Every finding on record at Glendale Post Acute Center

Based on observation, interviews, and record review, the facility failed to develop a resident centered care plan for one of three sampled residents (Resident 1), who routinely refused showers due to a preference for bed baths. This deficient practice had the potential for Resident 1 continuous refusal of and missed opportunities for the facility to provide care in accordance with the resident's choices.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE], with a diagnosis to include Paraplegia( paralysis affecting both lower legs), quadriplegia (severe weakness affecting legs and arms), and Anxiety ( excessive worry, fear, or nervousness). During a review of Resident 1's Minimum Data Set ( MDS- a resident assessment tool), dated 4/1/2026, the MDS indicated the Resident 1 is cognitively intact ( fully alert, oriented, and able to make decisions and participate in care planning) Requiring only supervision or touching assistance (helper provides verbal cues and or touching / steadying and or contact guard assistance as resident completes activity when performing oral hygiene, upper body dressing and personal hygiene ( combing hair, shaving, washing/ drying face and hands ). During an interview on 7/8/2026 at 9:56AM with Resident 1, Resident 1 stated the facility provided showers to him on Mondays and Thursdays. Resident 1 stated if he declined a shower on those days, the facility did not provide a shower or bed bath that week. Resident 1 stated he preferred bed baths and that was the reason he would refuse showers. Resident 1 stated he preferred bed baths since he had previously fallen while being transferred in a Hoyer lift ( a mechanical lift used to transfer residents) for showering which continued to cause fear and anxiety . Resident 1 stated he wished to complete his bed bath independently and required only assistance with washing his legs and back. Resident 1 stated the facility is aware of this preference, but some staff continued to deny the requested supplies and instead documented that the resident had refused bathing. Resident 1 stated only a few certified nurse assistants (CNAs) honored his preference for a bed bath, while others did not consistently accommodate his choice. During a concurrent interview and record review on 7/8/2026 ay 12:05pm with MDS, Resident 1's active care plans were reviewed. MDS stated no care plan had been developed that specified Resident 1's preferences for bed baths instead of showers. MDS stated that without an individualized care plan, there was a lack of continuity of care. During an interview on 7/8/2026 at 12: 21 PM with CNA 2, CNA 2 stated she was Resident 1's assigned CNA on most days. CNA 2 stated Resident 1 has reported not wanting to shower because he was afraid the shower would get his wound dressing wet and increased Resident 1's fear of developing an infection. During an interview on 7/8/2026 at 2:24 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she did not know that Resident 1 preferred a bed bath instead of a shower. LVN 1 stated Resident 1's preference for wanting a bed bath should be care planned so staff were aware of Resident 1's preferences when providing care to Resident 1. During an interview on 7/8/2026 at 3:05 PM with Administrator (ADM), the ADM stated Resident 1's preference in bed baths over showering should be care planned, and without the specific care plan, Resident 1's consistency of care provided would be affected since staff did not know Resident 1's specific needs. During a review of the facility's policy and procedure ( P&P) titled, Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated that a comprehensive, person- centered care plan is to be developed and implemented for each resident and include measurable objectives and interventions based on the resident's assessed physical, psychosocial, and functional needs. The policy indicated that the care plan is to reflect the resident' stated goals, preferences, desired outcomes, services to be provided, and interventions necessary to maintain the resident's highest practicable level of well-being.

Based on observation, interview, and record review, the facility failed to ensure that Treatment Nurse (TXN) 1 observed the facility's Enhanced Barrier Precautions (EBP, an infection control strategy used in nursing homes to prevent the spread of multi-drug resistant organisms [MRDO, hard to treat, drug resistant germs]) policy and procedure and the facility's Infection Control policy and procedure when TXN 1 failed to wear a personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing wound care for one of three sample residents (Resident 3). This deficient practice resulted in the failure to follow the facility's Infection Control policy to ensure the facility maintained a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections and had the potential to result in the spread of bacteria such as MDROs and viruses among the residents, staff, and visitors within the facility. Findings: During a review of Resident 3's admission Record (AR), the AR indicated that the facility admitted Resident 3 on 6/1/2026 with diagnoses that included sepsis (a life-threatening blood infection), Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 3's Order Summary Report, the order, dated 6/2/2026, indicated that Resident 3 had a sacrum (lower back area above the buttocks) pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence), left gluteus (the buttocks muscle) pressure injury and a left gluteal fold (the crease where the buttocks muscle and upper thigh meet) pressure injury with a wound care treatment to clean with normal saline, pat dry, apply medihoney gel (antibacterial honey ointment) and calcium alginate (type of wound care dressing), and cover with dry dressing every day for 30 days. During a review of Resident 3's Order Summary Report, the order, dated 6/2/2026, indicated that Resident 3 had a left above the knee amputation (AKA, surgical removal of the portion of the leg above the knee) with wound care treatments to clean with normal saline, pat dry, apply a wet to dry dressing (wound care technique) with Vashe solution (wound care solution), wrap with kerlix (gauze bandage roll) dressing, and tape every day for 21 days. During a review of Resident 3's care plans, dated 6/3/2026, the care plans indicated that Resident 3 had a left above the knee amputation, a stage 3 (full-thickness loss of skin. Dead and black tissue may be visible) left gluteus pressure injury, a stage 3 left gluteal fold pressure injury, and a stage 3 sacrum pressure injury. The care plans interventions included providing wound care daily and notifying the physician for signs and symptoms of infection such as redness, drainage, pain, and warmth at the site. During an observation on 6/5/2026 at 1:43 PM by Resident 3's room, an EBP sign was posted outside Resident 3's room. The EBP sign indicated that residents who had a blue dot next to their name plate indicated that those residents had EBP during high contact activities. During an observation on 6/5/2026 at 1:45 PM by Resident 3's room, TXN 1 was observed preparing his wound care treatments and supplies for Resident 3. After TXN 1 prepared his wound care treatments and supplies, TXN 1 was observed entering Resident 3's room without wearing a gown. For about 45 minutes, TXN 1 was observed performing Resident 3's wound care treatments to the left gluteal fold site, left gluteus site, sacrum, and left above the knee amputation wound without wearing a gown. During an interview on 6/5/2026 at 2:38 PM with TXN 1 after Resident 3's wound care treatment, TXN 1 stated that he did not wear a gown while performing Resident 3's wound care treatments because the wounds did not have any discharge or secretions. During the same interview and record review on 6/5/2026 at 2:40 PM with TXN 1, the EBP sign posted by Resident 3's room, was reviewed. TXN 1 stated that the EBP sign and blue dot by Resident 3's name indicated that Resident 3 had EBP precautions. TXN 1 stated that the EBP sign indicated that providing wound care was one of the high contact resident activities and staff were supposed to wear gowns and gloves prior to providing direct patient care. During an interview on 6/5/2026 at 3:10 PM with the Director of Nursing (DON), the DON stated that EBP were used to protect the spread of MDROs between residents and staff. The DON stated that any residents with open wounds and in-body medical devices were automatically placed on EBP. The DON stated any staff member providing wound care treatments to residents with EBP were supposed to wear gowns and gloves. During a review of the facility's policies and procedures (P&P) titled Infection Control, dated 10/2018, the P&P indicated that the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infection, and the P&P applied to all personnel within the facility including residents, employees, contractors, and visitors. During a review of the facility's policies and procedures (P&P) titled Enhanced Barrier Precautions, dated 8/2022, the P&P indicated that Enhanced Barrier Precautions were used to as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. The P&P indicated that EBP included the use of gown and gloves during high contract resident care such as but not limited to wound care (any skin opening requiring a dressing).

Based on interview and record review, the facility failed to identify resident's needs and care for one of four sampled residents (Resident 1) in accordance with the resident's preferences, goals of care and professional standards of practice as indicated on facility's Policy and Procedure (P&P) when, 1)Resident 1 was admitted on [DATE] had Moisture-Associated Skin Damage (MASD- an inflammatory skin condition caused by prolonged exposure to moisture, such as sweat, urine, or wound exudate) in the groin area extended to the gluteal fold and there was no care plan (CP) to care for MASD. Resident 1 was discharged home on 4/21/2026 with MASD in the groin area extended to the gluteal fold. 2)Resident 1 who had history of stage 3 pressure injury (pressure ulcer [PU]- a localized damage to the skin and underlying tissues caused by prolonged, unrelieved pressure, friction or shear forces) and was moderate risk for PU and did not have a weekly skin assessment and updated CP from 3/20/26 to 4/20/2026. These deficient practices resulted in Resident 1 did not receive any assessments and care plan with measurable objectives and timeline to resolving the MASD, potential PU to reoccur, and was discharged with MASD still on the groin site. Findings: During a review of Resident 1's admission record indicated the resident was admitted on [DATE] with diagnoses that include but not limited to hemiplegia and hemiparesis (paralysis, half/partial weakness) affecting left dominant hand, cerebral infarction (the death of tissue caused by a lack of blood supply and oxygen to that area), diabetes (a chronic condition where body either cannot produce enough insulin or cannot effectively use the insulin it makes cause blood sugar too high and led to serious complications) and obesity (too much body fat that increases the risk of other serious health problems). During a review of Minimum Data Set (MDS, a resident assessment tool), dated 2/8/2026, indicated Resident 's cognitive skills (ability to make daily decisions) were intact. The MDS indicated, Resident 1 requires setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with eating, and partial/moderate assistance (helper does less than half the effort) oral hygiene, and dependent (helper does all the effort) with toileting, bathing and dressing. During a review of Resident 1's Order Summary Report (OSR) dated 2/5/2026, the OSR indicated, Resident 1 had a treatment posterior groin extending to gluteal folds for MASD - clean with water and soap pat dry apply A&D ointment and zinc, report to MD if worsening. During a concurrent interview and record review on 6/1/2026 at 12:45 PM with DON (Director of Nursing), Resident 1's EHR-electronic health record dated 2/4/2026 (admission) to 4/21/2026 (discharge) was reviewed. Resident 1's EHR indicated: -Resident 1 was admitted on [DATE] and had a planned discharge on [DATE]. -Resident 1 did not have CP for MASD and updated PU CP. -Resident 1's last weekly skin assessment by skin doctor (SD) and Treatment Nurse (TN) 1 was on 3/20/2026. DON stated, he was not sure why there was no CP for MASD and updated PU care plan, and why there was no weekly skin assessment after 3/20/2026 it was part of our standard of practice. During an interview on 6/1/2026 at 2:25 PM with TN 1, TN 1 stated, he forgot to initiate a care plan for Resident 1's MASD and updated PU care plan. TN1 stated, after Resident 1's left rear thigh PU resolved on 3/17/2026, his last weekly skin assessment was 3/20/2026 and forgot to continue it. TN 1 stated, Resident 1's MASD was just stable but not resolved. During a concurrent interview on 6/1/2026 at 2:27 PM with TN 1, TN 1 stated, Resident 1's care plan for MASD and PU was important so there's a goal for its resolution, and revision of treatment if needed. TN 1 stated, Medical Doctor (MD) was not aware Resident 1's MASD was not resolving. During a concurrent interview on 6/1/2026 at 2:29 PM with TN 1, TN 1 stated, as a standard of care he should have continued Resident 1's weekly skin assessment, and Resident 1 having a history of stage 3 PU, not having a weekly monitoring potentially could result in reoccurrence. During a review of Resident 1's Progress Notes (PN) dated 4/21/2026, the PN indicated, Resident 1 had MASD on groin site extended to gluteal fold upon discharge. During a concurrent interview and record review on 6/1/2026 at 4:40 PM with DON, Resident 1's Braden Scale-for Pressure Ulcer Risk Evaluation dated 2/4/2026 was reviewed. The Braden Scale indicated Resident 1' score was 15 (score of 12 or less indicates high risk / score of 19 or higher indicates low risk). DON stated Resident 1's score of 15 indicated moderate risk to acquire pressure ulcer. During a concurrent interview and record review on 6/1/2026 at 4:41 PM with the DON, Resident 1's Braden Scale-for Pressure Ulcer Risk Evaluation dated 4/17/2026 was reviewed. The Braden Scale indicated Resident 1' score was 14. DON stated Resident 1's score of 14 indicated moderate risk to acquire pressure ulcer. During an interview on 6/1/2026 at 4:42 PM with the DON, DON stated it is the facility's standard of practice and facility's policy, and procedure (P&P) also indicate, assessment, documentation, prevention and CP is required to prevent and heal PU and any skin breakdown. DON stated, Resident 1's MASD is a wound so it should have a care plan and weekly skin assessment to proper monitor if it is getting better or not and address it accordingly. DON stated, not having a care plan and a weekly skin assessment, resulted in Resident 1 not having a measurable objective and timetable in resolving the MASD, also potentially result in the reoccurrence of PU which can negatively affect Resident 1's quality of life. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, indicated; a) the comprehensive , person-centered care plan includes measurable objectives and time frames, resident's goals and outcomes, b) assessment of residents are ongoing and care plans are revised as information as information about the residents and the resident's condition changed. A review of the facility's P&P titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 4/2018, indicated, a)nursing staff and practitioners will assess and document an individual significant risk factors for developing pressure ulcers, such as immobility and history of pressure ulcer, b)during resident visits the physician will evaluate and document the progress of wound healing especially for those with complicated, extensive, or poorly healing wounds, and c)the physician will guide the care plan as appropriate, especially when wounds are not healing. A review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, dated 4/2020, indicated; a) assess the resident for existing pressure injury risk factors and repeat the risk assessment weekly and upon any change of condition and b)evaluate, report and document potential changes in the skin.

The facility failed to ensure care and services were provided to one of two sampled residents (Resident 1) as ordered by the physician by failing to: 1. Document Resident 1's high blood pressure (when the force of the blood pushing against the artery walls is too high) on 5/17/20262. Notify the physician of Resident 1's high blood pressure This deficient practice had the potential to delay assessment and treatment of uncontrolled hypertension Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included quadriplegia (partial or total paralysis of all four limbs (both arms and both legs) and the torso), atrial fibrillation (irregular heartbeat). During a review of Resident 1's History and Physical (H&P), dated 5/7/2025, 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 4/08/2026, the MDS indicated Resident 1is dependent (helper does all the effort. Resident does none of the effort to complete the activity) for toileting, shower, upper and lower body dressing and putting on and taking off footwear. The MDS further indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) for personal hygiene. During a review of Resident 1's Care plan for altered cardiovascular status at risk for hypertension/hypotension related to hypertension initiated on 4/07/2026, the care plan indicated to monitor vital signs as ordered, notify MD of significant abnormalities. Resident 1's care plan further indicated to monitor, document, report to MD as needed any signs and symptoms of malignant (very high blood pressure that comes on suddenly and quickly): headache, visual problems, confusion, disorientation, lethargy, nausea . During a review of Resident 1's Progress notes dated from 5/15/2026 to 5/18/206, the Notes did not indicate Resident 1's elevated blood pressure of 175/105, MD notification or monitoring for elevated blood pressure. During a review of Resident 1's Progress noted dated 5/18/2026 timed at 6:25 PM written by the Director of Nursing (DON), the note indicated Resident complained about care received on 5/17/2026. The Noted indicated Resident 1 stated he went to the nursing station around 4 PM because he did not feel good and asked why his call light was not answered and licensed vocational nurse (LVN) 2 was seated at the nurses' station. LVN 2 stated she was not on duty, and LVN 1 was walking back to the nurse's station. LVN 1 then went to address Resident 1's concerns. During an interview on 5/19/2026 at 1:53 PM with LVN 1, LVN 1 stated around 3:40 PM she was in a Residents room when she heard an overhead page asking for Resident 1's nurse to go to Resident 1's room. LVN 1 stated she was in the middle of passing medication and was unable to go to Resident 1's room right away. LVN 1 stated about 15 minutes later she was still passing medication and heard an over head page asking for Resident 1's nurse to go to Resident 1's room, LVN 1 stated she did not stop medication pass to go to Resident 1's room because she assumed another nurse would assist Resident 1 since it was the second time they were paging . LVN 1 stated once she finished passing medication she went towards Resident 1's room to see if he had been helped when she saw him in his wheelchair going towards the nursing station. LVN 1 stated she observed 3 licensed nurses sitting at the nurse's station then observed Resident 1 telling them he had been waiting for help because he wasn't feeling well and no one came to help him. LVN 1 stated she then assisted Resident 1 back to his room and Resident 1 told her he was not feeling well and asked her if he could check his BP. LVN 1 stated she checked Resident 1's BP and it was 178/105 and she asked Resident 1 if he was feeling ok to which Resident responded he was upset and not feeling well then proceeded to ask her to give him his medication for his Angina (chest pain or discomfort that happens when your heart muscle doesn't get enough oxygen-rich blood) diagnosis. LVN 1 stated she administered Resident 1's medication and then returned one hour later to re-check Resident 1BP and it had returned to Resident 1's baseline. During an interview on 5/19/2026 at 2:31 PM with Resident 1, Resident 1 stated on Sunday. 5/17/2026 in the afternoon he was not feeling well and pressed the call light to ask for help. Resident 1 stated no one came to help him, so he decided to call the facility phone and told the nurse who answered he had pressed his call light because he was not feeling well and needed help. Resident 1 stated he heard them overhead page 2 times, but no one came to help him. Resident 1 stated he could hear the nurses sitting at the nursing station talking. Resident 1 stated his head was hurting and felt like it was pounding in pain, so he decided to go to the nursing station himself to ask for help since no one was coming to help him. Resident 1 stated when he got to the nurse's station, he saw 3 nurses sitting there talking and that's when his assigned nurse LVN 1 came out of another patient's room to ask if he still needed help. Resident 1 stated his nurse LVN 1 helped him back to his room and took his BP which was 178/105. Resident 1 started LVN 1 then gave him his medication. Resident 1 stated during the time he was calling for help he felt his heart racing, his head was hurting and terrified because he could hear the nurse talking and laughing in the nurse's station while he was calling for help and no one would come to help him. During a concurrent interview and record review on 5/19/2026 at 4:08 PM with LVN 1, Resident 1's records were reviewed. LVN 1 stated she forgot to document Resident 1's elevated BP on 5/17/2026. LVN 1 stated she did not notify Resident 1's physician (MD) of Resident 1's elevated BP because she assumed it was high because Resident 1 was upset. LVN 1 stated Resident 1's usual BP was low, and she had never seen it that high before. LVN 1 stated she should have made a progress note of Resident 1's condition and elevated BP and notified Resident 1's MD but she forgot. During an interview and concurrent record review on 5/19/2026 at 4:50 PM with the DON, DON stated there was no documentation on Resident 1's medical record of an elevated BP on 517/2026. The DON stated LVN 1 should have notified Resident 1's MD of Resident 1's elevated BP and symptoms immediately. DON stated LVN 1 should have documented Resident 1's vitals and assessment in Resident 1's medical record. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status , with a revision date of 2/19/2021, the P&P indicated The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition, specific instructions to notify the physician of changes in the resident's condition.

Based on observation, interview and record review, the facility failed to ensure effective pain management was provided for one out of three sample residents (Resident 1) by failing to: Re-evaluate the effectiveness of nonpharmacological interventions (non-chemical, and non-invasive health interventions that treat conditions without medication).Ensure Resident 1 received pain medications as ordered. This deficient practice had the potential to result in unmanaged pain which could delay recovery, decrease mobility, and reduce the quality of life. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of displaced fracture of anterior process of right calcaneus( break in the front part of right heel bone that has moved out of place) , fracture of right talus ( broken right ankle bone) , fracture of scaphoid of right foot ( a small broken bone in right foot) and dislocation of tarsometatarsal joint (displacement of middle foot bones connected to the long foot bones or toes) of right foot . During a review of Resident 1's History and Physical (H&P) dated 12/10/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/13/2025, the MDS Resident 1 had pain present occasionally. During a review of Resident 1's Order Summary Report, dated 12/09/2025, the Report indicated to monitor for pain level on a pain scale (a tool used by healthcare professionals to objectively measure and quantify a patient's subjective experience of pain intensity. It typically uses a 0 to 10 scale (0 = no pain, 10 = worst possible pain) every shift. During a review of Resident 1's Order Summary Report, dated 12/09/2025, the Report indicated for non- prescription behavioral interventions to be done every shift, and to document if interventions were effective or not as indicated by a yes or no. During a review of Resident 1's Order Summary Report, dated 12/09/2025, the Report indicated an order for Lyrica (medication used for Nerve pain) 100 milligrams (mg a unit of measurement) oral tablet for severe pain (7-10 on pain scale) as needed (PRN). During a review of Resident 1's Order Summary Report, dated 12/09/2025, the Report indicated an order for Tramadol (medication used for moderate to moderately severe pain) 50 mg oral tablet for moderate pain (4-6 on pain scale) two times a day PRN. During a review of Resident 1's Order Summary Report, dated 12/09/2025, the Report indicated an order for Tylenol (medication used for mild to moderate pain and fever) 325mg oral tablet for mild pain (1-3 on pain scale) two times a day PRN. During a review of Resident 1's Care Plan (CP) titled the resident has fracture related to displaced avulsion chip of right talus (a fracture where a ligament or tendon pulls a small piece of bone away from the talus in the ankle, causing it to shift), displaced fracture of navicular right foot (a serious, often high-energy, injury where the boat-shaped, midfoot bone breaks and separates, risking chronic pain), dislocation of tarsometarsal joint (involves the disruption of ligaments and bones in the midfoot), and dislocation of right ankle (a serious injury where the ankle bones (tibia, fibula, talus) are forced out of alignment, causing severe pain, swelling, deformity, and inability to bear weight, requiring immediate medical attention to prevent nerve/blood vessel damage, often treated with pain relief), initiated on 12/26/2025, the CP indicated interventions for monitoring and documenting any signs or symptoms of hip fracture complications such as pain. The CP intervention indicated to administer medications as ordered and monitor and document effectiveness. During a review of Resident 1's Care Plan for at Risk for Pain related to disease process, revised on 1/22/26, the Care Plan indicated interventions to administer medications as ordered, to assess the intensity of the pain, to evaluate effectiveness of pain interventions, and to monitor for pain characteristics and side effects. During a review of Resident 1's Medication Administration Record (MAR) for the month of January 2026, the MAR indicated to monitor for pain level on a pain scale (0-10) every shift. The MAR indicated during the 7 AM to 3 PM shift on 1/7/2026, Resident 1's pain level was documented as an 8 out of 10 pain. The MAR indicated only non-pharmacological interventions were performed by licensed vocational nurse (LVN) 2 by using reassurance and diversion. There was no medication administered for Resident 1's 8/10 pain and there was no reevaluation of effectiveness for the non-pharmacological interventions conducted. During an interview on 1/22/2026 at 11:06 AM with Resident 1, Resident 1 experiencing ongoing right ankle pain and swelling. Resident 1 stated he would report being in pain to nursing staff, but the nursing staff did not provide any medication to address Resident 1's pain. During an interview on 1/22/2026 at 11:56AM with LVN 2, LVN 2 stated never being informed of Resident 1 experiencing any pain. LVN 2 further stated it was the treatment nurse who monitored if the resident was having pain. During an interview on 1/22/2026 At 1:30 PM with Resident 1, Resident 1 stated when he reports experiencing pain to nursing staff, pain medications were not administered. Resident 1 stated he felt that his pain was not being addressed 'seriously' by facility staff. During a concurrent interview and record review on 1/22/2026 at 1:36 PM with Registered Nurse Supervisor (RN1), Resident 1's MAR from December 2025 to January 2026 was reviewed. The MAR indicated on 1/7/2026 during the 7 AM to 3 PM shift, Resident 1 reported an 8 out of 10 pain with no pain medication documented as being administered on 1/7/2026. RN1 stated no pharmacological intervention was provided. RN1 further stated no reevaluation was documented. During a concurrent interview and record review on 1/22/2026 at 2:29 PM with LVN 2, Resident 1's MAR dated 1/7/2026 was reviewed. The MAR indicated nonpharmacological interventions of redirection and diversion along with verbal cues and reassuring were provided without being reevaluated for effectiveness for a pain level reported of 8 out of 10. LVN 2 stated on 1/7/2026 at 10:58 AM she provided Resident 1 with non-pharmacological intervention since that was always the first step when a resident reported pain prior to administering any pain medications. LVN 2 stated she had not documented that the nonpharmacological interventions were effective. During a concurrent interview and record review on 1/22/2026 at 3:01 PM with RN1, Resident 1's MAR for January 2026 was reviewed. The MAR indicated no reassessment had been completed for nonpharmacological intervention conducted on 1/7/2026. RN1 stated if pain was not properly assessed, treated or monitored, the resident may experience unrelieved physical pain and suffering and could experience a change of condition. RN1 further stated that Resident 1 should have received pain medication, such as Tramadol which was ordered for pain levels from 7-10. RN 1 stated pain medications should have been administered. During a concurrent interview and record review on 1/22/2026 at 3:14 PM with the Director of Nursing (DON) Resident 1's MAR for January 2026 was reviewed. The MAR indicated, on 1/7/2026, for the 7 AM to 3 PM shift, no reevaluation for nonpharmacological interventions was conducted. The DON stated if Resident 1 still had pain after the nonpharmacological intervention was done, Resident 1 should have been administered pain medications. The DON further stated not managing Resident 1's pain effectively could result in the resident feeling increased anxiety and continued pain without relief. During an interview on 1/22/2026 at 3:54 PM with Resident 1, Resident 1 stated he would like to receive pain medications for pain rather than nonpharmacological interventions, since non-pharmacological interventions did not relieve his pain. Resident 1 stated he would like for pain medications to be administered when Resident 1 complained of pain, and that no one cares about my pain. During a review of the facility's policy and procedure ( P&P) titled, Pain Assessment and Management, dated October, 2022, the P&P indicated, the pain management program is based on a facility - wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management further indicating pain management is a multidisciplinary care process that includes monitoring for the effectiveness of interventions.

Based on observation, interview, and record review, the facility failed to ensure three of six sampled residents (Resident 59, 72, and 84) could hold the Resident Council meeting (an independent group of nursing home residents that convenes at least once a month to discuss their concerns, offer suggestions, and plan activities) independently, without staff presence. This failure violated the resident's rights from exercising their right to hold Resident Council meetings privately without the presence of the facility staffs, as well as participating in and voicing grievances without fear of retaliation. Findings: During a review of Resident 59's admission Record (AR), the AR indicated the facility admitted resident on 12/29/2018 with diagnoses that include but not limited to diabetes mellitus (chronic disorder characterized by insulin resistance, difficulty in blood sugar control and poor wound healing) and End Stage Renal Disease (irreversible kidney failure). During a review of Resident 59's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/16/2025, the MDS indicated Resident 59 had intact cognition (ability to understand and make decisions). During a review of Resident 72's AR, the AR indicated the facility admitted the resident on 2/17/2023 with diagnoses that included hypertension (HTN-high blood pressure) and dysarthria (difficulty speaking) followed by cerebral infarction (brain damage due to interruption of blood flow in the brain or stroke). During a review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72 had intact cognition. During a review of Resident 84's admission Record (AR), the AR indicated the facility admitted resident on 8/29/2024 with diagnoses that include but not limited to hypertension and cerebrovascular accident with no residual effect. During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84 had intact cognition.During a Resident Council meeting on 12/2/2025 at 10:32 am with Resident 59, 72 and 84, Resident 59 stated that the Resident Council member do not want DON (Director of Nursing) or facility Administrator (ADM) or Activity Director (AD - a facility staff in charge of the social, recreational, and therapeutic programs in the facility to increase the resident's physical, mental and emotional health) to be present at the Resident Council meetings. Resident 72 and Resident 84 stated they both agreed with Resident 59. During an interview on 12/2/2025 at 10:32 am, Resident-59, 72 and 84 stated that Resident Council members were not previously made aware by the facility that Resident Council meetings can be conducted without the facility staff being present in the meeting. During an interview on 12/2/2025 at 12:29 pm with Activity Assistant (AA1 - a facility staff that coordinates recreational, and therapeutic programs to the residents). AA1 stated either the DON, facility ADM or AD were always present in Resident Council meetings. AA1 stated she is sometimes asked by the AD to be present in the meeting,. During an interview on 12/3/2025 at 9:25 am with AD, AD stated that there is always a facility staff present during the monthly Resident Council meetings to help resolve any issues residents might have. AD stated she never reviewed with the residents the right to conduct Resident Council meetings that indicated the resident council meetings could be help without the staff being present in the meeting. During an interview on 12/3/2025 at 3:19 pm with DON, DON stated that either DON, ADM or the AD is always present in monthly Resident Council meetings, to help resolve any issues residents might have. During an interview with on 12/4/2025 at 1:30pm, DON stated that DON was not aware of the residents right to conduct Resident Council meetings without any facility staff being present in the meeting. During a review of the facility's Policy and Procedure (P&P) titled, Resident Council, dated 2/2021, the P&P indicated that the staff, visitors, or other guests may attend the Resident Council meetings if invited by respective resident group.

Based on observation, interviews, and record review, the facility failed to maintain the low air loss (LAL - specialized air mattress with tiny holes that constantly released air, creating a gentle airflow to keep skin dry, manage moisture, and prevent painful pressure ulcers (a skin injury due to prolonged unrelieved pressure and friction]) for people who could not move much) mattress at the proper inflation, weight, and therapy settings, and did not follow the care plan for Resident 40, one of two sampled residents identified as high risk for developing pressure ulcers and reviewed for pressure ulcer prevention. The facility failed to: Ensure the LAL mattress was correctly set at an inflation level consistent with Resident 40's weight and clinical needs. Implement Resident 40's care plan interventions to adjust the LAL mattress according to the resident's weight and comfort level. These deficient practices had the potential to compromise effective pressure redistribution and increase the risk of developing or worsening pressure injuries for Resident 40. Findings: During a concurrent observation and interview, on 12/1/2025 at 11:21 AM, in Resident 40's room, the LAL mattress was observed to be set to alternating therapy mode, with a normal pressure system status and a comfort level of two. According to manufacturer specifications, comfort level one supports residents up to 120 pounds, while levels two through five supports up to 500 pounds. Comfort level one is considered softer, and level five firmer. Resident 40 expressed discomfort with the mattress, stating it felt different from previously used LAL mattresses and that she never felt the air moving around as expected. Resident 40 further stated that she had informed facility staff 100 times but they don't listen. During a review of Resident 40's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included pressure ulcer of sacral region (a wound that developed on the tailbone area from constant pressure, like sitting or lying in one spot too long cutting off blood flow, killing skin cells, and causing the skin and tissue to break down into painful, open sores that could get infected) irritable bowel syndrome (a common gut problem that caused stomach pain, cramping, bloating, gas, and changes in bowel habits), and paraplegia (paralysis of the legs and lower body). During a review of Resident 40's History & Physical (H&P) dated 4/21/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 40's Braden Scale for Predicting Pressure Sore Risk (a simple, six part checklist used by healthcare providers to spot resident's at high risk for bedsores by rating their sensory perception, moisture, activity, mobility, nutrition, and friction/shear) dated 7/23/2025 at 9:12 AM, the Braden Scale indicated the resident's perception was slightly limited, was occasionally moist, bedfast, very limited in mobility, had adequate nutrition and had a problem with friction and shear. The Braden Scale resulted in a score of 13, indicating the resident was at moderate risk for pressure sores. During a review of Resident 40's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/23/2025, the MDS indicated the resident's Cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated the resident had occasional pain and had a pressure ulcer/injury. The MDS indicated the resident was at risk for developing pressure ulcers/injuries and had three stage four pressure ulcers. The MDS indicated the resident's skin and ulcer/injury treatment consisted of a pressure reducing device for chair, a pressure reducing device for bed, and pressure ulcer/injury care. During a review of Resident 40's Nutrition assessment dated [DATE] at 3:11 AM, the Nutrition Assessment indicated the resident's most recent weight was 87 pounds. The Nutrition Assessment indicated identification of risk factors included underweight body mass index (BMI, a simple number calculated from your weight and height to estimate body fat). The Nutrition Assessment indicated the resident was on a fortified/high protein diet (boosting your regular meals with extra protein and calories by adding protein-rich ingredients to foods you already eat without making the portion size much bigger, to help with muscle, healing, or weight management when you need more nutrition.) and was receiving Pro-Stat (concentrated, fast-absorbing liquid protein supplement for people needing extra protein due to wounds, poor appetite, or muscle loss, helping with healing and preserving body mass). During a review of Resident 40's LAL Mattress Care Plan dated 11/8/2025, the Care Plan indicated a goal for the resident's skin to remain intact. The Care Plan interventions included setting the LAL Mattress according to the residents' weight or comfort and providing education regarding the risks and benefits of LAL Mattress use. During a review of Resident 40's Physician's Wound Care Orders and Visit dated 12/1/2025, the Orders indicated for the resident, facility pressure injury prevention and relief protocol. The Treatment Goals indicated healing was exapted to be delayed due to identified barriers to healing such as impaired mobility (difficulty moving freely and easily impacting daily life and independence), incontinence (the involuntary loss of bladder control [urine] and bowel control [stool]), and non-adherence/lifestyle choices. During an interview on 12/4/2025 at 9:33 AM, the Treatment Nurse (TN) 1 stated Resident 40 was under 100 pounds and pressure ulcer prevention interventions included repositioning the resident, high protein meals and snacks, and a low air loss mattress. TN 1 stated the treatment nurses were the ones who check the LAL mattress settings to ensure the resident was comfortable. During a concurrent observation and interview on 12/4/2025 at 9:44 AM, TN 1 stated the LAL mattress setting should have been set at level one because of Resident 40's weight and also based on the verbalized comfort of the resident. TN 1 stated the purpose of the LAL mattress was to distribute the resident's weight to improve her wounds and that incorrect settings could result in worsening of pressure injuries and increased pain and suffering for the resident. During a review of the facility's policy and procedure (P&P) titled Support Surface Guidelines revised 2/7/2024, the P&P indicated The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The P&P indicated General Guidelines included Redistributing support surfaces are to promote comfort for all bed or chairbound residents, promote circulation and provide pressure relief or reduction. The P&P indicated Guidelines for Selecting Appropriate Pressure-Relieving Devices included Individuals at risk for developing pressure ulcers should be placed on a redistribution support surface, such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. During a review of the facility's P&P titled Prevent of Pressure Injuries revised February 2024, the P&P indicated The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The P&P indicated Support Surfaces and Pressure Redistribution included Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice and Device-Related Pressure Injuries included Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device and monitor regularly for comfort and signs of pressure-related injury.

Based on observation, interview, and record review, the facility failed to provide a safe and accident-free environment for three of 3 sampled residents (Resident 23, 135 and Resident 10) by failing to: 1. Post the required No Smoking/Oxygen in Use signage in the resident's doorway in the presence of supplemental oxygen for Residents 23 and 101 in accordance with the facility's policy and procedure (P&P) titled Oxygen Administration. 2. Supervise and implement safety measures for Resident 10 during a smoking break. These deficient practices had the potential to result in a significant fire hazard and compromise the safety and life of the residents, staffs and visitors in the facility. Findings: 1.A Review of Resident 23's admission Record indicated the resident was originally admitted into the facility on 3/5/2025, with diagnosis that included, fracture (broken bone) of neck of left femur (thigh bone) , fracture of greater trochanter ( thigh bone) of left femur ( thigh bone) , metabolic encephalopathy (a condition of the brain caused by chemical imbalances ) and Alzheimer's disease unspecified(progressive brain disorder that slowly destroys memory and thinking skills). A review of Resident 23's History and physical (H&P), dated 4/15/2025, the H&P indicated, Resident 23 does not have the capacity to understand and make decisions. A review of Resident 23's Minimum Data Set (MDS – a standardized assessment and care screening tool) dated 10/20/2025, indicated Resident 23 has severe cognitive impairment (has significant deficits in memory and thinking, requiring support for safety awareness, decision – making, and reporting needs or changes in condition). The MDS indicated Resident 23 requires maximal assistance with showering needs and moderate assistance for dressing and personal hygiene and sit to stand position. A review of Resident 23's Fall Risk Assessment – V3, dated 10/22/2025, indicated based on answers to questions on fall Risk assessment Resident 23 was a high risk for fall. A review of Resident 23's Care plans indicated Resident 23 has had 1-2 falls in the past 2-6 months and had chronic Nasal bone fracture ( from CT scan result done 2/23/2025) prior to admission, The Care Plan interventions included to assist the Resident to bathroom or toilet as necessary and do frequent visual checks to ensure and assist to maintain proper body positioning while in bed and wheelchair. A review of Resident 23's Care plan (CP) dated 6/10/2025 and revised on 10/29/2025 indicated Resident 23 was at high risk for falls related to behavioral problems, impaired balance, cognitive impairment, and recent femur fracture The CP goal indicated for Resident 23 to be free from falls and demonstrate safe participation in care and mobility routines through review date of 1/18/2026. A review of Resident 23's CP, initiated on 11/07/2025 indicated Resident 23 has spontaneous behavior of getting out of bed/chair, and the CP goal for the resident to be free from injury, target date 1/18/2026. The interventions included, for the facility to provide frequent visual checks and activity participation, implement fall precautions including bed/chair alarms, low bed position, and call light withing reach at all times and to ensure supervised mobility with assistive devices during all transfers and ambulation. Review of Nursing Staffing Assignment and sign in sheet for 12/01/2025 7AM – 3PM, indicated Certified Nursing Assistant (CNA5) was assigned to room [ROOM NUMBER]A at start of shift ( 7AM – 11AM) then removed from assignment. During a concurrent observation and interview on 12/1/2025 at 10:20AM with Licensed Vocational Nurse (LVN5), Resident 23's room, was dark upon entry with the,privacy curtain drawn completely around the bed, preventing visual observation of the resident. Upon exiting room Resident 23's feet were observed protruding under the curtain. LVN 5 entered the room and was asked to pull back the curtain, revealing Resident 23 on the floor with his back against the bed. No bed alarm was present. LVN5 stated not being sure if the resident is supposed to have a bed alarm but that this is his usual behavior to fall out of bed. LVN 5 stated the resident should have been monitored and placed in the activity room for safety. When asked why the curtain was drawn around the resident and who had pulled it closed, LVN 5 stated he did not know and stated the curtain was not to be drawn around the resident due to the fact he requires supervision. During a Concurrent observation and interview on 12/1/2025 at 10:41AM with Director of Nursing (DON) in Resident 23's room, resident observed lying in bed. DON stated that Resident 23 reported he had been sitting on the side of the bed and slipped, sliding from the bed to the floor, and confirmed this was an unwitnessed fall. The DON stated Resident 23's privacy curtain should not have been shut and that the curtain should only be closed when staff are providing care for privacy, adding that staff are not able to properly monitor the resident if the privacy curtain is drawn. The DON further stated that current interventions for Resident 23 are to include having the resident located closer to the nursing station, frequent monitoring and or up in the activity room for safety. The DON also stated it was his opinion that resident 23 does not have the capacity to draw the curtains himself. During an interview , on 12/2/2025 at 2:56PM Certified Nursing assistant ( CNA5) stated she was a new CNA and had been assigned to care for Resident 22A. CNA 5 stated she was providing activities of daily living ( ADLs), including diaper changes, feeding , vital signs, and breakfast, to residents on her assignment. CNA 5 stated that prior to providing care to Resident 23, Licensed Vocational Nurse (LVN 6) told her not to worry about providing care for resident 23 and that he would have an alternate CNA to monitor this resident while she completed her other care. CNA 5 stated that when she entered the room, LVN6 told her to leave. CNA5 stated that before leaving the room, she noted or believed Resident 23 was in his bed and observed privacy curtain drawn completely around him. CNA 5 stated, I did look prior to leaving room, the resident was still in his bed and stated she did not know who had drawn the curtain around the resident or why. CNA5 stated the LVN did not want her to provide care for this resident. CNA 5 further stated that later, while she was showering her assigned resident, another CNA (unknown) came to her, informing her that resident 23 had fallen on the floor and that she would be in trouble. Unknown CNA stated, how could she leave this resident knowing they were a high risk for falls. CNA 5 stated that afterward she was brought into the Administrators office and was required to sign a corrective action form. 2. During a review of Resident 135's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure with hypoxia (a long-term problem where they could not get enough oxygen into your blood causing tissues and organs to not get the oxygen they need), interstitial pulmonary disease (a group of disorders where lung tissue around the air sacs [alveoli] get inflamed, scarred, and thickened, making oxygen hard to get into the blood, leading to shortness of breath, a dry cough, and fatigue). During a review of Resident 135's History and Physical (H&P) dated 11/29/2025, the H&P indicated the resident had capacity to understand and make medical decisions. During a review of Resident 135's Physician's Order Summary Report dated 11/28/2025, the Physician's Order Summary Report indicated for the resident's oxygen NC to be change every week on Monday and PRN (with name and date label) in the morning every Monday. During an observation of Resident 135's room on 12/1/2025 at 11:36 AM, the resident's room did not have a No Smoking/Oxygen in Use sign posted. During a concurrent observation and interview on 12/1/2025 at 1:05 PM, LVN 1 confirmed Resident 135's room did not have a No Smoking/Oxygen in use sign posted outside while the resident was receiving supplemental oxygen. LVN 1 stated the sign was important for alerting facility staff and visitors the presence of oxygen in use, which required avoiding open flames due to the risk of fire or explosion. LVN 1 further stated that not having the sign posted was a safety concern and could negatively impact the resident's quality of care if staff were unaware that oxygen was in use. LVN 1 stated that such signage should have been posted in accordance with the facility's protocols. During a concurrent observation and interview on 12/3/2025 at 10:03 AM, the DON stated there should have been a No Smoking/Oxygen in Use sign posted as a safety protocol to make sure everyone knew the resident was using supplemental oxygen and no one should make a fire or light a cigarette. The DON stated the facility staff were not following the physician's orders and without a sign posted, there was potential for an explosion. During a concurrent interview and record review of the facility's P&P titled Oxygen Administration revised February 2024, the P&P indicated The purpose of this procedure is to provide guidelines for safe oxygen administration. The P&P indicated Place a no smoking sign on the outside of the room entrance door. And place an Oxygen in Use sign in a designated place on or over the resident's bed. The DON stated they were not following the policy because the facility did not place a sign over the resident's bed and for Resident 135 did not have a sign posted at all. The DON stated the facility should have been following the policy so everyone would know the resident was on oxygen and there would not be an explosion. 3. During a review of Resident 10's admission Record (AR), the AR indicated the facility admitted Resident 10 on 4/11/2024 with diagnoses that include but not limited to major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 feeling down, depressed, or hopeless 2-6 days in the previous 2 weeks of the assessment. Resident 10 is wheelchair dependent. Resident 10 need assistance with setting up or clean-up for eating. Resident 10 need assistance with oral hygiene, upper body dressing and personal hygiene. Resident 10 need substantial/maximum assistance with toileting hygiene, shower/bathe self, lower body dressing pulling on/taking off footwear. During an observation on 12/2/2025 at 8:50 am in facility's designated smoking area (at the corner of facility parking lot), Resident 10 was smoking. No staff or other residents were present in facility's designated smoking area. During an interview on 12/2/2025 at 11:07 am with Resident 10, Resident 10 stated that Resident 10 is allowed to smoke outside the designated smoke break times. Resident 10 stated the facility staff is only present in the facility's designated smoking area during the smoking break times. During an interview on 12/3/2025 at 10:19 am with MDS nurse, MDS nurse stated that Resident 10's smoking assessment was done on 6/30/2025 and was not completed after that. MDS nurse stated that the Resident 10's medical condition could have changed and without a complete smoking assessment (facility tool to evaluate resident's smoking habit, physical and cognitive ability to smoke with supervision or without supervision and fire safety risks), Resident 10 was not safe to smoke without supervision. MDS nurse stated that the resident was at risk of an accident, fire and burns. During an interview on 12/3/2025 at 3:19 pm with DON, DON stated that if a resident missed a quarterly smoking assessment and still going for smoking without supervision, there is risk of fire and resident safety since resident's medical condition can be changed from last quarterly smoking assessment. During a review of the facility's Policy and Procedure (P&P) titled, Smoking Policy - Residents, dated 1/2024, the P&P indicated that a resident's capability to smoke safely is re – evaluated every quarter to smoke safely and without supervision. A review of the facility's policy and procedure ( P&P) titled, Falls and Fall Risk, managing dated 2/7/2024, indicated staff, based on previous evaluations and current data, to identify resident – specific risk factors and causes and implement interventions to help prevent residents from falling and minimize complications from falls. The Policy identified environmental risk factors for falls, that included poor lighting and required a resident – centered approach to managing falls and fall risk. A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents dated 7/2023, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility – wide priorities. The policy also indicates individualized, Resident – centered approach to safety to include addressing safety and accident hazards for individual residents by using a system approach of supervision at its core component. The type and frequency of resident supervision is determined by the individual resident's assessed for needs.

Based on observation and interview and record review, the facility failed to label a used by date for the following food items in accordance with the facility's policy and procedure Food Receiving and Storage and with the professional standards for food service safety by failing to: 1. Indicate the used by date of an opened box with five pieces of pie shell 2. Indicate the used by date of an opened plastic container of dill pickle relish 3. Indicate the used by date of an opened bag of brownie powder and the facility staff failed to perform hand hygiene after engaging in activities that contaminate the hands and prior to dispensing meal trays to residents for three of ten sampled residents (Resident 64, Resident 119, and Resident 134) in accordance with the facility's policy and procedure (P&P) titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices. These deficient practices had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food and negatively affect the health of the residents who consumed it and result in a widespread infection in the facility. 2. During a review of Resident 64's admission Record (AR), the AR indicated the facility admitted Resident 64 on 5/10/2024 with diagnoses that included unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and hyperlipidemia (high level of fat in the blood). During a review of Resident 64's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/13/2025, the MDS indicated Resident 64 had severely impaired cognitive (ability to understand and make decisions) skills for daily decision making that required supervision or touching assistance with eating, partial/moderate assistance with oral hygiene, substantial/maximal assistance with personal hygiene, and was dependent on toileting hygiene, chair/bed-to-chair transfer, and shower/bathe self. During a review of Resident 119's AR, the AR indicated the facility originally admitted Resident 119 on 5/14/2022 and readmitted her on 1/12/2023 with diagnoses that included unspecified dementia and hypertension (high blood pressure). During a review of Resident 119's MDS, dated [DATE], the MDS indicated Resident 119 had severely impaired cognition and memory. The MDS indicated Resident 119 required setup or clean-up assistance with eating, and substantial/maximal assistance with oral hygiene, personal hygiene, toileting hygiene, chair/bed-to-chair transfer and shower/bathe self. During a review of Resident 134's AR, the AR indicated the facility admitted Resident 134 on 11/28/2025 with diagnoses that included type II diabetes mellites (a condition that happens when your blood sugar is too high) and hypertension. During a review of Resident 134's MDS, dated [DATE], the MDS indicated Resident 134 had moderately impaired cognition and memory. The MDS indicated Resident 134 was independent with eating, and required supervision or touching assistance with oral hygiene, personal hygiene, toileting hygiene, chair/bed-to-chair transfer and shower/bathe self. During a dining observation on 12/1/2025 at 12:13 PM in the dining room, Certified Nursing Assistant (CNA) 4 did not perform hand hygiene between multiple task when she picked up four soiled cups from four different residents and put the cups on top of a meal tray cart, then, she removed the newspaper from a resident's hands and threw it in a trash bin. Next, CNA 4 picked up Resident 64's meal tray from the meal cart and set up the food and utensils on the table for Resident 64. Then, CNA 4 picked up Resident 119's meal tray from the meal cart and set up the food and utensils on the table for Resident 119. Afterwards, CNA 4 picked up Resident 134's meal tray from meal cart and set up the food and utensils on the table for Resident 134. During an interview on 12/1/2025 at 12:29 PM with CNA 4, CNA 4 stated she did not perform hygiene after collecting soiled cups from the residents and after discarding the newspaper into the trash bin. CNA 4 stated she did not perform hand hygiene before passing meal trays to residents and between residents. CNA 4 stated she should perform hand hygiene after each task that could contaminate her hands and before handling food to prevent spread of infection. During an interview on 12/4/202 at 10:55 AM with the Director of Nursing (DON), the DON stated the CNAs are expected to perform hand hygiene both before and after handling and passing meal trays to each resident. The DON stated, this practice is important to prevent the potential spread of foodborne illness and to ensure the safety and well-being of residents. During a review of the facility's P&P titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 11/2022, the P&P indicated employees must wash their hands after handling soiled equipment or utensils and after engaging in other activities that contaminate the hands. During a review of the facility's P&P titled Handwashing/ Hand Hygiene, dated 10/2023, the P&P indicated hand hygiene is indicated immediately before touching a resident, after touching a resident, and after touching the resident's environment, to help prevent the spread of infections to other personnel, residents, and visitors. Findings: 1.During an initial kitchen tour and interview with the Dietary Supervisor (DS) on 12/1/2025 at 8:45 AM the following were observed without a label with a used by date. In the freezer: -an open box with five pieces of pie shell In the refrigerator: -an open plastic container of dill pickle relish In the food dry storage area: -an open bag of brownie powder During a concurrent interview on 12/1/2025 at 8:45 AM DS stated, the pie shells are used to make residents pies, the pickle relish are used to add with residents' food, and the brownie powder is used to make residents brownie. The open food items should have a used by date label to ensure it was still fresh for consumption, because it potentially could be old and contaminated that could get residents sick when consumed. During an interview on 12/2/2025 at 3:15 PM, the Director of Nursing (DON) stated that, per facility policy, food in the kitchen should be labeled with a use by date. The DON explained having the used by date ensures food freshness, helps kitchen staff know when to discard expired items, and prevents serving unsafe food to residents. The DON stated that failure to follow the policy could lead to food contamination and the growth of microorganisms, potentially causing foodborne illnesses that may negatively impact residents' health and quality of life. A review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised 11/2022 indicated, a) dry food removed from packaging dated with used by date, b) all foods stored in the refrigerator or freezer are labeled and dated with a used by date. A review of the Food Code 2022, indicated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Indicated READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES.

Based on observation, interview, and record review, the facility failed to properly dispose garbage and refuse (food waste, scraps) by having the lids of two of three metal dumpsters (large trash container designed to be emptied into a truck) to closed completely and did not contain excess garbage bags, the garbage area was clear of litters, used opened boxes on the ground and used wooden pallet in accordance with the facility's policy and procedure titled, Food- Related Garbage and Refuse Disposal. This deficient practice had a potential to attract birds, flies, insects, pest, rodents, and possibly spread infection to residents, visitors and staffs in the facility.Findings: During a concurrent observation and interview on 12/1/2025 at 9AM with the Dietary Supervisor (DS) in the facility's' garbage area, observed the lids of two of three metal dumpsters was unable to close completely due to much garbage bags, also the garbage area had opened boxes on the ground and a wooden pallet. DS stated, the dumpsters cannot completely close because of too much trash bags, and the garbage area should always be clean without those opened boxes and the wood pallet. DS stated, the garbage area had the potential to attract birds, flies, insects, pest, rodents, and possibly spread infection to residents, visitors and staffs in the facility. During an interview on 12/2/2025 at 3:15 PM with Director of Nurses (DON), DON stated, it was important to ensure the dumpsters lids are completely closed and the garbage surrounding are clean and free of litter, such as opened boxes and a wooden pallet, because it potentially can attract birds, flies, insects, pest, and rodents. DON stated, it could cause the spread of diseases and/or infections that could affect the life and safety of residents, visitors and staffs. A review of the facility's policies and procedures (P&P) titled Food- Related Garbage and Refuse Disposal, (10/2017), indicated: a) garbage and food wastes will be stored in a manner that is inaccessible to pests, and b) outside dumpster provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices in accordance with facility policy and procedures and professional standards for two of four sampled residents (Resident 3 and Resident 135) by failing to: 1. Ensure Certified Nursing Assistant (CNA) 2 wore an isolation gown when providing care one of one sampled residents (Resident 3) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to the resident having gastrostomy tube (GT-tube inserted through the abdominal wall directly into the stomach used to deliver nutritional formula, fluid and medications). 2. Label Resident 135's nasal cannula (NC, a small, flexible plastic tube with two prongs that fit into your nostrils to deliver extra oxygen from a tank or concentrator) and humidifier (a fluid in the bottle attached to the oxygen to keep the air moist when inhaled by the residents through the NC to prevent dryness in the nose) in accordance with the physician's order and the facility's policy and procedure (P&P). These deficient practices had the potential to result in Resident 3 acquiring MDROs and/or spreading MDROs to other residents in the facility and Resident 135 to be at risk from misidentification of equipment and increased infection control concerns related to unlabeled respiratory equipment that could compromise the quality of care and quality of lifeFindings: 1.During a review of Resident 3's admission Record (AR), dated 4/11/2024, indicated Resident 3 was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included respiratory failure (don't have enough oxygen in the tissues in your body), end stage renal disease (kidneys have failed to get rid of extra fluid and toxins) and dysphagia (difficulty swallowing). During a review of Resident 3's Minimum Data Set (MDS) -a resident assessment tool dated 11/7/2025, indicated Resident 3's cognitive status (ability to process and comprehend information) was severely impaired. The MDS indicated Resident 3 was dependent (helper does all the effort) with all ADLs (Activities of Daily Living). During an observation on 12/1/2025 at 11 AM Resident 3's door had a signage indicating Enhanced Barrier Precautions, also observed Resident in bed with head of bed elevated receiving feeding formula via G-tube. During a review of Resident 3's Order Summary Report (OSR) [GG1] dated 12/3/2025, the OSR indicated Resident 3 was placed on: a) on Enhanced Barrier Precautions due to G-tube status, b) Enteral Feed Order (Novasource Renal (feeding formula) via G-tube. During an observation on 12/3/2025 at 8 AM by Resident 3's doorway had a signage EBP indicating staff must wear gloves and isolation gown during high contact resident care activities and Certified Nurse Assistant (CNA) 2 was observed caring for and providing care to Resident 3. During a concurrent observation and interview on 12/3/2025 at 8:10 AM with CNA 2 who was standing by Resident 3's doorway, CNA 2 came out of the privacy curtain of Resident 3's bedside without wearing a Personal Protective Equipment (PPE) such as isolation gown. CNA 2 stated, she washed the face, cleaned the mouth and changed the brief of Resident 3. CNA 2 stated she did not use isolation gown because she forgot. CNA 2, stated, she could spread infection for not wearing isolation gown. During an interview on 12/3/2025 at 8:15 AM with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, Resident 3 was on EPB because she has a G-Tube. LVN 3 stated, close contact care requires the staff to wear PPE's which includes wearing isolation gown. LVN 3 stated, performing personal hygiene and changing briefs is considered close contact care, so CNA 2 should have worn the isolation gown. LVN 3 stated, not wearing isolation gown during close contact care had the potential to result in Resident 3 acquiring MDROs and/or spread MDRO's in the facility. During an interview on 12/3/2025 at 8:41 AM with Infection Preventionist Nurse (IPN), IPN stated, Resident 3 was on EBP because of her G-Tube, which creates a direct access to the body, which makes Resident 3 more vulnerable to acquire/spread MDROs. IPN stated, wearing PPEs which includes the isolation gown during close contact care was essential to prevent Resident 3 from acquiring MDROs, as well as preventing the spread of MDROs in the facility. During an interview on 12/3/2025 at 4:15 PM with the Director of Nurses (DON), DON stated, He expects for Resident on EBP, staff should wear PPEs which includes the isolation gown. DON stated, not wearing an isolation gown during a close contact care of a Resident on EBP had the potential to result in introduction MDROs to the Resident and/or spread of MDROs to other residents in the facility which could negatively affect their health and quality of life. A review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised on 4/2024, the P&P indicated: a) enhanced barrier precautions (EBP) are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents, b) EBPs employ isolation gown use during high contact resident care activities, and c) examples of high contact resident care activities requiring the use of isolation gown for EBPs include: providing hygiene and changing briefs. A review of the facility's policy and procedure (P&P) titled, Policies and Practices – Infection Control, revised 4/2025, the P&P indicated, the facility infection control policies and practices are intended to facilitate a safe and sanitary environment to help prevent and manage transmission of diseases and infection. 2. During a review of Resident 135's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure with hypoxia (a long-term problem where they could not get enough oxygen into your blood causing tissues and organs to not get the oxygen they need), interstitial pulmonary disease (a group of disorders where lung tissue around the air sacs [alveoli] get inflamed, scarred, and thickened, making oxygen hard to get into the blood, leading to shortness of breath, a dry cough, and fatigue). During a review of Resident 135's History and Physical (H&P) dated 11/29/2025, the H&P indicated the resident had capacity to understand and make medical decisions. During a review of Resident 135's Physician's Order Summary Report dated 11/28/2025, the Physician's Order Summary Report indicated for the resident's oxygen humidifier to be changed every week on Monday and as needed (PRN) when consumed (with name and date label) in the morning. During a review of Resident 135's Physician's Order Summary Report dated 11/28/2025, the Physician's Order Summary Report indicated for the resident's oxygen NC to be change every week on Monday and PRN (with name and date label) in the morning every Monday. During an observation in Resident 135's room on 12/1/2025 at 11:33 AM, the resident's NC did not have a label with the date or resident's name. The resident's NC humidifier had the date but did not have the resident's name. During an interview on 12/1/2025 at 1:02 PM, Licensed Vocational Nurse (LVN) 1 stated the facility staff should have changed the resident's NC's once a week and they should have been labeled. LVN 1 stated if the nasal cannula was not labeled the resident could be at risk for infection because the facility staff would not know how long the NC was used for and the resident could have a respiratory infection or may not be getting the correct amount of oxygen if the NC was damaged. During a concurrent observation and interview on 12/3/2025 at 9:58 AM, the DON stated the nasal cannula should have had a date and a name to know when the NC was changed to make sure the facility staff was following physician's orders. The DON stated if the NC was not labeled the facility staff would not know when the NC was changed and that was an infection control issue. The DON stated dirt could get in or something could accumulate during breathing treatments and the facility staff needed to keep the NC clean. During a concurrent interview and record review of the facility's P&P titled Oxygen Administration revised February 2024, the P&P indicated The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Assemble the equipment and supplies as needed. The DON stated the facility was not following the policy but should have been.

Based on observation, interview and record review, the facility failed to ensure two of 2 sampled residents (Resident 23 and 101) were provided care in a manner that maintained dignity and respect when: 1.Licensed Vocational Nurse (LVN) 6 left Resident 23 was lying in bed uncovered and exposed without replacing the blanket or gown to maintain the resident's privacy after care was provided. 2.The Treatment Nurse (TN1) was standing next to Resident 101 while assisting the resident to eat during dinner. This failure had potential to negatively affect the residents sense of dignity and respect during the care. Findings: 1. During a review of Patient 101's admission Record (AR), the AR indicated the facility admitted the patient on 8/26/2025 with diagnosis that included but not limited to moderate protein-calorie malnutrition (a condition from not getting enough nutrients) and dysphagia (difficulty or pain during swallowing food or liquids). During a review of Patient 101's MDS (Minimum Data Set-a resident assessment and care screening tool) dated 8/30/2025, the MDS indicated Patient 101's nutritional assessment as malnutrition. The MDS dated [DATE] indicated the resident is alert, oriented and has a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 (BIMS score 13 - normal cognitive/brain function). During an observation on 12/1/2025 at 12:24 PM, in facility's dining room, Patient 101 was eating protein ice cream (ice cream with higher protein content than regular ice-cream). TN 1 went to Patient 101 after Patient 101 stopped eating the protein ice and provided feeding assistance to the patient while standing up. Patient 101 had to look up at TN 1 during the feeding since Patient 101 was sitting on the wheelchair during that time. During an interview on 12/01/2025 at 12:34 PM, TN 1 stated all staff must be sitting down at the patient's eye level while providing feeding assistance to the patients. TN 1 stated the Patient 101 must have felt belittled when TN 1 provided feeding assistance to Patient 101 while standing up and not at the Patient 101's eye level. During an interview on 12/01/2025 at 12:34 PM with DON, DON stated if any staff provide feeding assistance to any patient in the facility that is a dignity issue. DON stated if a patient in the facility has a normal cognitive function, the patient will feel really bad if not provided the feed assistance at patient's eye level. During a review of the facility's Policy and Procedure (P&P) titled Assistance with Meals dated 3/2022, the P&P indicated the facility residents will be fed with consideration of safety, comfort and dignity and the facility staff will not provide the assistance while standing over the residents while assisting them with meals. During a review of the facility's Policy and Procedure (P&P) titled Resident Rights dated 2/2021, indicated that the facility residents will be treated with respect, kindness and dignity during the resident's stay in the facility. 2.During a review of Resident 23's admission Record indicated the resident was originally admitted into the facility on [DATE], with diagnosis that included, but not limited to, fracture of of neck of left femur (thigh bone), fracture of greater trochanter ( thigh bone) of left femur (thigh bone) , metabolic encephalopathy (a condition of the brain caused by chemical imbalances) and Alzheimer's disease unspecified(progressive brain disorder that slowly destroys memory and thinking skills, unspecified means details like late or early onset are not specific). During a review of Resident 23's History and physical (H&P), dated 4/15/2025, the H&P indicated, Resident 23 does not have the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS – a standardized assessment and care screening tool) dated 10/20/2025, the MDS indicated Resident 23 had severe cognitive impairment (has significant deficits in memory and thinking, requiring support for safety awareness, decision – making, and reporting needs or changes in condition). The MDS indicated Resident 23 requires maximal assistance with showering needs and moderate assistance for dressing and personal hygiene and sit to stand position. During an observation on 12/1/2025 at 10:45 AM in Resident 23's room, Licensed Vocational Nurse (LVN) 6 was observed performing vital signs check to Resident 23, including blood pressure, heart rate, and respirations. Upon completing the assessment, LVN 6 left Resident 23 uncovered and exposed, without replacing the blanket or gown to maintain the resident's privacy. During a concurrent observation and interview with the Director of Staff Development (DSD) in Resident 23's room, on 12/1/2025 at 10:55AM, the resident was observed lying in bed wearing a hospital gown that was lifted, exposing the resident's brief (adult diaper). Resident 23 did not have a blanket covering his body at the time of the observation. The DSD stated that the resident should not have been left in that condition and stated, the resident is exposed with his brief showing. The DSD acknowledge that this situation was an issue of dignity and privacy. During a review of the facility's policy and procedure (P&P) titled, Dignity dated 2021, indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well- being. Level of satisfaction with life and feeling of self-work and self- esteem. Indicating that staff must promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatments. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity.

Based on observation, interview and record review, the facility failed to ensure residents call lights (a device used by residents to signal his or her needs for assistance) were within reach for two of two sampled Residents (Resident 88 and 127) for reasonable accommodation of needs. Resident 88 who was legally blind and Resident 127 were at risk for accident and fall. This deficient practice had the potential for Residents to be unable to call for assistance in an emergency which could lead to a fall and/or injury.Findings: 1. During review of Resident 88's admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (circulation disorder caused by narrowing, blockage or spasms in a blood vessel), legal blindness (severe vision loss where you see so poorly that you can't perform normal daily tasks, even with glasses) and absence of left great toe. During a review of Resident 88's History and Physical Examination (H&P), dated 6/19/2025, indicated Resident has fluctuating capacity to understand and make decisions. During a review of Resident 88's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2025, indicated Resident 88 required partial/moderate assistance (helper does less than half the effort) with toileting, bathing, dressing and personal hygiene and substantial/maximal assistance (helper does more than half the effort) with chair/bed-to-chair transfer (the ability to transfer to and from a bed to chair). During a review of Resident 88's care plan (CP) for risk for falls with injury with injury related to gait/balance problems, incontinence, poor safety awareness and vision hearing problems, revised 6/17/2025 indicated intervention includes to be sure call light is within reach. During a review of Resident 88's facility document titled Quarterly Risk Data Collection Tool under fall risk assessment dated [DATE], indicated Resident 88 was at risk for fall. During a concurrent observation and interview on 12/1/2025 at 10:14 AM with Certified Nurse Assistant (CNA)1 and Licensed Vocational Nurse (LVN) 2 in Resident 88's room, Resident 88 was observed in bed asleep, with her call light on the floor. CNA 1 stated, Resident 88's call light needs to always be within reach, she cannot reach that call light on the floor, she uses it when she needs assistance. LVN 2 stated, Resident 88 knows how to use the call light, and she uses it for assistance. LVN 2 stated, Resident potentially could fall and/or injure self-trying to reach for the call light on the floor, when she needs assistance. 2. During review of Resident 127's admission Record indicated Resident 127 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included polyneuropathy (multiple nerves in the body are damaged, leading to symptoms like pain, numbness, tingling, and weakness), dementia (decline in mental ability that interferes with daily life), muscle wasting and difficulty walking. During a review of Resident 127's MDS, dated [DATE], indicated Resident 127's cognitive skills was intact. The MDS indicated, Resident 127 required partial/moderate assistance with personal hygiene, and dependent with toileting, bathing, dressing and chair/bed-to-chair transfer. During a review of Resident 127's care plan (CP) for risk for falls related to gait/balance problems and limited mobility, revised 4/17/2025 indicated intervention includes to be sure call light is within reach. During a review of Resident 127's facility document titled Quarterly Risk Data Collection Tool under fall risk assessment dated [DATE], indicated Resident 127 was at risk for fall. During a concurrent observation and interview on 12/1/2025 at 10: 56 AM with Resident 127 and Treatment Nurse (TN) 1, Resident 127 was observed in bed awake and alert with her call light was on the floor and out of reach. Resident 127 stated, she did not know why the call light was on the floor and complained that she could not reach it to call for assistance. Resident 127 stated, relies on her call light to get assistance from staff. TN 1 stated that the call light should never be on the floor and must always be within the resident's reach. TN 1 stated that Resident 127's inability to access her call light could result in staff being unaware of her needs, especially in emergency situations. During an interview on 12/2/2025 at 3:31 PM with the Director of Nurses (DON), DON stated, he expects call lights to be within reach of residents, it is facility policy, especially to those who can use it. DON stated, it is essential for the call light to be within reach so Residents can call for assistance especially for emergency. DON stated, for resident not able to reach for the call light had the potential for fall and/or injury from trying to get up to call for help. A review of the facility's policy and procedure (P&P) titled, Call Light dated 1/2024, indicated; a) each resident is provided with means to call staff directly for assistance from his/her bed , from toileting/bathing facilities and from the floor, b) resident call light shall be within reach, and c) answer the resident call system in a timely manner.

Based on observation, interview and record review, the facility failed to provide a homelike environment for two of two sampled residents (Residents 100 and Resident 42) by ensuring Resident 100 and 42's wall clock in the room displays the accurate time of the day at all times. This deficient practice had the potential to cause disorientation, that could negatively affect Resident 100 and Resident 42's quality of life.Findings: 1.During a review of Resident 100's admission Record indicated the facility admitted Resident 100 on 10/15/2025 with diagnoses that included hemiplegia and hemiparesis (paralysis or severe weakness), hypertension (high blood pressure), and lack of coordination. During a review of Resident 100's Minimum Data Set (MDS - a resident assessment tool), dated 10/19/2025, indicated Resident 100's cognitive status (ability to think and reason) was severely impaired. Resident 100 was dependent (helper does all the effort) with toileting, bathing, dressing and personal hygiene. During a concurrent observation and interview on 12/1/2025 at 10:29 AM the wall clock in the shared room of Resident 100 and Resident 42 was noted to display an incorrect time (4:25), while the actual time was 10:29 AM. LVN 1 stated maintaining accurate time on the wall clock supports a homelike environment and prevent disorientation, especially for alert or confused residents. FAM 1 expressed appreciation for the surveyor's attention to the issue, noting that Resident 100 is becoming more alert and benefits from proper orientation. FAM 1 also shared that she became aware of the incorrect time after Resident 42 expressed frustration earlier that morning, asking for the correct time. 2. During a review of Resident 42's admission Record indicated the facility originally admitted Resident 42 on 7/1/2024 and readmitted on [DATE] with diagnoses that included diabetes (blood sugar, is too high), mild cognitive impairment (memory or thinking problems), and anemia (blood lacks enough healthy red blood cells). During a review of Resident 42's MDSdated 10/19/2025, indicated Resident 100's cognitive status was moderately impaired and was dependent with toileting, bathing, dressing and personal hygiene. During a concurrent observation and interview on 12/1/2025 at 10:45 AM with Resident 42, in Resident 100 and Resident 42's room. The rooms wall clock now reads the right time 10:45 (shorthand pointed at #10 and long hand pointed at #9). Resident 42 just gave a thumbs up when asked how he feels about seeing the right time on the wall clock but did not want to be interviewed further. During an interview on 12/2/2025 at 3:25 PM with the Director of Nurses (DON), DON stated, it is the responsibility of the facility's responsibility to provide a homelike environment to all the residents of the facility, which includes ensuring the wall clock in residents rooms to read the right time regardless of the resident's level of alertness. DON stated having the right time on resident's wall clocks helps prevent confusion and disorientation, which could negatively impact residents' quality of life. A review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised 2/2021, indicated; a) Residents are provided with safe, clean, comfortable, and homelike environment, and b) homelike setting includes: clean, sanitary, and orderly environment.

Based on Interview and record review, the facility failed to ensure that the facility informed one of eight residents (Resident 129) reviewed for resident's rights. Resident 129 and/or the representatives were not informed in writing the facility's policy on bed hold and return ( the facility keeps the resident's bed/room saved for up to 7 days while the resident is temporarily out of the facility) and keeps the document in the resident's clinical record that the resident was placed on bed hold at the time of transfer to the General Acute Care Hospital (GACH) on 9/9/2025 in accordance with the facility's policy and procedure (P&P) titled Bed-Holds and Returns, This deficient practice had the potential for residents' bed not to be appropriately held during hospitalization and to lose their room or their right to return to the same bed. Findings: A review of the admission record indicated Resident 129 was originally admitted to the facility on [DATE] with a diagnosis of pressure ulcer of sacral region (localized skin injury or underlying tissue of the lower spine due to unrelieved pressure, friction and shear), neurocognitive disorder with Lewy bodies( progressive brain disorder that causes problems with thinking, memory, movement , and behavior due to abnormal protein deposits in the brain) and diabetes ( disease in which the amount of sugar in the blood is too high). A review of the Minimum Data Set (MDS - s standardized assessment and care screening tool) dated 6/18/2025, indicated Resident 129 had severely impaired mental status cognition (ability to think and reason) requiring total assistance from staff in activities of daily living. A review of Resident 129's nursing note titled Transfer to Hospital, dated 9/9/2025, indicated Resident 129 was transferred to GACH on 9/9/2025, there was no documented evidence in the nurse's note that the facility notified the responsible party regarding the bed hold option. A review of Resident 129's Order Summary Report, dated 9/9/205, indicated to transfer to Resident 129 to GACH ER for further evaluation due to altered mental status and failure to thrive. The order report did not include a physician's order to put Resident 129's bed on hold for 7 days. A review of Resident 129's Transfer Form dated 9/9/2025, indicated Resident 129 was transferred to GACH on 9/9/2025 for further evaluation due to altered mental status and failure to thrive. A review of Facility Census reports dated 9/8/2025 through 9/18/2025 indicated that on 9/8/2025, Resident 129 was listed as occupying room [ROOM NUMBER]B. For 9/9/2025 to 9/18/2025, the census listed room [ROOM NUMBER]B as empty (no resident occupying the bed) but with no indication that the bed was on behold status for Resident 129. During a concurrent interview and record review of Resident 129's clinical records on 12/3/2025 at 2:51 PM with Director of Nursing (DON), DON stated no documented evidence in the resident's clinical record that the physician ordered to place Resident 129 bed on hold was when the resident was transferred to the hospital. In addition, the DON was unable to provide a bed-hold notification form. DON stated every time a resident is to transfer out a bed hold must be ordered to ensure a bed is available on return. During a review of the Facility's policy and procedure (P&P) titled Bed-Holds and Returns, dated 10/2022, the P&P indicated residents and or representatives are informed (in writing) of the facility and state bed-hold policies.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP) for two of seven residents (Resident 55 and 35) reviewed for comprehensive care plan by failing to: 1. Develop a CP to ensure Resident 55 received necessary care and interventions while receiving Ambien (a medication used to treat insomnia (a sleep disorder that can make it hard to fall asleep or stay asleep). 2. Develop a CP to ensure Resident 35 received necessary care and intervention while on hospice care (an end-of-life care). These deficient practices placed Resident 55 at risk of not receiving appropriate interventions to prevent the unnecessary use of psychoactive medications, which could result in adverse side effects (undesired effects). Additionally, these practices had the potential to compromise individualized care and negatively impact the quality of services provided to Resident 35. 2.During a review of Resident 35's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia (your lungs had a long-term problem where they could not get enough oxygen in your blood, causing tissues and organs to not get the oxygen they need), heart failure (the heart could not pump enough blood and oxygen to meet the body's needs), chronic obstructive pulmonary disease (COPD, a progressive lung disease that locked airflow, making breathing hard to do). During a review of Resident 35's History & Physical (H&P) dated 6.26.25, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 35's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 10/17/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was receiving oxygen therapy (extra oxygen when you could not get enough from the air) and Hospice care (compassionate, comfort-based care for people with a serious illness when a cure was not possible, shifting the goal from curing the disease to ensuring the best quality of life for the time remaining). During a review of Resident 35's Order Summary Report dated 7/11/2025, the Order Summary Report indicated the resident was admitted to hospice care due to chronic respiratory failure with hypoxia. During a review of Resident 35's Comprehensive (complete) Care Plan, dated 7/11/2025, the Care Plan did not include information regarding hospice care. During an interview on 12/4/2025 at 10:49 AM, the Registered Nurse Supervisor (RNS) stated the facility staff who received the order from the physician to admit the resident to hospice would be the person to create the care plan. The RNS stated there should have been a care plan for hospice for Resident 35 for the safety of the resident. The RNS stated if there was no care plan for hospice, the facility staff would not know who to contact and what to do for the resident. During an interview with the Registered Nurse Supervisor (RNS), it was stated that the facility staff member who received the physician's order to admit a resident to hospice would be responsible for initiating the hospice care plan. The RNS emphasized that a hospice care plan should have been developed for Resident 35 to ensure the resident's safety. The RNS further explained that in the absence of a hospice care plan, facility staff would lack critical guidance on who to contact and what actions to take to appropriately care for the resident. During a concurrent interview and record review on 2/4/2025 at 10:36 AM, the Director of Nursing (DON) stated a care plan was the plan of care for the resident of what the facility would do for any problems the resident would have including their diagnoses and how the facility would care for the resident. The DON stated Resident 35 should have had a Hospice Care Plan because if the facility did not have a hospice care plan the facility staff would not know how to care for the resident in different circumstances. The DON stated the facility was not following the policy but should have been otherwise the facility staff would not know how to care for the resident because nothing would be there. During a review of the facilities policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered revised March 2022, the P&P indicated, The facility will develop a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and assessments of residents are ongoing. The care plans are revised as information about the residents' and the resident's conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition and at least quarterly, in conjunction with the required quarterly MDS assessment. Findings: 1.During a review of Resident 55's admission Record (AR), the AR indicated the facility admitted Resident 55 on 1/16/2025 with diagnoses that included panic disorder (sudden periods of intense fear) and type II diabetes mellites (a condition that happens when your blood sugar is too high). During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/16/2025, the MDS indicated Resident 55 had intact cognition (ability to understand and make decisions) and memory that required setup or clean-up assistance with eating, and supervision or touching assistance with oral hygiene, toileting hygiene, personal hygiene, chair/bed-to-chair transfer, and shower/bathe self. During a review of Resident 55's Order Summary Report, dated 12/3/2025, the report indicated on 11/28/2025 the physician renewed the order of Ambien Oral Tablet five milligram (MG, a measurement unit) one tablet to be administered by mouth every 24 hours as needed for insomnia. During a review of Resident 55's Medication Administration Record (MAR), dated 11/2025 and 12/2025, the MARs indicated Resident 55 was administered Ambien five MG one tablet as needed for 25 days from 11/1/2025 to 12/2/2025. During a concurrent interview and record review on 12/3/2025 at 1:12 PM Licensed Vocational Nurse (LVN) 4 stated, Resident 55 had been taking Ambien at bedtime as needed for sleep but there was no CP in place to indicate the care and interventions to implement while Resident 55 had been taking Ambien. LVN 4 stated the nurse who received the initial order of Ambien was responsible to initiate the CP. LVN 4 stated it was important to develop a CP for the use of Ambien because Ambien was a psychotropic medication (medication that affects mood and disorder), and it required close monitoring of the adverse reaction, side effects and effectiveness or ineffectiveness of the medication to treat the insomnia and to ensure consistent and safe care to the residents. During a concurrent interview and record review of Resident 55's CP on 12/4/2025 at 10:59 AM, the DON stated the assigned nurse did not develop a CP for Resident 55 for the use of Ambien. The DON stated that the nurse should have initiated the care plan to ensure safe and appropriate care for the resident, especially considering that Ambien is a psychotropic medication requiring monitoring for effectiveness and potential side effects. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated the comprehensive, person-centered care plan is developed for each resident within seven days of completion of required MDS assessment, and no more than 21 days after admission.

Based on observation, interview and record review, the facility failed to ensure the peripheral Intravenous (IV-small catheters inserted into a vein used to administer fluids, blood and medications) sites for one of eight (Resident 52) on the right and left arms peripheral IV dressings were dated and initialed by the staff who changed the dressing in accordance with the facility's policy and procedure titled Peripheral and Midline intravenous and the physician's order. This deficient practice had the potential to increase the risk for result IV infection, IV site skin breakdown, IV infiltration (IV fluid leaking out from the veins and into the tissues causing swollenness, pain and tissue damage) Findings: A review of the admission records indicated Resident 52 was admitted originally on 11/04/2025, with a diagnosis of acute embolism ( a blockage in the blood vessel caused by something that has traveled there through the bloodstream such as a blood clot) and thrombosis (a blood clot ) of left femoral vein (a large vein in the upper leg/groin area) , respiratory failure (when lungs cannot get enough oxygen into the blood that result in difficulty breathing) A review of Resident 52's Minimum Data Set ( MDS- standardized comprehensive assessment tool) dated 10/01/2025, indicated Resident shows moderate impairment in memory and thinking abilities, and may need repetition, cues, and assistance for making decisions and recalling information and is dependent on staff to complete most activities such as dressing , personal hygiene, showering and toileting hygiene as well. A review of an Order Summary Report with an order date of 12/1/2025 indicated to change Resident 52's peripheral IV dressing every 7 days and with site change as needed and every Sunday. During an observation on 12/1/2025 at 10:09 AM in Resident 52's room, the resident's right and left peripheral IV dressing site was observed without the date the IV dressing was changed and the initial of the staff that changed the dressing. During a concurrent observation and interview on 12/1/2025 at 10:15AM with Registered Nurse Supervisor (RN) 2 in Resident 52's room,the resident's right and left peripheral IV dressing sites were observed without the date the IV dressing was changed and the initial of the staff that changed the dressing. RN2 stated, IV dressing should be changed every Sunday and the peripheral IV site must be dated so staff can monitor when the dressing need to be changed and to assess for signs of infection. During a concurrent observation and interview on 12/1/2025 at 10:18 AM, in Resident 52's room with Director of Nursing (DON), stated it was important to have a date of when the IV was inserted and when the IV dressing was changed to know when the dressing will be changed again as indicated in the facility's policy and procedure. During a review of the facility's policy and procedure ( P&P) titled, Peripheral and Midline IV Dressing Changes dated 3/2022, the policy indicated purpose of procedure is to prevent complications associated with intravenous therapy including catheter related infections associated with contaminated, loosened or solid catheter-site dressings and to include in steps in the procedure labeling of dressing with the date and time of dressing change, and initials.

Based on observation, interview and record review the facility failed to ensure Resident 102 was free from significant medication error by failing to administer the correct dose of Retacrit ( a stimulating agent used to increase red blood cell production used to treat anemia (not enough healthy red blood cells that carry oxygenated blood to the tissues) reducing the need for blood transfusions) as ordered by the physician. This deficient practice had the potential to further worsened Resident 102's anemia and compromise resident's well-being and that may lead to the need for urgent blood transfusion and hospitalization. Findings: A review of the admission record indicated Resident 102 was admitted to the facility originally on 11/05/2025, with a diagnosis that included hemiplegia(paralysis affecting one side of the body) and hemiparesis (weakness or inability to move on one side of body) , anemia, and diabetes (Chronically high blood glucose ( sugar) levels). A review of resident 102's History and Physical (H&P), dated 11/06/2025, indicated Resident 102 had the capacity to understand and make decisions. A review of resident 102's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 11/21/2025, indicated Resident 102 was cognitively (though process or ability to reason and remember) intact. A review of Resident 102's Order Summary Report indicated the physician ordered on ordered on 11/18/2025 to start 11/19/2025 to administer Retacrit injection solution) inject 6000 unit subcutaneously (injected into the skin on the fatty tissue) one time a day every Monday, Wednesday and Friday for anemia. A review of Resident 102's Medication Administration Record (MAR), dated 12/3/2025 at 9AM indicated, LVN 4 administered Retacrit Injection solution 6000 units subcutaneously to Resident 21's upper left arm for anemia. During an observation and interview of a medication pass on 12/3/2025 at 7:46 AM with LVN4 was observed drawing up medication and administering Retacrit 3000units (1ml) subcutaneously to Resident 102. When asked if she had administered the correct dose as ordered by the physician, LVN 4 looked at the vial label and checked the physician's order that indicated to administer Retacrit 6000units subcutaneously. LVN 4 stated she had made a medication error and needed to administer another dose. During an observation and interview on 12/3/2025 at 08:41AM with Director of Nursing (DON) and LVN 4, the physician's order and the medication vial for Retacrit for Resident 102 were reviewed and compared. The DON stated that the LVN 4 had administered 3,000units, and therefore made a medication error and needed to administer one more vial to total the ordered amount of 6,000 units. The DON further stated that an underdose of Retacrit for Resident 102, who had anemia, could result in adverse (unwanted or harmful result) signs and symptoms related to low hemoglobin such as shortness of breath, need for blood transfusion and worsening fatigue. A review of the facility's policy and procedure (P&P) titled Administering Medications, dated 4, 2023, indicated Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method(route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of four sampled residents (Resident 55) as evidenced by having dust with white debris, a drinking cup, a medication cup, a piece of cotton swab, a pack of food condiments, and old dry liquid stains on the floor under the resident's bed. This deficient practice had the potential to result in Residents 55's non homelike environment that affects the resident's quality of life and self-image. During a review of Resident 55's admission Record (AR), the AR indicated the facility admitted Resident 55 on 1/16/2025 with diagnoses that included type II diabetes mellites (a condition that happens when your blood sugar is too high) and hypertension (high blood pressure). During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 10/16/2025, the MDS indicated Resident 55 had intact cognition (ability to understand and make decisions) and memory that required setup or clean-up assistance with eating, and supervision or touching assistance with oral hygiene, toileting hygiene, personal hygiene, chair/bed-to-chair transfer, and shower/bathe self. During an observation on 12/1/2025 at 9:06 AM in Resident 55's room, the floor under Resident 55's bed was dusty with small debris particles, a drinking cup, a medication cup, a piece of cotton swab, a pack of food condiments, and some old dry liquid stains. During a concurrent observation and interview on 12/2/2025 at 11:45 AM with Resident 55, the floor in Resident 55 remained dirty as observed on the previous day 12/1/2025. Resident 55 stated the floor was very dirty and no one came to clean and mop the floor. Resident 55 stated the staff came to his room to pick up his trash and they had not cleaned the floor for three to four weeks. Resident 55 stated the dirty floor made him uncomfortable and he would like a clean space. During a concurrent observation and interview on 12/2/2025 at 11:56 AM with the Maintenance Supervisor (MS), the MS stated floor in Resident 55's room was dirty, and the housekeeping staff did not clean and mop the floor every day. The MS stated he did not know for how long the floor was not cleaned and there was no document indicating when this room was last cleaned. The MS stated the housekeeping staff should clean and mop every resident's floor daily to provide a clean and sanitary environment for the residents. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, dated 2/2021, the P&P indicated the facility to provide a safe, clean, and comfortable environment.

Based on observation, interviews, and record review, the facility failed to provide the required minimum of 80 square feet (sq. ft., unit of measurement) per resident in 34 out of 45 resident bedrooms. Specifically, Resident Bedrooms 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 41, 42, 43, 44, 45, 46, and 47 were measured and found to provide less than 80 square feet per resident. These rooms consisted of 31 three-bed capacity bedrooms and three two-bed capacity bedrooms. This deficient practice had the potential to negatively impact residents by limiting adequate space for safe nursing care, reducing privacy, and potentially increasing the risk of accidents or compromised care delivery due to overcrowded conditions. Findings: During a review of the Client Accommodation Analysis (CAA, a form used to identify the room sizes and number of beds in the room) form completed by the facility on 12/1/2025, the Client Accommodation Analysis indicated the facility had 34 bedrooms in the facility that measured less than 80 sq. ft. per resident care area as listed below: room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (2 beds) 143 sq. ft.; 71.5 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (2 beds) 143 sq. ft.; 71.5 sq. ft., per resident. room [ROOM NUMBER] (3 beds) 220 sq. ft.; 73.3 sq. ft., per resident. room [ROOM NUMBER] (2 beds) 143 sq. ft.; 71.5 sq. ft., per resident. During a review of the facility's request for additional room waiver dated 12/1/2025, the request indicated the licensee contends this waiver was necessary to avoid an unreasonable financial hardship and would be able to provide care and services without adversely affecting the health and safety of the facility's residents. The request indicated the following residents' bedrooms: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 18, 19, 23, 24, 25, 26, 28, 29, 30, 31, 32, 33, 34, 41, 42, 43, 44, 45, 46, and 47. During an interview on 12/4/2025 at 8:45 AM, Certified Nursing Assistant (CNA) 1 stated there was enough space to transfer and care for the residents. CNA 1 stated that sometimes the facility staff would need to move the resident's bedside table or bed to make space but doing so did not affect resident care. During an interview on 12/4/2025 at 8:52 AM, Licensed Vocational Nurse (LVN) 2 stated there was enough space to care for the residents and CNAs could move stuff around to transfer and care for the residents as needed. LVN 2 stated the limited space did not affect the residents care or safety. During an interview on 12/4/2025 at 9 AM, LVN 7 stated CNAs would move the bedside table, bed, or wheelchair to make space when using a Hoyer lift (a mechanical device like a mobile crane for people, that used a sling to safely lift and move someone who could not move themselves) to transfer a resident. LVN 7 stated the facility staff were able to work around and make sure there was enough space to transfer residents from the bed to the chair, from the chair to the bed, and in and out of the room safely. During an interview on 12/4/2025 at 9:01 AM, Resident 136 and the Responsible Party (RP) stated they felt there was enough living space in the bedroom. The RP stated the overall space was okay but sometimes the resident or the facility staff needed to move things around but that was not an issue. During an interview on 12/4/2025 at 9:04 AM, Resident 34 stated there was enough space in the bedroom and was glad for the open area near the window. Resident 34 stated the facility staff have never had an issue getting around the room to assist the resident. During an interview on 12/4/2025 at 9:09 AM, Resident 56 stated there was enough living space to do the things the resident wanted to do in the bedroom. Resident 56 stated there have not been issues with space when staff assist and the staff have never complained there was not enough room when providing care. During an interview on 12/4/2025 at 9:31 AM, CNA 6 stated there was enough space to tend to the resident's care and needs and the residents have not complained about the space. CNA 6 stated for the most part, the bedroom was spacious but looked small because of the curtains in all of the bedrooms. During the course of the re-certification survey between 12/1/2025 to 12/4/2025, the above listed bedrooms had sufficient space for the residents' freedom of movement. The bedrooms had adequate space to provide nursing care, privacy during care, and the ability to maneuver resident care equipment with the room. The room size did not have any adverse effect on the residents' personal space, nursing care, and comfort. During an interview on 12/4/2025 at 2:40 PM, the Administrator (ADM) stated the facility would like to request a room waiver for this year. The ADM stated residents, families, and staff have not complained about the space being too small or being unable to care for the residents due to the space.

Based on interview and record review, the facility failed to identify the provision of monitoring and supervision to prevent abuse and intoxication of illicit/recreational drugs ([street drugs] refers to the use and misuse of illegal and controlled drugs) for one of two sampled residents (Resident 1) reviewed for substance abuse, and with a recent history of taking recreational drugs by failing to: 1. Accurately assess, monitor, and develop interventions to provide additional monitoring and ensure the safety of Resident 1 who had a history of methamphetamine (meth - a powerful synthetic stimulant drug with a high potential for addiction) use for potential of continued meth use when Resident 1 tested positive for amphetamine as indicated in the General Acute Care Hospital (GACH 1) Toxicology Report (details the analysis of biological samples to identify and quantify the presence of drugs, poisons, or other chemicals in a person's system), on 4/25/2024. 2. Secure and prevent Resident 1 from keeping smoking items (cigarettes, glass pipe, and lighters) in his possession, when Resident 1 was assessed by the facility and documented as a non-smoker on 10/8/2024. 3. Develop and implement interventions to ensure the safety of Resident 1 and other residents when lighters were found present in Resident 1's room on 6/4/2025, who had orders to receive continuous oxygen daily. 4. Ensure the facility has a plan of action in place on how to care for residents who does not comply with the facility's smoking policy titled Smoking Policy - Residents that indicated oxygen use is prohibited in smoking areas and independent smoking privileges may not have or keep any smoking items, except under direct supervision. These failures resulted in Resident 1 experiencing tachycardia (rapid heart rate, defined as a heart rate exceeding 100 beats per minute [bpm]), oxygen (O2) desaturation (oxygen levels in the blood drop below normal for an extended period, normal blood oxygen level is 95 percent [%] to 100% ), shortness of breath (SOB, difficulty breathing) and being transported by emergency medical services (EMS or 911) to General Acute Care Hospital (GACH) 2 on 6/4/2025 at 5:54 p.m. GACH 2 toxicology dated 6/4/2025, indicated Resident 1 tested positive for amphetamines (a synthetic, addictive, mood altering drug, used illegally as a stimulant and legally as a prescription drug) and methamphetamines upon arrival to GACH 2, requiring intubation (a way to secure the airway and support breathing, often in critical or emergency situations). On 6/5/2025, the police report indicated police officer (PO) 1 was dispatched on 6/5/2025, regarding Resident 1's found property. The Report indicated narcotics, and a meth pipe were found in one of the resident's rooms (Resident 1). The Report further indicated under drug information that PO 1 found meth in clear baggie and candy dispenser, and was documented as amphetamines/ methamphetamines with quantity documented as 1 (one) gram (gm, unit of measurement by weight). Findings: During a review of Resident 1's admission Record (AR, contains demographic and medical information), the AR indicated the facility admitted Resident 1 on 7/12/2021 and readmitted on [DATE] with diagnoses that include paraplegia (the inability to voluntarily move the lower parts of the body), incomplete (some degree of movement and sensation may be retained below the injury site), Emphysema is a type of chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), Atrial fibrillation (Afib, irregular heart beat), Hypertensive heart disease (a group of heart conditions that develop as a result of prolonged high blood pressure) with heart failure (when the heart cannot pump enough blood and oxygen), and depression (a constant feeling of sadness and loss of interest). During a review of Resident 1's GACH 1 Toxicology Report, dated 4/25/2024, timed at 3:01PM, the Report indicated, Resident 1 tested positive for Amphetamine during a drug screen, urine test. During a review of Resident 1's History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 5/1/2024, the H&P indicated, Resident 1 have the capacity to understand and make decisions. During a review of Resident 1's Interdisciplinary team (IDT- a group of professionals from different fields in the nursing facility that work together to address a patient's needs) note, dated 5/2/2024, at 11:15 a.m., the IDT note indicated, IDT spoke to resident regarding result of his urine drug screen that was completed while he was in the hospital. Urine drug screen read that he was positive for amphetamine . Explained to resident that taking recreational drugs is not tolerated in the facility. Provided education on risks and effects of taking recreational drugs, while taking other prescribed medications and resident's current health status. Informed resident that further investigation will be conducted regarding this matter .IDT met to discuss resident urine drug screen result of positive for amphetamine. IDT recommends continuing to educate resident on effect of recreational drug use while on prescribed medications, continue to provide education on the effects of recreational drug use based on his health status, remind resident that recreational drug use is not tolerated in the facility. There was no documented evidence to indicate that the facility staff had monitored Resident 1 for illegal substance use after Resident 1's urine tested positive for amphetamine in GACH 1. During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 3/19/2025, the MDS indicated Resident 1 ' s cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 1 needed supervision for eating and oral hygiene, partial assistance for personal hygiene, and substantial/maximal assistance to dependent on physical assistance by staff for toileting, bathing, dressing, and transfer from bed to wheelchair. During a review of Resident 1's GACH 1 History and Physical (H&P) dated 6/30/2024, at 1:41 p.m., the H&P indicated, Social History .He does have a history of methamphetamine (a man-made [synthetic], highly addictive stimulant that speeds up brain and body functions and is illegal without a prescription) use. During a review of Resident 1 ' s Smoking Assessment, dated 10/8/2024, the form indicated Resident 1 does not smoke. During a review of Resident 1's Change of Condition [COC] Evaluation (details significant deviations from a resident's baseline status, including physical, cognitive, behavioral, or functional changes), dated 4/16/2025, at 1 p.m., Resident 1's COC indicated, Resident [1] noted with tachycardia and desaturation. Gave 15 L (liter, unit of measure by volume) of oxygen with his head elevated 90 degrees. Called paramedics immediately. Assessed by paramedics and recommended to transfer patient to hospital but resident strongly refused. MD notified . During a review of an Order Requisition for laboratory tests with collection date of 4/24/2025, the Requisition indicated Resident 1 refused laboratory draw and again on 4/28/2025. During a review of Resident 1's Nursing Progress Note, dated 4/30/2025, at 8:25 a.m., Resident 1's Nursing Progress indicated, Resident [1] refused laboratory (test) 3x (three times). Explained risk and benefits but still strongly refused. During a review of Resident 1's COC Evaluation, dated 6/4/2025, at 5:35 p.m., Resident 1's COC indicated, Resident [1] noted with SOB, desaturation 88% O2 at 2 LPM via NC, and tachycardia with a HR of 174 bpm. HOB (head of bed) elevated for comfort and for easily breathing. O2 given at 15 LPM via nonrebreather mask (NRB, a type of oxygen delivery device used in emergency situations to provide a high concentration of oxygen to a patient who can breathe on their own but has low blood oxygen levels). MD made aware with an order to transfer resident to GACH 2 via 911 for further evaluation. During a review of Resident 1's EMS Runsheet (a medical record for ambulance services), dated 6/4/2025, timed at 5:32 p.m., the EMS Runsheet indicated, Facility called EMS for a patient with respiratory distress. Facility stated patient pulse oximetry was 85 % on room air. Upon arrival, patient was sating at 88 % with NRB (non-rebreather mask) at 15 L per minute. Staff denied any recent illness or injury. Patient [Resident 1] complained of SOB for the past 10 minutes .history of methamphetamine use. They stated they found a lighter on the patient. During a review of Resident 1's GACH 2 ED (Emergency Department) Report, dated 6/4/2025, at 5:54 p.m., the GACH 2 ED Report indicated, Resident 1 arrived by ambulance .was having hypotension (low blood pressure) and shortness of breath at a nursing facility and was sent for further evaluation. Resident 1's ED Report indicated, Individual has a history of methamphetamine use. Patient arrived hypotensive. He is speaking gibberish .Diagnostics .methamphetamines - Presumptive Positive, Abnormal, dated 6/4/2025, at 8:25 p.m.Re-evaluation and Summary .admitted patient [Resident 1]. The patient's [Resident 1] condition required additional management, and care was escalated to admission .sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection) protocol was initiated. During a review of Resident 1's Nursing Progress Note, dated 6/4/2025, timed at 9:09 p.m., Resident 1's Nursing Progress indicated, It was observed that resident has a long lighter on his table. This was identified as a fire hazard because the resident is using an oxygen concentrator, which increases the risk of fire in the presence of open flames or ignition sources. During a review of Resident 1's Case Management/ Social Worker (CM/SW) Screening, dated 6/5/2025, at 2:19 p.m., the Screening indicated, SW reviewed Pt's chart and noted that Pt (Resident 1) admitted to (GACH 2) on 6/4/2025 with initial dx (diagnosis) of Sepsis (the body's extreme reaction to an infection), per Facesheet .Per MD (physician), Pt [Resident 1] tested positive for Meth . Pt [Resident 1] is now intubated, unsure where Pt [Resident 1] received the drugs. During a review of Resident 1' s Order Summary Report (OSR), the OSR indicated active orders as of 6/6/2025, Resident 1 OSR included the following: 1. Admit to Skilled Nursing from general acute care hospital (GACH) 1, dated 4/30/2024 under the service of primary care physician (MD) 1 with the following diagnosis: Amphetamine abuse, septic shock, acute renal failure, multiple infected wounds and pressure sore. 2. Administer Oxygen at 2 (two) liters per minute (LPM) via nasal cannula continuously to keep the oxygen (O2) saturation at 92 percent (%), every shift for shortness of breath (SOB), with order dated 4/16/2025. 3. OK to go out on pass for 6 hours with responsible party, with order dated 4/30/2025. During a review of Resident 1's Care Plan (CP- a document that outlines a resident's needs, treatment, and expected outcomes), dated 6/5/2025, the care plan focus indicated, The resident tested positive for Methamphetamine in the hospital after being transferred by 911 for tachycardia, tachypnea (rapid and shallow breathing), SOB, and desaturation. During an interview on 6/6/2025, at 12:35 p.m., the facility Administrator (ADM) reported on 6/4/2025 Resident 1 had a fast heartbeat (tachycardia) and was moved to the hospital (GACH 2) via a 911 call (emergency service phone call). ADM stated the hospital informed the facility on 6/5/2025, that a drug test (toxicology screening) showed Resident 1 tested positive for amphetamine (a synthetic, addictive, mood-altering drug). The ADM noted that Resident 1 was not being monitored for the use of amphetamines or methamphetamines. ADM stated that after being notified of Resident 1's positive test result, staff found an open black bag in Resident 1's room. ADM stated that he took possession of the bag and discovered a glass meth (methamphetamine) pipe inside (a smoking device used for meth). ADM stated the local police were called, and an officer arrived on June 5, 2025, at 5 p.m. to remove the glass pipe for proper disposal (safe removal and discard). ADM stated Resident 1 shares a room with two other residents. The ADM added that Resident 1 is usually very quiet and private, which made this discovery surprising to the staff. During an interview on 6/6/2025, at 5:13 p.m., the Director of Staff Development (DSD) stated that the charge nurse, Licensed Vocational Nurse (LVN) 3, notified her that Resident 1 was experiencing tachycardia, with a fluctuating heart rate (HR) of 174 beats per minute (normal HR: 60-100 bpm) on 6/4/2025. The DSD stated that Resident 1 initially refused to go to the hospital. The DSD stated before Resident 1's change in condition (COC), the resident was playing games in his room. Additionally, the DSD stated she observed that Resident 1 had a lighter in his room and the DSD could not explain why Resident 1 would keep a lighter in his room. During a telephone interview on 6/6/2025, at 5:28 p.m., with the Director of Staff Development (DSD) present, LVN 3 was contacted. LVN 3 stated while was delivering evening medications to other residents in Resident 1's room, LVN 3 observed that Resident 1 was having difficulty breathing (shortness of breath, SOB). LVN 3 stated Resident 1 was receiving oxygen, looked pale, and was sweaty. LVN 3 stated she informed DSD and the Director of Nursing (DON) to reassess Resident 1. LVN 3 stated when Resident 1 began having trouble talking, 911 was called. LVN 3 stated, no evening medications were given to Resident 1. LVN 3 noted that this was the worst episode of breathing difficulty she had seen in Resident 1, even while on oxygen. She was not aware if Resident 1 was taking any medication from outside. LVN 3 stated Resident 1 orders food delivered to the facility and has a friend who brings groceries. LVN 3 stated that on Wednesday, June 4, 2025, she saw a long, orange and black lighter in Resident 1's room, and Resident 1 does not leave the room to smoke. During a review of the police report dated 6/5/2025, at 3:02 p.m., the police report indicated PO 1 was dispatched regarding found property. Report indicated upon arrival PO 1 spoke with the facility's ADM that stated he found narcotics and a meth pipe in one of his patient's (Resident 1) room. Report indicated, I collected the meth pipe and narcotics. I booked the narcotics for destruction and placed the meth pipe in the disposal bin property room. Police report indicated under drug information, found meth in clear baggie and candy dispenser, type was documented as amphetamines/ methamphetamines and quantity documented was 1 (one) gram (gm, unit of measurement by weight). During a telephone interview on 6/6/2025, at 5:45 p.m., with LVN 4 in the presence of the DSD, LVN 4 stated that Resident 1 watches TV and uses his iPad. LVN 4 stated that during the morning shift (7 a.m. to 3 p.m.) on June 4, 2025, Resident 1 was fine. LVN 4 stated, Resident 1 did not complain of SOB and took all of his morning medications. During a telephone interview 6/11/2025, at 3:11 p.m., with Resident 1 present and GACH 2's Case Manager/Social Worker (CM/SW) present, Resident 1 was asked about the glass pipe found in a black bag identified as his. Resident 1 said, The meth pipe has been in my bag for a long time. I got depressed and could not handle my situation. I am paralyzed and felt hopeless in my life. I try really hard to be strong. I just don't know. I meant to throw it (meth pipe) away. Resident 1 explained that he used methamphetamines in the past to help him cope with his depression. Resident 1 did not say when he last used the meth pipe or who provided him with methamphetamine or the meth pipe. During an interview on 6/12/2025, at 2:09 p.m., LVN 4 reported that Resident 1 used to smoked and that facility staff would assist the resident with a wheelchair to go outside to smoke. LVN 4 stated on 6/4/2025, during the day shift (7 a.m. - 3 p.m.), Resident 1 showed no signs of breathing difficulty. LVN 4 stated Resident 1 moves both arms, remained alert and oriented x4 (fully aware of person, place, time, and situation), and could use a lighter independently. LVN 4 stated Resident 1 used oxygen continuously. LVN 4 stated that the facility required visitors to bring any items for Resident 1 to the nursing station so staff could add them to Resident 1's personal belongings inventory (a record of resident possessions) list. LVN 4 stated without this process, the facility could not track when Resident 1 received new items, such as lighters, alcohol, or cigarettes. LVN 4 stated that Resident 1's room contained clutter, including food, bags, and containers, and that staff had not added the items to the resident's inventory, which left the staff unaware of what was inside of Resident 1's bags. During another interview on 6/12/2025, at 3:30 p.m., with LVN 4, LVN 4 stated he was unaware that Resident 1 had tested positive for amphetamines/methamphetamines in 2024. LVN 4 stated that the facility should have informed staff about any past positive tests so they could monitor Resident 1 for potential repeated use. LVN 4 stated that the facility has not provided any training on methamphetamine use or on recognizing its signs and symptoms. LVN 4 stated, If I knew about the positive urine test for amphetamine in 2024, I would have checked his (Resident 1) inventory, monitored the resident for amphetamine use, and educated the CNAs (Certified Nurse Assistants) on signs and symptoms to watch for and when to notify the charge nurse. LVN 4 stated that a resident using amphetamines may show symptoms such as rapid breathing, hallucinations, tachycardia (rapid heart rate), rapid pulse, and shortness of breath. During an interview and record review on 6/12/2025, at 3:39 p.m., with Medical Records Director (MRD), MRD provided Resident 1's personal belongings inventory list dated 2/7/2023. MRD stated there was no new or updated personal belongings inventory list for Resident 1. During an interview on 6/12/2025, at 4:26 p.m., with a Registered Nurse (RN) 1 stated that Resident 1 used to smoke in the patio area. RN 1 stated that on June 4, 2025, Resident 1 was transferred to the hospital (GACH 2) for breathing problems, low oxygen saturation, and tachycardia (fast, irregular heart rate). RN 1 stated that the facility did not monitor Resident 1 for illegal drug use or behavior issues related to drug use. RN 1 described signs of amphetamine/methamphetamine use as including altered mental status, confusion, trouble breathing, and tachycardia. She noted that Resident 1 had difficulty breathing on June 4, 2025, and earlier in April 2025. RN 1 stated she was not informed that Resident 1 had tested positive for methamphetamines in April 2024. RN1 said that if she had known Resident 1 had a history of methamphetamine use, she would have closely monitored the resident, reported signs of drug use to the DON and Administrator, and set up a care plan for a history of methamphetamine use. RN 1 stated a lighter was found in Resident 1 room on his table at 5:30 p.m., on June 4, 2025, during the resident's transfer to the hospital (GACH 2). RN 1 emphasized that it is illegal for Resident 1, who receives oxygen, to have a lighter in his room because the combination could cause a fire or explosion. RN 1 added that the facility should check Resident 1's belongings to prevent such risks. During an interview on 6/12/2025, at 5:01 p.m., the ADM stated that the facility did not file an incident report because Resident 1 had been transferred to the hospital on June 4, 2025, for tachycardia. ADM stated when the facility received a call from the hospital reporting that Resident 1 tested positive for methamphetamine, the facility called the police. ADM explained that Resident 1 left behind inside of the resident's room an opened black bag containing a meth pipe, three lighters, and an opened pack of cigarettes. During an interview on 6/12/2025, at 5:09 p.m., with the DON, DON stated, he did not know Resident 1 had three lighters inside of his room. DON stated that he and other licensed staff do rounds in the morning and look for anything visible. DON stated he did not ask Resident 1 if he could check the belongings inside of the resident's room. DON stated he did not know Resident 1 had a history of methamphetamine use. During an interview on 6/12/2025, at 5:37 p.m., with the Administrator, the ADM stated that no personal belongings inventory list had been maintained for Resident 1 since February 7, 2023. ADM admitted he did not know Resident 1 had ever tested positive for methamphetamine and found no record of monitoring the resident for meth use. ADM stated had he known of Resident 1's history of methamphetamine use, he would have placed Resident 1 on supervised visits due to the risk to others. ADM stated he discovered the resident's meth history on June 12, 2025, and noted there was no smoking safety assessment (a check to ensure it was safe for a resident receiving oxygen to smoke), so Resident 1 was removed from the resident smoking list. ADM acknowledged that he should have reviewed a May 2, 2024, IDT note, which confirmed a positive amphetamine urine test and reminded Resident 1 that recreational drug use is not tolerated in the facility. During a concurrent interview and record review on 6/12/2025, at 6:24 p.m., the Director of Nursing (DON) and Administrator (ADM) reviewed Resident 1's admission Record, Care Plans, Physician Orders, and IDT notes from April 2024 through June 2025. They found that no care plan for amphetamine use had been created when Resident 1 was readmitted on [DATE], after a positive test was reported by GACH 1. The DON noted that methamphetamine use can cause tachycardia, tachypnea, oxygen desaturation, and shortness of breath, and recalled observing these symptoms on April 16, 2025, when paramedics were called, although the resident refused hospital transport. He also observed that there was no documentation of the resident's physician being notified about his refusal to complete laboratory orders on April 30, 2025. The ADM could not find an investigation report from the May 2, 2024, IDT meeting and noted that the facility did not monitor Resident 1's methamphetamine use; the May 17, 2025, IDT meeting did not address his drug history, and no updated personal belongings inventory was completed after his readmission in June 2024. On June 5, 2025, the facility took possession of Resident 1's lighters, baggies with white residue, and glass pipe, and turned these items over to the police. During a review of the facility's undated Policy and Procedure (P&P) titled, Hazardous Areas, Devices and Equipment, indicated, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . 1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee. 2. The safety committee will consist of members from the interdisciplinary team, which will include a representative from the clinical, leadership, maintenance, and environmental services teams . A hazard is defined as anything in the environment that has the potential to cause injury or illness . Assessment and analysis of hazardous areas and equipment will include resident-specific information including identification of vulnerable residents . Resident vulnerability to hazards may change over time. Ongoing assessment helps identify when elements in the environment pose hazards to a particular resident . Improper or inappropriate use of equipment and devices will be identified as part of the hazards assessment and analysis . Interventions will address the specific hazards identified and may be facility-specific or resident-specific . Resident-specific interventions may include changes to the plan of care and/or increased supervision . Interventions will be accompanied by communication with staff and leadership, residents, family and visitors. The administrator is responsible for communicating all safety recommendations adopted by the safety committee to the appropriate departments within the facility. During a review of the facility's undated Policy and Procedure (P&P) titled, Smoking Policy - Residents, indicated, Oxygen use is prohibited in smoking areas .Residents who have independent smoking privileges are permitted to keep cigarettes, electronic-cigarettes, pipes, tobacco, and other smoking items in their possession .Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision .The facility maintains the right to confiscate smoking items found in violation of our smoking policies. Confiscated resident property is itemized . The P&P further indicated that Prior to and upon admission, residents are informed of the facility's smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. During a review of the facility's undated P&P titled, Personal Property, indicated, Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of other residents . If it is determined through observation of the resident that he or she may have brought an illegal substance(s) into the facility, it is immediately reported to the charge nurse or supervisor. The supervisor and the DNS determine whether the situation warrants a referral to law enforcement .If items or illegal substances that belong to the resident are in plain view, and these pose a risk to the residents' health and safety, the items may be confiscated by facility staff. The circumstances, description of the item(s), and rationale for confiscating are documented in the resident's record .The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary. During a review of the facility's undated P&P titled, Care Planning - Interdisciplinary Team, indicated, The interdisciplinary team is responsible for the development of resident care plans . Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). During a review of the facility's undated P&P titled, Visitation, indicated, Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents such as . denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility which places residents' health and safety at risk . If it is determined that an illegal substance(s) has been brought into the facility by a visitor, it is immediately reported to the charge nurse or supervisor. The supervisor and the DNS determine whether the situation warrants a referral to law enforcement. a. If the supervisor notifies law enforcement, in accordance with state laws, he or she immediately implements measures to protect the health and safety of all residents, visitors and staff. This may include supervising the visitation until the situation is addressed or law enforcement arrives. b. If items or illegal substances are in plain view, and these pose a risk to the residents' health and safety, the items may be confiscated by facility staff. The circumstances, description of the item(s), and rationale for confiscating are documented in the resident's record.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from sexual abuse (a non-consensual sexual contact of any type with a resident) by Certified Nurse Assistant (CNA) 1 on 2/21/2025, as evidenced by a video recording showing, CNA 1 pull his penis out and used Resident 1's hand, stroke his (CNA 1) penis. CNA 1 stated he stroked Resident 1's penis until he (Resident 1) ejaculated (the release of semen through the penis during orgasm [the height or peak of sexual arousal]) then used Resident 1's blanket to clean the resident. This deficient practice resulted in Resident 1 being sexually abused by CNA 1 on 2/21/2025. CNA 1's identified non-compliance resulting from the sexual abuse incident against Resident 1 on 2/21/2025, had a negative psychosocial (refers to the combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) impact on Resident 1, as verbalized by Licensed Vocational Nurse (LVN) 2 that Resident 1 had been having a hard time sleeping after the sexual abuse incident. The Social Services Director (SSD) documented in Resident 1's records Resident 1's facial expression of disgust (a strong sense of dislike) was clearly defined (evident), as a result of the sexual abuse incident by CNA 1, during an SSD visit in Resident 1's room on 2/25/2025. Psychologist 1 wrote on his progress note dated 2/26/2025, Resident 1 displayed hopelessness, frustration, inconsistent sleep patterns, along with a noticeable lack of energy and difficulty concentrating, which have persisted for more than two weeks . which represented a clear departure from Resident 1's baseline (starting point) functioning. On 2/25/2025 at 4:33 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation [IJ, a situation in which the provider's noncompliance (not following rules) with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death of a resident] regarding the facility's failure to ensure Resident 1 was free from non-consensual sexual contact. The surveyor notified the Administrator (ADM) of the IJ situation on 2/25/2025 at 4:33 PM, due to the facility's failure to protect Resident 1 against non-consensual sexual contact. On 2/26/2025 at 4:25 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 2/26/2025 at 4:46 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM. After the IJ was removed, the surveyor verified that the facility's non-compliance remained at the lower scope and severity of isolated, actual harm, that is not immediate jeopardy. The IJ Removal Plan included the following information: o On 2/21/25 at around 1:30 to 3:30 AM, Resident 1 was assigned a different Certified Nurse Assistant (CNA 2). At around 5 AM, the ADM arrived at the facility and interviewed staff on duty. According to the Registered Nurse (RN) Supervisor, the police officers did not disclose any information surrounding the arrest of CNA 1. At around 5 AM, the ADM spoke with Emergency Contact (EC) 1, who informed the ADM of the allegation of sexual abuse towards Resident 1 by CNA 1. EC 1 indicated that this allegation was triggered by an installed hidden camera with audio and video recording capabilities. EC 1 recognized that she did not request permission nor made facility staff aware prior to installation of a hidden camera. o The ADM reported the incident to the California Department of Public Health (CDPH) and Ombudsman (an advocate for residents that act as an independent, fair mediator [bridge between two parties] to investigate complaints against organizations or government agencies) on 2/21/25. o The ADM reported initiation of sexual abuse allegation investigation to the Medical Director on 02/21/2025. o A change of condition documentation for sexual abuse allegation was completed on 2/21/25 by a licensed nurse on Resident 1 notifying his primary physician and responsible parties. A head-to-toe body assessment was conducted by a licensed nurse. No new skin discoloration or impairments noted. o Resident 1 was placed on 72 hour every shift monitoring for a change of condition related to sexual abuse allegation. Plan of care (POC) was updated by licensed nurses to provide resident with 2 CNAs when providing care. o Resident 1 was placed under a one-to-one supervision and monitoring for 72 hours utilizing the one-to-one observation daily monitoring form to document supervision and monitoring effective 2/21/25, 3 to 11 shift to provide safe environment. o Resident 1 was seen by primary physician on 2/25/25 with no new orders. o The Psychiatrist (a medical doctor who specializes in mental health) assessed and evaluated Resident 1 on 2/25/25 and was found with no signs of agitation. Succeeding psychiatrist visits would be scheduled monthly for 3 months and as needed and would be coordinated with Resident 1's responsible party. o The SSD conducted visits to Resident 1 on 2/21/25, 2/24/25 and 2/25/25 to provide psychosocial (having to do with the mental, emotional, social, and spiritual needs of a residents) support. o Resident 1's POC was reviewed and updated on 2/24/25 by a licensed nurse to reflect current needs and monitoring: 1.Providing one-to-one supervision and monitoring as needed 2. Body check assessment for unusual skin discoloration, cuts, abrasions 3. Psychology and psychiatry consult as needed 4. Psychosocial wellness visits (a healthcare visit focused on assessing and discussing an individual's mental, emotional, and social well-being) o A Quality Assurance Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services were meeting quality standards) plan was developed surrounding Abuse Management and was discussed by the ADM, Director of Nursing (DON) and Medical Director on 2/21/25. This would be presented during the Quality Assurance Meeting (QAA- a process that ensures healthcare activities and products meet the required standards of excellence and compliance) on 2/26/25 at 1 PM . with emphasis on sexual abuse on male staff towards cognitively (anything related to thinking, learning, and understanding) impaired resident, with the following attendees: Medical director, ADM, Interdisciplinary team (IDT - a group of health care professionals from different specialties who work together to provide care). o CNA 1 was terminated by the ADM on 2/21/25 and reported to the CNA licensing body for gross misconduct (extremely serious and unacceptable behavior by an employee that could lead to immediate termination). o DON, Activities Director and EC 1 met on 2/21/25 and discussed recent alleged abuse event. IDT recommended one-to-one supervision, body check, psychiatry consult, and SSD to provide psychosocial wellness visit. o On 2/21 /25, the IDT members conducted an interview and observation to all other 120 residents and 44 cognitively impaired and 77 cognitively intact residents, utilizing the Sexual Screening Assessment tool regarding potential concerns surrounding sexual abuse with emphasis on sexual inappropriateness of staff/caregiver towards residents. No other residents were affected. o The Director of Staff Development (DSD) provided the initial in-service education to Department Manager, nursing staff (CNAs and Licensed Nurses) on 2/21/25 regarding Abuse prohibition and Management with emphasis on the following: a. Sexual abuse, with emphasis on sexual contact without consent towards cognitively impaired residents b. Identifying signs and symptoms of abuse to non-verbal residents such as moaning, grimacing, refusal of care, unexplained skin injuries and any unknown in origin incident. c. One-to-one supervision management maintaining resident psychosocial needs. d. Reporting and investigation of abuse allegations and providing a safe environment for all residents. e. Developing interventions to mitigate risk towards abuse incidents. f. Behavior observation and monitoring. g. Utilization of Sexual Screening Assessment tool for incidents involving sexual abuse allegations. h. Utilization of Sexual Capacity Assessment tool for residents done during new admission and/or re-admissions. o As of 2/26/25, a total of 119 out of 153 actively employed facility staff were provided an in-service. The Inservice re-education would continue until 100% was achieved by 3/1/25. Any facility staff that were not re-educated due to vacation and or leave of absence would be provided re-education on abuse prevention and management before the start of their next shift by the DSD and/or designee. o Beginning 2/26/2025, the DSD and/or designee would facilitate background checks and at least two reference checks prior to hire and quarterly background checks thereafter. o Beginning 2/26/2025, the DSD and/or designee would conduct abuse training to facility staff upon hire and quarterly thereafter. o Beginning 2/26/25, the Sexual Screening Assessment tool would be utilized by licensed nurses for incidents involving sexual abuse allegations and as needed, as part of initial interventions. o Beginning 2/26/25, the IDT would conduct an abuse risk assessment during the scheduled quarterly care conference meetings to review any potential and/or risk of abuse, particularly sexual abuse. o Beginning 2/26/25, the Sexual Capacity Assessment tool for residents would be completed as part of the admission assessments for new admissions and/or re-admissions. o The Department Managers and other staff assigned would continue to complete daily Resident Care Room Rounds effective 02/21/2025 utilizing the Resident Care Room Rounds form, with emphasis on inquiring if residents may have been touched by residents or staff without their permission, daily Monday to Friday and would discuss findings during daily stand-up meeting for further review and interventions. o Beginning 2/26/25, licensed nurses would conduct verbal endorsement daily at the start of each shift with licensed nurses and CNAs and as needed to discuss and identify any potential concerns surrounding abuse prohibition that may potentially affect cognitively impaired residents. Any identified findings that need further investigation would be reported immediately to the facility ADM and/or Designee for immediate follow up. o The ADM and/or Designee would conduct random observation rounds weekly beginning 2/26/2025 and as needed to validate compliance on abuse prevention and management. Any findings would be discussed during the daily stand-up meeting for further recommendations and interventions. o Beginning 2/26/25, Social Service and/or Designee, would conduct a resident council meeting twice within the next (30) days. The first meeting would be offered on 02/27/2025 and the subsequent offering would be held on 03/13/2025, then monthly and as needed to validate and identify further opportunities surrounding abuse prohibition. An invite would be provided to all Residents and any/all families acting as responsible parties willing to attend pending approval by the resident council president. Additionally, the Ombudsman Office would be notified of these and future scheduled meetings. o The ADM and/or designee would discuss any pattern of findings related to any alleged abuse investigation and conclusions with emphasis on sexual abuse allegations manifested by staff's inappropriate and unwelcome touching towards cognitively i mpaired to Medical Director and QAA committee monthly for further interventions and recommendations and or until the deficient practice was resolved. Findings: During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted the resident on 10/29/2024, with diagnoses including cerebral infarction (stroke - a stroke happens when there is a loss of blood flow to part of the brain) encephalopathy (a disease, disorder, or damage that affects the brain's structure or function), adult failure to thrive (a decline caused by chronic diseases and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). The AR indicated Resident 1 had two family members named as the responsible party (RP) as (RP 1) and emergency contact (EC) as (EC 1). During a review of Resident 1's History and Physical (H&P) dated 11/21/2024, 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 federally mandated resident assessment tool) dated 2/4/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was dependent (helper did all of the effort and the resident did none of the effort to complete the activity) on facility staff for all self-care and mobility. During a review of Resident 1's Communication Difficulties due to Neurological Impairments Care Plan (CP) dated 2/21/2025, the CP indicated a goal to improve the resident's ability to convey needs and understand instructions to promote safety and engagement in ADLs. During a review of Resident 1's Nursing Progress Note dated 2/21/2025 timed at 9:25 AM, the Progress Note indicated that on 2/21/2025 at around 1:30 AM the resident's EC (EC 1) called the facility and asked who the nurse for Resident 1 was. The Progress Note indicated the Registered Nurse Supervisor (RNS 1) responded to EC 1's phone call and informed EC 1 that CNA 1 was assigned to Resident 1 during the 11 PM to 7 AM shift dated 2/21/25 timed at 1:30 AM. The Progress Note indicated that around 2 AM, six (6) police officers entered the facility looking for CNA 1 and questioned CNA 1. The Progress Note indicated the DON was notified, and the resident was assigned a new CNA. The Progress Note further indicated that at 3:30 AM, EC 1 arrived at the facility and stayed at Resident 1's bedside. The Progress Note indicated at 3:35 AM, the police officers left the facility with CNA 1. The Progress Note further indicated that at 4:15 AM, more police officers gathered Resident 1's personal belongings. The Progress Note indicated the ADM was notified at this time. The Progress Note indicated on the same day, 2/21/2025 at 6:30 AM, the ADM arrived at the facility and met with EC 1. The Progress Note indicated the ADM conducted an in-service (training that take place while someone was employed) regarding abuse and proper care with the residents to the staff in the facility and Resident 1's physician was notified. At 7:30 AM, the police forensics team (a group that examine and analyze evidence from a crime [an act that was against the law and harmful to society] scenes to develop objective findings that could assist in the investigation and prosecution of perpetrators of crime) continued their investigation. During a review of the Video Footage date-stamped dated 2/21/2025, from the hidden camera installed by family members in Resident 1's room on 2/25/2025 at 1:15 PM, the video footage showed Resident 1 in bed with CNA 1 wearing black scrub suit (a loose-fitting, usually two-piece garment clothing worn by healthcare personnel) holding a mobile phone on his right hand with the phone facing towards Resident 1's body. The video footage showed CNA 1 used his left hand to lift up his (CNA 1) shirt and pull down his (CNA 1) pants. The video footage showed CNA 1's penis was quickly displayed. The video footage showed CNA 1 took Resident 1's hand to stroke his (CNA 1) penis. The video footage showed after 11 seconds, CNA 1 used his left hand and typed on his phone and then pulled his (CNA 1) pants up. The video footage showed CNA 1 held Resident 1's hand and pushed Resident 1's hand and then placed a bed sheet and a personal blanket over Resident 1. The video footage showed the CNA 1 opened the bedside curtain and walked away. During a review of the local Police Department's (PD) Initial Report dated 2/21/2025 documented and timed at 12:20 AM, the Initial Report indicated on 2/21/2025 at Approximately 0200 (2 AM) hours, I (PD) responded to a radio call regarding a suspicious circumstance at the facility. The Initial Report indicated Officers arrived on scene, spoke to (EC 1), observed video footage (a section of recorded video or film, usually captured by a camera) of the crime as it (crime) occurred, and took the suspect (a person thought to be guilty of a crime) (CNA 1) into custody (a person was under arrest or being held by the police in a secure location). The Initial Report indicated the offense information included sexual battery (a crime that involves unwanted sexual contact with another person) on a medically institutionalized person (someone placed in a specialized institution for long-term care) and sexual battery involving unconscious person (someone who was not aware of their surroundings and could not respond to stimuli). During a review of the same PD Initial Report dated 2/21/2025 documented and timed at 12:20 AM, the Initial Report indicated EC 1 noted Resident 1 seemed to shut off and not his usual self which caused EC 1 to install a hidden camera (in Resident 1's room) to capture any abuse or reason that caused the change in his (Resident 1) behavior. The Report indicated EC 1 stated at approximately 2 AM (2/21/2025), the video footage from the hidden camera showed a male nurse (CNA 1) sexually abusing Resident 1. The suspect was dressed in black scrubs with a ring to the left hand and a tattoo to the right wrist and showed CNA 1 pull his penis out and use Resident 1's hand to stroke his penis. The Initial Report indicated the video footage then showed Resident 1 move his hand away from CNA 1's penis then purposely reaching for Resident 1's hand and putting it around his penis once again to stroke himself. The video then showed CNA 1 grab Resident 1's penis and begin to stroke him (Resident 1). During a review of the same PD Initial Report dated 2/21/2025 documented and timed at 12:20 AM, the Initial Report indicated Officer 1 and Officer 2 observed the suspect (CNA 1) walking out of the facility lobby to the door and based on CNA 1's behavior and matching description, the police officers detained (to force someone officially to stay in a place) CNA 1. Officer 1 told CNA 1 they were conducting an investigation and to be honest and CNA 1 stated Resident 1 grabbed his (CNA 1) penis. CNA 1 stated he initially approached Resident 1 to check on him and noticed he had an erect penis (when a person's penis becomes hard and enlarged from an increase in blood flow) and felt sorry for Resident 1's physical condition and wanted to manipulate his penis sexually. The PD Initial Report indicated CNA 1 at first grabbed Resident 1's hand and used his hand to stroke his penis and when CNA 1 noted Resident 1 moved his hand away, CNA 1 grabbed Resident 1's hand and placed his hand back on his penis. The PD Initial Report indicated Officer 1 asked CNA 1 if he understood that Resident 1 was physically unable to move, fight back, or give consent and CNA 1 stated he was aware of the resident's condition and knew what he was doing was wrong but kept going. CNA 1 stated he stroked Resident 1's penis until he (Resident 1) ejaculated (the release of semen through the penis during orgasm [the height or peak of sexual arousal]) and then used Resident 1's blanket to clean the resident. During a review of the same PD Initial Report dated 2/21/2025 documented and timed at 12:20 AM, the Initial Report indicated evidence collected from Resident 1's room included: digital clock hidden camera with charging cable, a hot spot [from a wireless network operator] with charging cable, keys belonging to suspect's (CNA 1) vehicle (car), medical gown, blanket, wedge pillow (special triangle-shaped pillows that raise the top half of the body while lying in bed) case from the right side of Resident 1's body, bed sheet (over Resident 1), bed sheet (under Resident 1), soiled diaper, small blanket, a black back brace (a device worn to support the back), cloth from trash, paper towel from trash, plastic gloves, two possible DNA (an abbreviation for deoxyribonucleic acid - a molecule inside the body's cells that could be used to identify suspects and victims of crimes) swabs (a DNA sample from a person with a known connection to the crime scene) from left and right hands of CNA 1, two reference swabs from CNA 1, black jacket from CNA 1, blue scrub shirt from CNA 1, blue scrub pants from CNA 1, left and right shoe from CNA 1, two reference swabs from Resident 1, and two possible DNA from left and right hands of Resident 1. During a review of the same PD Initial Report dated 2/21/2025 documented and timed at 12:20 AM, the Initial Report indicated based on the video footage and statements from CNA 1, Officer 1 arrested CNA 1 for sexual battery on a medically institutionalized person and sexual battery involving an unconscious person. The PD Initial Report indicated CNA 1's mobile phone was given to assault detectives (officers who oversee crime scenes) for further investigation. During a review of Resident 1's Change of Condition (COC) dated 2/21/2025 at 2:17 AM, the COC indicated the resident had an alleged abuse. The COC indicated at 2 AM, a police officer interviewed LVN 1 regarding Resident 1's cognitive and physical abilities. The COC indicated at 3:30 AM the police officers took all of Resident 1's linen. The COC indicated at 7:30 AM a forensics team interviewed LVN 1 and swabbed the resident's skin. During a review of Resident 1's IDT Meeting Notes dated 2/21/2025 at 7:13 PM, the IDT Note indicated the meeting consisted of EC 1, the DON, the MDS Coordinator, a CNA (CNA 2), and the Social Services Director (SSD). The IDT Note indicated EC 1 stated she lost faith in everything after the incident between CNA 1 and Resident 1. The IDT Note indicated CNA 1 admitted to the police that the incident in question (sexual abuse) had happened more than once. The IDT Note indicated EC 1 stated the resident was acting strange on Tuesday (2/18/25) and was requesting to transfer the resident to another facility closer to family. During a review of Resident 1's Nursing Progress Note (PN) dated 2/21/2025 at 11:16 PM, the PN indicated the resident was on monitoring for alleged sexual abuse and was provided a one-to-one sitter (a person who takes care of someone side by side). The PN indicated the resident was noted to be having a hard time sleeping and the facility staff member (LVN 2) ensured Resident 1 was safe and provided a calm environment. During a review of Resident 1's Risk for Safety Concerns related to Alleged Physical/Sexual Abuse CP dated 2/21/2025, the CP indicated a goal for the resident to remain safe. The CP interventions included assigning two (2) CNA's when providing care, monitor for any changes of condition, and to provide privacy to the resident when doing perineal care (cleaning the area between the genitals and anus, essentially washing your private parts). During a review of Resident 1's Physician's Order (PO) dated 2/24/2025 at 10:02 AM, the PO indicated a Psychiatric (a mental health assessment that could help diagnose and treat emotional, behavioral, or developmental disorders) and Psychology Evaluation (a process that assess a person's mental health and behavior). During a review of Resident 1's Social Service (SS) Note dated 2/25/2025 at 5:44 PM, the SS Note indicated the SSD conducted a psychosocial intervention visit. The SS Note indicated as the resident was nonverbal and SSD wanted to capture the resident's vocal tone, facial expressions, and bodily movements as communication regarding the events on the evening of 2/21/2025. The SS Note indicated the resident's facial expression for disgust was clearly defined. The SS Note further indicated Perhaps as a feeling of revulsion (a strong feeling of dislike) and disapproval around something unpleasant or offensive. The muscles of his face contracted, indicating the need to remove thoughts of the experience. The expression was in the form of a raised upper and lower lip, wrinkled nose, and lowered eyebrows, representing the emotional state of disgust of his experience. The SS Note indicated the resident closed his eyes and was still, as if the resident was sleeping. During a review of Resident 1's Psychological Evaluation (PE) dated 2/27/2025 at 12:20 PM, authored by a Psychologist (Psychologist 1), the PE indicated Resident 1's cognitive functioning was severely impaired. The PE indicated Resident 1's behavior was guarded/irritable, was bed bound (confined to bed), and affect (a general term for feelings or emotions) observed was sad/agitated. The PE indicated communication with Resident 1 was difficult, challenging, and time-consuming as he is nonverbal and has difficulty with speech communication. The PE indicated Resident 1 was too cognitively impaired to participate or benefit from psychotherapy treatment at this time and psychological services were not recommended. The PE indicated Resident 1 displayed hopelessness, frustration, inconsistent sleep patterns, along with a noticeable lack of energy and difficulty concentrating, which have persisted for more than two weeks. The PE indicated These symptoms are not attributable (it is likely that it was caused by that event, situation or person) to the direct physiological effects of the (Resident 1's previously medical history) stroke or another medical condition and represent a clear departure from (Resident 1's) baseline (starting point) functioning. During an interview on 2/25/2025 at 7:36 AM, RNS 1 stated the police found a clock (hidden camera in the clock) that the resident's family (EC 1) placed in Resident 1's room. RNS 1 stated on 2/21/2025 at 1:30 AM, (EC 1) called the facility asking who Resident 1's nurses were and RNS 1 stated the nurses taking care of Resident 1 were CNA 1 and LVN 1. After a few minutes six (6) police officers entered the facility looking for CNA 1 and arrested CNA 1 right away. RNS 1 stated she was unaware what was going on and the police officers would not disclose any information. RNS 1 stated when the ADM arrived at the facility, he did not informed facility staff exactly what happened but did an in-service on physical/sexual abuse. RNS 1 stated Resident 1 could not talk or move and was a totally dependent resident. RNS 1 stated at 7:30 AM, the forensics came with the police and after they left the facility staff were able to enter Resident 1's room and completed a total body skin assessment. RNS 1 stated the resident's body was okay and had no bruising or bleeding including the resident's genitals (a person's external organs of reproduction). During a telephone interview on 2/25/2025 at 8:30 AM, EC 1 stated that Responsible Party (RP) 1 had the video clip on the cloud (a network of remote servers accessible through the internet where users could store data) and released the video to the police. EC 1 stated she did not want to continue with the telephone interview anymore and did not want to elaborate more on Resident 1's sexual abuse incident with CNA 1. During an observation in Resident 1's room on 2/25/2025 at 8:58 AM, Resident 1 was sitting up in bed with his face turned to the right side and a blanket covering the resident's body. The resident did not respond verbally or acknowledge a presence during the introduction, including eye contact. During an interview on 2/25/2025 at 9:17 AM, the ADM stated EC 1 sent the ADM a text message (an electronic communication sent and received by mobile phone) on 2/21/2025 at 4 AM to discuss an urgent matter and he (ADM) informed (EC 1) he (ADM) would be at the facility in one hour. The ADM stated he (ADM) contacted RNS 1 who informed him (ADM) that the police were in the facility and arrested CNA 1. The ADM stated the police interviewed LVN 1 to ask about Resident 1's cognitive status and photographed a 360 view (to capture a complete, panoramic image of a person from all angles, essentially allowing the viewer to see them as if they were rotating around the subject giving a full perspective of their appearance from every direction) of LVN 1. The ADM stated after concluding the interview with LVN 1, the police arrested CNA 1 around 1:30 AM to 2 AM. During the same interview on 2/25/2025 at 9:17 AM, the ADM stated he arrived at the facility on 2/21/2025 to meet with EC 1 at 5 AM. The ADM stated EC 1 was woken up at midnight due to an activity notification on the hidden camera she installed in Resident 1's room that the facility was unaware of. The ADM stated EC 1 stated the video footage showed a nurse fondling (stroke or caress lovingly or erotically) or engaging in sexual activity with Resident 1. The ADM stated he did not have a recorded copy of the video because the PD told EC 1 not to give the video footage to anyone. The ADM stated he was unable to have any conversations with the PD or verify what was on the video because the event was still under investigation. During the same interview on 2/25/2025 at 9:17 AM, the ADM stated the SSD, MDS Coordinator (MDSC), and the DON created a tool to screen interviewable and non-verbal/cognitively impaired (someone had difficulty with thinking, learning, remembering, understanding, or making decisions, often due to a problem with their brain function) residents for physical/sexual abuse. The ADM stated they screened all the residents in the entire building to check if any other residents may be affected by the alleged sexual abuse. The ADM stated CNA 1 was terminated on 2/21/2025. During an interview on 2/25/2025 at 10:48 AM, LVN 1 stated due to Resident 1's history of stroke (when blood flow to the brain was blocked or a blood vessel in the brain bursts) the resident could not really move his left side and only had right-handed strength and could only grip with his right hand. LVN 1 stated Resident 1 was unable to defend himself because he could not talk, yell, or move fast. During a telephone interview, conducted on 2/25/2025 timed at 11:41 AM, the detective (Detective 1) in charge of Resident 1's sexual abuse police investigation stated she was unable to disclose any information at this date and time, because the investigation was ongoing, and CNA 1 was still in custody. During another attempt for a telephone interview conducted on 2/25/2025 timed at 12:30 PM with EC 1, EC 1 declined to be interviewed and would not respond to any more questions with regards to the sexual abuse incident against Resident 1. During a concurrent observation and interview in Resident 1's room in the presence of LVN 2 on 2/25/2025 at 3:16 PM, Resident 1 did not look at LVN 2 upon introduction but when LVN 2 held Resident 1's hand, Resident 1 gripped LVN 2's hand tightly. LVN 2 stated Resident 1 was not able to speak and would not be able to verbally express if something was bothering him. During an electronic mail (e-mail) exchange with EC 1's attorney, another attempt was made to contact EC 1 on 2/25/2025 at 4:35 PM. The Attorney wrote that EC 1 declined further interviews from CDPH. During a telephone interview on 3/6/2025 at 9:11 AM, a clarification of the PD Initial Report documented with date and time of 2/21/2025 at 12:20 AM was clarified with Detective 1. Detective 1 was asked why the PD Initial Report was [NAME]/ed at 12:20 AM. Detective 1 stated the PD Call for Service (CFS- a request for police assistance with an emergency or issue) came around 12:20 AM and the detectives that responded to the scene were called around 2 AM on 2/21/2025 for in depth interviewing of the suspect (CNA 1) and facility staff at the facility. During a review of the facility[TRUNCATED]

42854 42878 During observations, interviews, and record reviews, the facility failed to implement an ongoing infection prevention and control program (IPCP) to prevent, control the onset and spread of gastrointestinal (GI, the organs of the body that play a part in food digestion) infection, for 26 of 106 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26),and 16 of 150 facility staff (CNAs 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, LVNs 1, 3, 4, and Ancillary Staff 1, who presented with GI illness (conditions affecting the digestive system) from 12/5/2024 to 12/18/2024 (14 days) by failing to: 1. Implement preventative measures to address the outbreak (a greater number of disease cases than expected in a specific area or group of people over a given time) of GI illness among residents and staff in the facility that included but not limited to placing affected residents on transmission based precautions, prohibiting staff from working and not come back to work at the facility until symptom free for at least 48 hours, collect stool specimens of affected residents. 2. Ensure the facility placed 26 residents (Residents 1 to 26) on transmission-based precautions (precautions used to stop the spread of germs in a healthcare setting) when these residents had signs and symptoms of vomiting and diarrhea (loose, watery, stools [bowel movement]), from 12/5/24 to 12/18/24. 3. Ensure facility staff that included CNA 1 and CNA 2 who had active diarrhea and vomiting were prohibited from providing care to the residents to control further spread of infection and made aware of the current surveillance (the analysis of health information to look for problems that may be occurring in the workplace that require targeted prevention) of residents having GI illness. 4. Investigate an outbreak of GI illness (nausea, emesis and/or diarrhea) among residents and staff to address and identify both individual cases and trends (changes in direction) to provide appropriate preventative interventions. 5. Ensure the Infection Preventionist (IP) nurse started the facility's surveillance tracking tool to monitor residents and staff with GI illness after the occurrence of three or more cases of the same GI infection over a specified period of time and included accurate information, necessary to identify infections and trends among facility staff and residents, in accordance with the facility's policy and procedure (P&P) on Outbreaks of Communicable Diseases. 6. Notify the local health department between 12/5/24 to 12/15/24, of the possible outbreak of GI illness among residents and staff, after the occurrence of three or more residents with GI symptoms in accordance with the facility's P&P on Outbreak of Communicable Diseases. 7. Ensure the facility staff follow hand hygiene procedures consistent with accepted standards of practice and infection control procedure which had the potential to cross contaminate the ice served for the residents and cause food borne illness in residents, staff and visitors who consume the ice in the facility, when: a. There was no properly installed handwashing sink near the Ice dispensing room, located in the facility's dirty utility room. b. One CNA did not wash hands after entering the utility room and before putting ice in the water pitcher that belongs to a resident. As a result of these deficient practices, the facility placed 26 residents (Residents 1 to 26) and 16 staff (CNAs, LVNs and Ancillary Staff) at risk for complications from vomiting and diarrhea included dehydration (a condition that occurs when the body loses more fluids than it takes in) that could lead to hospitalization , and possible death. The facility also placed 80 remaining residents and 134 remaining staff at risk for GI infection. Residents 1 and 25's Laboratory (Lab) Results Report for Norovirus 2 [a contagious virus that causes severe vomiting, diarrhea by Polymerase Chain Reaction (PCR, a test that checks for material in a specimen sample to diagnose certain infectious diseases)] came back positive for Norovirus 2 upon collection/testing on 12/18/24. On 12/17/2024 at 5:52 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation [IJ, a situation in which the provider's noncompliance (not following rules) with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident] regarding the facility's failure to implement an ongoing IPCP to prevent, recognize, and control the onset and spread of infection to the extent possible under 42 Code of Federal Regulation, S483.80 Infection Control. The surveyor notified the Administrator (ADM) and the Assistant Director of Nursing (ADON) of the IJ situation on 12/17/2024 at 5:52 AM, due to the facility's failure to implement an ongoing IPCP to prevent, recognize, control the onset and spread of GI infection. On 12/19/2024 at 5:56 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 12/19/2024 at 6:32 PM, while onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the Director of Nursing (DON). The IJ Removal Plan included the following information: 1. The facility initiated preventative measures to address an outbreak of GI illness among residents and staff in the facility. The following actions have been activated: A. Notification to the local health department that an outbreak investigation had been initiated on 12/16/2024. B. The facility's IP nurse completed and updated the cumulative (the total sum of data as it grows with time) line listing (table containing a list of people with a specific disease or exposures) of Residents with GI symptoms with onset dates (the day a sick person first had a symptom or condition) of 12/05/2024 through 12/19/2024, reporting 28 cases (1) case has been excluded by the Public Health officer due to having a community acquired origin, (17) resolved cases and (10) active. C. The facility will send the updated line listing/contract tracing to the local health department daily before the end of day from 12/05/2024 until further notice from the Public Health Department. 2. The facility has posted a Notice to all visitors of a declared outbreak for the investigation of GI related illness on all facility entrances on 12/17/2024. The notice informs all visitors, including all medical professionals and healthcare workers of the symptomatology that is present within the premises and provided educational precautions to help mitigate the spread of infection to oneself and others. The notice discouraged anyone who is exhibiting symptoms indicated within the notice to refrain from visiting unless symptoms resolve. A. All visitors are subject to registration before entering the premises. Reception personnel provided notification of the outbreak status notice are requesting visitors to complete a questionnaire screening to detect and defer only those with similar symptomatology. 3. The DON and the IP nurse completed an evaluation and assessment of 109 total residents on 12/17/2024 to ensure no other residents have been identified with GI symptoms outside of those indicated with the Infection control line listing provided to the local health department for infection surveillance. The resident assessments were documented and indicated in a log form. Isolations precautions (safety barriers put in place to create a barrier between people and germs) had been activated for all identified symptomatic cases. A. Symptomatic Residents identified had the following action plans initiated: -Change of condition (COC) completion. -Developed care plans specific to resident's symptoms (nausea/ vomiting and /or diarrhea). -Notification to each resident's attending physician. -Physicians orders obtained for laboratory testing. -Residents responsible agents have been contacted and informed of the Residents health condition. -Environmental cleaning and sanitation. B. Nursing personnel are conducting clinical assessments of all symptomatic Residents to manage symptoms and prevent fluid deficits and discomfort, including Medical Doctor (MD) reporting. The licensee had provided additional disinfectant products at the Nursing Stations, medication/treatment carts, as well as corridors to be used on high touch surfaces. C. The contracted Registered Dietitian (RD) Resources made a service visit on 12/17/2024 to assess active cases and subsequent visit 12/19/2024 to monitor affected Residents as well as any new reported cases. The DON and the Dietary Services Supervisor (DSS) will report any new cases to the RD daily for follow-up. Nursing staff will continue to follow up with the RD's recommendations in collaboration with the facility's attending physician. D. Current symptomatic nursing employees had been removed from work schedules pending resolution of symptoms and deemed free of symptoms. E. An educational in-service training was initiated and completed by the Regional IP- Director of Staff Development (DSD 2) Resource with all Dietary on the following topics: Foodborne illness (any sickness caused by eating contaminated food or beverages), prevention of the spread of foodborne illness, handwashing, appropriate dress code to prevent unsanitary conditions. F. An all-staff educational in-service was initiated on 12/18/2024 for all Nursing and Non-Nursing personnel to address the following topics: Identification, prevention and management of GI related illness or symptom like conditions. The in-service stressed the urgency to have employees self-report illness and not report to duty when experiencing illness. The in-service stressed hand hygiene before and after deliver of care and services, disinfection of equipment before and after resident use. This educational in-service offered to approximately 150 active employees and will be ongoing to be completed by 12/20/2024. Any employees off schedules for vacation/leave will be in serviced by the DSD/IP prior to their return. 4. The Nursing Department will continue to complete shift huddle/handoff to identify any changes of condition related to GI symptoms. Such cases will be reported to the DON, the IP and Administration staff. These cases will be reviewed daily during clinical standup to determine reporting status with the assistance of Medical Records. 5. For the facility's Ice Process: The Dietary and Nursing personnel will complete handwashing hygiene with soap and water before handling ice. A. Nursing personnel will continue to maintain its ice source within the existing utility room and require employees to handwash with soap and water before handling ice. 6. Food service workers were in-serviced by the Regional IP-DSD Resource on 12/18/2024 with emphasis on the following topics: Foodborne illness and hand hygiene. 7. The food service workers were screened prior to commencement of duties to ensure they are free of gastrointestinal symptoms. 8. The IP nurse included Environmental services (a department within an organization that focuses on protecting the environment) personnel within the offered in-service on 12/18/2024 previously mentioned and have been directed by Administrator to increase disinfection of high touch surfaces throughout the facility and affected resident rooms and general common areas. 9. Laundry personnel will continue to monitor linen handling, washing, and drying to ensure proper processing temperatures and sanitizing is maintained by the following measures implemented: -Separate soiled linen/clothing receptacles for active isolations rooms. -wash all affected linens/ clothing separately. -dry washed linens/ clothes on high heat. -clean and disinfect washer and dryer between use with unaffected linens/clothing. -laundry staff will wear appropriate PPE (gowns and gloves). -Avoid unnecessary agitation of affected linens/clothing. 10. The IP and the DON will continue to monitor the above measures in a collaboration with the local health department to mitigate (make something less severe, serious) additional spread of possible illness transmission until all cases have been resolved. 11. The facility regional consultant provided an in-service for the facility leaders (Admin, DON, ADON, IP nurse, DSD) on 12/19/2024 regarding reportable diseases and conditions with the emphasis on reporting occurrence of any unusual diseases. 12. The facility regional consultant provided a one-on-one in-service to the facility IP nurse on 12/18/2024 regarding proper identification of health illnesses that constitute a reportable condition, proper investigation and tracking of such conditions and the development and dissemination (distribution) of educational information to all relevant employee to mitigate (lighten/relieve) and control the spread of contagion (a disease spread by close contact). Findings: 1. During a review of Resident 1's Admission Record (AR), the AR indicated the facility admitted the resident on 1/26/2024, with a primary diagnosis of chronic pancreatitis [a progressive disorder associated with destruction of the pancreas (an organ in the abdomen that aids in digestion)], osteoarthritis (a joint disease that affects the joints causing pain). During a review of Resident 1's History and Physical Examination (H&P) dated 1/31/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 1's Change in Condition (COC, a medical document used to record any significant alterations in a patient's health status) Evaluation dated 12/16/2024 timed at 3:35 PM, the COC indicated Resident 1 noted (on 12/16/24) with loose bowel movement for two times. Medication (did not indicate the name of the medication) given/offered. The COC indicated MD 1 was made aware on 12/16/2024 at 3:00 PM. The COC indicated there were no new orders received. During a review of Resident 1's untiled care plan, initiated on 12/16/2024, the care plan indicated Resident 1 has diarrhea. The care plan interventions included educate Resident 1 on the causes of diarrhea and steps to take in avoiding diarrhea and its complications, monitor intake, output (a medical procedure that measures the amount of fluids that enter and leave the body), and laboratory test as ordered by the physician, administer medications as ordered by the physician, report to the physician as needed for sign and symptoms of dehydration, dry skin, and mucous membranes (the moist, inner lining of some organs and body cavities), poor skin turgor (elasticity of the skin), weight loss, anorexia (a disorder characterized by restriction of food intake), malaise (a general feeling of being unwell or discomfort), hypotension (abnormally low blood pressure), increased heart rate, fever, abnormal electrolyte (are minerals in the blood and other body fluids that carry an electric charge and affect how the body functions) levels. During a review of Resident 1's Order Summary Report with active orders date of 12/17/2024, the Report indicated on 12/17/2024, MD 1 ordered for Resident 1 to be on Contact Isolation Precaution [Contact precautions are required when interacting with people known or suspected to have infections or diseases that can be transmitted through either direct or indirect contact with people, objects or environmental surfaces that have infectious matter on them. Contact precautions are used when Standard Precautions (the basic level of infection control that should be used in the care of all patients all of the time) might not be enough to stop the spread of infection and to prevent the spread of germs that are transmitted by touching a person or an object they have touched] at all times (due to diarrhea episodes). During a review of Resident 1's Laboratory (Lab) Results Report for Norovirus 2 [a contagious virus that causes severe vomiting, diarrhea by PCR with collection date of 12/18/24 and report date of 12/26/24, the Lab Report indicated Norovirus 2 was detected (found). 2. During a review of Resident 2's AR, the AR indicated the facility readmitted the resident on 12/12/2024, with a primary diagnosis of pressure ulcer (localized damage to the skin and/or underlying tissue that usually occurs over a bony prominence of sacral region (region located at the base of spine just above the buttocks), and Type 2 Diabetes mellitus (a condition that results from insufficient production of insulin, causing high blood sugar). During a review of Resident 2's untitled care plan initiated on 12/13/2024 with a revision date of 12/16/2024, the care plan indicated Resident 2 has Clostridium Difficile (C-Diff., a bacterium known for causing serous diarrheal infections) with active symptoms. The care plan interventions included for Resident 2 to receive diet as ordered by the physician, and Registered Dietician consult as needed. The interventions also included for staff to educate the residents, family members, visitors, and caregivers regarding C-Difficile and how C-Difficile spread, monitor the labs diagnostic testing as ordered by physician, and administer medications as ordered by the physician. During a review of Resident 2's COC Evaluation dated 12/14/2024 timed at 6:54 AM, the COC indicated Resident 2 was noted (on 12/14/24) with episodes of vomiting and diarrhea before shift change (time was not indicated). During a review of a facility document titled, Gastrointestinal illness/Norovirus (a highly contagious viral disease that causes vomiting, diarrhea and stomach pain) Outbreak Line List for Healthcare Facilities-Patient/Residents, dated 12/16/2024, provided by the facility's IP nurse on 12/16/2024 at 5:11 PM and a concurrent review of the resident's records, the List included the 20 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21) with their corresponding illness descriptions that included symptoms such as vomiting or diarrhea and onset dates. During the concurrent resident's (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21) record reviews, the following Line List indicated 13 residents had vomiting, six residents had diarrhea, and one resident had vomiting and diarrhea. The Line List indicated 10 of the 20 residents had unresolved vomiting and diarrhea as indicated below: Resident 2 (vomiting=Yes) (diarrhea=Yes) with onset date of 12/14/24 and resolved date indicated blank. Resident 3 (vomiting=Yes) (diarrhea =No) with onset date of 12/12/24 and resolved date indicated blank. Resident 4 (vomiting = Yes) (diarrhea = No) with onset date 12/13/24 and resolved date indicated blank. Resident 5 (vomiting = No) (diarrhea = Yes) with onset date 12/13/24 and resolved date indicated blank. Resident 6 (vomiting = No) (diarrhea = Yes) with onset date 12/14/24 and resolved date indicated blank Resident 7 (vomiting = No) (diarrhea = Yes) with onset date 12/13/24 and resolved date indicated blank Resident 8 (vomiting = Yes) (diarrhea = No) with onset date 12/15/24 and resolved date indicated blank Resident 9 (vomiting = No) (diarrhea = Yes) with onset date 12/15/24 and resolved date indicated blank Resident 10 (vomiting = No) (diarrhea = Yes) with onset date 12/15/24 and resolved date indicated blank Resident 11 (vomiting = Yes) (diarrhea = No) with onset date 12/08/24 and resolved date indicated blank Resident 12 (vomiting = No) (diarrhea = Yes) with onset date of 12/8/24 and resolved date of 12/16/24. Resident 13 (vomiting = Yes) (diarrhea =No) with onset date of 12/12/24 and resolved date of 12/15/24. Resident 14 (vomiting = Yes) (diarrhea = No) with onset date 12/12/24 and resolved date of 12/15/24. Resident 15 (vomiting = Yes) (diarrhea = No) with onset date 12/12/24 and resolved date of 12/15/24. Resident 16 (vomiting = Yes) (diarrhea = No) with onset date 12/13/24 and resolved date of 12/14/24. Resident 17 (vomiting = No) (diarrhea = Yes) with onset date 12/09/24 and resolved date of 12/13/24. Resident 18 (vomiting = Yes) (diarrhea = No) with onset date 12/10/24 and resolved date of 12/12/24. Resident 19 (vomiting = Yes) (diarrhea = No) with onset date 12/07/24 and resolved date of 12/09/24. Resident 20 (vomiting = Yes) (diarrhea = No) with onset date 12/06/24 and resolved date of 12/7/24. Resident 21 (vomiting = Yes) (diarrhea = No) with onset date 12/05/24 and resolved date of 12/7/24. During a concurrent interview with the IP nurse and review of a facility provided document titled, Gastrointestinal illness/Norovirus Outbreak Line List for Healthcare Facilities-Staff, on 12/16/2024 at 5:11 PM. The List included seven (7) facility staff written on a pre-made template with the staff's Demographics, Location [date last worked/returned to work], Illness Descriptions [vomiting or diarrhea, onset dates, and date symptoms resolved]. The Line List for Staff indicated 4 staff had vomiting, watery diarrhea, with date of symptoms resolved. However, the rest of the 3 staff (CNAs 5 and 6 and LVN 3) on the list remained blank on their illness descriptions, date of onset and date symptoms resolved. The IP nurse stated the Line List included six CNAs (CNAs 1, 2, 3, 4, 5, 6) and one LVN (LVN 3) with date of GI illness onset as follows: -CNA 1 - Date of Illness onset (12/11/24); Date symptoms resolved (12/13/24) -CNA 2 - Date of Illness onset (12/9/24); Date symptoms resolved (12/14/24) -CNA 3 - Date of Illness onset (12/14/24); Date symptoms resolved (12/15/24) -CNA 4 - Date of Illness onset (12/11/24); Date symptoms resolved (12/14/24) -CNA 5 - Date of Illness onset (blank) -CNA 6 - Date of Illness onset (blank) -LVN 3 - Date of Illness onset (blank) During a review of an email communication forwarded by the IP nurse received by the facility from the local health officer with jurisdiction to the facility, the email response dated 12/16/24 timed at 10:51 PM, indicated Thank you for reaching out to us for support for your outbreak of diarrhea and vomiting at the facility. The email communication indicated a link to an educational material regarding norovirus and an instruction to collect information about staff and residents who are sick including name, date of birth, date of illness onset, and symptoms. The email communication further indicated Los Angeles Department of Public Health (LACDPH) will reach out to you in the morning to assist with the outbreak. Please also report this outbreak to the Health Facilities Inspection Division: http://publichealth.lacounty.gov/hfd/. The email communication indicated the IP nurse wrote that the facility' IP nurse reported the facility's outbreak of diarrhea and vomiting to the local health department via a phone call at night (no time) before (12/16/2024). During a review of a letter issued by the local health officer to the facility titled, Gastrointestinal Outbreak Notification Letter, dated 12/17/2024, the Outbreak Notification Letter indicated Based on the preliminary investigation, we [local health department (LADPH)] are recommending the following actions: -Close the facility to new admissions and transfers . -Staff, including kitchen and/or housekeeping staff, and visitors who are showing any of the symptom described above should stay home until they are symptom free for at least 48 hours. -Maintain the same staff-to-resident assignments. -Thoroughly clean and disinfect surfaces immediately after an episode of illness such as vomiting and diarrhea, by using a bleach solution . -Enforce strict handwashing procedures for all residents/staff, especially washing hands with warm water and soap before meals and after visiting the toilet. -Discontinue all group activities, including group dining . -Collect stool specimens as instructed by the Public Health Nurse. -Notify Public Health immediately about newly symptomatic residents and/or staff. During a review of an updated resident's line list dated 12/18/24, titled Gastrointestinal illness/Norovirus Outbreak Line List for Healthcare Facilities-Patients/Residents, provided by the IP nurse on 12/18/24. The List included an updated/revised residents information affected by GI illness from 12/5/24 to 12/18/24. The List indicated six (6) more residents (Residents 1, 22, 23, 24, 25, and 26) were added to the Outbreak Line List for Healthcare Facilities-Patients/Residents. The List dated 12/18/24 included a total of 26 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 26), when the Line List for residents were revised on 12/18/24. Residents 1, 22, 23, 24, 25, and 26 illness description indicated the following information: Resident 1 (vomiting=No) (diarrhea=Yes) with onset date of 12/16/24 and resolved date indicated blank. Resident 22 (vomiting=No) (diarrhea =Yes) with onset date of 12/17/24 and resolved date indicated blank. Resident 23 (vomiting = No) (diarrhea = Yes) with onset date 12/17/24 and resolved date indicated blank. Resident 24 (vomiting = No) (diarrhea = Yes) with onset date 12/18/24 and resolved date indicated blank. Resident 25 (vomiting = No) (diarrhea = Yes) with onset date 12/18/24 and resolved date indicated blank Resident 26 (vomiting = No) (diarrhea = Yes) with onset date 12/18/24 and resolved date indicated blank During a review of Resident 25's Norovirus Lab Results Report which was another resident added to the facility's most updated Resident Line listing dated 12/18/2024, Resident 26's Lab Results Report for Norovirus 2 by PCR with collection date of 12/18/24 and report date of 12/26/24, indicated Norovirus 2 was also detected (found) on Resident 25. During a review of an updated staff line list dated 12/19/24, titled Gastrointestinal illness/Norovirus Outbreak Line List for Healthcare Facilities-Staff provided by the IP nurse and the DSD on 12/19/24 at 5:30 PM. The List included an updated/revised facility staff information affected by GI illness from 12/6/24 to 12/18/24. The List indicated six (6) more CNAs (CNAs 7, 8, 9, 10, 11, 12), two (2) more LVNs (LVNs 1 and 4), and one (1) ancillary staff (Ancillary Staff 1) were added to the Outbreak Line List for Healthcare Facilities-Staff. The List dated 12/19/24 included a total of 16 facility staff members when the Line List for staff were revised. The following staff information with date of illness onset and dates GI symptoms resolved indicated as follows: -CNA 1 - Date of Illness onset (12/11/24); Date symptoms resolved (12/13/24) -CNA 2 - Date of Illness onset (12/9/24); Date symptoms resolved (12/14/24) -CNA 3 - Date of Illness onset (12/14/24); Date symptoms resolved (12/15/24) -CNA 4 - Date of Illness onset (12/11/24); Date symptoms resolved (12/14/24) -CNA 5 - Date of Illness onset (12/12/24); Date symptoms resolved (12/15/24) -CNA 6 - Date of Illness onset (12/13/24); Date symptoms resolve (blank) -CNA 7 - Date of Illness onset (12/6/24); Date symptoms resolved (12/7/24) -CNA 8 - Date of Illness onset (12/6/24); Date symptoms resolved (12/7/24) -CNA 9 - Date of Illness onset (12/9/24); Date symptoms resolved (12/10/24) -CNA 10 - Date of Illness onset (12/11/24); Date symptoms resolved (12/13/24) -CNA 11 - Date of Illness onset (12/12/24); Date symptoms resolved (12/14/24) -CNA 12 - Date of Illness onset (12/17/24); Date symptoms resolved (blank) -LVN 1 - Date of Illness onset (12/18/24); Date symptoms resolved (blank) -LVN 3 - Date of Illness onset (12/11/24); Date symptoms resolved (12/13/24) -LVN 4 - Date of Illness onset (12/11/24); Date symptoms resolved (12/14/24) -Ancillary Staff 1 - Date of Illness onset (12/18/24); Date symptoms resolved (blank) During an interview on 12/16/2024 at 12:04 PM, with the ADM, the ADM stated he was aware the facility had a few residents who presented with GI symptoms/illness, but the residents were random. The ADM stated random means the residents presenting with GI illness was not like a mass issue coming through the building and that there was nothing indicative of a larger problem. The ADM stated that things like this usually happen to some residents this time of the year (winter season) because of a cold or something like that. The ADM stated he checked the local health department's Reportable Diseases and Conditions printout list and Norovirus disease was not included in the reportable conditions that is why the facility did not notify the local health department. During an interview on 12/16/2024 at 12:25 PM, with the IP nurse, the IP nurse stated the facility had a total of seven (7) residents (Residents 11, 12, 17, 18, 19, 20, 21) sick within a week (from 12/05/24 to 12/11/24) from having GI symptoms/illness, but no residents were put on contact isolation or transmission-based precautions due to their GI symptoms/illness. The IP nurse stated only one resident (Resident 12) whose test result came back positive for C-Diff. was put on contact isolation but had been discontinued earlier today (12/16/24) due to the resident had a formed stool. The IP nurse stated he (IP nurse) suspected the residents with GI symptoms in the facility might have Norovirus based on the residents and staff' GI symptoms but there was no residents or staff had been tested for Norovirus as of today (12/16/24). During an interview on 12/16/24 at 1:45 PM, with Certified Nursing Assistant (CNA 2), CNA 2 stated she worked on 12/08/2024 (7 AM to 3 PM) and in the morning of 12/09/24. CNA 2 stated she developed strong, sharp stomach aches that were on and off prior to coming to the facility on [DATE]. CNA 2 stated she came to work on 12/09/2024 and informed the Registered Nurse Supervisor (RNS) and the DSD in the morning (unable to recall the time) on 12/9/24 that she (CNA 2) was not feeling well and had strong, sharp stomach aches. CNA 2 stated she was instructed by the DSD on 12/9/2024, to let her know how she was feeling throughout the day and continued working, however, CNA 2 stated her stomach pain became so severe throughout the morning of 12/9/2024 and she started to have diarrhea. CNA 2 stated she had to ask the DSD and the RNS if she can go home early on 12/9/2024. CNA 2 stated she left the facility some time before noon (on 12/9/24). During an interview on 12/16/2024 at 2:06 PM with CNA 1, CNA 1 stated she began having GI symptoms (vomiting and stomach pain) on 12/10/2024 during the morning shift (7 AM to 3 PM). CNA 1 stated prior to 12/10/2024, she had worked in the facility from 12/4/2024 to 12/7/2024 and was not made aware or informed by the IP nurse or the DSD that there were residents with GI in the facility or to self-monitor for GI symptoms. CNA 1 stated she continued to work in the facility on 12/11/2024 during the morning shift while having nausea and diarrhea. CNA 1 stated she informed the RNS and the DSD that she had had vomiting on 12/11/2024 but still worked through the end of her shift. CNA 1 stated that on 12/11/2024, after completing her shift on 12/11/2024 she had to call off from work the next day because her GI symptoms got worst. CNA 1 stated upon her return to work on 12/13/2024, she was given an in-service by the IP nurse and the DSD about handwashing and disinfecting because a lot of facility staff were sick, but she was not interviewed regarding who were the residents she had cared for or when her GI symptoms started. During an observation of Residents 1, 11 and 12's rooms on 12/16/2024 between the hours of 3:00 PM to 4 PM, Residents 1, 11 and 12's rooms were not placed on transmission-based precautions. There was no signage outside nor inside of these resident's rooms to notify staff and visitors of these residents' isolation precautions for their GI sympto [TRUNCATED]

Based on interview and record review, the facility failed to ensure 3 of 3 sampled residents (Residents 2, 6, and 7) residing at the facility were free from sexual abuse (non- consensual [something is not agreed to by one or more of the people involved] sexual contact) from Resident 1, who had a diagnosis of Alzheimer ' s disease ((a brain condition that causes a progressive decline in memory, thinking, learning and organizing skills), by failing to: 1. Protect Resident 6 from nonconsensual sexual contact (any physical contact with another person of a sexual nature without effective consent) when Resident 1 grabbed Resident 6 ' s left arm and pulled down Resident 6 ' s sleeve on [DATE]. 2. Protect Resident 7 from nonconsensual sexual contact, in accordance with the facility ' s policy and procedures (P&P) on Abuse Prevention Program, when Resident 1 swiped his open palms across Resident 7 ' s breasts on [DATE], as witnessed by an unknown group of residents in the facility ' s Activity Room. 3. Protect Resident 2 from nonconsensual sexual contact when Resident 1 grabbed/cupped Resident 2 ' s left arm tightly and left breast with both hands, as witnessed by Housekeeper (HK) 1, on [DATE]. Resident 2 complained of pain when Resident 1 grabbed her left breast with both hands. 4. Protect and prevent further nonconsensual sexual contact of Resident 1 to other residents when the facility failed to develop a comprehensive, resident specific care plan on [DATE], in accordance with the physician order dated [DATE], to monitor Resident 1 ' s behavior episodes of mood disorder (a mental health condition that affects a person ' s emotional state of long periods of extreme feelings) of inappropriately touching females (residents and staff) in a sexual manner. 5. Ensure the Interdisciplinary Team (IDT - of professionals plan, coordinate and deliver you personalized health care) implement safeguards to prevent further potential sexual abuse, in accordance with the facility ' s policy and procedure on Abuse Prevention Program, when female facility staff reported having knowledge of Resident 1 ' s sexually inappropriate behaviors (for an unknown period of time) among female residents and staff such as grabbing arms, breasts, kissing, and asking for oral sex. 6. Ensure to have a system in place to implement care plan interventions that are relevant to Resident 1 ' s behavioral needs, diagnosis and sufficient staff assigned to manage behaviors and effectively monitor/supervise the resident ' s whereabouts throughout the shifts to protect other female residents from non-consensual sexual contact, in accordance with the facility ' s P&P titled Behavioral Health Services. As a result, Resident 7 verbalized being in a state of shock after Resident 1 swiped his open palms across her breast on [DATE], and Resident 2 reported pain to the left arm and breast after Resident 1 grabbed her left breast with both hands on [DATE]. Resident 2 expressed feeling of sadness, embarrassed, upset, worried, and afraid that the incident of Resident 1 grabbing her by the arm and breast may happen again. Resident 6 verbalized being upset when Resident 1 grabbed her left arm and pulled her (gown) sleeve down. These deficient practices placed other female residents at risk for sexual abuse or non-consensual sexual contact from Resident 1 and cause psychosocial (covers a person's mental, emotional, social, and spiritual health) distress, physical injuries, hospitalization , and death. On [DATE] at 6:25 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider ' s noncompliance [not following rules] with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility ' s failure to ensure Residents 2, 6, and 7 were free from non-consensual sexual contact against Resident 1. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of the IJ situation on [DATE] at 6:25 PM, due to the facility ' s failure to protect Residents 2, 6, and 7 against non-consensual sexual contact against Resident 1. On [DATE] at 1:40 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 5:02 PM, while onsite and after the surveyor verified/confirmed the facility ' s full implementation of the IJ Removal Plan through observation, interview, and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and the DON. The IJ Removal Plan included the following information: -On [DATE] at 9 AM, the facility ADM reported to CDPH an allegation of sexual abuse by Resident l towards Resident 2 manifested by inappropriate touching. -A changed of condition form was completed on [DATE], by a licensed nurse on Resident l and Resident 2 ' s records notifying their respective physician and responsible parties. -Resident 2 was evaluated by her primary physician on [DATE] with no new orders made. -Resident l and 2 were seen and evaluated by the psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) on [DATE]. -Resident 2 and 6 ' s psychology (the scientific study of the human mind and its functions, especially those affecting behavior) consult referral was made on [DATE], by the ADM and scheduled on [DATE] at 10 AM. -Resident l was placed under a one-to-one supervision and monitoring on [DATE] utilizing the one-to-one Observation daily monitoring form to document supervision and monitoring effective [DATE], to provide a safe environment for Resident 1 and other residents, indefinitely for two shifts (7 AM to 3 PM and 3 PM to 11 PM) while residents are awake and modified into 3 shifts (7AM to 3PM, 3 PM to 11 PM and 11 PM to 7 AM) on [DATE], until an appropriate placement is identified for the resident. -The one-to-one sitter [staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act] was written in the physician order on [DATE] indicating the one-to-one sitter for behavior monitoring and clarified physician order on [DATE] to reflect one-to-one sitter for monitoring and supervision for all shifts. The one-to-one sitter was indicated in the assignment sheet each shift and Resident l ' s care plan revision on [DATE]. -An in-service education was provided by the Director of Staff Development [DSD] on [DATE], surrounding one-to-one sitter as intervention for Resident 1 to nursing staff. -The Social Service Director [SSD] conducted a visit to Resident l on [DATE], to provide psychosocial support (a type of support that helps people meet their mental, emotional, social, and spiritual needs). -The SSD conducted a visit to Resident 2 and 6 on [DATE], to provide psychosocial support and identify any psychosocial distress (unpleasant emotions) or concerns with no other findings noted. - The SSD completed a wellness visit with Resident 2 at bedside noting resident resting in bed with appropriate affect and a clearer thought content and direct eye contact than previous day and offered psychological support. -Resident 6 was reassessed by a licensed nurse on [DATE], for any signs of psychosocial distress from an incident that happened on [DATE], and noted resident feel safe, happy and no other concerns identified at this time. -Resident 6 ' s allegation of physical altercation towards Resident l on [DATE], was reported to CDPH, ombudsman (serves as an advocate for patients and help settle complaints within an organization/facility) and law enforcement by the facility ADM. -Resident 6 and 1 ' s allegation of physical altercation reported on [DATE], was again reviewed by the new facility ADM on [DATE] surrounding interviews, investigations and conclusions. -Resident 7 is no longer a resident of the facility and expired on [DATE]. The facility ADM initiated review of the previous investigation records on [DATE], and unable to locate written facility interviews and summaries. -Resident l ' s plan of care was reviewed and updated on [DATE], by a licensed nurse to reflect current needs and action plan surrounding the resident ' s behavior. -The IDT met with Resident 1 ' s responsible party with the following attendees: Interim Director of Nurses (DON), ADM, SSD, DSD to discussed resident ' s plan of care with emphasis on the on-to-one sitter for supervision and monitoring in all shifts and family agrees with the resident ' s plan of care. An in-service education was provided by the DSD to nursing staff regarding Resident l ' s plan of care. -Resident 2 and 6 ' s plan of care was reviewed and updated by a licensed nurse on [DATE] to reflect current needs and plan surrounding previous allegation of abuse incidents on [DATE] and [DATE]. -A Quality Performance Improvement (QAPI) was developed surrounding Abuse Management on [DATE] at 1 PM that will include the IJ received on [DATE], with emphasis on inappropriate touching towards female residents by a male resident. -The IDT members conducted an interview and observation to all 57 female residents on [DATE] to [DATE], utilizing the Resident Centered Care Room Rounds tool regarding potential concerns surrounding abuse with emphasis on inappropriate touching and or sexual inappropriateness from a male resident and no other concerns identified. -The ADM and the DSD conducted an interview with the facility staff to identify any information surrounding potential residents affected by Resident l ' s behavior of inappropriate touching with no identified concerns noted on [DATE] to [DATE]. - A Resident Council Meeting was conducted and attended by 12 residents including the resident council president by the Regional Nurse Resource on [DATE] at 2:15 PM, with no concerns identified surrounding abuse with emphasis on inappropriate touching. -The DSD provided the initial in-service education to nursing staff (Certified Nurse Assistants and Licensed Nurses) on [DATE] and [DATE] regarding Abuse prohibition and Management. The ln-service re-education will continue until 100% is achieved by [DATE]. The IDT with the involvement of the Medical Director reviewed the abuse investigation process to include internal guideline procedures ensuring that the Residents are free from any type of abuse such as sexual, mental, financial, isolation, neglect and misappropriation of properties on [DATE] to be effective immediately. -The IDT and the Medical Director discussed the abuse investigation process to include internal guideline procedures ensuring that the Residents are free from any type of abuse such as sexual, mental, financial, isolation, neglect and misappropriation of properties during the Emergency Quality Assurance Committee meeting on [DATE]. -The Abuse investigation process Internal guideline in-service was provided by the DSD on [DATE] to the nursing staff to be made aware of such procedure -The IDT will review all residents upon admission/re-admission during clinical meetings Mondays to Fridays to identify any existing behaviors/conditions that may affect other residents and develop plan of care interventions surrounding supervision, monitoring and medication management that provides resident psychosocial needs and wellbeing. -The Department Managers will conduct a Resident Care Room Rounds utilizing the Resident Care Room Rounds form daily Monday to Friday and will discuss findings during daily stand-up meeting. - The licensed nurses will conduct verbal huddle endorsement daily at the start of each shift with licensed nurses and Certified Nurse Assistants (CNAs) and as needed to discuss and identify any potential concerns surrounding abuse prohibition that may potentially affect other Residents. -The ADM and/or Designee will conduct random observation rounds weekly and as needed to validate compliance on abuse prevention and management. -The SSD and or Social Service Assistant [SSA] will conduct resident council meeting monthly and as needed replacing the current Activity department presiding the meeting in-order that the SSD will have a direct engagement and communication to the resident on any feedback being gathered during the meeting and to validate and identify further opportunities surrounding abuse prohibition and signs of being affected by other residents' behaviors. An invite will be provided to any families acting as responsible parties willing to attend pending approval by the Resident council president. Any findings during resident council meetings will be shared with the facility administrator and/or Designee for further follow-up. -The SSD is made aware of the new expectations of conducting the Resident Council meeting monthly and as needed on [DATE], provided by the Regional Resource Nurse. Monitoring was put in place to sustain compliance. Findings: 1. During a review of Resident 1 ' s Admission Record [AR] indicated the facility admitted the resident on [DATE], with a diagnosis of Alzheimer ' s Disease. During a review of Resident 1 ' s Change of Condition [COC] evaluation dated [DATE], indicated Resident 1 was having episodes of Inappropriate sexual behavior towards the staff. During a review of Resident 1 ' s Care Plan dated [DATE], indicated a care plan was developed on Resident 1 ' s episodes of inappropriate sexual behavior (did not indicate specific sexual behavior) toward staff. The care plan interventions included was to assign a male CNA to reduce behavior episodes, monitor for episodes of inappropriate sexual behavior towards staff. During a review of Resident 1 ' s Order Summary Report dated [DATE], indicated to monitor behavior episodes of grabbing random things and staff every shift. During a review of Resident 1 ' s History and Physical [H&P - a comprehensive physician ' s note regarding the assessment of the patient ' s health status) dated [DATE], indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS; a care assessment screening tool) dated [DATE], indicated the resident had severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated the resident required supervision or touching assistance providing verbal cues while assisting resident to complete activities of daily living (eating, oral hygiene, toileting hygiene, showering and bathing). During a review of Resident 1 ' s COC evaluation dated [DATE], indicated Resident 1 had altercation becoming verbally and physically aggressive pulling at the sleeves of a female resident [Resident 6]. During a review of Resident 1 ' s care plans dated [DATE], the care plan indicated the resident ' s physical behavior and poor impulse control (difficulty controlling actions or reactions) as evidenced by Resident 1 grabbing sweater sleeve of female resident and pulling it down. The care plan interventions included to intervene prior to agitation escalating (increasing rapidly) and to walk calmly away. During a review of Resident 1 ' s COC evaluation dated [DATE], the COC evaluation indicated Resident [1] brushed his arm against another resident ' s chest. The COC evaluation indicated the physician recommended for the resident to be followed by social service, Psychologist and Psychiatrist. During a review of Resident 1 ' s care plan dated [DATE], the care plan indicated Resident 1 brushing his arm against another resident ' s chest, with interventions included, for staff to closely monitor Resident 1 for inappropriate behaviors such as inappropriate grabbing, touching, brushing, kissing, hugging and other behaviors that may be deemed inappropriate. During a review of Resident 1 ' s Psychiatric Follow up note dated [DATE], the Psychiatric Follow up note indicated Resident 1 had an adjustment disorder [a recognized short-term health condition that occurs when one goes through a change in life and has difficulty adjusting to it], with disturbance of conduct - inappropriate sexual advances towards women. During a review of Resident 1 ' s Order Summary Report for [DATE], indicated a physician order dated [DATE], to monitor Resident 1 ' s behavior episodes of mood disorder (a mental health condition that affects a person ' s emotional state of long periods of extreme feelings) which indicated touching females sexually inappropriately and count/document every shift for Trileptal (mood stabilizer medication) usage. During a review of Resident 1 ' s COC evaluation dated [DATE], the COC evaluation indicated Resident 1 had episodes of inappropriate behavior of touching another resident's hand and breast. The COC Evaluation findings suggested that the resident had the ability to understand and follow simple instructions but due to Alzheimer ' s disease shows unpredictable behavior. During a review of Resident 1 ' s care plan dated [DATE], the care plan indicated Resident 1 had episodes of inappropriate physical behavior of touching left hand and breast of another resident. The care plan interventions included to inform the responsible party of Resident 1 ' s behavior, monitor behavior every shift, and report to the physician, if persistent. During a review of Resident 1 ' s Order Summary Report for [DATE], indicated a physician order dated [DATE], to monitor behavior episodes of mood disorder which included touching females sexually inappropriately, every shift. 2. During a review of Resident 7 ' s AR indicated the facility admitted the resident on [DATE], with diagnoses that included radiculopathy (pinched nerves which cause pain, weakness and numbness). During a review of Resident 7 ' s H&P dated [DATE], the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 7 ' s MDS dated [DATE], the MDS indicated the resident was cognitively intact. During a review of Resident 7 ' s Police Report dated [DATE], the Police Report indicated the police officer ' s interview with Resident 7 while in the facility, on [DATE]. The Police Report indicated that according to Resident 7, Resident 1 was known to be touchy-feely (touching and holding people more than usual, often in a way that makes other people uncomfortable), explaining that Resident 1 grabs female residents by the hand, including herself (Resident 7), and tells them he loves them. The Police Report indicated Resident 7 verbalized Resident 1 has Alzheimer ' s disease but has periods of reality. The Police Report indicated Resident 7 stated that on [DATE], while she was in the Activity group, Resident 1 swiped his open palm across her breasts. The Police Report indicated Resident 7 verbalized being in shock, including the other residents who were present in the Activity group and witnessed Resident 1 swiping his open palm across Resident 7 ' s breasts. The Police Report further indicated, Resident 7 stated she was in the facility for her Physical disability [any physical limitations or disabilities that inhibit the physical function] and is in complete control and awareness of her mental faculty [the abilities or capacities of the mind, including the ability to think clearly, reason, and understand]. 3. During a review of Resident 2 ' s AR indicated the facility admitted the Resident on [DATE], with diagnoses that included cerebral infarction (blood flow to brain is blocked causing tissue death). During a review of Resident 2 ' s H&P dated [DATE], indicated the resident had the capacity to understand and make decisions. During a review of Residents 2 ' s MDS, dated [DATE], indicated the resident was cognitively intact (has sufficient judgment, planning, organization, self control and able to manage the normal demands of environment). During a review of Resident 2 ' s Social Service [SS] Note dated [DATE], timed at 6:58 PM, the SS note indicated the resident appeared to still be upset regarding the incident with Resident 1. The SS Note indicated while Resident 2 was on her way to a smoke break, Resident 1 followed her in his wheelchair, took her by the arm and grabbed/cupped her left breast. The SS Note indicated Resident 2 stated he should not have done that and that she told him Please don't do that. During a review of the facility ' s written Final Investigation Report regarding Resident 1 and Resident 2 ' s sexual abuse allegation, (undated), signed by the facility ' s ADM. The Report indicated that on [DATE], HK 1 witnessed Resident 1 touched [Resident 2 ' s] left breast while in the facility ' s hallway. The Report indicated HK 1 told Resident 1 to stop. The Report indicated HK 1 reported the incident to the charge nurse. The Report indicated Resident 1 denied Resident 2 ' s allegations and instead stated that Resident 2 was the one who put Resident 1 ' s hand on Resident 2 ' s breast. The Report indicated a one-to-one sitter was assigned to Resident 1 on [DATE] (two days after Resident 2 ' s allegation of inappropriate touching was made against Resident 1). The Report indicated the facility would continue to monitor Resident 1 ' s behaviors. During a review of Resident 2 ' s SS Note dated [DATE] timed at 10:32 AM, the SS Note indicated a Follow up wellness visit [a visit from a professional to detect potential concerns early] to Resident 2 indicated the resident was doing well but the incident left her feeling embarrassed. 4. During a review of Resident 6 ' s AR, the AR indicated the facility admitted the resident on [DATE], with diagnoses that included history of ischemic attack (mini stroke) and cerebral infarction (a stroke that results in death of brain tissue). During a review of Resident 6 ' s Health Status Note dated [DATE], the Note indicated that at around 11:50 AM, Resident 1 was witnessed roaming around the facility in his wheelchair in the Activity Room, then engaged in a verbal and physical altercation with Resident 6 and suddenly grabbed the left arm and pulled Resident 6 ' s sleeve down. During a review of Resident 6 ' s COC evaluation dated [DATE], the COC evaluation indicated Resident 1 was witnessed grabbing Residents 6 ' s arm and pulling her (gown) sleeve down. Resident 6 was encouraged to verbalize feelings at that time. The COC evaluation indicated Resident 6 stated she was upset at this time. During a review of a facility document titled Incident Summary dated [DATE], the incident summary indicated Resident 1 admitted to pulling down the sleeve of Resident 6 and acknowledged the inappropriateness of his actions. During a review of Resident 6 ' s MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment (a condition where a person ' s intellectual functioning is significantly below average, along with significant deficits in behavior) requiring moderate assistance with transfers from chair to bed, shower to chair. During an interview with Resident 2 on [DATE] at 11:30 AM, Resident 2 stated than on [DATE] while she was rolling her wheelchair down the facility hallway going to the Smoking Area, Resident 1 came out of his room and started rolling in his chair towards her. Resident 1 stated that when Resident 1 was closer to her, Resident 1 grabbed her left arm tightly and said, I love you. Resident 2 stated she had told Resident 1 No! Please let go of me! Resident 2 stated after that Resident 1 grabbed her left breast with both hands. Resident 2 stated It was painful and i was embarrassed. I feel afraid and worried because I think it might happen again. Resident 2 stated We are supposed to feel safe in a place like this, I should not worry. Resident 2 stated that after the incident with Resident 1, the facility did not tell her anything about what the facility was going to do to keep her safe or how the facility staff would make sure Resident 1 does not hurt her again. During an interview with the ADM on [DATE] at 11:45 AM, the ADM stated Resident 1 had a history of grabbing and inappropriate touching to others. The ADM stated the facility staff are monitoring Resident 1 more frequently, however, the facility did not have specific set of times or frequency of monitoring Resident 1. The ADM stated that Resident 1 ' s monitoring was being documented in the progress notes once a shift by the Licensed Vocational Nurses [LVN]. During an interview with the SSD on [DATE] at 11: 59 AM, the SSD stated he assessed Resident 2, and the resident stated she felt embarrassed and was not feeling well. The SSD stated he offered Resident 2 a psychiatric consultation to be able to discuss her feelings. During an interview with LVN 1 on [DATE], at 12:18 PM, LVN 1 stated she was aware of Resident 1 ' s history of inappropriate behaviors (grabbing, touching women inappropriately). LVN 1 stated the facility staff tried to assign Resident 1 to male CNAs and remind the CNAs of Resident 1 ' s behavior (touching women inappropriately, grabbing). LVN 1 stated the facility staff would monitor Resident 1 and check on the resident ' s whereabouts for 72 hours. LVN 1 stated the facility staff does not have a set time or frequency in which the staff monitors the resident ' s behaviors and whereabouts and document. LVN 1 stated the facility would document Resident 1 ' s status once, every shift. During an interview with CNA 1 on [DATE] at 12:40 PM, CNA 1 stated she was usually the assigned primary CNA for Resident 1. CNA 1 stated Resident 1 had episodes of hostile (being ready for a fight, angry, or stubborn) behaviors and touching women inappropriately. CNA 1 stated Resident 1 would sometimes attempt to kiss her. During an interview with Registered Nurse (RN) 2 on [DATE] at 9:15 AM, RN 2 stated after each Resident 1 ' s incident of behaviors such as inappropriate touching, the facility staff would have an Inservice, and notify all staff that included CNAs, LVNs, and Activity staff to monitor Resident 1. RN 2 stated the LVNs assigned to Resident 1 would document the resident ' s status in the progress notes once a shift. RN 2 stated there was no specific/assigned person responsible to ensure Resident 1 are monitored or supervised to ensure incidents of inappropriate touching/grabbing were prevented. During an interview with MDS LVN 3 on [DATE] at 9:30 AM, MDS LVN3 stated she was in charge of developing and revising the residents ' care plans. MDS LVN3 stated the licensed nurses monitor Resident 1's behavior every shift and document once a shift in Resident 1 ' s progress notes. MDS LVN 3 stated that monitoring and documentation of Resident 1 ' s behaviors and whereabouts, once a shift was not adequate and should be conducted more frequently than once a shift. During an interview with CNA 5 on [DATE] at 1:29 PM, CNA 5 stated she witnessed Resident 1 pull other female residents by the arm and ask the residents to go inside his room. CNA 5 stated she witnessed this type of behavior several times and had reported Resident 1 ' s behaviors to the charge nurse. CNA 5 stated she was unable to recall which residents, in particular. During an interview with CNA 6 on [DATE] at 1:50 PM, CNA 6 stated Resident 1 was very hypersexual (extremely or excessively sexual or given to sexual activities) and has grabbed CNA 6 on multiple occasions. Resident 1 stated the resident had grabbed her head down to his lap during the times that she was assisting Resident 1 in the shower. CNA 6 stated Resident 1 asked her for oral sex in the past, but she did notify the charge nurse. During an interview with the SSD on [DATE] at 2:40 PM, the SSD stated that the current interventions in place for Resident 1 ' s behaviors to prevent Resident 1 from touching other residents are not working. The SSD stated the interventions the facility currently had in placed, were to provide constant education and try to redirect Resident 1 from his inappropriate behaviors (inappropriate touching other female residents). During a telephone interview with Family Member 2 (F2 [ Resident 6 ' s family member]) on [DATE] at 9:16 AM, F2 stated she was notified by the facility over the phone that there was a verbal and physical altercation between another resident and Resident 6. F2 stated the facility staff said another resident had grabbed Resident 6 by the arm and the facility staff had made a police report. F2 stated the facility did not mention anything about inappropriate behavior was made towards Resident 6. F2 stated Resident 6 had several strokes in the past, making it difficult for Resident 6 to communicate. F2 stated Resident 6 was able to understand simple phrases or words but struggled to verbally respond to questions or to make all needs and feelings known. During a random resident interview with another resident [Resident 8] on [DATE] at 3:18 PM, Resident 8 stated he was familiar with Resident 1 ' s behavior of reaching out to touch female staff and residents from the behind. Resident 8 stated he had witnessed Resident 1 speaking rudely to female staff and residents as well. Resident 8 stated he witnessed Resident 1 swinging (to try to hit someone or something by moving something, such as a fist) at Resident 7 in the past. During a concurrent interview and record review on [DATE] at 3:46 PM, with the DON, Resident 1 ' s care plan dated [DATE] was reviewed. The DON stated no care plan had been developed for Resident 1 ' s mood behaviors which included touching females sexually on [DATE] and [DATE]. The DON stated the facility should have developed a comprehensive resident centered care plan for Resident 1 ' s behavior that was geared towards females in general that included female residents and not just female staff to manage the resident ' s behaviors and protect the residents and staff. During a concurrent interview and record review on [DATE] at 3:50 PM with the ADM, Resident 1 ' s IDT meetings dated [DATE], was reviewed. The ADM stated she was unable to find documented evidence that the IDT, developed interventions specific to safeguard and protect female residents from potential further sexual non-consensual contact from Resident 1. When sked what did the facility do on [DATE] at 9 AM, to ensure not only was Resident 2 safe but all female residents were free from further non-consensual sexual contact from Resident 1, the ADM stated frequent monitoring was initiated to be documented once a shift, by the LVN in the resident ' s progress notes. The ADM stated the SSD was to visit Resident 2 for five days and stated the facility staff separated Residents 1 and 2. The ADM stated there was no physician order, IDT interventions or developed care plan to indicate the frequency or duration of Resident 1 ' s additional interventions that included frequent monitoring. During a concurrent interview and record review on [DATE] at 3:50 PM, Resident 1 ' s care plans dated [DATE], of inappropriate physical behavior of touching left hand/breast of another resident and Resident 1 ' s care plan dated [DATE], when the resident brushed his arm against another resident ' s chest were reviewed with the ADM. The ADM stated the care plans did not indicate resident specific interventions how facility staff would monitor or managed Resident 1 ' s behaviors specified in the care plans ([DATE] and [DATE]). During a telephone interview with another family member [(F1) - Family member of Resident 7], on [DATE] at 10:49 AM, F1 stated Resident 7 passed away about two months ago, but F1 remembered Resident 7 ' s incident with Resident 1 of inappropriate touching, very well. F1 stated she was notified by Resident 7, when Resident 1 swiped Resident 7 ' s breasts with his open palms on [DATE] in front of facility staff and other[TRUNCATED]

Based on observation, interview and record review, the facility failed to notify the resident ' s physician immediately, for one of two sampled residents (Resident 1), who was severely impaired in cognition (thought process), of a change in the resident ' s condition from a fall incident that occurred in the facility. On 9/2/2022 between the hours of 3 PM to 3:30 PM, Resident 1 was found lying on the floor next to the resident ' s bed by Certified Nurse Assistance (CNA) 1. The resident was placed back to bed by facility staff (CNAs 1, 2, and Licensed Vocational Nurse [LVN] 1) with no additional interventions, no head-to-toe assessment of the resident to identify potential injuries and other complications from the fall. This deficient practice resulted in the delay in treatment and interventions such as an X-ray (a photographic or digital image of the internal composition of a part of the body) of the right shoulder, pain relief, and arm sling (a medical device generally made of sturdy fabric or flexible vinyl which is worn over clothing, consisting of a pocket to hold the lower arm in and a strap to secure it to the body) to immobilize Resident 1 ' s right shoulder fracture (break). On 9/2/22, at 11:30 PM (approximately 8 hours after the fall incident), on 9/3/2022 at 2 AM, on 9/3/2022 at 4 AM and on 9/3/2022 at 11:30 AM (approximately 20 hours after the fall incident on 9/2/2022), Resident 1 experienced severe pain manifested by facial grimacing, and moaning upon movement of the right upper arm. Cross referenced to F656, F689, F697, F711, and F755. Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical (H&P) dated 2/23/2020, indicated Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 7/28/2022, indicated the resident ' s cognition was severely impaired. The MDS indicated Resident 1 required extensive one-person assistance during bed mobility, transfers, toilet use, dressing, locomutation on the unit, and personal hygiene. The MDS indicated Resident 1 could not walk. A review of Resident 1 ' s nurses notes dated 9/3/2022 and timed at 11:33 AM (7 AM to 3 PM shift) documented by LVN 2 indicated upon assessment noted resident with right upper arm swollen and discoloration when attempt to touch and lift the arm resident grimace in pain. Right side of the patient is weak, and the right arm is contracted (sic). The nurses note indicated attempted to call MD (Physician 1) and left message waiting for response. Will follow up and continue to monitor the resident. A review of Resident 1's Patient Report for the X-ray examination of the right humerus (long bone from the elbow to the shoulder up to the shoulder blade) dated 9/3/2022 timed at 8:29 PM, indicated an acute (acute fracture is a break in a bone that occurs quickly, rapidly, and usually traumatically), complete (breaks the bone into separate pieces), transversely oriented (straight across the bone), displaced (the ends of the bones are displaced, meaning they do not line up anymore) proximal (situated close) humerus neck. A review of Resident 1 ' s Physician orders indicated the following orders: a. On 9/3/2022 timed at 1:59 PM, indicated Right upper arm X-ray STAT (immediately; without delay) for swollen and discoloration. b. On 9/3/2022 timed at 2 PM, indicated to administer two tablets of acetaminophen (pain medication) 500 milligrams (mg) by mouth (every six hours) as needed for mild to moderate pain (pain level of 3 to 6 out of 10 pain scale). c. On 9/3/2022 timed at 9:52 PM, indicated to administer Ibuprofen (anti-[CONDITION(S)] drug used for pain and inflammation) tablet 600 mg, give one tablet by mouth for breakthrough pain. d. On 9/3/2022 timed at 9:58 PM, indicated to apply right arm sling every shift. e. On 9/3/2022 timed at 10:31 PM, indicated to administer [MEDICATION(S)] (narcotic pain reliever) tablet 5-325 mg, give one tablet by mouth as needed for severe pain (7 to 10 pain level) for seven days. f. On 9/3/2022 timed at 10:34 PM, indicated to refer Resident 1 to orthopedic (relating to the branch of medicine dealing with the correction of deformities of bones or muscles) physician. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique used to facilitate prompt and appropriate communication) Communication Form (SBAR) dated 9/3/2022 (no time), indicated Resident 1 noted with discoloration and swollen right upper arm. The SBAR indicated Resident 1 would moan and grimace in pain when the arm is slightly lifted. The SBAR indicated Resident 1 was having symptoms of new pain and showed non-verbal signs of pain such as occasional moan or groan, low-level of speech with a negative or disapproving quality, facial grimacing, tense, distressed pacing, and fidgeting. The SBAR form indicated Physician 1 was notified on 9/3/2022 at 11 AM, and Family 1 was notified on 9/3/2022 at 12 PM. The SBAR form indicated Physician 1 ordered for X-ray and pain medication (Acetaminophen 500mg PO 2 tabs for mild to moderate pain PRN). A review of the facility ' s investigation report witness statements indicated the following: 1. Report dated 9/6/22 timed at 10:25 AM, signed by CNA 1, indicated, on 9/2/2022, at around 3:00-3:30 PM, CNA 1 was doing her rounds for the change of shift when CNA 1 found Resident 1 on the floor mat on her right side. CNA 1 indicated she called for help to put the resident back to bed. 2. Report dated 9/6/22 (no time) signed by CNA 3, indicated, on 9/2/2022, 11 PM - 7AM shift, during rounds Resident 1 was seen agitated, CNA 3 did a body check, CNA 3 saw that there was a discoloration on the right and seen patient grimacing and moaning. CNA 3 called LVN 1 and reported what was observed. The report indicated, LVN 1 stated yes, there ' s discoloration. 3. Report (no date and time) signed by LVN 1 indicated, During the start of shift on 9/2/2022 between 3-3:30 PM, she saw two CNAs assisting resident back to bed from the floor. She (LVN 1) saw patient on the floor lying on her right side and at the right side of the bed . The report indicated Resident 1 verbalized no pain and was not in acute distress so LVN 1 opted not to report to the RN supervisor of 3 to 11 PM shift. During an observation inside Resident 1 ' s room, on 9/20/2022 at 9:30 AM, Resident 1 was observed in bed, with the bed side rails up. Resident 1 was not oriented to self, time, place, and situation and unable to respond appropriately to interview. During an interview on 9/20/2022 at 10:30 AM, Director of Nursing (DON) 1 stated if there was any resident change in condition, falls (either witnessed or unwitnessed), any unusual incidents with a resident, the licensed nurse should perform a head-to-toe assessment, including pain assessment, fill out the facility incident report form, inform the physician, inform the resident ' s family and document in the resident ' s records. During an interview on 9/20/2022 at 10:40 AM, DON 1 stated that on 9/2/2022 during the 3 PM to 11 AM shift, CNA 1, CNA 2, and LVN 1 found Resident 1 lying on the floor inside her room. CNA 1, CNA 2, and LVN 1 transferred Resident 1 back to bed. DON 1 stated that based on the resident ' s records and interview with LVN 1, LVN 1 did not perform head to assessment on Resident 1, did not inform Family 1 and Physician 1 of Resident 1 being found on the floor. DON 1 stated that LVN 1 did not document the resident ' s fall on the facility ' s Change of Condition (COC) form and SBAR form. DON 1 stated that based on the interviews with CNA 1 and CNA 2, they did not report the incident to anybody else because they assumed LVN 1 reported and performed the appropriate interventions. DON 1 stated that LVN 1 did not follow the facility ' s policy to notify Physician 1, assess Resident 1 for pain and administer pain medication. DON 1 stated the facility suspended LVN 1 for three days and then LVN 1 resigned from the facility. During an interview on 9/20/2022 at 11:09 AM, DON 1 stated that LVN 1 was assigned to Resident 1 on 9/2/2022 during the 3 PM to 11 PM and 11 PM to 7 AM shifts. DON 1 stated LVN 1 worked a double shift. During an interview on 9/20/2022 at 11:12 AM, LVN 2 stated she was assigned to Resident 1 on 9/3/2022, during the 7 AM to 3 PM shift. LVN 2 stated that on 9/3/2022 between the hours of 10:30 AM to 11 AM, CNA 4 informed her of Resident 1 ' s discoloration and swelling on the right shoulder. LVN 2 stated Resident 1 would grimace in pain when she lifted the resident ' s right arm. LVN 2 stated she performed a head-to-toe assessment, on 9/3/2022 at 11 AM notified Physician 1, and on 9/3/2022 at 12 PM notified Family 1. LVN 2 stated she provided Resident 1 nonpharmacological interventions (any type of health intervention which is not primarily based on medication) for pain since there was no physician order to administer pain medication during that time. LVN 2 stated Resident 1 received the first dose of pain medication on 9/3/2022 at 2:10 PM for a pain level of 7 ([severe pain] 10 being the highest level of pain and 1 being the lowest). During an interview on 9/20/2022 at 11:20 AM, LVN 2 stated that according to the facility ' s policy, if facility staff finds a resident on the floor, the facility staff should report to the Registered Nurse (RN) supervisor and to perform a head-to-toe assessment, including pain assessment. LVN 2 stated LVN 1 could have known that Resident 1 had been in pain and had sustained injury from the fall. During an interview on 9/20/2022 at 11:30 AM, CNA 4 stated that on 9/3/2022 around 10 AM to 10:30 AM, she noticed Resident 1 ' s discoloration to the right arm. CNA 4 stated she reported to LVN 2 immediately. CNA 4 stated she could not recall if Resident 1 was in pain or not. During a telephone interview on 9/20/2022 at 2:30 PM, Family 1 stated he was not notified by the facility staff that Resident 1 had a fall on 9/2/2022. During a telephone interview on 9/22/2022 at 12:17 PM, CNA 3 stated she was assigned to Resident 1 on 9/2/2022, during the 11 PM to 7 AM shift. CNA 3 stated during the start of her shift at around 11:30 PM, while doing her initial rounds, she noticed that Resident 1 was agitated and moaning. CNA 3 stated she observed facial grimacing from Resident 1. CNA 3 stated she performed a body check and notice discoloration on Resident 1 ' s right arm. CNA 3 stated she informed LVN 1 (who stayed to work for the next shift [11 PM to 7 AM]) at that moment. CNA 3 stated that LVN 1 came to Resident 1 ' s room but did not know if LVN 1 performed any assessment on Resident 1. CNA 3 stated she left Resident 1 ' s room to check on other residents. During the same interview, on 9/22/2022 at 12:17 PM, CNA 3 stated that during her second residents ' rounds at around 2 AM (approximately two and a half hours later), Resident 1 was still moaning with noted facial grimacing. CNA 3 stated that during her last residents ' rounds at around 4 AM (approximately four and a half hours later), Resident 1 was still moaning with noted facial grimacing. CNA 3 stated she did not report Resident 1 ' s moaning with noted facial grimacing to any other licensed nurse or facility staff during that time. During a telephone interview on 9/23/2022 at 3:22 PM, CNA 2 stated that on 9/2/2022 during the 3 PM to 11 PM shift at around 3 PM to 3:30 PM, CNA 2 observed Resident 1 lying on the floor. CNA 2 stated the three of them (CNA 1, CNA 2, and LVN 1) assisted Resident 1 back to bed. CNA 2 stated Resident 1 was confused and was talking to herself. On 9/20/2022 and 9/23/22, attempts for a telephone interview with LVN 1 was unsuccessful. During a concurrent interview and record review of Resident 1 ' s physician orders for 9/2/2022 and licensed nurses notes from (9/02/22 to 9/3/2022) on 10/5/2022 at 10:05 AM, Registered Nurse (RN) 1 stated he could not find documented evidence of a post fall assessment, pain assessment, and physician notification on 9/2/22 during the 3 PM to 11 PM shift (evening shift) and during the 11 PM to 7 AM shift (night shift). RN 1 stated he could not find documented evidence that LVN 1 took appropriate interventions which included head-to-toe assessment, including pain assessment, post fall assessment, family, and physician notification after Resident 1 had the fall in the afternoon of 9/2/22. On 10/5/2022 at 11:50 AM to 12:10 PM, during a concurrent interview and record review of Resident 1 ' s Medication Administration Records (MAR) and nurses notes for September 2022 with RN 2 and assistant director of nurses (ADON), RN 2 stated the first dose of pain medication that Resident 1 received was on 9/3/22 at 2:10 PM. During an interview on 10/7/2022 at 2:38 PM, CNA 1 stated that Resident 1 was bed bound (bedridden or unable to move or even sit upright). CNA 1 stated she was assigned to Resident 1 on 9/2/2022 during the 3 PM to 11 PM shift. CNA 1 stated that between the hours of 3 PM to 4 PM, CNA 1, CNA 2 and LVN 1 found Resident 1 lying on the floor next to her bed and assisted the resident back to bed. CNA 1 stated she could not recall if the bed side rails were up or not when Resident 1 was found on the floor. CNA 1 stated she did not inform the RN supervisor that Resident 1 was found on the floor due to a suspected fall. A review of the facility ' s policy titled Change of Condition revised in February 2021 indicated: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. I. The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source. 3.Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source . A review of the facility ' s policy and procedure, revised in December 2021 and titled, Assessing falls and Their Causes, indicated: After a fall I. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities (arms and legs).2. Obtain and record vital signs (clinical measurements for hearth rate, blood pressure, respiratory rate, and temperature) as soon as it is safe to do so. 3.If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately.4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position. 5.Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone .

Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had severely impaired cognition (thought process), was at risk for falls, and had a physician ' s order to monitor for [CONDITION(S)] activity (Uncontrolled movements, such as shaking of arms or legs that can lead to loss of consciousness), was provided an environment free of hazard, assessed to require constant (occurring continuously over a period of time) supervision by facility staff, and a nursing care plan for [CONDITION(S)] disorder to identify, manage and avoid precipitating factors that could lead to potential injury. On 9/2/22, Certified Nursing Assistant (CNA) 1 observed the resident sliding down by the foot of the bed, with the resident ' s head doing repetitive movements and described the resident as exhibiting helicopter movements (the whole body kept moving) while in bed. CNA 1 did not inform the licensed nurse of the Resident 1 ' s need for constant supervision. This deficient practice resulted in Resident 1 being found lying on the floor by CNA 1 on 9/2/22 between the hours of 3 PM to 3:30 PM. Resident 1 experienced severe pain as manifested by agitation, facial grimacing and moaning, during the nightshift of 9/2/2022 at 11:30 PM, 2 AM, and 4 AM, and the start of the following morning shift around 11:33 AM, (20 hours after being found on the floor). On 9/3/2022, Resident 1 ' s X-ray (a photographic or digital image of the internal composition of a part of the body) result revealed the resident had a right shoulder fracture (break). Cross referenced to F580, F656, and F697 Findings: A review of Resident 1's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unspecific convulsion (certain kinds of seizures, uncontrolled electrical disturbance in the brain manifested by uncontrollable jerking movements of the body loss of consciousness or awareness) [CONDITION(S)] (paralysis on one side of the body ) following cerebral infarction (stroke [a damage to tissues in the brain due to a loss of oxygen to the area]), and Type II Diabetes (a condition of high blood sugar). A review of Resident 1 ' s care plan titled Resident at risk for falls and injury initiated on 6/15/2018, indicated the resident ' s risk for falls, and injury were due to impaired physical mobility, impaired cognition, unsteady gait (manner of walking), [CONDITION(S)] disorder and right sided weakness. The care plan goal with a target date of 10/26/2022 indicated having a decrease in Resident 1 ' s number of falls. The care plan interventions indicated Resident 1 was in the facility ' s Falling Star Program that included monitoring resident ' s safety, placing the bed in the lowest position possible, reminding the resident and reinforcing safety awareness. A review of Resident 1's History and Physical (H&P) dated 2/23/2020, indicated Resident 1 had a diagnosis of [CONDITION(S)] and stroke. The H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's History and Physical (H&P) updated on 12/23/2021, indicated Resident 1 was cognitively impaired. The H&P ' s Fall Risk Assessment indicated Resident 1 scored a five (5) that was considered at risk for falling. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 7/28/2022, indicated the resident ' s cognition was severely impaired. The MDS indicated Resident 1 required extensive (means when a resident is totally dependent or requires weight - bearing support while performing part of an activity), one-person assistance during bed mobility, transfers, toilet use, dressing, locomutation on the unit, and personal hygiene. The MDS indicated Resident 1 could not walk. A review of Resident 1 ' s PT (Physical Therapy) Evaluation and Plan of Treatment dated 8/25/2022 indicated the resident having a decline in range of motion (ROM- capacity for movement at a given joint) in a specific direction of the right lower extremity. The PT evaluation indicated contractures (abnormal shortening of muscle tissues causing it to be stiff and deformed) to Resident 1 ' s impaired right knee and ankle. A review of Resident 1 ' s OT (Occupational Therapy) Evaluation and Plan of Treatment dated 8/27/2022 indicated the resident presented with decreased strength, poor safety, low endurance for task, impaired functional mobility, decreased activity tolerance, poor postural control, and decreased balance. The OT evaluation indicated Resident 1 having right shoulder, elbow, forearm, and wrist ROM impairments. The OT evaluation indicated Resident 1 having poor safety awareness. A review of Resident 1's Order Summary Report in the facility for September 2022, indicated the following physician order dated 2/24/2020, Monitor for episodes of [CONDITION(S)], secondary to use of [MEDICATION(S)] every shift. A review of Resident 1 ' s nurses notes dated 9/3/2022 and timed at 11:33 AM (7 AM to 3 PM shift) documented by LVN 2 indicated upon assessment noted resident with right upper arm swollen and discoloration when attempt to touch and lift the arm resident grimace in pain. Right side of the patient is weak, and the right arm is contracted (sic). The nurses note indicated attempted to call MD (Physician 1) and left message waiting for response. Will follow up and continue to monitor the resident. A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a technique used to facilitate prompt and appropriate communication) Communication Form (SBAR) dated 9/3/2022 (no time), indicated Resident 1 noted with discoloration and swollen right upper arm. The SBAR indicated Resident 1 would moan and grimace in pain when the arm is slightly lifted. The SBAR indicated Resident 1 was having symptoms of new pain and showed non-verbal signs of pain such as occasional moan or groan, low-level of speech with a negative or disapproving quality, facial grimacing, tense, distressed pacing, and fidgeting. The SBAR form indicated Physician 1 was notified on 9/3/2022 at 11 AM, and Family 1 was notified on 9/3/2022 at 12 PM. The SBAR form indicated Physician 1 ordered for X-ray and pain medication (Acetaminophen 500mg PO 2 tabs for mild to moderate pain PRN). A review of Resident 1's Patient Report for the X-ray examination of the right humerus (long bone from the elbow to the shoulder up to the shoulder blade) dated 9/3/2022 timed at 8:29 PM, indicated an acute (acute fracture is a break in a bone that occurs quickly, rapidly, and usually traumatically), complete (breaks the bone into separate pieces), transversely oriented (straight across the bone), displaced (the ends of the bones are displaced, meaning they do not line up anymore) proximal (situated close) humerus neck. A review of the facility ' s investigation report witness statements indicated the following: 1. Report dated 9/6/22 timed at 10:25 AM, signed by CNA 1, indicated, on 9/2/2022, at around 3:00-3:30 PM, CNA 1 was doing her rounds for the change of shift when CNA 1 found Resident 1 on the floor mat on her right side. CNA 1 indicated she called for help to put the resident back to bed. 2. Report dated 9/6/22 (no time) signed by CNA 3, indicated, on 9/2/2022, 11 PM - 7AM shift, during rounds Resident 1 was seen agitated, CNA 3 did a body check, CNA 3 saw that there was a discoloration on the right and observed patient grimacing and moaning. CNA 3 called LVN 1 and reported what was observed. The report indicated, LVN 1 stated yes, there ' s discoloration. 3. Report (no date and time) signed by LVN 1 indicated, During the start of shift on 9/2/2022 between 3-3:30 PM, she saw two CNAs assisting resident back to bed from the floor. She (LVN 1) saw patient on the floor lying on her right side and at the right side of the bed . The report indicated Resident 1 verbalized no pain and was not in acute distress so [LVN 1] opted not to report to the Registered Nurse (RN) supervisor of 3 to 11 PM shift. During an observation inside Resident 1 ' s room, on 9/20/2022 at 9:30 AM, Resident 1 was observed in bed. Resident 1 was not oriented to self, time, place, and situation and unable to respond appropriately to interview. During an interview on 9/20/2022 at 10:40 AM, DON 1 stated that on 9/2/2022 during the 3 PM to 11 AM shift, CNA 1, CNA 2, and LVN 1 found Resident 1 lying on the floor inside her room. CNA 1, CNA 2, and LVN 1 transferred Resident 1 back to bed. DON 1 stated that based on the resident ' s records and interview with LVN 1, LVN 1 did not perform head to assessment on Resident 1, did not inform Family 1 and Physician 1 of Resident 1 being found on the floor. DON 1 stated that LVN 1 did not document the resident ' s fall on the facility ' s Change of Condition (COC) form and SBAR form. During an interview on 9/20/2022 at 11:12 AM, LVN 2 stated she was assigned to Resident 1 on 9/3/2022, during the 7 AM to 3 PM shift. LVN 1 stated that on 9/3/2022 between the hours of 10:30 AM to 11 AM, CNA 4 informed her of Resident 1 ' s discoloration and swelling on the right shoulder. LVN 2 stated Resident 1 would grimace (facial expression) in pain when she lifted the resident ' s right arm. LVN 2 stated she performed a head-to-toe assessment, notified Physician 1 and Family 1. LVN 2 stated she provided Resident 1 nonpharmacological interventions (therapy that does not involve drugs) for pain since there was no physician order to administer pain medication during that time (10:30 AM to 11 AM). LVN 2 stated when she received the physician orders for pain medication, LVN 2 administered the first dose of pain medication (Tylenol 2 tablets, 500 milligrams by mouth) on 9/3/2022 at 2:10 PM for a pain level of 7 ([severe pain] 10 being the highest level of pain and 1 being the lowest). During an interview on 9/20/2022 at 11:30 AM, CNA 4 stated that on 9/2/2022 around 10 AM to 10:30 AM, she noticed Resident 1 ' s discoloration to the right arm. CNA 4 stated she reported to LVN 2 immediately. During a telephone interview on 9/22/2022 at 12:17 PM, CNA 3 stated she was assigned to Resident 1 on 9/2/2022, during the 11 PM to 7 AM shift. CNA 3 stated during the start of her shift at around 11:30 PM, while doing her initial rounds, she noticed that Resident 1 was agitated and moaning. CNA 3 stated she observed facial grimacing from Resident 1. CNA 3 stated she performed a body check and noticed discoloration on Resident 1 ' s right arm. CNA 3 stated she left Resident 1 ' s room to check on other residents. During the same interview, on 9/22/2022 at 12:17 PM, CNA 3 stated that during her second residents ' rounds at around 2 AM (approximately two and a half hours later), Resident 1 was still moaning with noted facial grimacing. CNA 3 stated that during her last residents ' rounds at around 4 AM (approximately four and a half hours later), Resident 1 was still moaning with noted facial grimacing. CNA 3 stated she did not report Resident 1 ' s moaning with noted facial grimacing to any other licensed nurse or facility staff during that time. During a telephone interview on 9/23/2022 at 3:22 PM, CNA 2 stated that on 9/2/2022 during the 3 PM to 11 PM shift at around 3 PM to 3:30 PM, CNA 2 observed Resident 1 lying on the floor. CNA 2 stated the three of them (CNA 1, CNA 2, and LVN 1) assisted Resident 1 back to bed. CNA 2 stated Resident 1 was confused and was talking to herself. On 9/20/2022 and 9/23/22, attempts for a telephone interview with LVN 1 was unsuccessful. During an interview on 10/7/2022 at 2:38 PM, CNA 1 stated that Resident 1 was bed bound (bedridden or unable to move or even sit upright). CNA 1 stated she was assigned to Resident 1 on 9/2/2022 during the 3 PM to 11 PM shift. CNA 1 stated between the hours of 3 PM to 4 PM, CNA 2 and LVN 1 found Resident 1 lying on the floor next to her bed and assisted the resident back to bed. CNA 1 stated she could not recall if the bed side rails were up or not. CNA 1 stated she did not inform the RN supervisor of Resident 1 ' s fall or resident being found on the floor. During a telephone interview on 10/11/2022 at 12:10 PM, Family 1 stated Resident 1 had a stroke [AGE] years ago, since then she was taking [CONDITION(S)] medication . Family 1 stated that three to four months ago he observed Resident 1 having a [CONDITION(S)], the whole body was shaking with eyes rolling up . Family 1 stated he could not remember the exact date of this incident and the name of the facility staff that came to the resident ' s room . During another interview with CNA 1 on 10/12/2022 at 10:03 AM, CNA 1 stated Resident 1 could not verbalize her needs. CNA 1 stated on 9/2/2022 at the beginning of her shift (3PM to 11 PM shift), she observed the resident was sliding down by the foot of the bed and every time she would check, Resident 1 would be laying by the half of the bed (middle portion of the bed) and needed to pull the resident up from the middle of the bed. CNA 1 described Resident 1 ' s movements like a Helicopter, because the whole body kept moving. CNA 1 stated she would pull her up in bed and after a few minutes later, Resident 1 ' s head would sometimes be on the side rail already. CNA 1 further stated Resident 1 ' s head was also observed having repetitive movements. CNA 1 stated she placed pillows at the side of the bed for safety. CNA 1 stated she did not inform the Charge nurse of Resident 1 ' s repetitive sliding down the bed and behavior because it was the start of her shift, and she did not really know if that behavior was Resident 1 ' s normal behavior CNA 1 stated she found Resident 1 on the floor around 4:30 PM. CNA 1 stated she did not know Resident 1 needed to be monitored the for [CONDITION(S)] activities, since the facility staff did not instruct her to monitor the resident for seizures. During an interview on 10/12/2022 at 2:20 PM, DON 1 stated Resident 1 ' s medical records had a care plan indicating Resident is at risk for falls and injury d/t (due to) impaired physical mobility, impaired cognition, has unsteady gait, [CONDITION(S)] disorder, right sided weakness. DON 1 stated there was no other care plan found specific for Resident 1 ' s [CONDITION(S)] disorder with [CONDITION(S)] precautions. On 10/12/2022 at 3:10 PM, during an interview with LVN 4 and concurrent record review of Resident 1's care plans, LVN 4 stated she could not find a care plan developed that indicated Resident 1 ' s [CONDITION(S)] precautions. LVN 4 stated care plan for [CONDITION(S)] precautions should include interventions such as monitoring how long the resident ' s [CONDITION(S)] activity would last, what type of [CONDITION(S)], and having padded side rails in bed. A review of the facility ' s policy and procedure for titled Falls Clinical Protocol, revised on March 2018, indicated the following information: 1. The physician will identify medical conditions affecting fall risk . the risk for significant complications of falls . 2. The physician will help identify individuals with a history of falls and risk factors for falling. 3. Falls often have medical causes; they are not just a nursing issue. 4. The staff and practitioner will review each resident's risk factors for falling and document in the medical record . 5. Falls categories included Other circumstances such as sliding out of a chair or rolling from a low bed to the floor. 6. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. A review of the facility ' s policy and procedure titled Care Plans, Comprehensive Person-Centered revised on March 2022, indicated that The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The policy indicated that the comprehensive, person-centered care plan included information such as: 1. Measurable objectives and timeframes. 2. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including which professional services are responsible for each element of care. 3. Reflects currently recognized standards of practice for problem areas and conditions. 4. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 5. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Follow up the discharge order of the General Acute Care Hospital (GACH) physician when Resident 1 was readmitted back to the facility on [DATE] to see an [CONDITION(S)] provider (Infectious Disease physician). 2. Administer antiretroviral therapy (ART, medication treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices resulted to a delay in treatment, Resident 1 missing eight (8) doses of [CONDITION(S)] Medication 1 and nine (9) doses of [CONDITION(S)] Medication 2, and affected Resident 1's psychological well-being, which could result in severe and life-threatening infections, other health complications and possibly leading to hospitalization and/or death. On 5/18/2022 at 12:09 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and Assistant Director of Nursing (ADON) regarding the facility's failure to ensure Resident 1's antiretroviral therapy was received consistently as ordered. On 5/19/2022 at 5:28 PM, the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and ADON. The acceptable IJ Removal Plan included the following: 1. An Infectious Disease consult was established and scheduled for 5/20/2022 at 4pm. 2. The ADON initiated in-services to licensed nurses and will be completed on 5/19/2022 on the following topics: a. Follow-up on admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] b. Timely Physician notification when resident is non-compliant with labs works or other orders. c. medication refills d. The need to reeducate residents that are noncompliant with necessary care, development of care plan, implementation, and intervention. e. The need for licensed nurses and social service designee to reeducate residents when they are refusing care, explaining risk and consequences of their refusal 3. The Administrator initiated in-services to Social Service Designee (SSD) and will be completed on 5/19/2022 on the following topics: a. Following up on appointments b. Referrals/ consults c. Collaborating and communicating with licensed nurses about scheduled appointments d. Proper documentation of scheduled appointments and arranged transportation e. The need for and importance of checking appointment logs daily f. The need to reeducate residents that are noncompliant with necessary care, development of care plan, implementation, and intervention. 4. Clinical resource consultant provided follow up in services on 5/19/2022 to Licensed Nurses, SSD, Minimum Data Set (MDS, a screening and assessment tool) coordinator and ADON regarding the following topics: a. Follow-up of admission/readmission ordered including special instructions from discharge orders. b. Timely MD notification when resident is non-compliant with lab works or another other orders. c. Medication refills d. The need for and importance of LN and SSD to check appointment logs daily e. Medication administration and how to prevent medication error. f. How to care for Resident with [CONDITION(S)], antiretroviral medication therapy, side effects, life threatening complications when medication is not received consistently and when laboratory tests are omitted. g. Medications to be held, and what medication to hold while residents are on at [CONDITION(S)], depending on physician orders. h. Follow up in-service by Consultant Pharmacist (CP) on 5/24/22. 5. The facility initiated the use of an appointment binder for all physician referrals and consults, and kept in each nursing station, Nurse station 1 and Nurse Station 2. The appointment binders were checked daily by LN and the SSD, and ensure compliance by the ADM. 6. An Assigned Registered Nurse Supervisor and SSD will follow up and monitor the [CONDITION(S)] care (laboratory monitoring, follow up appointments, and medication refills), and will be over seen by the ADON. Findings: A review of Resident 1's Admission Record indicated an initial admission to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/7/2021, Resident 1 was readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History and Physical (H&P), dated 8/1/2021 indicated Resident 1 did not have the capacity to understand or make decisions. A review of Resident 1's quarterly MDS, dated [DATE] indicated Resident 1 was assessed as having intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). MDS indicated Resident 1 required extensive assistance (staff provide weight bearing support) with one-person for bed mobility, transfers, dressing, and personal hygiene. MDS indicated Resident 1 required supervision with eating and was totally dependent with toilet use. During an interview on 5/16/2022 at 8:47 AM, Resident 1 stated he was admitted to the facility three years ago after having a stroke and was unable to use the left side of his body. Resident 1 stated he did not receive his [CONDITION(S)] medication since 1/2020 when his medications were last refilled. Resident 1 stated, he started receiving all three [CONDITION(S)] medications ([CONDITION(S)] Med 1, 2 and 3), about three weeks ago (could not provide actual date). A review of Resident 1's GACH physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress note indicated Resident 1' s [CONDITION(S)] drug regimen needs to be restarted with Resident 1's primary [CONDITION(S)] provider. A review of Resident 1's monthly Physician visits, dated 9/2/2021, 10/1/2021, 11/2/2021, 12/3/2021, 1/4/2022, 2/3/2022, 3/1/2022, 4/1/2022, and 5/3/2022 indicated Resident 1 was seen by Physician 3 (PCP 3), with no new events. It also indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's monthly Physician visit by PC3, dated 1/14/2022, indicated to continue [CONDITION(S)] medications. The document did not indicate referrals or labs ordered. A review of Resident 1's Change of Conditions (COC), dated, 3/18/2022, 4/2/2022, and 4/16/2022, did not indicate any coordination in care and services for Resident 1 to be seen by an Infectious Disease physician for ART regimen or physician notification for the lack of [CONDITION(S)] medications as indicated on the GACH discharge orders on 7/7/2022. A review of Resident 1's Order Summary Report as of 5/16/2022, indicated the following orders on 4/21/2022: 1. Refer to infectious disease physician for consult and evaluation 2. [MEDICATION(S)]-Tenofovir ([CONDITION(S)] Med 1) give 1 tablet by mouth one time a day for [CONDITION(S)] 3. Fosamprenivir Calcium ([MEDICATION(S)]) ([CONDITION(S)] med 2) tablet 700 mg 1 tablet by mouth one time a day for [CONDITION(S)] 4. [MEDICATION(S)] (used with other antiviral medicines to treat people with [CONDITION(S)]) [[CONDITION(S)] Med 3] tablet 100 mg, give two (2) tablets by mouth one time a day for [CONDITION(S)]. During an interview on 5/16/22 at 12:25 PM, the Assistant Director of Nurses (ADON) stated Resident 1 was a long-term care resident in the facility who was alert and oriented times four (refers to someone who was alert and oriented to person, place, time and event). The ADON stated she was unaware of Resident 1's [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON further stated, Resident 1 asked to be back on his three [CONDITION(S)] medications ([CONDITION(S)] 1, 2 and 3). The ADON stated Resident 1 was restarted on his [CONDITION(S)] medications on 4/21/2022. During a concurrent interview with the ADON and record review of Resident 1's Physician Orders on 5/16/2022 at 1:16 PM, the ADON stated Resident 1's [CONDITION(S)] medications were discontinued when the resident was transferred to the GACH and there was no physician's order to restart the [CONDITION(S)] medications when the resident was readmitted to the facility on [DATE]. The ADON stated Resident 1 had not received his three [CONDITION(S)] medications ([CONDITION(S)] medications 1, 2 and 3) and have not consulted with Infectious Disease (ID) Physician in accordance with the GACH physician's orders. During a concurrent interview with the ADON and record review of Resident 1's Multidisciplinary Care Conference on 5/16/2022 at 2:15 PM, the ADON stated the Care Conferences were conducted on 6/18/2021, 9/16/2021, and 12/22/2021. The ADON stated there were no other care conferences documented in Resident 1's electronic health record. The ADON stated on all three conferences, Resident 1's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated Resident 1's need for ID consult follow up should have been addressed during the care conferences. During an interview on 5/16/2022 at 2:36 PM, the ADON stated prior to the GACH transfer on 6/25/2021, PCP 1 had discontinued Resident 1's [CONDITION(S)] medications due to the resident being transferred to GACH. During a telephone interview on 5/16/22 at 3: 10 PM, in the presence of the ADON, PCP 1 could not state the reason for discontinuing Resident 1's [CONDITION(S)] medications. PCP 1 stated he had requested for an ID consult. PCP 1 stated, You can never discontinue [CONDITION(S)] medications, unless they go to hospice (Hospice care, designed to give supportive care to people in the final phase of terminal illness). PCP 1 stated [CONDITION(S)] medications are a lifelong therapy. PCP1 stated an ID consult was required to care for Resident 1's [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's clinical record prior to 4/21/2022 indicated no documented evidence that an ID consult was ordered by PCP 1. During an interview in Resident 1's room on 5/16/2022 at 3:56 PM, Resident 1 stated he had been on the three [CONDITION(S)] meds ([CONDITION(S)] meds 1, 2 and 3) since June 2006. Resident 1 stated he was out of state and once he was originally admitted to the facility in 12/2019. Resident 1 stated it was very difficult to get his [CONDITION(S)] medications renewed, since the facility did not assign him an ID physician. Resident 1 stated the facility had not obtained laboratory work, such as CD4 count (CD4 count is used to check the health of the immune system in people infected with [CONDITION(S)]) and [CONDITION(S)] load ([CONDITION(S)] load measures how much [CONDITION(S)] there is in a drop of blood). Resident 1 stated until recently, as of 4/21/2022, the facility wanted to draw his labs, but he refused because he was not taking his [CONDITION(S)] medications, So it felt like it did not matter. During an interview on 5/16/2022 at 4:43 PM, Registered Nurse 1 (RN 1) stated she had not followed up with an ID physician and could not state who facility appointed ID physician was since it was an outside service. During an interview on 5/16/2022 at 6:37 PM, the ADON stated PCP 2 had referred Resident 1 to ID physician on 4/21/2022. The ADON stated social service designee (SSD) was to follow up with the ID 1's clinic. During a telephone interview on 5/17/2022 at 1:58 PM, SSD stated prior to 4/21/2022, SSD had not scheduled for any ID consult for Resident 1 and that it was the responsibility of either social service or nursing to follow up on referral for appointments and consults. The SSD stated Resident 1 had a pending consult with the ID physician ordered on 4/21/2022, and there had not been confirmation, or follow up efforts notifying the ordering physician of the inability to see an ID physician. The SSD stated she did not follow up with the ID consultation or did she document the inability to confirm a set appointment for Resident 1 to see an ID physician. During a telephone interview on 5/17/2022 at 2:07 PM, Pharmacist stated she was unaware Resident 1 was on [CONDITION(S)] medications prior to 4/21/2022. Pharmacist stated when a resident stop taking [CONDITION(S)] medications, the risk for infections increases and would be detrimental to the resident's health. Pharmacist stated when [CONDITION(S)] medications are not taken as ordered, or doses are skipped, the Resident was at risk in developing resistance to the [CONDITION(S)] therapy plan. Pharmacist stated since Resident 1 was [CONDITION(S)] positive, an ID physician was required for Resident 1's treatment plan. During an interview on 5/18/2022 at 9:40 AM, Resident 1 stated, Now everyone knows about my [CONDITION(S)]. I went through hell, I cried at night. During an interview on 5/19/2022 at 2:40 PM, Treatment Nurse 1 (TN1) TN 1 stated he never scheduled an infectious disease consult for Resident 1 since original admission on 12/20/2019. TN 1 stated Resident 1's ID physician consult was critical for the care of Resident 1's [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . TN 1 stated since no follow up or consults were done, Resident 1's immune system could further decline resulting in the worst- death. During a concurrent observation in Nurses Station 1, and interview on 5/19/2022 at 3:23 PM, in the presence of Licensed Vocational Nurse 3, the ADON was observed counting Resident 1's [CONDITION(S)] Med 1 from Medication Cart 1. The [CONDITION(S)] Medication 1 bottle with a pharmacy label was observed with a fill date of 4/21/2022 and a quantity of 30 tablets. The label indicated to take one tablet by mouth daily. The ADON verified there were 10 remaining tablets in the [CONDITION(S)] Medication 1's bottle. The ADON stated the remaining quantity was incorrect because there should only be two (2) tablets remaining in the bottle. The ADON stated there were eight doses of [CONDITION(S)] med 1 not given to Resident 1. During a concurrent observation in Nurses Station 1, and interview on 5/19/2022 at 3:28 PM, in the presence of Licensed Vocational Nurse 3, the ADON was observed counting Resident 1's [CONDITION(S)] Medication 2 bottle from Medication Cart 1. The [CONDITION(S)] Medication 2 bottle with pharmacy label was observed with a fill date of 4/21/2022 and a quantity of 60 tablets. The label indicated instructions to take 1 tablet by mouth daily for [CONDITION(S)]. The ADON stated the remaining tablets in [CONDITION(S)] Med 2's bottle was 41, which was incorrect. During a concurrent interview on 5/19/22 at 3:40 p.m. with the ADON and record review of Resident 1's electronic medication administration record (eMAR) from 4/2022 to 5/2022, the ADON stated seven (7) doses of [CONDITION(S)] medication 1 were not administered to Resident 1. The ADON stated there was a discrepancy between the number of missed [CONDITION(S)] medication 1 dose as documented on the eMAR and the number of tablets left in the [CONDITION(S)] medication 1 bottle. The ADON stated nine doses of [CONDITION(S)] medication 2 were not administered to Resident 1. The ADON stated licensed nurses should follow up with the physician when medications are missed. A review of the facility's undated Policy and Procedure (P&P) titled, Medication Holds, indicated temporary medication holds may be ordered by the residents attending physician. The policy indicated the attending physician must provide an explicit order as to when to restart a medication that has been held, either at the time the order was given to hold the medication or subsequently. If the medication was discontinued, a new order must be given. A review of the facility's Policy and Procedure titled, Abuse Prevention Program, revised 12/2016, indicated resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. A review of the facility's Policy and Procedure titled, Medication Administration, dated 4/2008, indicated medications are administered in accordance with written orders of the attending physician. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medication.

Based on observation, interview and record review, the facility failed to provide interventions as indicated in the care plan to prevent a fall for one of five sampled residents (Resident 1). On 8/25/19 at 4:30 a.m., while Certified Nursing Assistant 1 (CNA 1) was changing Resident 1's adult brief, CNA 1 left the resident unattended on the bed in a high position to answer the call light (device used by the residents to signal his or her need for assistance) from the another room. As the result, Resident 1 fell from the bed and sustained a fracture to the left distal tibia and fibula (broken leg bones), with lacerations (a deep cut) to the head, skin tears to the left forearm (part of the arm from the elbow to the wrist) and right hand. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on the same day for further evaluation and treatment. Findings: A review of Resident 1's Admission Record indicated the facility initially admitted the resident on 11/11/15 and readmitted the resident on 12/21/18. Resident 1's diagnoses included, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and right knee contracture (permanent shortening of the muscles or joints). A review of Resident 1's History and Physical (H&P), dated 8/30/19, indicated the resident had no capacity to understand and make decisions. A review of Resident 1's Fall Risk Assessment, dated 7/15/19, indicated the resident was assessed as at risk for fall. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 7/15/19, indicated Resident 1's cognitive skills (ability to think and process information) for daily decisions making was severely impaired. Resident 1 required extensive to total assistance from staff (staff provide weight-bearing support to full support) for activities of daily living such as bed mobility and personal hygiene. A review of Resident 1's Care Plan for Fall revised on 7/23/19, indicated the resident was at risk for fall and injury due to poor safety awareness, vision impairment. The goal was for Resident 1 to be free from falls. The approached interventions were for staff to position Resident 1's bed at the lowest level with floor mats, and do not leave the resident unattended while providing care. A review of Resident 1's Multidisciplinary Care Conference Notes, dated 7/30/19, indicated Resident 1 was confused, disoriented, unable to verbalize needs. The notes indicated Resident 1 needed total assistance with activities of daily living and mobility. A review of Resident 1's Change in Condition Evaluation Assessment, dated 8/25/19 at 7:12 a.m., indicated Resident 1 had fallen on 8/25/19 in the morning. The assessment indicated Resident 1 had a laceration on the right scalp, skin tears on the left arm and right hand. Resident 1 was not able to rate the pain scale, with occasional moan (continuous low sound to express physical or mental suffering) and groan (strong, deep-throated sound in response to pain). A review of Resident 1's Nurses Progress Notes, dated 8/25/19, at 8:02 a.m., indicated Licensed Vocational Nurse 2 (LVN 2) was called to attention at 4:30 a.m., Resident 1 was found on the floor in her room. The notes indicated CNA 1 was providing care for Resident 1 when she had to check on a call-light from a room next door. The notes indicated CNA 1 came back to Resident 1's room and found the resident on the floor with the arms and head bleeding. A review of Resident 1's Nurses Progress Notes, (late entry) dated 8/27/19, at 4:55 p.m., written by Registered Nurse 1 (RN 1) indicated on 8/25/20, at 4:30 a.m., CNA 1 told LVN 2 that Resident 1 had fallen off the bed. The note indicated CNA 1 was providing care for Resident 1 but had to respond to the call light from another room; and Resident 1 had rolled onto the floor before she came back. The notes indicated Resident 1 was found lying down on her right side with a 2 centimeters (cm, metric unit of length) laceration to the right temporal area (behind the eye between the forehead and the ear) with mild bleeding, a 2 cm skin tear to left forearm and 1 cm skin tear to dorsum (back) of right hand. Resident 1 was alert but confused, first aid treatment was given with firm pressure dressing to stop the bleeding from the head laceration. Paramedics arrived at 4:55 a.m., and transferred Resident 1 to GACH 1 at 5:00 a.m. A review of Resident 1's Fall Scene Investigation Report, undated, indicated Resident 1 had an unwitnessed fall on 8/25/19, at 4:30 a.m. The factors observed during the time of fall including Resident 1's bed height not appropriate. A review of GACH 1's Final Report dated 8/29/19 indicated Resident 1 was unable to provide information due to dementia. The report indicated Resident 1 had a fracture of left distal tibia and fibula after the Resident 1 fell in the nursing home. The report indicated Resident 1 was evaluated by the orthopedic surgeon and advised conservative management because the resident was non-ambulatory and not in acute distress. During an observation on 9/11/19 at 2:33 p.m., CNA 3 and LVN 1 was proving care for Resident 1. The resident was smiling while receiving care. The resident was non-verbal. During a telephone interview on 3/25/20, at 3:06 p.m., CNA 1 stated on 8/25/19, from 4:30 to 5 a.m., she changed Resident 1's adult brief and repositioned the resident. CNA 1 stated she left Resident 1 on the bed for two minutes to answer the call light from a room next door. CNA 1 stated when she came back, she saw Resident 1 lying on the floor with the resident's her head toward the foot of the bed and legs toward the head of the bed. CNA 1 stated Resident 1's bed was at the level of CNA 1's waistline without floor mats at the bedsides. CNA 1 stated her height was five feet six inches (5'6). CNA 1 stated staff (in general) needed to be at Resident 1's bedside during care to prevent the resident from falling off the bed. During a telephone interview on 3/26/20, at 7:38 a.m., LVN 2 stated on 8/25/19, at 5 a.m., CNA 1 reported to him that Resident 1 was on the floor. LVN 2 stated he went into Resident 1's room and saw the resident was lying on the floor and the resident's face was bleeding moderately. LVN 2 stated Resident 1 was wearing a gown, without adult brief or pants. LVN 2 stated RN 1 assessed Resident 1, then they assisted the resident back to bed. LVN 2 stated CNA 1 was changing Resident 1's adult brief but had not finished with the task and she went next door to answer the call light. LVN 1 stated when CNA 1 returned to Resident 1's room, she saw Resident 1 on the floor. During a telephone interview on 3/31/20, at 4 p.m., RN 1 stated CNA 1 left Resident 1 unattended during care to answer the call light from the other room. RN 1 stated Resident 1 slipped off from the low air loss mattress (inflatable air tubes that mimicking the residents' movements to prevent bed sores) and landed on the floor. A review of the facility's policy and procedures, titled Fall and Fall Risk, Managing, revised in December 2007, indicated that based on previous evaluation and current data, staff would identify interventions related to the resident's specific risks and causes to prevent the resident from falling and minimize complications from falling.

Based on observation, interview, and record review, the facility failed to follow safety measures to prevent falls for one of four sampled residents (Resident 1), who was at risk for falls, had [MEDICAL CONDITION] (inability to move or feel one side of the body), and required limited assistance from staff for walking, including: 1. Failure to assist Resident 1 when the resident was observed walking without staff assistance. 2. Failure to implement Resident 1's Care Plan for Falls by not anticipating Resident 1's needs to walk. 3. Failure to implement the facility's policy on Fall Prevention Program by not applying a yellow star outside Resident 1's room, by the nameplate, for staff to identify Resident 1 at risk for falls, and by not removing a wheelchair from Resident 1's room entrance which posed an accident hazard. As a result, Resident 1 fell on [DATE] and on 9/3/18. On 9/3/18, Resident 1 sustained a head injury from the second fall, and was transferred to General Acute Care 1 (GACH 1) where the resident was diagnosed with [REDACTED]. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Plan of Care developed on 3/25/18 for Resident 1's high risk for falls related to [MEDICAL TREATMENT] and, [MEDICAL CONDITION] with the goal for Resident 1 to be free from falls and injury. The interventions were for staff to anticipate and meet Resident 1's needs, and response to the resident's requests for assistance. A review of Resident 1's history and physical examination [REDACTED]. A review of Resident 1's Minimum Data Set (MDS, standardized assessment and care-planning tool), dated 6/29/18, indicated Resident 1 had no memory problems, was able to communicate. Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with one-person assist for transfers, bed mobility, walking in room and in corridor, toilet use, and personal hygiene. The MDS indicated Resident 1 was not steady while walking (with an assistive device if used) and was only able to stabilize with staff assistance. A review of the Quarterly Risk assessment dated [DATE], indicated Resident 1 was at risk for falls. A review of the Nursing Progress Notes, dated 9/1/18, timed at 7:04 a.m., indicated Resident 1 tripped over the over-bed-table and landed on the trash bin while the resident was returning to his bed, from using the restroom. The notes indicated Resident 1 sustained a bruise on his chin with minimal bleeding. The notes indicated Resident 1 complained of severe pain, 8/10 on the pain rating scale from zero to 10 (zero indicating no pain, ten indicating the worst pain possible), and required pain medication. A review of the Nursing Progress Notes, dated 9/3/8, timed at 7:50 p.m., indicated after Resident 1 used the telephone at the Nursing Station and talked with the nurses, the resident walked toward his room using a walker (assistive device). The notes indicated that Resident 1 walked without staff assistance, he suddenly lost his balance, fell , and sustained a laceration (skin cut) to the left occipital (backside of the head) area with profuse (a lot of) bleeding. The notes indicated facility's staff transferred Resident 1 to GACH 1 for evaluation. A Review of the POS [REDACTED]. A review of GACH 1 Final Report, dated 9/6/18, indicated Resident 1 was transferred from the facility after a mechanical fall (caused by gravity or by something other than a medical reason) with a head injury and laceration of the scalp. A computed tomography (CT - a series of radiological (x-ray) images taken from different angles to create cross-sectional images of bones, blood vessels and soft tissues inside the body) showed intracranial bleeding (bleeding inside the skull and around the brain). The physician admitted Resident 1 to GACH 1 on 9/3/18 and discharged the resident back to the facility on [DATE]. During a tour of the facility accompanied by Registered Nurse 1 (RN 1), on 10/3/18 at 1:15 p.m., several rooms had a yellow star outside the residents' room but not outside Resident 1's room. A concurrent interview was conducted; RN 1 explained the yellow stars outside the residents' rooms were to inform staff the residents were high risk for falls. RN 1 indicated Resident 1's room should have the yellow star since he had fallen and was at high risk for fall. During an interview on 10/3/18 at 3:52 p.m., Resident 1 stated the staff did not assist him with walking, and he needed to walk on his own to go to the restroom or to do other activities. Resident 1 explained the last time he fell (9/3/18), he was walking by himself to enter his room and there was a wheelchair blocking the entrance. Resident 1 stated he tried moving the wheelchair but lost his balance and fell . A review of the facility's un-dated policy and procedure titled, Fall Prevention Program, indicated for residents who met the falling star criteria, place the yellow star outside of the residents' room on the nameplate, the bedside, the wheelchair. Supervise/assist the residents with transfers and ambulation. Universal fall preventions for all residents included clearing the environment of clutter. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, revised on 12/ 2007, indicated that based on previous evaluation and current data, staff would identify interventions related to the resident's specific risks and causes to prevent the resident from falling and minimize complications from falling.

Based on interview and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor / modify interventions when necessary for one sampled resident (Resident 1). For Resident 1, who was assessed as a high fall risk, the facility failed to develop an initial plan of care with interventions to address the resident's identified risk for falls and failed to develop a falls prevention care plan. These deficient practices resulted in Resident 1 suffering a fall with injuries, which included a fractured hip and required surgery. Findings: According to the Admission Face Sheet, Resident 1, was an [AGE] year old, admitted to the facility, on 2/6/15, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a care planning and screening tool), dated 2/19/15, indicated Resident 1 was alert, but not interviewable, required extensive assistance with activities of daily living (ADLs), such as walking, dressing, toilet use, and personal hygiene. The resident was incontinent (unable to retain urine and feces) of bowel and bladder and was not on a toileting program. The Care Area Assessment (CAA) summary indicated Resident 1 triggered for ADL function and falls, which required care planning in these areas. A review of the Fall Risk Assessment, dated 2/6/15, 5/15/15, 8/15/15, and 11/15/15 indicated Resident 1 was considered a high risk potential for falls, with a score of 20. The assessment form indicated a prevention protocol should be initiated immediately and documented on the care plan. A review of Resident 1's care plans with the director of nursing (DON) indicated upon admission, the facility did not initiate a care plan for potential falls on 2/6/15. On 2/20/15, the care plan indicated Resident 1 had an actual incident of a fall with no injury. The care plan goal indicated Resident 1 would be free from future falls and free from complications of falls. The care plan approach indicated to encourage the resident not to get up without assistance. A review of the Fall Risk Assessment, dated 5/15/15, 8/15/15, and 11/15/15 indicated Resident 1 was identified as a high risk for potential falls, but the care plan for falls was not revised or updated. This indicated the care plan for falls had not been revised or updated for approximately 10 months. During an interview and record review, on 1/5/16, at 2:08 p.m., the MDS coordinator stated she was unable to locate the care plan for falls for Resident 1. The MDS coordinator stated residents with a high risk for falls should have a care plan to ensure proper intervention was provided for the resident to prevent falls and injury. During an interview and record review, on 1/5/16, at 2:30 p.m., the DON stated she was unable to locate the care plan for falls. The DON stated a care plan should have been initiated and revised as needed. A review of Licensed Personnel Progress Notes, dated 12/23/15, at 5:15 a.m., indicated the registered nurse (RN 1) heard a sound and went to check on Resident 1. The resident was found on the floor in a sitting position. The Progress Notes indicated Resident 1 tried to stand, and walk a few steps while four staff members helped the resident back to bed. Resident 1 stated he had pain as he pointed to his right hip. Tylenol 650 milligrams was given. At 12/23/15, at 10 a.m., the Licensed Personnel Progress Notes indicated Resident 1 was transferred to the acute care hospital for further evaluation. A review of the emergency department report from the acute care hospital, dated 12/23/15, at 10:41 a.m., indicated Resident 1 received Morphine (a controlled substance or drug used to treat moderate to severe pain) 4 milligrams (mg). A review of the x-ray report from the acute care hospital, dated 12/23/15, at 12 p.m., indicated Resident 1 sustained an acute right proximal femoral intratrochanteric fracture (right hip fracture). A review of the Surgery and Procedure report from the acute care hospital, dated 12/23/15, at 10:30 p.m., indicated Resident 1's preoperative [DIAGNOSES REDACTED]. The Surgery and Procedure report indicated the operative procedure performed was an intramedullary hip screw fixation of the right hip and femur under general anesthesia. A review of the Surgery and Procedure report, dated 12/23/15, at 10:40 p.m., indicated Resident 1 experienced uncontrolled post-operative pain and an additional procedure of a right fascia illiaca (hip and thigh) peripheral nerve block for post-operative pain control was performed (a procedure in which an anesthetic agent is injected directly near the nerve to block pain). A review of the facility's policy and procedure titled, Fall Risk Assessment Form, dated 5/2007 indicated if the total score was 10 or greater, the resident should be considered at high risk for potential fall and a prevention protocol was initiated and documented on the care plan. The facility's undated policy and procedure titled, Care Plan, indicated the resident care plan must address the needs, strengths, and preferences of the resident as identified on the comprehensive assessment and care plans should be oriented to prevention of avoidable declines in functioning or functioning levels. The policy indicated care plans must show evidence of facility's effort to address or manage risk factors and care plans were to be reviewed, once every quarter (every 90 days) and whenever necessary, to assure the continued accuracy of the assessment.

Based on observation, interview, and review of clinical record, the interdisciplinary team (IDT) that included the registered dietician (RD) failed to prevent a progressive severe weight loss of fourteen pounds (10.8 percent) in approximately five months for a resident who had chewing difficulties and was on a mechanically altered diet by failing to continuously assess the resident to determine the resident's need for adequate nourishments, failed to monitor and evaluate the resident's daily food consumption (17), failed to ensure a resident (3) with [DIAGNOSES REDACTED]. Findings: a. According to the admission information Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. The annual Minimum Data Set (MDS- a standardized comprehensive assessment of the resident's problems and conditions) dated February 15, 2012, indicated the resident had clear speech, usually understood and sometimes understand others, and required supervision for eating. The care plan re-evaluated in February and May of 2012, indicated the resident had difficulty chewing, was on a mechanically altered diet and was below her usual body weight, which was 129-138 lbs. The interventions included to monitor her meal intake, monitor her weight and get a registered dietician (RD) evaluation as needed. A review of the monthly weight record indicated the following: On January 5, 2012, the resident weighed 129 pounds (lbs). On February 6, 2012, the resident weighed 128 lbs (lost one lb). On March 7, 2012, the resident weighed 126 lbs (lost three lbs.) On April 6, 2012, the resident weighed 125 lbs (lost four lbs). On May 4, 2012, the resident weighed 120 lbs (lost nine lbs). On June 6, 2012, the resident weighed 115 lbs (lost fourteen lbs). The resident had a progressive weight loss of fourteen pounds in five months or 10.8 percent in five months. According to State Operations Manual (SOM), a weight loss greater than 10 percent in six months is considered severe weight loss (SOM October 2010, Page 306). A review of the Nutritional Progress Notes revealed the last evaluation assessment the RD conducted was on August 30, 2011. During an interview on June 4, 2012, at 11:30 a.m., the dietary service supervisor (DSS) said the RD did not re-evaluate the resident because the resident was above her ideal body weight (IBW). The resident's IBW was 83-101 lbs. The DSS also said all residents should get a quarterly evaluation by the RD. He could not explain why the resident did not get a quarterly evaluation in December of 2011, and April of 2012. b. On May 31, 2012 at 4:20 p.m., Resident 3 was observed in bed with GT feeding of [MEDICATION NAME] 1.0 infusing at 60 cubic centimeters per hour (cc/hr). According to the admission information Resident 3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a standardized comprehensive assessment of the resident's problems and conditions) dated April 30, 2012, indicated the resident had clear speech, sometimes understood and sometimes understands, and dependent on staff for all activities of daily living including eating. The physician's orders [REDACTED]. Turn off at 8 a.m., and on at 12 noon. Flush GT with 110 cc of additional water every four hours. There was no indication as to how many calories the resident was to receive. The physician's orders [REDACTED]. The weight record dated May 24, 2012, indicated the resident weighed 94 pounds. His ideal body weight was 95-117 pounds (lbs). The physician's orders [REDACTED]. A review of the records revealed there was no assessment by the registered dietician (RD) upon readmission and the resident had a recent GT feeding placement. Due to the lack of a nutritional assessment, it was unclear whether the tube feeding as ordered by the physician was adequate and was contributing to the weight loss suffered by the resident. During an interview on June 1, 2012, at 11 a.m., the dietary service supervisor (DSS) was asked why the RD had not done an assessment on the resident. The DSS said he gave the RD referral form to the RD on May 29, 2012, with the resident's name on the list. He could not explain what happened and why the RD did not do an assessment on the resident. The resident had been in the facility seven days and had not been assessed by the RD. After the evaluator intervened, the RD came to the facility and did an assessment on the resident on the same date. The Nutritional Assessment form dated June 1, 2012, indicated the RD recommended changing the GT feeding formula from [MEDICATION NAME] 1.0, to Glucerna 1.2 at 65 cc per hour for 20 hours to provide 1300 cc per 1560 calories, 78 grams of protein and 1797 cc of free water. She also recommended increasing the water flushes from 110 cc every four hours (660 cc) to 250 cc every shift (750 cc). The nutritional assessment also indicated the resident had a recent weight change of 22 lbs in six months. According to the facility's policy on Interdepartmental Notification of Diet (undated), nursing services shall notify the physician and RD when a nutritional problem (e.g. weight loss, pressure ulcer, eating problem, etc.) has been identified and shall collaborate with the RD and physician to initiate an appropriate process of clinical review for causes of the nutritional problem. The facility failed to ensure that the nutritional needs of two residents were met resulting in severe weight loss for both residents.