandwich mold. 4. Portion and spread the ground/minced pimento cheese salad with thick sauce or gravy over the bottom layer of minced bread and then top with the other portion of minced bread. During an observation of the kitchen tray line (a system of food preparation, in which trays move along an assembly line) on 8/14/2024 at 11:39 a.m., under the supervision of the DS and RD, a dietary aide (DA 1) was observed calling out the diets from a resident meal ticket (resident diet and food preference) and CK 1 was plating (arrangement of food on a plate) the lunch meal. CK 1 was observed plating the pimento cheese sandwich for the meal tickets when DA 1 was calling out for dysphagia minced and moist diet and the mechanical chopped diets (a texture-modified diet that provides foods that are easy to swallow and require minimal chewing). During a concurrent observation and interview on 8/14/2024 at 12:20 p.m., with Certified Nursing Assistant (CNA 3), Resident 81 was observed receiving her meal tray in the room. CNA 3 delivered the meal tray to Resident 81 bedside. Resident 81's meal tray was observed containing the ground pimento cheese salad served on two slices of white bread (not minced and not moist), including the crust, with a scoop of ground pimento cheese in between the bread, sliced in half. Resident 81 meal ticket was observed on the tray and indicated Dysphagia minced and moist, mechanical soft diet. CNA 3 stated she was at the bedside to assist Resident 81 for eating. CNA 3 stated the bread served was not safe for Resident 81 to consume because the resident tends to pocket her food and she could choke. During a concurrent observation and interview on 8/14/2024 at 12:25 p.m., with DS in the kitchen, the DS was asked to check Resident 53's lunch tray before the meal cart (transportation method to bring meal trays to the residents) went out to the resident room. Resident 53's meal ticket, on the tray, indicated the resident was on dysphagia minced and moist diet. However, Resident 53's tray was observed containing a pimento cheese sandwich (ground pimento cheese salad in between two white breads with crust, sliced in half). The DS stated, this sandwich was appropriate for Resident 53 based on the dietary spreadsheet and the tray with sandwich was observed sent out for delivery to Resident 53. During an interview on 8/14/2024 at 12:35 p.m., the RD stated the type of sandwich with ground pimento cheese salad in between two non-minced and not moist two pieces of white bread with crust, sliced in half served to the residents on dysphagia minced and moist diet was appropriate based on the facility's Diet Spreadsheet. The RD stated, we must follow what corporate (umbrella company) wanted and this Diet spread Sheet was what they sent/approved. During a concurrent interview and record review on 8/14/2024 at 2:33 p.m., the RD stated she spoke with CK 1 who informed her (RD) that she (CK 1) was not provided with the MM5 diet recipe for the ground pimento cheese salad sandwich when she was preparing these kinds of sandwiches for lunch on 8/14/2024. CK 1 stated she made a mistake of looking at the spread sheet and preparing the MM5 diet the same as the mechanical soft diet (did not call for mincing bread). The RD stated the purpose of the dysphagia minced and moist diet was to eliminate the need for a lot of chewing to promote easy swallowing. The RD stated bread was soft so the residents would be able to eat it. Concurrently during an interview on 8/14/2024 at 2:33 p.m., the RD reviewed facility's Diet Manual (DiningRD.com 2022 edition) under dysphagia minced and moist diet (MM5) and stated the manual indicated foods to avoid for the dysphagia minced and moist diet included soft bread and rolls. The RD stated the potential outcome of giving residents on MM5 diet foods that were supposed to be avoided placed the residents at the risk for choking, aspiration, and respiratory distress (stop breathing). The RD stated it was not appropriate to serve the ground pimento cheese salad sandwich on a regular slice of soft that was not minced and was not moist white bread with crust to Resident 10, 11, 50, 53, 62, 81, and 83, who were on the dysphagia minced and moist diet. During an interview on 8/14/2024 at 2:55 p.m., CK 1 stated when she was preparing food for lunch on 8/14/2024, she was looking at the Dietary Spreadsheet and read the dysphagia minced and moist diet the same as the mechanical soft diet. CK 1 stated for dysphagia minced and moist diet whole sandwich should be ground up, but it was overlooked, and CK 1 was not paying attention. CK 1 did not provide an answer as to why the dysphagia minced and moist menu was not followed and stated, I do not know what happened. CK 1 stated all residents, including Resident 10, 11, 50, 53, 62, 81, and 83 who were on dysphagia minced and moist diet, received the ground pimento cheese salad sandwich for lunch on 8/14/2024 served on bread that was not minced but on a regular slice of soft white bread. During an interview on 8/14/2024 at 3:05 p.m., ST 1 stated bread with crust was a high choking risk. The ST 1 stated serving food that did not meet dietary standards for a dysphagia diet was a safety risk and the whole sandwich should have been ground up for a minced and moist diet. During an interview on 8/15/2024 at 9:49 a.m., DA 1 stated the usual presentation for a minced and moist diet looked like finely ground pieces and bread was usually soaked in a liquid. DA 1 stated she knew the bread did not look correct for the dysphagia diet, but she did not question it because CK 1 prepared the food, and she (CK 1) was the cook. DA 1 stated she should have brought up her concern to the DS. DA 1 stated if a wrong diet was given to the residents they could choke. During an interview on 8/15/2024 at 1:36 p.m., LVN 4 stated she was checking the lunch meal carts on 8/14/2024 and pimiento cheese sandwiches were provided to the residents on bread that was not minced. LVN 4 stated she did not see anything wrong with the pimento cheese sandwiches served bread that was not minced served to the residents on the dysphagia minced and moist diet. During an interview on 8/15/2024 at 1:56 p.m., the Director of Rehab (DOR) stated it was important to follow closely the ST's recommendations because ST was the one evaluating the safety of the resident's swallowing. The DOR stated the resident's diet was based on the ST's clinical evaluation which was then reviewed by the physician following with a diet order. The DOR stated if the diet was not followed, there was a high risk for aspiration. During an interview on 8/15/2024 at 3:36 p.m., the DS stated he had not realized CK 1 did not have the recipe for pimiento cheese sandwich under MM5 diet. DS stated he assumed CK 1 prepared sandwiches based on the facility's recipe for the mechanical soft diet (makes food easy to chew) which was not the same as dysphagia minced and moist. The DS stated he was not concerned about the ground pimiento cheese salad sandwich being served to the dysphagia residents until the RD read in Diet Manual what foods to avoid. During an interview on 8/15/2024 at 4:24 p.m., the DON stated it was important to follow physician's diet orders. The DON stated residents were placed on a dysphagia diet due to having issues with swallowing or chewing. The DON stated it was important to follow the dysphagia minced and moist diet recipe to prevent choking. The DON stated residents on dysphagia minced and moist diet, should have little effort on chewing to consume the food. The DON stated the licensed nurses who were checking the meal trays with pimento cheese sandwiches served on bread that was not minced, should have returned the trays to the kitchen due to incorrect food texture posing a choking hazard. The DON stated CNAs should also recognize the proper diet consistencies and food texture and bring it to the licensed nurse's attention when serving trays. During a review of the facility's Long Term Care Diet Manual by DiningRD.com 2022 edition, the Diet Manual indicated the International Dysphagia Diet Standardization Initiative ([IDDSI] a global framework that provides standardized definitions and terminology for describing thickened liquids[ liquids that have been made thicker to help residents who have difficulty swallowing) and texture modified foods) level 5- Minced and Moist (MM5) dysphagia diet was designed for individuals with mild to moderate oral dysphagia. Foods will conform to this diet if they are ground, moist, and of the size that would fit between the tongs of a typical fork. The Diet Manual indicated to avoid breads such as soft bread, rolls, cake, and crackers unless the breads are modified to a fine, soft bread crumb texture and moistened. During a review of the facility's policy and procedure (P&P) titled Dining Program dated 1/1/2012, the P&P indicated licensed nurses were to check the Residents meals against the attending physician orders. The P&P indicated the CNAs were to check diet cards (meal tickets) against the meal served and notify the dietary department of any discrepancies. The P&P indicated the dietary staff was to check the tray cards (meal tickets) against the meal served at tray line and correct any discrepancies. During a review of the facility's P&P titled Dysphagia Diets and Thickened Liquids dated 1/1/2012, the P&P indicated the purpose of the policy was to provide appropriate food and fluid consistencies to residents with dysphagia or swallowing problems, to ensure adequate hydration and diminish the risk for asphyxiation (the process of being deprived of oxygen). During a review of the facility's P&P titled Dietary Department- General dated 6/1/2014, the P&P indicated the primary objective of the dietary department included preparation and provision of nutritionally adequate, well-balanced meals that are consistent with physician orders. During a review of the facility's P&P titled Standardized Recipes dated 7/1/2014, the P&P indicated the recipes would have adjustments or separate recipes for therapeutic and consistency modifications. The P&P indicated the Dietary Manager or designee would monitor and routinely verify the recipes used by the cooks. During a review of the facility's job description for Registered Dietician dated 10/9/2023, the job description indicated their essential job duties included coordinating with the dietary manager (DS) to review the customization of the regular and therapeutic menus. (Cross reference: F726, F802, and F808)

Based on observation, interview, and record review the facility failed to implement infection control practices to prevent the spread and transmission of coronavirus (COVID 19, a potentially severe respiratory illness caused by a virus and characterized by fever, coughing, and shortness of breath) for four of eight sampled residents (Residents 9, 11, 15, and 24). The facility failed to: 1. Separate COVID 19 positive residents (Resident 16 and 17) from COVID 19 negative resident (Resident 9) and COVID 19 positive residents (Resident 13 and 14) from COVID 19 negative resident (Resident 15). Resident 9 and 15 who were COVID 19 negative on 12/22/22 were sharing rooms with COVID 19 confirmed positive residents and tested positive on 12/29/22. 2. Initiate COVID 19 facility wide testing (testing all residents and staff) for facility staff exposed to COVID 19. The facility first identified COVID19 case on 12/23/22, and staff testing was conducted on 12/28/22. 3. Ensure Medical Doctor (MD) 2 who was examining residents in isolation (COVID 19 positive residents) area sanitized her personal stethoscope (medical instrument for listening to the action of someone's heart or breathing,) before and after used with Residents 11 and 24. Resident 11 was COVID 19 confirmed negative, and Resident 24 was COVID 19 confirmed positive resident. 4. Ensure Director of Staff Development/Infection Preventionist Nurse (DSD/IPN) and Director of Nursing (DON) were aware of infection control guideline and the facility's Infection Control Policies and Procedure (P&P) requiring confirmed COVID 19 positive residents be isolated from confirmed COVID 19 negative residents to mitigate (lessen) the transmission of COVID 19. 5. Ensure Certified Nurse Assistant (CNA) 3 donned (put on) gown and gloves when entering resident's rooms in the red zone (designated area for residents who have confirmed COVID 19)/isolation area to deliver and setup food trays. These deficient practices resulted in the spread of COVID-19 infection to Resident 9 and 15 and placed other residents, staff, visitors, and the community at a high risk for cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and increased the spread COVID-19 infection. On 12/29/22, at 4:25 p.m., in the presence of the Administrator in Training (AIT) and the Director of Nursing (DON), an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident), was identified, and declared due to the facility's failure to separate COVID 19 positive residents (Resident 16 and 17) from COVID 19 negative resident (Resident 9) and COVID19 positive residents (Resident 13 and 14) from COVID 19 negative resident (Resident 15). Resident 9 and 15 who were COVID 19 negative on 12/22/22 were sharing a room with COVID 19 confirmed positive residents and tested positive on 12/29/22. Failure to initiate COVID 19 facility wide testing for facility staff exposed to COVID. The facility first identified COVID 19 case on 12/23/22, and staff testing was conducted on 12/28/22. Failure to ensure MD 2 who examined residents in isolation area sanitized her personal stethoscope before and after used with Residents 11 and 24. Resident 24 was confirmed COVID 19 positive residents. Failure to ensure DSD/IPN and DON were aware of infection control guideline and the facility's P&P requiring confirmed COVID 19 positive residents be isolated from confirmed COVID19 negative residents to mitigate transmission of COVID 19. Failure to ensure CNA 3 donned gown and gloves when entering resident's rooms in the isolation area to deliver and setup food trays. On 12/30/22, at 3:50 p.m., the Administrator submitted an acceptable IJ Removal Plan ([IJRP] a plan with interventions to immediately correct the deficient practices). The acceptable IJRP included the following corrective actions: 1.On 12/29/22, the licensed nurses conducted COVID 19 antigen tests (test designed for the rapid diagnoses of active infection) to COVID 19 negative residents who were cohorted (group together) with COVID 19 positive residents. DON and designee reviewed all COVID 19 positive residents to ensure that no other COVID-19 positive residents were cohorted with COVID 19 negative residents. 2. On 12/29/22, the DON immediately provided in - service education to all CNAs on site regarding the facility's infection control P&P with emphasis on personal protective equipment ([PPE] equipment worn to minimize exposure to infection) use and will continue with all three shifts. The DON/Designee initiated an inservice education to facility staff regarding facility's Infection Control P&P with emphasis on response to test results, cohorting of residents, required PPE for each area of the facility, disinfection of equipment before and after resident use and designation of space. 3.On 12/29/22, the Administrator immediately notified the Medical Director to provide education to MD 2 regarding infection control, with emphasis on sanitizing equipment before and after each resident use. 4.On 12/29/22, the Regional Quality Management Consultant (RQMC) provided immediate remote education to the Administrator, DON, and DSD, regarding the facility's infection control P&P, with emphasis on cohorts/designation of space to prevent the spread of the virus. RQMC also provided education on response testing. 5.The licensed nurses-initiated point of care ([POC] tests produce rapid, reliable results that aid in identification and monitoring of acute infections) testing to 27 residents who have had high risk exposure to COVID19 positive residents. 6. The DON/Designee initiated observation of staff to ensure facility staff provided care to COVID 19 negative residents first before COVID 19 positive residents (clean to dirty), the proper use of PPE, and equipment sanitation in between resident use. 7.During daily clinical meeting on Mondays to Fridays, the Interdisciplinary ([IDT] health professionals from different disciplines, along with the patient, working collaboratively as a team) will review COVID 19 positive residents' room placements to ensure that no positive residents are cohorted in the same room as COVID 19 negative residents. 8.The DON/Designee will conduct rounds and observations bi-weekly until COVID 19 outbreak has cleared, to ensure that COVID -19 positive residents were not cohorted in the same room as COVID 19 negative residents. Facility staff, outside vendors, and physicians adhere to required PPEs in each area of the facility, and disinfection of equipment in between resident use. Staff will provide care to COVID-19 negative residents first before COVID 19 positive residents if there are no designated staff for each cohort. 9. The Administrator and DON will be responsible in monitoring and sustaining compliance. 10.The Director of Nursing will present the results of the Infection Control Audits to the Quality Assurance ([QA] identification, assessment, correction and monitoring of important aspects of patient care) and Performance Improvement (focuses on performance within a healthcare organization) committee for review monthly for the next three months and quarterly thereafter. On 12/30/22, at 3:50 p.m., the Department of Public Health removed the IJ while onsite after the surveyors verified the facility implemented the facility's IJRP by observations, interviews, and record reviews. The DON and DSD were informed. Findings: 1. a) During a review of facility's census on 12/28/22, Resident 9 shared a room with Resident 16 and 17. During a review of Resident 9's Admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), and epilepsy (seizure disorder - sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). During a review of Resident 9's Minimum Data Set ([MDS], a comprehensive assessment and care-screening tool), dated 11/17/22, the MDS indicated Resident 9 had severely impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS indicated Resident 9 was totally dependent with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. During a review of Resident 9's laboratory (lab) report dated, 12/23/22, the lab report indicated COVID 19 test result was negative. During a review of Resident 9's COVID 19 Resident Testing Record dated, 12/29/22 indicated Resident 9 test result was positive for COVID 19. During a review of Resident 9's care plan titled, Residents with COVID 19 or suspected COVID 19, dated, 12/29/22, the care plan indicated Resident 9 was positive for COVID 19. Goals included ensure implementation of guidelines regarding the care of all residents during the COVID 19 outbreak and be updated with most current guidelines. Interventions included place resident in a private room with own bathroom, room sharing might be necessary if there are multiple residents with known or suspected COVID 19, and keep door closed. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 had intact cognitive skills for daily decision making, was totally dependent on staff for bed mobility, transfers, toileting, personal hygiene, bathing, and required extensive assistance with dressing and eating. During a review of Resident 16's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. During a review of Resident 17's MDS dated [DATE], the MDS indicated Resident 17 had intact cognitive skills for daily decision making, was totally dependent for toilet use, required extensive assistance with bed mobility, transfers, dressing, personal hygiene, bathing, and required limited assistance with eating. During a review of Resident 17's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. b). During a review of facility's census on 12/28/22, Resident 15 shared a room with Resident 13 and 14. During a review of Resident 15's AR, the AR indicated Resident 15 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves) and type 2 diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly). During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 had intact cognitive skills for daily decision making, was totally dependent on staff for bed mobility, transfers, toileting, personal hygiene, and bathing, required extensive assistance with eating, and supervision with eating. During a review of Resident 15's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was negative. During a review of Resident 15's COVID 19 Coronavirus Resident Testing Record dated, 12/29/22 indicated Resident 15 test result was positive for COVID 19. During a review of Resident 15's Care Plan titled, Residents with COVID 19 or suspected Covid-19, dated, 12/27/22, the care plan indicated resident 15 was positive for Covid 19. Goals included ensure implementation of guidelines regarding the care of all residents during the COVID 19 outbreak and be updated with most current guidelines. Interventions included place resident in a private room with own bathroom, room sharing might be necessary if there are multiple residents with known or suspected COVID 19, and keep door closed. During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had severely impaired cognitive skills for daily decision making, and was totally dependent with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. During a review of Resident 13's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had severely impaired cognitive skills for daily decision making, and was totally dependent for toilet use, personal hygiene, bathing, required extensive assistance with bed mobility, transfers, dressing, and required limited assistance with eating. During a review of Resident 14's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. During an interview on 12/29/22 at 8:25 a.m. with Registered Nurse (RN) 1, RN 1 stated the entire facility was changed to red zone/isolation with COVID 19 positive and COVID 19 negative residents cohorting in the same rooms together. RN 1 stated she does not know who made the decision to transition the entire facility to a red zone and she does not know the date the isolation began. During an interview on 12/29/22 at 9:07 a.m., with Licensed Vocational Nurse (LVN) 1, at Nursing Station 2, LVN 1 stated the entire facility was transitioned into a red zone and she was taking care of both COVID 19 negative and COVID 19 positive residents. LVN 1 stated her assignment included two rooms that have COVID 19 negative and COVID 19 positive residents cohorting together in the same rooms. LVN 1 stated the red zone should be designated for COVID 19 positive residents and with designated staff. LVN 1 stated having COVID 19 positive resident in the same room with COVID 19 negative residents will lead to all residents becoming infected with the COVID 19 virus and can lead to severe respiratory illness for residents with lots of medical problems. LVN 1 stated best practice was to have COVID 19 positive resident isolated in the red zone away from COVID 19 negative residents. During a concurrent observation and interview on 12/29/22 at 10:25 a.m., with LVN 3, in the east hall, LVN 3 stated she was taking care of Residents 13 and 14 who are confirmed COVID 19 positive, and isolated in a room with Resident 15 who was confirmed COVID 19 negative. LVN 3 stated she was also caring for Residents 16 and 17 who were COVID 19 positive and was isolated in a room with Resident 9 who was confirmed COVID 19 negative. Residents 13, 14, and 15 were observed isolated in the same room, and Residents 9, 16, and 17 were observed isolated in the same room. LVN 3 stated the red zone was for residents that are positive for COVID 19 and residents who were COVID 19 negative are at a higher risk of developing COVID 19 when the residents are in the same room with COVID 19 positive residents. During an interview on 12/29/22 at 3:39 p.m., with DON, DON stated the facility follows Center for Disease Prevention and Control (CDC), California Department of Public Health (CDPH), and Los Angeles County Department of Public Health (LAC-DPH) COVID 19 infection control guidance which indicate the red zone is designated for COVID 19 positive residents. DON stated COVID 19 positive resident must be isolated in the red zone to contain the virus and prevent other residents and staff from becoming infected. DON stated even after receiving negative COVID 19 test results for residents who were exposed to virus she made the decision to isolate all resident in place causing COVID 19 negative and COVID 19 positive resident to be in the same room. DON stated best practice was isolate COVID 19 positive residents in red zone only. During an interview on 12/30/2022 at 11:40 a.m. with DSD, the DSD stated Resident 9 and Resident 15 were initially confirmed negative with COVID 19 on 12/23/22 and was in the same room with COVID 19 positive residents. DSD stated Resident 9 and Resident 15 tested positive with COVID 19 on 12/29/22. 2. During an interview on 12/29/22 at 10:50 a.m., with CNA 5, CNA 5 stated she was informed by the DSD/Infection Preventionist Nurse (IPN) the facility was in a COVID 19 outbreak starting on 12/26/2022. CNA 5 stated the first time she was tested during the current outbreak was on 12/28/22. During an interview on 12/29/22 at 11:40 a.m., with DSD/IPN, DSD/IPN stated the facility covid outbreak was confirmed on 12/23/22 after 14 residents and five (5) staff tested positive for COVID 19. DSD/IPN stated facility wide testing was conducted for staff on 12/28/22, five (5) days after the outbreak began. DSD/IPN stated she was not aware of the facility's P&P for initial outbreak testing for staff during a covid outbreak. During an interview on 12/29/22 at 3:39 p.m., with the DON, the DON stated a COVID 19 outbreak is when 2 or more resident tested positive for COVID 19. DON stated response testing for staff and residents should start immediately after knowledge of an outbreak. The DON stated she does not know why there was a delay in testing staff. The DON stated any delay in testing put residents, visitors, and staff at risk for developing and spreading the COVID 19 virus. 3. During a review of Resident 11's AR, the AR indicated Resident 11 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism (underactive thyroid [small, butterfly-shaped gland located at the base of the neck]) and anemia (low number of red blood cells). During a review of Resident 11's COVID 19 resident testing record dated, 12/29/22, the lab report indicated COVID 19 test result was negative. During a review of Resident 24's AR, the AR indicated Resident 24 was admitted to the facility on [DATE] diagnoses that included dementia and hypertension (HTN - high blood pressure). During a review of Resident 24's lab report dated, 12/23/22, the lab report indicated COVID 19 test result was positive. During a concurrent observation and interview on 12/29/22 at 9:55 a.m., in the east hall and middle halls in the red zone, MD 2 was observed going into Resident 11's room and used her personal stethoscope to listen to Resident 11's chest. MD 2 placed her personal stethoscope on a belt hook/holder, removed her gown and gloves, exited the room and sanitized her hands. MD 2 did not sanitize personal stethoscope. MD 2 put on a gown and gloves, entered Resident 24's room and used her personal stethoscope and listen to Resident 24's chest. MD 2 removed her gown and gloves sanitized her hands and exited the room. MD 2 stated she was aware the facility was in a COVID 19 outbreak, and she know she should sanitize her stethoscope before and after using it on a resident in an isolation area. MD 2 stated she did not know facility had wipes to sanitize the stethoscope. During an interview on 12/29/22 at 3:39 p.m., with the DON, the DON stated it is the facility's policy that disposable stethoscope should be used in isolation rooms. The DON stated if personal stethoscope was used it must be sanitized before and after use on a resident to prevent cross contamination and to prevent the spread of COVID 19. 4. During an interview on 12/29/22 at 11:40 a.m., with DSD/IPN, DSD/IPN stated she did not receive guidance for the Department of Public Health (DPH) on converting the entire facility to a red zone. DSD/IPN stated the red zone should be designated for COVID 19 positive residents. DSD/IPN stated the decision was made by DSD/IPN and DON to not move the COVID 19 positive resident into the red zone and isolate away from COVID 19 negative residents, instead DSD/IPN and DON decided to isolate all residents in place which led to COVID 19 positive resident being in the same room with covid negative resident. During an interview on 12/29/22 at 3:39 p.m., with the DON, the DON stated RN 1 conducted room changes initially and cohorting was done without the guidance of DON/DSD/IPN. DON stated male COVID 19 positive residents were isolated in one room and female COVID 19 positive residents in another room. The DON stated after receiving negative and positive COVID 19 lab results on 12/26/22 the decision was made not to move any residents, so the entire facility was declared a red zone and COVID 19 negative resident were isolated in the same rooms with COVID 19 positive resident. 5. During an observation on 12/29/22 at 12:26 p.m., CNA 3 entered room [ROOM NUMBER] that was occupied by two COVID 19 confirmed positive residents and one COVID 19 confirmed negative resident and delivered lunch tray without wearing gloves and gown, exited the room, went back to the tray cart and took another lunch tray into the room without hand washing. During an observation on 12/29/22 at 12:28 p.m., CNA 3 entered room [ROOM NUMBER] that was occupied by two COVID 19 confirmed positive residents and delivered lunch tray without wearing gloves and gown, exited the room, went back to the tray cart and took another lunch tray into the room without hand washing. During an interview on 12/29/22 at 2:39 p.m. with CNA 3, CNA 3 stated she was not aware which residents were COVID 19 positive and which residents were COVID 19 negative. CNA 3 stated she was not aware she needs to don a gown and gloves when delivering lunch tray to the resident. CNA 3 stated she did not wash her hands in between residents. During an interview on 12/29/22 at 4:01 p.m. with the DON, the DON stated room [ROOM NUMBER] and 33 were red cohort/isolation, all staff must follow the infection control practices and all staff must use all the necessary PPE required to contain the COVID 19 outbreak and prevent the spread of the COVID 19 virus. During an interview on 12/30/22 at 8:06 a.m., with the RN 2, the RN 2 stated all staff must wear all required PPE (gown and gloves) when entering room in the isolation area to prevent cross contamination and transmit COVID 19 infection from staff to resident and vice versa. During a review of the facility's policies and procedures (P&P) titled Designation of Areas to Contain the Spread of COVID 19 dated 5/20/2020, the P&P indicated To minimize the risk of transmission of COVID 19, the facility will keep separate residents who are infected with COVID 19, residents who are suspected or potentially infected and residents who are low risk or free from COVID 19 infection. During a review of the facility's COVID-19 Mitigation Plan (MP), revised on 10/2/22, the MP indicated The facility has policies in place for designated spaces within the facility to ensure separation of infected residents from non-infected residents. Isolation is only for residents who have laboratory confirmed COVID 19 with or without symptoms - regardless of vaccination status. Residents who test positive will be isolated in the designated COVID19 positive area of the facility. Gowns and gloves are worn for every resident encounter in an isolation cohort. All healthcare providers who have had a high-risk exposure and residents who have had close contacts, regardless of vaccination status, will be tested promptly (not earlier than 24 hours after exposure, with day of exposure counted as day zero (0) and if negative again at three (3) days and again at five (5) days after exposure. During a review of the facility's P&P, titled Management of COVID 19, dated, 10/11/22, the P&P indicated Standard (minimum infection prevention and control practices ) and transmission-based precaution ( a set of practices specific for patients with known or suspected infectious agents that require additional control measures to prevent spread ) will be implemented for patients suspected or confirmed to have COVID 19 based on the Center for Disease Prevention and Control (CDC) guidance. For the purpose of this policy, transmission based precautions may include wearing N95 (respiratory protective device) upon entry into the patient's room or while in a designated area for isolation or quarantine, in addition to the recommended PPE and keeping the door to the patient's room closed.

Based on observation, interview, and record review, the facility failed to identify the hazards of a resident's wandering behavior (moving from place to place without a fixed plan), conduct an elopement (leaving without permission) risk assessment, implement interventions to supervise the resident due the resident being newly admitted , being confused, deaf (hearing impairment) and non-English speaking to prevent accidents and injuries and to ensure the facility's staff were aware of the resident's wandering and elopement behaviors for one of three sampled residents (Resident 1). Resident 1, a newly admitted resident, was left unsupervised in the facility after the facility observed Resident 1 wandering and requesting to go home and Physical Therapist Assistant 1 (PTA 1) opened the door for Resident 1 on 11/8/19 in the morning (specific time not determined) and Resident 1 left the facility unsupervised. This deficiency practice resulted in Resident 1 wandering the streets for over three hours on 11/8/19 after being found by a civilian (relating to a person who is not a member of the police or the armed forces) who called the police. Resident 1 was admitted to a general acute care hospital (GACH 2) for five (5) days for care and treatment after the elopement. This deficient practice had the potential to result in Resident 1's health condition to decline due to lack of access to medication, food, and water, and death from accidents. On 11/12/19 at 5:30 p.m., the Department declared an Immediate Jeopardy ((IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm, impairment, or death to a resident) regarding the facility's failure to conduct an assessment of the resident's elopement risk, provide supervision for Resident 1 and communicate to the staff of the resident's risk for elopement. The Administrator (ADM) and Director of Nursing (DON) were notified of the immediacy and seriousness of the facility's failures to Resident 1's health and safety and the potential of the facility's failures to affect other residents. On 11/12/19 at 9:45 p.m., the facility provided an acceptable written plan of action (POA) as follows: 1. A wander guard system (a set perimeter around living area to alert when a resident leaves the area) was put in place and readily available to be used for residents who are at risk for elopement immediately upon identification. 2. All resident's admitted will be assessed by the admitting licensed nurse for cognition, hearing, and vision, and language barriers within 24 hours of admission and for behavioral attempt of wanting to leave the facility and or wandering behavior within four (4) hours of admission to provide constant supervision of the resident as an elopement risk. 3. Residents identified to be at risk for elopement will be monitored by staff every hour. 4. All ambulatory residents, with a Brief interview of mental status ((BIMS) mental assessment) score of 0-12, who were severely and moderate impaired in cognition (thought process), were assessed for elopement risk and none were identified as at risk for elopement. 5. In-service to all facility's staff was initiated on 11/8/19 and 1/11/19 regarding the elopement policy including the code for elopement (Code Brown). 6. A list of residents at risk for wandering and elopement will be reviewed during daily clinical meeting when applicable. On 11/13/ 19 at 7:20 p.m., the IJ was lifted, after the team verified the POA was implemented through observation, interview and record review. Findings: A review of Resident 1's GACH Progress Note, dated 11/3/19 and timed at 10:02 a.m., prior to admission to the skilled nursing facility (SNF), indicated Resident l 's mental status had changed from alert and oriented times three (to person, place and time) to alert and oriented with intermittent (at irregular intervals) confusion. The GACH's progress note indicated on 11/4/19 at 9:59 a.m., Resident 1 was assessed as alert but very restless and agitated, unable to answer simple questions. The GACH's registered nurse (RN) was to follow-up with a sitter for Resident 1 to assist the family due to Resident l 's impaired cognition, impulsivity (acting or done without forethought), and mobility. The GACH documented a chair alarm (alarms upon rising) had to be used to prevent Resident 1 from falling and leaving. According to the GACH's Progress Note, dated 11/4/19 and timed at 9:59 a.m., Resident 1's behavior had worsened with agitation and he became a significant fall risk requiring a sitter and bed/chair alarm. The GACH's progress note on 11/6/19 at 2:30 p.m., indicated Resident 1 was disoriented to place, time, and situation. The resident was agitated, anxious, with severe impairment for personal safety, at risk for behaviors demonstrated, impulsive and unaware of consequence of deficits, such as functional and cognitive deficits. The GACH's Progress Note, dated 11/7/19 and timed at 12:48 p.m., indicated prior to Resident 1's discharge from the GACH, Resident 1's family voiced concerns of Resident 1 being discharge due to his confusion. At 1:45 p.m., on 11/7/19, the GACH's Physical Therapy ((PT) deals with conditions such as chronic or acute pain, soft tissue injuries, cartilage damage, arthritis, gait disorders and physical impairments) Plan included the importance of providing supervision to Resident 1 for mobility safety due to the resident's impulsiveness. The PT note indicated someone would always have to supervise Resident 1. A review of Resident 1's GACH's Discharge Summary, dated 1/7/19, indicated Resident 1 would be admitted for an evaluation for short-term at a SNF. A review of Resident 1's SNF Admission Face Sheet indicated Resident 1 was admitted to the facility on [DATE] from a GACH status [REDACTED]. A review of Resident 1's Admission Report (without a date or time) indicated Resident 1 was alert and oriented times one (to person) and deaf. A review of Resident 1's Baseline Evaluation, dated 11/7/19, indicated Resident 1 was disoriented (confused and unable to think clearly) and had a gait (walking) balance problem. Resident 1 was incontinent (inability to control) of urine and had an indwelling urinary catheter (a tube placed in the bladder to drain urine) and required an extensive assist (staff provide weight bearing support) in care. There was no elopement evaluation included in Resident 1's evaluation. A review of Resident 1's care plan, dated 11/7/19 and titled, At Risk for impaired Communication, (speaks only mandarin). The staff's plan of approach included for translation to be done by the family or use of communication device. A review of Resident 1's nurses' note, dated 11/7/19 and timed at 6 p.m. indicated Resident 1 was alert and verbally responsive and was admitted to the facility from a GACH with family members at the bedside. A review of Resident 1's nurse's note, dated 11/7/19 and timed at 11 p.m., indicated Resident 1 was awake and roaming in and out of resident's rooms. A review of a nurse's note, dated 11/8/19 and timed at 2:10 a.m., indicated Resident 1 was alert and verbally responsive with a language barrier and hearing impairment; facility staff was using signs and gestures to understand what the resident needed. The note indicated Resident 1 required extensive assistance with activities of daily living (ADLs). A review of a police report, dated 11/8/19 and timed at 8:56 a.m., indicated the police was called once Resident 1 was identified as missing on 11/8/19 at 8:30 a.m. The police report indicated Resident 1 was last seen in the facility at 7:30 a.m. on 11/18/ 19. The police report indicated a check (for whereabouts) for Resident 1 met with negative results. The police report indicated Resident 1 walked away from facility in attempt to go home. On 11/8/19 at 2:35 p.m., during an observation, the Administrator showed the facility's recorded security surveillance footage (used for observing an area) for the morning that same day (11/8/19). During the viewing of the surveillance video, Resident 1 was walking with a front wheel walker (FWW) while leaving his room; Resident 1 was walking pass Nurse's Station 1 (where RN 1 was sitting) and he proceeded to the facility's front lobby. When Resident 1 reached the front door, PTA 1, who was entering the facility's front door, opened and held the door, allowing Resident 1 to exit the facility. There was no visual interaction between PTA 1 and Resident 1. On 11/8/19 at 2:38 p.m., during an interview, RN 1 stated Resident 1 passed by the Nurse's Station the morning he eloped. RN l stated Resident 1 was just admitted to the facility the night before (11/7/19) and the night nurse reported Resident 1 was confused during the night, had pulled out his indwelling urinary catheter, and was only sleeping at intervals. On 11/8/19 at 3 p.m., during an observation of Resident 1's room, there was no communication device at the bedside for Resident 1 to use to communicate with the staff, as confirmed by the Social Service Director (SSD). During a concurrent interview, while in Resident 1's room, Resident 1's roommate, Resident 2, who was alert, stated Resident 1 was repeatedly getting up and going in and out the room's patio door stating he wanted to go home. Resident 2 stated Resident 1 was very anxious and restless and not able to remain seated. Resident 2 stated no staff came into the room to check Resident 1, despite him (Resident 2) hearing the staff in the hallway talking. On 11/8/19 at 3:45 p.m., during an interview and review of Resident 1's assessments, the DON stated there was no elopement assessment included in Resident 1's the Resident Baseline Evaluation Assessment. The DON stated she could not provide a reason why Resident 1's elopement assessment was not done and the facility missed completing it for Resident 1. On 11/8/19 at 4:10 p.m., during an interview, the SSD stated she did not see Resident l for an assessment because he was newly admitted . The SSD stated a new admitted resident is usually evaluated within 24 hours, and if the resident is not able to communicate, he/she is given a communication board at the bedside. A review of a handwritten note by RN 2, dated 11/12/19 indicated Resident 1 was observed speaking with the family (on 11/7/19) and when asked what Resident 1 was saying, the family member stated, He is saying he wants to go home. On 11/12/19 at 2:55 p.m., during an interview, Certified Nursing Assistant 1 (CNA l) stated on 11/8/19 at 7 a.m., he saw Resident 1 standing at his room door, wearing boxers and a white shirt. CNA l stated he only said Hi to Resident 1 and Resident 1 only nodded and did not say anything. CNA1 stated he returned to Resident 1's room a short time later and he observed Resident 1 behind the door, putting on his pants. CNA 1 stated he did not offer the resident any assistance. CNA 1 stated he was told Resident 1 was a new admit and no other information was provided about Resident 1. On 11/12/19 at 3:11 p.m., during an interview, CNA 2 stated Resident 1 was a new admission and she greeted the resident on 11/7/19 and left the room. CNA 2 stated she was not aware the resident was at risk for elopement. On 11/12/19 at 3:15 p.m., during an interview, PTA 1 stated she was returning inside the facility when she noticed Resident 1 was having a hard time opening the door. PTA 1 stated Resident 1 was dressed in his own clothes using a walker, so she opened the door for him and allowed him to leave. PTA 1 stated she thought Resident 1 was a visitor, so she said nothing to him. On 11/12/19 at 3:58 p.m., during an interview, RN supervisor (RN 2) stated Resident 1 was alert and oriented times one (to person), Mandarin speaking and the family would translate. RN 2 stated she was required to complete an elopement assessment on new residents at admission. RN 2 stated Resident 1's elopement assessment was not done upon admission and should have been done because Resident 1 was confused. RN 2 stated Resident 1 was confused and wanted to go home which made Resident 1 at risk for elopement. RN 2 stated they should have enforced the elopement protocol and informed all staff of Resident 1's elopement risk and need for supervision, and ensure the doors were closed. On 11/13/19 at 3:25 p.m., during a telephone interview, Resident 1's family member (FM 1) stated Resident 1 became confused from the drugs after the surgery on 10/31/19. FM 1 stated Resident 1 was so confused and restless that he had a sitter while in the GACH. FM l stated Resident 1 was trying to get out of the bed and pulled the indwelling urinary catheter out several times. FM l stated on 11/7/19, after leaving Resident 1 at the SNF, the facility's staff called him several times during the night due to the resident being confused and restless. FM l stated the family arrived at the facility the next day on 11/8/19, at approximately 9 a.m. and was told Resident 1 was missing. During the telephone interview, on 11/13/19 at 3:25 p.m., FM 1 stated on 11/18/19 at 12 p.m., he was notified by the police Resident 1 was taken to GACH 2. FM l stated Resident 1 was said to be dehydrated (use or lose more fluid than you take in), in pain and had pulled the urinary catheter out again. FM l stated Resident 1 remained very confused now. FM l stated he asked the SNF's staff to keep an eye on Resident 1 when they left him there on 11/7/19 and he did not understand how the facility staff (PTA 1) could have let him leave unsupervised. FM l stated they did not want Resident 1 to return to the facility on ce discharged from GACH 2. A review of GACH 2's H/P, dated 11/8/19 and timed at 3:40 p.m. indicated Resident 1 was brought to the emergency room (ER) after being found wandering and delirious (an acutely disturbed state of mind) after eloping from a SNF on 11/8/19. Resident 1 was assessed to be confused with an unclear etiology (the cause, set of causes, or manner of causation) without the ability to recognize family members; thinking he was at home and did not remember eloping from the SNF. The H/P indicated Resident 1 underwent an extensive workup for confusion. The H/P indicated Resident 1 remained confused and was discharged to another SNF on 11/12/19, as the family refused readmission to the SNF he eloped from. A review of the facility's undated policy and procedures titled Elopement Risk Reduction Approaches, indicated as necessary, provide new residents (to the facility, wing, unit, etc.) with additional staff assistance until they are comfortable in their new environment to ensure residents are monitored and remain safe. Training: Facility staff needs to know how to identify and understand the resident's needs, the residents' propensity to wander and the triggering conditions and the consequence of unsafe wandering. A review of the facility's undated policy and procedures titled, Wandering & Elopement, indicated the facility will identify residents at risk for elopement. A review of the facility's policy and procedures titled, Admission Assessment indicated the Licensed Nurse (LN) would complete an admission assessment for residents upon admission to the facility and disseminate the information to the staff.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was at high risk for falls, had her bedside rails up while in bed, her bed was in a low position, and that the staff were monitoring the resident closely to prevent falls and injuries. This deficient practice result in Resident 1 falling from a bed without the side rails up, sustaining a right shoulder dislocation with a fracture (broken bone) and requiring 17 day stay in the general acute care hospital (GACH). Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE], with a most recent readmission on 7/7/18. Resident 1's [DIAGNOSES REDACTED]. A review of a physician's orders [REDACTED]. A review of Resident 1's care plan, dated 7/9/18, titled, At Risk for Falls due to weakness, impaired mobility, medications, and unable to transfer without assistance. The staff's interventions included to educate the resident in safety awareness, keep call light within reach and answer promptly, and reorient the resident to the environment. A review Resident 1's care plan, dated 7/9/18 and titled, Side Rails Management, indicated the goal was that Resident 1 would be provided with education in the safe use of side rails daily. The staff's interventions included to check side rails periodically for safety/security and assess the bed and side rails for possible entrapment. A review of a Fall Risk Data Collection, dated 9/7/18 indicated Resident 1 had a score of 11 (a score of 10 and above indicates high fall risk). A review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 9/12/18, indicated the resident was not able to understand and be understood by others. Resident 1 was severely impaired in cognitive skills with a Brief Intervention of Mental Status (mental assessment) score of 0 (0-7 = severe cognitive impairment). According to the MDS, Resident 1 required minimal assistance from staff with bed mobility, transferring from a bed and chair to a standing position, moving from one location in the facility to another, dressing, eating toilet use and personal hygiene. The MDS also indicated Resident 1 used a wheelchair for mobility and was incontinent (inability to control) of bowel and bladder functions. A review of a Weekly Summaries, from 11/30/18 through 12/6/18, indicated Resident 1 required an extensive assistance from the staff with bathing, dressing, hygiene, and bed mobility. It also indicated the resident was totally dependent on the staff's assistance with transferring and mobility. A review of a Situation Background Assessment and Recommendation (SBAR) Communication Form, dated 12/7/18 and timed 1:50 p.m., indicated Certified Nursing Assistant 1 (CNA 1) found Resident 1 on the floor. The SBAR indicated Resident 1 had a right shoulder dislocation (displacement of a body part from its original place) and complained of pain to the right shoulder rated at 6/10 (10 being the worst) and left side head pain rated at 4/10. A review of a Physician Discharge Summary, dated 12/7/18, indicated Resident 1 was found on the floor and complained of pain to the left side of the head and sustained a right shoulder dislocation. A review of an Interdisciplinary Team Conference Record ((IDT) group of disciplines that work together towards a common goal) dated 12/7/18 indicated Resident 1 was found on the floor lying on the right side. The note indicated the resident was noted with signs of dislocation and the physician ordered to transfer the resident to a GACH. A review of a Fall Incident and Evaluation, dated 12/10/18, indicated on 12/7/18, at 1:45 p.m., Resident 1 was found in a right side lying position on the floor. The note indicated Resident 1 sustained a right shoulder dislocation and was transferred to a GACH. A review of the GACH's Emergency Documentation (ED) dated 12/7/18 and timed 2:56 p.m., indicated Resident 1 was brought into the ED after falling at a skilled nursing facility. It indicated the resident complained of a right shoulder and hip pain at 10/10. A review of another ED report, dated 12/7/18, timed 7:05 p.m., indicated Resident 1 had a shoulder reduction. According to this report, the resident's family (FM 1) had concerns that Resident 1 was abused at the skilled nursing facility and did not want Resident 1 to return to the facility upon discharge. This report also indicated Resident 1 was to wear a C-collar (a neck brace used to support the neck after an injury to prevent further injuries) until her injuries were resolved. A review of the GACH's Inpatient Progress Note dated 12/10/18 and timed 9:57 p.m., indicated Resident 1 had an unstable right shoulder fracture that required neurological checks (to check for level consciousness) every two (2) hours, and medications for pain. A review of a GACH Consultation Note, dated 12/10/18 and timed 7:51 a.m., indicated Resident 1 was treated with the following: [MEDICATION NAME] 325 milligram (mg) (mild pain medicine) every 6 hours (hrs) by mouth (PO) as needed (PRN) for pain, intravenous ((IV) through the veins) fluids, and [MEDICATION NAME] (blood thinner to prevent clotting) 30 mg subcutaneously ((SQ) injection under the skin) every 12 hrs. A review of a right shoulder x-ray, dated 12/12/18 and timed at 5:43 p.m., indicated Resident 1 had a right shoulder comminuted (when a bone breaks into more than two fragments and occurs after high impact-trauma) humeral neck (top of the long bone in the upper arm) fracture. A review of a right upper extremity computerized tomography ((CT) process of taking pictures from different angles of the bones, blood vessels and soft tissue to diagnose injuries or diseases), dated 12/18/18 and timed at 4:38 p.m., indicated Resident 1 had a right humeral (long bone in the upper arm) head dislocation. A review of Resident 1's right shoulder CT, dated 12/18/18 and timed at 5:43 p.m., indicated Resident 1 had a comminuted humeral fracture. A review of the GACH's Discharge Documentation, dated 12/24/18 and timed at 4:32 p.m., indicated Resident 1 was admitted to the GACH on 12/7/18 and discharged on [DATE] (17 days later). The discharge plan included non-weight bearing (NWB) to the right upper extremity (RUE) and to keep the shoulder externally (away from your body) rotated in a sling (device used to keep the arm from moving). On 1/4/19, at 12:34 p.m., during an interview, Restorative Nursing Assistant 1 (RNA 1) stated that prior to the accident on 12/7/18, Resident 1 was able to turn in bed with staff's assistance. According to the RNA, the resident's side rails must have been down, on that day (12/7/18). At 12:48 p.m., on 1/4/18, during an interview, the Director of Nursing (DON) was asked about Resident 1's fall with injury that occurred on 12/7/18, the DON stated Resident 1 was at risk for falls and required close monitoring. The DON stated Resident 1's bed was close to the nurses' station so that the staff could keep an eye on the resident. The DON also stated that Resident 1's bed was supposed to be in the lowest position and both side rails up, whenever the resident was in bed to prevent falls. The DON stated Resident 1's side rails were not up. On 1/4/19 at 1:08 p.m., during an interview, Registered Nurse 1 (RN 1) stated that on 12/7/18, at approximately 1 p.m. Resident 1 had an unwitnessed fall, complained of pain on the right shoulder and left side of the head. RN 1 also stated that the resident had a right shoulder dislocation. According to RN 1, Resident 1's curtain should have been opened for visual access to the staff. RN 1 stated that the resident's bed was elevated as if a staff was about to feed the resident and it should not have been. On 1/4/19 at 1:21 p.m., during an interview, the Director of Staff Development (DSD) stated that on 12/7/18, Resident 1 was observed on the floor crying in pain. The DSD stated that Resident 1 had a right shoulder subluxation (partial dislocation). According to the DSD, Resident 1's bed was observed to be elevated at the time the resident was found on the floor. The DSD stated that keeping side rails up could have protected and prevented the resident from falling out of the bed to the floor. At 1:34 p.m., on 1/4/19, during an interview, CNA 1 stated that on 12/7/18, between the times of 12 p.m. to 1 p.m., Resident 1's roommate pressed the call light and when CNA 1 answered the call light, she found Resident 1 lying on the floor next to her bed. CNA 1 stated Resident 1 did not have side rails up, the bed was elevated, and there was no floor mat. CNA 1 added that the resident had a tendency to lean on the right side and the side rails should be up to prevent falls and injuries. A review of the facility's policy titled, Falls Management Program, with a revised date of 11/16, indicated the purpose of the policy was to provide the residents with a safe environment that minimizes complications associated with falls. The policy indicated the facility will implement a Fall Management Program that supports providing an environment free from the hazards.

Based on interview and record review, the facility's nursing staff failed to ensure one of 17 sample residents (Resident 7), was continuously monitored and assessed, according to the plan of care for [MEDICATION NAME] (used to to slow the heart rate in patients with [MEDICAL CONDITION]) toxicity and that the nursing interventions were followed. The nursing staff failed to notify the physician of the recommendations made by the pharmacist to draw serum [MEDICATION NAME] levels for the month of June and August 2009. On October 31, 2009, the resident was transferred to an acute hospital for assessment and evaluation. The acute hospital's emergency room 's clinical record, indicated the resident's [MEDICATION NAME] level was 7.5 nanogram/milliliter (ng/ml), normal [MEDICATION NAME] levels are 0.8 to 2.0 ng/ml ([MEDICATION NAME] dosing). According (Drug Information Handbook for Nursing, 8th Edition) [MEDICATION NAME] toxicity signs and symptoms and complications are weakness, confusion, anorexia, heart failure and arrhythmias with an abnormal heart rate, characterized with a slow, a fast irregular heart rate. Failure to monitor and assess a resident on [MEDICATION NAME] medication, caused the resident's admission to the hospital with the [DIAGNOSES REDACTED]. Findings: On April 28, 2010, an unannounced visit was made at the facility and the Administrator was made aware of the complaint investigation. According to the admission record, Resident 7 was admitted on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. A physician's orders [REDACTED]. According to the Minimum Data Set (MDS), a standardized assessment tool, dated March 25, 2009, indicated the resident's cognitive skills for daily decision making were independently modified and the resident had no difficulty making herself understood. The Licensed Nurse's Progress Note dated October 31, 2009 at 1:30 p.m., indicated the resident was assessed with [REDACTED]. The resident's skin color was pale, her pulse was faint, with an undetectable blood pressure, and her oxygen saturation was 75 per cent on room air. A review of the plan of care dated January 9, 2009, indicated the resident was at risk for [MEDICATION NAME] toxicity, the resident taking the medication [MEDICATION NAME]. The nursing goal was to maintain the resident's [MEDICATION NAME] level within the [MEDICATION NAME] therapeutic range and to review every three months. The nursing intervention was to monitor the resident for sign and symptoms of [MEDICATION NAME] toxicity, such as anorexia (a prolonged disorder of eating due to loss of appetite), arrhythmias, dizziness, headache, stupor and hold [MEDICATION NAME] if pulse rate is below 60. A review of the Pharmacist's Consultation Report dated August 20, 2009, during the drug regimen review on June 15, 2009, indicated the resident's [MEDICATION NAME] level needs to be checked, and to have the resident's [MEDICATION NAME] levels drawn in the month of July 2009 and then every six months. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On October 25, 2009, at 5 p.m. there was a recorded blood pressure of 96/58. On October 28, 2009, at 9 a.m., the 125 mcg [MEDICATION NAME] was held because the resident's apical pulse rate was 55 bpm (normal apical pulse 60 to 100 bpm). On October 29, 2009 (Thursday) there were no orthostatic blood pressures recorded. A review of the resident's clinical record indicated there was no documented evidence on October 25, 2009. the physician was notified regarding the resident's blood pressure 96/58. On October 28, 29 and 30, 2009 there was no indication the 11 p.m. to 7 a.m., shift monitored the resident's apical pulse and blood pressure, as there was no apical pulse and blood pressure documented. On October 28, 29 and 30, 2009 there were no nursing assessments with documentation of the resident's mental status, complaints such as dizziness, pain, intake and output, or documentation the resident had no complaints after the documented apical pulse of 55 bpm. Further review of the resident's clinical record indicated no Change of Condition Assessment was completed after a documented apical pulse of 55 bpm. During an interview with the Acting Director of Nurses (ADON), on June 28, 2010 at 9:30 a.m., she reviewed the licensed nurse's progress notes, the Physician's Progress Notes, and the Pharmacy Consultation Book, and was unable to find written documentation of the physician being notified of the pharmacist's recommendations. The ADON was also unable to find written documentation of the physician's response to accept or reject the pharmacist's recommendations to have the [MEDICATION NAME] level drawn. The ADON further stated the last time the [MEDICATION NAME] level was drawn by the facility was on March 9, 2009, and that [MEDICATION NAME] level was low at 0.6 ng/ml. During the interview, the ADON stated she received the consultation report with the recommendations from the pharmacist. The ADON stated the supervising registered nurse (RN), such as herself or RN 2, is responsible for receiving the pharmacist's recommendations and to communicate that information to the physician. A review of the resident's clinical record at the facility, on April 28, 2010, of the acute hospital's emergency room 's records and the acute facility's History and Physical, dated October 31, 2009, indicated the following: According to the acute hospital's emergency room Admission records, the paramedics arrived at the nursing facility and found the resident lying in bed, alert and oriented times two with increased confusion. The blood pressure was 80 mm/Hg (millimeter of mercury) palpable (able to be felt by the hands, especially in a medical examination) by the emergency medical service. The emergency room 's physical examine indicated the resident's blood pressure was 75/46 mm/Hg a low blood pressure and the resident was very sluggish, somewhat lethargic and disoriented. The acute hospital's lab results indicated the resident's Blood Urea Nitrogen (BUN) was elevated at 70 mg/dl, (BUN normal levels are 6 - 26 mg/dl) and the Serum Creatinine was elevated at 2.1 mg/dl, (Serum Creatinine normal levels are 0.40 - 1.00 mg/dl) and a [MEDICATION NAME] serum lab was ordered and the [MEDICATION NAME] level was elevated at 7.5 ng/ml ([MEDICATION NAME] normal levels are 0.8 to 2.0 ng/ml). (www.nlm.nih.gov, MedlinePlus) The resident received 1000 milliliters of Normal Saline intravenously (IV) and was still hypotensive (low blood pressure) and an additional 500 milliliters of Normal Saline IV was administered and the resident's blood pressure was 104/57 mm/Hg. Also, the resident's urinary output slowly improved and increased with the Normal Saline intravenous (IV) fluids (1500 ml). A further review of the acute hospital's emergency room 's records dated, October 31, 2009, indicated the resident was in critical condition and was extremely dehydrated. The Electrocardiogram (an interpretation of the electrical activity of the heart - Wikipedia, the free encyclopedia), indicated the resident's heart rate was 58 bpm, a slow heart rate (normal heart rate 60 to 100 bpm) indicating [MEDICATION NAME] toxicity. The resident was admitted to the Intensive Care Unit (ICU) with [DIAGNOSES REDACTED]. The acute hospital's History and Physical, dated October 31, 2009, indicated the resident's altered level of consciousness was due to severe dehydration and [MEDICATION NAME] toxicity.

Based on interview and record review, the facility failed to assess and maintain patency of the Foley catheter to ensure normal urinary function for 1 of 20 sampled residents (Resident 7), which resulted in the resident having severe abdominal pain assessed as 10/10 (0 = pain free and 10 = severe pain) having to be hospitalized for [REDACTED]. Findings: Responding to a complaint allegation, Resident 7's clinical record was reviewed on April 28, 2010. A review of the general acute care hospital's (GACH) emergency room (ER) record dated March 27, 2010, indicated the resident was sent by the facility because of abdominal distention and lack of bowel movement for twenty-four hours, and upon arrival to the ER the resident had an indwelling Foley. The resident's abdomen was distended with diffuse tenderness to palpation. There does appear to be a central mass below the [DEVICE]. The ER document further indicated the nursing staff went to change the Foley, when it was removed the patient immediately had incontinence with an estimated 1-2 liters of urine coming from her urethra onto the bed. The patient's abdominal distention immediately resolved as did the abdominal mass. The document indicated the resident appeared to have a clogged Foley catheter. A review of the GACH physician's history and physical dated March 27, 2010, indicated the resident was assessed to have acute [MEDICAL CONDITION], "likely" secondary to obstruction. A review of the acute hospital's Discharge Summary indicated the resident was admitted to the inpatient services on March 27, 2010. Resident 7 was transferred back to the skilled nursing facility on March 30, 2010. On April 28, 2010 at 12:11 p.m., during an interview, Licensed Vocational Nurse (LVN 1), who transferred the resident to the hospital, stated she did a full body assessment and saw the resident's abdomen was hard. LVN 1 stated the resident's Foley catheter was draining urine and had some sediments. According to the daily medicare notes dated March 27, 2010 at 9:45 a.m., LVN 1 documented Resident 7's urine was yellow, cloudy, with some sediments noted in the Foley catheter tube. According to the facility's narrative notes dated March 27, 2010 at 9:45 a.m., LVN 1 documented the resident's abdomen was very hard to touch and that the resident complained of severe pain of 10/10, to abdominal area and had facial grimacing. The resident was repositioned for comfort. At 10:50 a.m., the resident was sleeping and the abdominal distention was still noted. At 11:40 p.m., the medical doctor gave a telephone order to send the resident to the ER for evaluation and to rule out possible bowel obstruction. At 1:10 p.m., the ambulance arrived to transport the resident to the GACH. The clinical record for Resident 7 was reviewed on June 26, 2010. A physician's telephone order dated March 19, 2010 indicated to insert a Foley catheter and change the Foley catheter as needed when plugged, and to change the Foley catheter for sediments. On June 26, 2010 at 8:27 p.m., during a telephone interview, LVN 2, who received the telephone order and inserted the Foley catheter, stated the Foley catheter was for the bad excoriation to the perineal and groin area of Resident 7. LVN 2 stated sediments can cause some blockage in urine flow, but with adequate urine output, the Foley catheter may not require changing. During an interview with the acting director of nurses (ADON), on June 28, 2010 at 9:15 a.m., she reviewed LVN 1's narrative notes dated March 27, 2010 and stated the documentation was of the resident's bowel status and that no registered nurse assessed the resident prior to the resident being transferred to the GACH. In a subsequent interview at 11:04 a.m., after reviewing the GACH's ER notes and LVN 1's narrative notes, both dated March 27, 2010, the ADON stated although the resident was assessed for bowels, a bladder assessment should have been done. The facility policy and procedure titled "Indwelling Catheter Care" dated March 2000, indicated for staff to inspect the catheter and tubing periodically to detect compression or kinking that could obstruct urine flow and to assess for bladder distention.