Every finding on record at Glenhaven Healthcare

Based on observation, interview, and record review the facility failed to document accurately in the resident's medical record in accordance with accepted professional standards and practices and facilities policy and procedure for three (3) of three sampled ( Resident 1, 33 and 45) residents by failing to: 1.For Resident 1's medical record did not document Zoloft ( a medication used to treat depression- a feeling of severe sadness and hopelessness) in the CAR consent (Client Authorization Request - a form completed by the licensed staff and the physician before administration of psychotropic medications). The consent form did not indicate the name of the medication the resident or responsible party was informed about the risk and benefits and side effect of medication. 2. For Resident 33, Restorative Nursing Assistant (RNA) 1 failed to accurately document in the weekly assessments on Restorative Nursing Weekly Summary as indicated in the facility's policy and procedure titled Standards for RNA Program. The RNA 1 weekly assessment was performed weekly but the documentation was not completed on 1/2/2026 due to the confusion of dates. 3. For Resident 45, Licensed Vocational Nurse (LVN) 1 documented in the resident's Medical Administration Record (MAR) that metoprolol tartrate was given which was help and not given due to low blood pressure. This deficient practice had the potential to result in the residents or responsible party not being fully informed of the correct treatments being administered, increased miscommunication between the resident/or responsible party and the medical provider. Findings: 1.During a review of Resident 1's admission Record indicated the facility admitted the resident on 9/28/2024, with a diagnosis of pneumonia (infection of the lungs making it difficult to breath) and depressive episodes (mental health condition characterized by persistent feelings of sadness, loss of interest or pleasure, and impaired daily functioning). During a review of Resident 1's Minimum Data Set ( MDS- a comprehensive assessment and screening tool) dated 10/2/2025, indicated Resident 1 had moderate cognition impairment ( may have difficulty with short term memory needing repetition or cues to understand information) and requires maximum assistance by helpers for most activities of daily living ( ADL's) such as personal hygiene. During a review of Resident 1's CAR consent dated 12/8/2025, the CAR did not include the name of the medication that the physician was obtaining a consent for use before administration. During a review of Resident 1's History and Physical (H&P) dated 12/9/2025, indicated Resident 1 does not have the capacity to make own decision. During a review of Resident 1's Order Summary (a physician order) dated 12/8/2025, indicated an informed consent was obtained by Medical Doctor to the resident and or responsible party for the administration of an antidepressant and the IDT (interdisciplinary Team) explained the risks and benefits of an antidepressant During a review of Resident 1's Order Summary dated 12/24/205, indicated an order to administer Zoloft two tablets given by mouth, one time a day. for depression manifested by verbalizing Sadness). During a concurrent interview and record review on 1/7/2026 at 3:27 PM with Registered Nurse (RN 2), Resident 1's informed consent dated 12/08/2025 for antidepressant medication administration was reviewed. RN 2 verified that the CAR consent form did not indicate the name of the antidepressant medication that Resident 1 was receiving. RN 2 further stated that it was important to double check the consent for the name of medication the physician obtained the consent for and check that the name of the medication is listed when completing the consent form to ensure the resident's consent is completed accurately. During a review of the facility's policy and procedures ( P&P) titled Psychoactive Medication Informed Consent dated March , 2024, indicated it is the policy of the facility to ensure that an informed consent is obtained for each resident's psychoactive medication is authorized in writing by a physician for specified time period and when necessary to protect the resident from self – injury or injury to others. The policy indicates the purpose of the policy is to ensure that informed consent has been obtained and verified prior to initiation of psychotropic medication use. 2. During a review of Resident 33's admission Record (AR) the AR indicated Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), aphasia (a disorder that makes it difficult to speak). During a review of the Minimum Data Set (MDS – a resident assessment tool), dated 10/31/2025, indicated Resident 33 had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 33 was dependent on oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene. The MDS also indicated that Resident 33 was dependent on staff for mobility rolling left to right, sitting to lying, lying to sitting on side of the bed, chair bed transfer, and tub/shower transfer. During a review of Resident 33's Order Listing Report dated 12/9/2025, indicated an order for Resident 33 to receive Restorative Nursing Program (RNA) program bilateral locked knee splints, bilateral hand splints, right ankle PRAFO (Pressure Relief Ankle Foot Orthosis) left ankle PRAFO for 5-6 hours every day 5 times a week or as tolerated every day shift. During an interview on 1/8/2026 at 10:01 AM with Restorative Nurse Assistant (RNA 1) stated the RNA 1 weekly assessments are done every Friday, and the last weekly assessment for Resident 33 and was last completed on Friday 12/26/2025. RNA 1 stated the following weekly assessment should have been completed on 1/2/2026 but RNA 1 was a confused with the dates and RNA 1 thought that the following weekly assessment was supposed to be done on 1/9/2026. RNA 1 stated that the count of days for the weekly assessment was wrong and the weekly assessment should have been done on Friday 1/2/2026. During an interview on 1/9/2026 at 1:01 PM with Director of Nurses (DON) stated the weekly assessment documentation due on 1/2/2026 was missed by the RNA's due to a miscount of days. DON stated the potential for this failure is the inability to assess for a possible or actual decline and a possible delay in care. During a review of the facility's policy and procedure titled, Standards for RNA program revised September 2019, it indicated that daily and weekly documentation will be done on the RNA flowsheet the RNA will document the treatment that was provided, the specific distance or repetitions, the use of assistive devices, the endurance and tolerance level, the amount of assistance needed, the reason assistance is needed, the RNA needs to document how the resident is progressing to the goal indicated, and compare with the last week any changes. Also, the RNA needs to document any unusual changes such as swelling, balance or pain. 3. During a review of Resident 45's admission Record, it indicated Resident 45 was admitted on [DATE] with diagnoses that included but not limited to: atherosclerotic heart disease (plaque buildup in the arteries of the heart), paroxysmal atrial fibrillation (a type of irregular heart beat), hypertension (high blood pressure) and cerebral ischemia (loss of blood flow to part of the brain). During a review of Resident 45's Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 2/24/2025, the MDS indicated Resident 45 has severely impaired cognitive skills for daily decision making and required a helper to do all of the effort for oral hygiene, toileting hygiene, shower/bathe, dressing, rolling left and right, sit to lying, chair/bed to chair transfer, and tub/shower transfer. During a review of Resident 45's physician's orders, dated 11/29/2025, the physician order indicated to give metoprolol tartrate (a prescription medication for high blood pressure) twice a day for hypertension and hold if the systolic blood pressure (the top number in blood pressure that indicates the pressure in the arteries when the heart contracts or squeezing blood to the arteries) is less than 110. During a review of Resident 45's Medication Administration Record (MAR), dated 1/7/2026, the MAR indicated on 1/6/2026, Resident 45 was given their evening dose (5pm) of metoprolol tartrate when it should have been held for a blood pressure of 102/66. During an interview on 1/8/2026 at 2:10 pm with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she charted that she administered metoprolol tartrate to Resident 45 in error. LVN 1 explained Resident 45 did not receive metoprolol tartrate that evening because the blood pressure was too low. LVN 1 stated documenting the metoprolol tartrate in error can cause confusion with physicians and staff over the treatment care. During a concurrent interview and record review on 1/8/2026 at 2:45 pm, with the Director of Nursing (DON), the Resident 45's MAR dated 1/7/2026 was reviewed. The DON stated the MAR indicated metoprolol tartrate was given to Resident 45, which was not given because the resident's systolic blood pressure of 102. The DON stated that metoprolol tartrate should not have been documented as given Resident 45. During a concurrent observation and interview on 1/8/2026 at 2:50 pm with the DON at the nurse's station medication cart, Resident 45's metoprolol tartrate was still in the bubble pack (a type of packaging that organizes medications in individual, sealed compartments) for the evening of 1/6/2026. The DON stated that the nurse documented the medication as given in the MAR was an error and an inaccurate documentation can lead to physician or care staff thinking a medical error happened.

Based on observation, interview, and record review, the facility failed provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for four of four sampled Residents ( Resident 2,8,27, and 39) in accordance with the facility's policy and procedure titled Scope of Infection Control Program, by failing to ensure: 1.Resident 2's and 8's humidification bottle (bottled of water that adds moisture to the oxygen flow to reduce dryness and irritation during oxygen therapy) was observed without date, and residents name. 2.Resident 27's nasal cannula (NC-a flexible tube with two prongs that rest in the nostrils to deliver supplemental oxygen) was observed without a label or date the last time it was changed (NC are changed every seven days). 3.Resident 39's NC was observed on the floor. These deficient practices had the potential for these equipment's to harbor pathogens (bacteria and viruses that cause disease) that could result in infections to Resident 2,8,27, and 39. Findings: 1.During a review of Resident 8's admission record indicated Resident 8 was admitted to facility on [DATE], with a diagnosis of sepsis (severe blood infection), diabetes( high blood sugar) and dementia (decline in memory, thinking and behavior). During a review of Resident 8's History and Physical ( H&P) dated [DATE] indicated , Resident 8 was not able to make their own decisions. During a review of Resident 8's Minimum Data Set ( MDS- comprehensive screening tool) dated [DATE], indicated the resident has severely impaired cognition ( very limited short-term and long – term memory) dependent on helper for all tasks of daily living such as eating , toileting, and personal hygiene. During a review of Resident 8's Medication Administration Record (MAR) for month of [DATE], indicated an order to change humidifier every week on Sundays 11-7 pm. During a review of Resident 2's admission record (AR) indicated Resident 2 was admitted to facility on [DATE], with a diagnosis of diabetes ( high blood sugar) , dementia (decline in memory, thinking and behavior) and heart failure( heart can not pump enough blood to meet the body's needs). During a review of Resident 2's History and Physical ( H&P) dated [DATE], indicated Resident does not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ( MDS – Comprehensive screening tool) dated [DATE], indicated the resident has moderately impaired cognition ( needing frequent redirection or reminder with inconsistent short-term memory) dependent on helper for most tasks of daily living ( ADL's) such as toileting hygiene and showers. During a review of Resident 2's Order summary dated [DATE], indicated a order to administer oxygen at 2-5 liters per minute via nasal canula as needed for Shortness of breath or oxygen saturation below 92 %. During a review of Resident 2's Order Summary dated 1224/2025, indicated to change humidifier every week ( Sunday) 11/7 AM. During an observation on [DATE] at 9:41AM in resident 8's room, observed humidification bottle without date, residents name. During an observation on [DATE] at 9:54AM in resident 2's room , observed humidification bottle without date, and residents name. During a concurrent observation and interview with Registered Nurse ( RN1) in shared room of Resident 8 and 2 observations of humidification bottle for both residents were made. RN1 stated the humidification bottles should be dated and labeled with resident's name. Stating if it is not dated it could be old and an infection control issue. Stated if not dated we do not know for sure when to change. During a review of the facility's policy and procedure titled Guidelines for changing of Disposable Respiratory Equipment dated August ,2017, indicated the purpose of policy was to decrease hospital acquired infections. All opened solutions are to be discarded after 24 hours and labeled with the resident's name, room number, and date changed. 2. During review of Resident 27's admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses that included chronic heart failure (the heart has trouble pumping blood through the body), acute respiratory failure (lungs cannot effectively exchange gases, oxygen and carbon dioxide from the blood), and generalized muscle weakness. During a review of Resident 27's Minimum Data Set (MDS – a resident assessment tool), dated [DATE], Resident 27 sometimes able to make self-understood (ability making concrete request) and understands (responds adequately to simple communication). MDS indicated Resident 27 required substantial/maximal assistance (helper does more than half the effort) with eating, and dependent (helper does all the effort) with toileting, bathing, dressing and personal hygiene. During a review of Resident 27's facility document titled Order Summary Report (OSR), dated [DATE], the document indicated Resident 27 was to receive oxygen at 2 to 4 liters per minute (the amount of oxygen, measured in liters, that is delivered each minute) via NC for shortness of breath or oxygen saturation below 92 percent titrate as needed. During a concurrent observation and interview on [DATE] at 9:51 AM with the Director of Nurses (DON) in Resident 27's room, Resident 27 was observed receiving oxygen via NC without a label or date of the last time it was changed. DON stated, Resident 27's NC was not labeled with date the last time it was changed to identify if the NC was new or old and changed weekly as per facility's policy. DON stated, if the NC was old or not changed weekly, it had the potential to harbor virus and/or bacteria that could cause infection and negatively affect Resident 27's quality of life. 3. During review of Resident 39's admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic heart failure, anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), and sleep apnea (condition that occurs when your breathing stops and restarts many times while you sleep). During a review of Resident 39's History and Physical Examination (H&P), dated [DATE], indicated Resident 39 was alert and oriented 1 to 2 (person and place). During a review of Resident 39's Minimum Data Set (MDS – a resident assessment tool), dated [DATE], Resident 39 sometimes able to make self-understood (ability making concrete request) and understands (responds adequately to simple communication). MDS indicated Resident 39 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene and dressing, and dependent (helper does all the effort) with toileting and bathing. During a review of Resident 39's OSR, dated [DATE], indicated to administer oxygen 2 to 4 liters per minute via nasal cannula may titrate every shift for shortness of breath (SOB) or oxygen saturation below 92 percent continuous. During a review of Resident 39's care plan (CP) for risk for ineffective airway clearance related to the diagnosis of sleep apnea, revised [DATE] indicated intervention includes administer oxygen 2 to 4 liters per minute via nasal cannula continuously. During an observation on [DATE] at 9: 15 AM in Resident 39's room at bedside, Resident 39 was in bed with eyes closed, was observed for at least five minutes not receiving her oxygen due to NC was on the floor. During a concurrent interview on [DATE] at 9: 20 AM in Resident 39's room with the Director of Nurses (DON), DON stated, Resident 39's nasal cannula on the floor was an infection control issue, it potentially be contaminated with virus and /or bacteria that could get Resident 39 sick and negatively affect her quality of life. A review of the facility's policy and procedure (P&P) titled, Guidelines for Changing of Disposable Respiratory Equipment's dated 8/2017, indicated a) purpose is to decease hospital acquired infection, b) respiratory equipment's used and the recommendations for routine changes: prefilled oxygen humidifiers - change every 72 hours or when empty, label with residents name, room number and date changed, nasal cannula – change every 7 days or as often as necessary. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, Delivery Device dated 8/2017, indicated, label the delivery device tubing at the point that it attaches to the humidifier of nipple adapter with the date. A review of the facility's policy and procedure (P&P) titled, Scope of Infection Control Program dated 6/2022, indicated the facility infection prevention and control program was to provide safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections.

Based on observation, interviews, and record review the facility failed to implement proper food sanitation and infection control practices as indicated in the facility's policy and procedure titled Hand Hygiene and Personal Hygiene for 3 of 3 sampled residents (Residents 6,10 and 29) and 41 residents served meals from the kitchen by failing to ensure: 1.Certified Nursing Assistant (CNA1) involved in food handling and resident care performed proper hand washing techniques prior to and after dispensing meal trays to the residents (Residents 6,10 and 29). 2. The [NAME] (Cook 1) covered his beard while preparing food in the kitchen food preparation area for 41 residents that were served meals from the kitchen. These deficient practices had the potential for the residents to develop a result in food born illness (an illness when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and result in a widespread infection in the facility. Findings: 1a. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on 9/27/2024, with a diagnosis of diabetes (high blood sugar), heart disease (a group of conditions that affect the heart and blood vessels) and hypertension (high blood pressure). During a review of Resident 6's History and Physical (H&P) dated 12/9/2025, the H&P indicated resident has the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set ( MDS- a resident assessment tool) dated 12/9/2025, the MDS indicated resident is cognitively intact ( meaning oriented and able to recall information , and can follow questions appropriately) but requires maximum assistance with most activities of daily life such as oral hygiene, toileting and showering. 1b. During a review of Resident 10's AR, the AR indicated the facility admitted Resident 10 on 12/11/2025, with a diagnosis of Diabetes (high blood sugar), hypertension (high blood pressure), and schizoaffective disorder (mental illness with symptoms of hallucinations ( sensing things that aren't real) , delusions( believing things that are not true) , and disorganized thinking ( thoughts come out confused ). During a review of resident 10's H&P dated 12/12/2024, the H&P indicated Resident 10 has the capacity to understand and make decisions. During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 has moderate cognitive impairment (some difficulty with memory, recall, or orientation). 1c. During a review of Resident 29's AR, the AR indicated the facility admitted Resident 29 on 07/25/2025 with a diagnosis of diabetes, chronic kidney disease (long term abnormal kidney function), and osteomyelitis (infectious inflammation of the bone marrow). During a review of Resident 29's H&P dated 11/22/2025, the H&P indicated Resident 29 has the capacity to understand and make decisions. During a review of Resident 29's MDS dated [DATE], the MDS indicated resident was cognitively intact (meaning oriented and able to recall information and can follow questions appropriately) completes activities of eating, personal, and oral hygiene by self. 2. During an observation on 1/6/2026 at 11:32 AM in the facility's kitchen, [NAME] 1 was observed with thick mustache that was not covered or a facial covering to over his mustache while preparing resident's food. During another observation on 1/6/2026 at 11:45 AM the cook started to put food on the meal plates for the tray line without facial hair cover for mustache. During an interview on 01/6/2025 at 11:58AM with Dietary Supervisor (DS), the DS stated she was unsure if facial hair, such as [NAME] 1's mustache, required to be covered during meal preparations. The DS stated she would need to check the policy. During a concurrent interview and record review on 1/6/2026 at 12:10 PM with Director of Nursing (DON), the facility's policy and procedure (P&P) titled Personal hygiene, dated April 2017 was reviewed. The DON stated the mustache was a type of body hair that required to be covered during the preparation of food to prevent hair from dropping into food and causing contamination. During an observation on 1/6/2026 at 12:42 PM, certified nurse assistant (CNA 1) was observed bringing Resident 6's meal tray to his bedside table and assisting the resident into a sitting position making physical contact during the assistance. CNA 1 then exited the room without performing hand hygiene. During an observation on 01/06/2026 at 12:43 PM, CNA1 was observed removing Resident 29's meal tray from the meal tray cart and placing the tray onto the resident's bedside table. CNA 1 then touched the resident's blankets and proceeded to set up the Resident 29's meal tray. CNA 1 then exited the resident's room without performing hand hygiene. During an observation on 01/02/2026 at 12:44 PM, CNA 1 was observed collecting Resident 29's meal tray from the resident's bedside table and then left the room without performing hand hygiene. During an interview on 01/06/2026 at 12:45 PM with CNA 1, CNA 1 was too busy and had forgotten to perform hand hygiene. CNA 1 further stated she should have performed hand hygiene after and before providing care to each resident. During an interview on 01/06/2026 at 3:30PM with Director of Nursing (DON), the DON stated the staff should perform hand hygiene before and after providing care to each resident to prevent the spread of infection. During a review of facility's policy and procedures (P&P) titled Hand Hygiene, dated August ,2017, the P&P indicated its purpose was to reduce transmission of pathogenic microorganisms to resident and personnel in the facility by following hand hygiene methods between contact with residents. During a review of facility's policy and procedures (P&P) titled Personal hygiene, dated April 2017, indicated the purpose of P&P was to promote a safe and sanitary department by ensuring beards or any body hair that may be exposed (i.e. arms) must be covered.

Based on observation and interview, the facility failed to promote dignity and respect in accordance with the facility's policy and procedure for 1 out of 8 residents (Resident 2) who was observed wearing a soiled gown. This deficient practice had violated Resident 2's rights and the potential to result in the resident's feeling decreased self - worth, dignity that could lead to psychosocial declined. Findings: During a review of Resident 2's admission record (AR) indicated Resident 2 was admitted to facility on 7/8/2025, with a diagnosis of diabetes ( high blood sugar) , dementia( decline in memory, thinking and behavior) and heart failure( heart cannot pump enough blood to meet the body's needs). During a review of Resident 2's History and Physical ( H&P) dated 8/23/2025, indicated Resident does not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ( MDS - Comprehensive screening tool) dated 10/29/2025, indicated the resident has moderately impaired cognition ( needing frequent redirection or reminder with inconsistent short-term memory) dependent on helper for most tasks of daily living ( ADL's) such as toileting hygiene and showers. During a review of a Care plan, dated 8/1/2025 indicated Resident 2 had alteration in cognition, with dementia, impaired ability to communicate and understand others and unable to make needs known. To ensure the resident's basic needs were met daily, the interventions included to provide the resident with assistance on activities of daily living and anticipating needs and to provide assistance as needed. During an observation on 1/6/2025 at 09:54 AM, in resident 2's room , Resident 2 was observed wearing a soiled gown with oatmeal colored food and liquid present on the chest area. During a concurrent observation and interview on 1/6/2026 at 10:01 AM with Registered Nurse (RN1) in Resident 2' s room, observed resident wearing gown soiled with food and liquid stains. RN1 stated the resident should not have been left in a soiled gown and that the gown should have been changed the resident's gown as soon as possible. RN1further stated that leaving the resident in a soiled gown had the potential to cause the resident to feel embarrassed. During a review of the facility' policy dated April 2018, titled Quality of Life - Dignity indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy's purpose states that all residents shall be treated with dignity and respect at all times which includes assisting in maintaining and enhancing his or herself - esteem and self - worth.

Based on observation, interview and record review, the facility failed to accommodate the resident's need to ensure that the call lights (a device used by residents to signal his or her needs for assistance) was within reach for one of four sampled Resident (Resident 39) who required assistance from staff with activities of daily living and care. This deficient practice had the potential for Resident 39 not able to call when needed assistance with activities of daily living or could not call in an event of an emergency that could lead to a fall and or injury. Findings: During review of Resident 39's admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic heart failure (the heart has trouble pumping blood through the body), anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), osteoarthritis (a joint disease, in which the tissues in the joint break down over time), and bilateral artificial knee joint (artificial knee prosthesis). During a review of Resident 39's History and Physical Examination (H&P), dated 6/16/2025, indicated Resident 39 was alert and oriented to person and place, and had weak extremities (arms, legs, hands, and feet). During a review of a Minimum Data Set (MDS - a resident assessment tool),dated 12/15/2025, indicated Resident 39 sometimes able to make herself understood (ability making concrete request) and understands (responds adequately to simple communication). MDS indicated Resident 39 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene and dressing, and dependent (helper does all the effort) with toileting and bathing. During a review of Resident 39's care plan (CP) for risk for falls with injury related to impaired mobility and needing assistance with activities of daily living, revised 11/17/2024 indicated intervention includes place the call light within reach and prompt response to all request for assistance. During a review of Resident 39's Fall Risk Assessment dated 12/16/2025, indicated Resident 39 cannot walk unassisted, and was a high risk for fall. During a concurrent observation and concurrent interview on 1/8/2026 at 8:12 AM with the Director of Nurses (DON) in Resident 39's room,Resident 39 was observed awake and touched her chest area when asked where was her call light? Resident 39's call light was on the floor, and not within reach of the resident. DON stated, Resident 39 was not able to reach her call light which had the potential for staff not being able to attend to Resident 39's needs especially during emergency. During an interview on 1/8/2026 at 11:48 AM with the 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 39, who was at high risk for fall was not able to use the call light for assistance 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, Fall Prevention Program dated 12/2016,indicated: a) the facility will identify interventions related to residents specific risks and causes to try to prevent the resident from falling, b) all precautions will be implemented to protect the resident according to the fall prevention, and c) place resident care articles within reach. A review of the facility's policy and procedure (P&P) titled, Answering Call Lights dated 8/2017, indicated: a) when call lights are used to respond to needs at the time of use, b) when resident is in bed the call light will be placed within easy reach of the resident, and c) resident call lights will be answer as soon as possible.

Based on interview and record review, the facility failed to inform and obtain an Advanced Directive (a legal document indicating resident preference on end-of-life treatment decisions) or properly fill out an acknowledgement of advanced directive form for two (2) of 13 sampled residents (Resident 9 and 53) in accordance with facility policy titled Advance Directives and regulatory requirements. This deficient practice has the potential for Residents 9 and 53 not to receive care and services according to the residents wishes especially during medical emergencies. Findings: 1.During a review of Resident 9's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] , and was readmitted on [DATE] , with a diagnosis of end stage renal disease( kidneys no longer work well enough to keep the person alive on their own) and dependance for Hemodialysis ( HD- a machine that cleans their blood because their kidneys no longer work). During a review of Resident 9's History and Physical (H&P) dated 12/23/2025, the H&P indicated Resident 9 had the capacity to understand and make decisions. During a review of Resident 9's Minimum Data Set ( MDS- a resident assessment tool) dated 12/23/2025, the MDS indicated the resident was cognitively intact ( the resident is alert and oriented and can understand information , making own decisions and can provide informed consent) but requires maximal assistance with most all activities of daily life ( ADL's) such as showering and dressing. During a record review of Resident 9' s medical chart, Resident 9's Advance Directive Acknowledgment Form was reviewed. The form did not indicate a date or signature by Resident 9 and did not indicate the resident's preferred intensity of care (care a resident wishes to receive or refuse if they become unable to communicate their own decisions) for authorization for treatment. During a concurrent interview and record review on 1/6/2026 at 11:10AM with the Director of Social Services (DSS) , Resident 9' s Advance Directive Acknowledgment was reviewed. DSS confirmed the advance directive acknowledgment form was not dated, signed by the physician and missing the authorization for intensity of care. DSS stated the form should have been completed upon admission. DSS stated when residents are admitted or reemitted the form must be redone and ensure that a date and signature was indicated on the form. The DSS stated the form was important to ensure residents' healthcare wishes and preferred care during medical emergencies were clearly identified, documented, and honored. 2. During a review of Resident 53's admission Record, it indicated Resident 53 was admitted on [DATE] with diagnoses that malignant neoplasm of the bladder (bladder cancer), hypertension (high blood pressure), and anxiety disorder. Resident 53 was in the facility for respite hospice care (short term inpatient service providing relief for primary caregivers of a terminally ill person) for 5 days. During a review of Resident 53's Physician Orders for Life-Sustaining Treatment (POLST), dated 10/23/2025, the POLST indicated Resident 53 has an advanced directive dated 9/29/2018. During a review of Resident 53's medical records, it did not indicate Resident 53 had a copy of the advance directive. During an interview on 1/8/2026 at 2:45 pm with the Director of Nursing (DON), the DON stated the POLST and advanced directive are different legal documents. Social Services should obtain a copy of the residents' advanced directive. During an interview on 1/9/2026 at 9:35 am with the Director of Social Services (DSS), the DSS stated a copy of the advanced directive was not in Resident 53's chart. The facility should have obtained a copy of the advanced directive. The advanced directive is to ensure that the resident's preferences in regards to care are being carried out properly. During a review of the facility's policy and procedure (P&P) titled, Advanced Directives, dated February 2017, the P&P indicated that a copy of the advanced directive must be obtained from the resident or legal representative and placed in the Resident's clinical record. The facility must document in a prominent part of the resident's clinical record whether the resident has issued an advance directive.

Based on observation, interview, and record review, the facility failed to provide necessary assistance with good grooming and personal hygiene during routine nursing care to one (1) of four sampled residents (Resident 27) with unshaved facial hair. This deficient practice had the potential to negatively impact Resident 27's self-image, quality of life, self-esteem (overall sense of personal worth), that can lead to feelings of helplessness and diminished self-worth. Findings: During review of Resident 27's admission Record indicated Resident 27 was admitted to the facility on [DATE] with diagnoses that included chronic heart failure (the heart has trouble pumping blood through the body), acute respiratory failure (lungs cannot effectively exchange gases, oxygen and carbon dioxide from the blood), and generalized muscle weakness. During a review of a Minimum Data Set (MDS - a resident assessment tool), dated 12/22/2025, Resident 27 sometimes able to make self-understood (ability making concrete request) and understands (responds adequately to simple communication). MDS indicated Resident 27 required substantial/maximal assistance (helper does more than half the effort) with eating, and dependent (helper does all the effort) with toileting, bathing, dressing and personal hygiene including shaving. During a review of Resident 27's Care Plan, revised on 1/3/2026 indicated Resident 27 needed assistance with Activities with Daily Living (ADLs) that included personal hygiene. The intervention included the staff will provide assistance with ADLs as needed. During and observation on 1/6/2026 at 9:51 AM in Resident 27's room, Resident 27 was in lying in bed rubbing his thick facial hair. When asked if he wanted to have his facial hair shave, Resident 27 agreed and nodded yes. During a concurrent observation on 1/6/2026 at 3:45 PM with Certified Nurse Assistant (CNA) 3, in Resident 27's room, Resident 27 was observed with thick facial hair remained unshaven. During an interview on 1/6/2026 at 4 PM with Registered Nurse (RN) 1, RN 1 stated, part of the routine morning care was to ensure all resident that needs assistance with ADLs are clean and well-groomed which includes shaving the resident's facial hair. RN 1 stated, not providing assistance with grooming during morning care had the potential to negatively affect Resident 27's self-esteem. A review of the facility's policy and procedure (P&P) titled, Routine Nursing Care dated 2/2017, indicated, Residents to receive the necessary assistance to maintain good grooming and personal hygiene. A review of the facility's policy and procedure (P&P) titled, Standards of Care: Activities of Daily Living dated 2/2017, indicated: a) dependence on others for ADL assistance can lead to feeling of helplessness, isolation, and diminished self-worth, and b) assist the resident to keep clean, neat well-groomed including nail care and shaving.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services for one of one sampled resident (Resident 52) who received the incorrect tube feeding (a liquid form of food when unable to eat or drink by mouth) formula. Resident 52 received Jevity 1.5 calorie (a type of tube feeding/nutritional formula) instead of Jevity 1.2 calorie that was ordered by the physician. This failure had the potential to result in Resident 52 to receive added calories that could lead to unplanned weight gain and/or not achieve the goal to received adequate nutrients to maintain the ideal weight. Findings: During a review of Resident 52's admission Record indicated Resident 52 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), gastrostomy (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of the History and Physical (H&P) Resident 52 had the capacity to understand and make decisions. During an observation on 1/6/2026 at 9:45 am in Resident 52's room, Resident 52 was receiving Jevity 1.5 calorie at 45 milliliters (a unit of measurement) per hour with the GT tubing was dated 1/5/2026. During a concurrent interview and record review of Resident 52's on 1/6/2026 at 4 PM with Licensed Vocational Nurse (LVN) 1, Resident 52's physician's order indicated to start Jevity 1.2 via feeding pump (a machine used to deliver tube feeding formula to the resident to the GT). LVN 1 stated Resident 52 was receiving the wrong tube feeding formula and it can lead weight gain. During an interview on 1/8/2026 at 10:50 AM with the Director of Nursing (DON), the DON stated, providing the incorrect tube feeding formula can lead the resident to nutritional deficiencies or surpluses, slow wound healing, weight gain and electrolyte imbalances (essential minerals in the body are not balanced). During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding Via Pump Administration, dated December 2017, the P&P indicated that all tube feedings should be compared against the physician's order.

Based on observation, interview and record review, the facility failed to provide continuous supplemental oxygen therapy as ordered by the physician for one of two sampled residents (Resident 39) who was ordered to receive oxygen at 2-4 liters per minute (a unit volume flow rate) continuously via nasal cannula (NC-a flexible tube with two prongs that rest in the nostrils to deliver supplemental oxygen). Resident 39's NC was on the floor and not connected to the resident. This deficient practice had the potential to result in Resident 39's lack of oxygenation and lead to respiratory decompensation (when respiratory system fails to meet the body's oxygen needs, requiring immediate intervention like oxygen) shortness of breath (SOB) and respiratory distress, that could negatively affect the resident. Findings: During review of Resident 39's admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic heart failure (the heart has trouble pumping blood through the body), anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues), and sleep apnea (condition that occurs when your breathing stops and restarts many times while you sleep). During a review of Resident 39's History and Physical Examination (H&P), dated 6/16/2025, indicated Resident 39 was alert and oriented to person and place. During a review of Resident 39's Minimum Data Set (MDS - a resident assessment tool), dated 12/15/2025, Resident 39 sometimes able to make self-understood (ability making concrete request) and understands (responds adequately to simple communication). MDS indicated Resident 39 required substantial/maximal assistance (helper does more than half the effort) with personal hygiene and dressing, and dependent (helper does all the effort) with toileting and bathing. During a review of Resident 39's facility document titled Order Summary Report (OSR), dated 12/4/2025, indicated to administer oxygen 2 to 4 liters per minute via nasal cannula may titrate (adjust) every shift for shortness of breath (SOB) or oxygen saturation below 92 percent (normal range 90-100%) continuously. During a review of Resident 39's care plan (CP) for risk for ineffective airway clearance related to the diagnosis of sleep apnea, revised 12/16/2025 indicated intervention includes administer oxygen 2 to 4 liters per minute via nasal cannula continuously. During an observation on 1/7/2026 at 9: 15 AM in Resident 39's room at bedside, Resident 39 was in bed with eyes closed, was observed for at least five minutes not receiving her oxygen due to NC was on the floor. During a concurrent observation and interview on 1/7/2026 at 9: 20 AM in Resident 39's room with the Director of Nurses (DON), Resident 39's oxygen NC was on the floor. DON stated, Resident 39 needed continuous oxygen due to her sleep apnea and she does not know why the NC was on was on the floor. DON explained if Resident 39 did not receive oxygen for five minutes she had the potential to experience respiratory distress. During an interview on 1/7/2026 at 1:40 PM with the DON, DON stated, it is the facility's policy to provide oxygen support to maintain adequate oxygenation to the facility's respiratory compromised residents. DON stated Resident 39's respiratory status was compromised and should have been receiving oxygen supplement as ordered. DON stated, since Resident 39 was not receiving oxygen for five minutes the resident had the potential to result in lack of oxygenation that could lead to respiratory decompensation, that may lead to SOB and respiratory distress, that could negatively affect Resident 39's quality of life. A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, Delivery Device dated 8/2017, indicated: a) facility to provide oxygen support when indicated via appropriate delivery device to achieve or maintain adequate oxygenation to the respiratory compromised resident, b) to maintain tissue oxygenation in the chronically - hypoxic resident. and c) check the oxygen setup regularly to prepare proper functioning.

Based on observation, interview, and record review, the facility failed to ensure resident's bedrooms measured at least 80 square feet (sq. ft., a unit of measurement) per resident in the room with multiple residents in the bedrooms for 12 of 16 rooms. Resident Rooms 2, 3, 4, 7, 8, 9, 10, 11, 12, 14, and 15 measured less than 80 sq. ft per resident. This deficient practice had the potential to have insufficient space for staffs and residents that can impact the ability to provide safe nursing care and privacy to the residents. Findings: During a review of the facility ' s Client Accommodation Analysis (CAA, a form used to identify the room sizes and number of beds in a room) form, dated 1/6/2026, the CAA form indicated 12 resident bedrooms did not measure 80 sq. ft per resident as listed below: room [ROOM NUMBER] - 155.6 sq ft with two (2) beds and two (2) occupied beds room [ROOM NUMBER] - 292 sq ft with four (4) beds and four (4) occupied beds room [ROOM NUMBER] - 155.6 sq ft with two (2) beds and two (2) occupied beds room [ROOM NUMBER] - 292 sq ft with four (4) beds and four (4) occupied beds room [ROOM NUMBER] - 286.5 sq ft with four (4) beds and four (4) occupied beds room [ROOM NUMBER] - 292 sq ft with four (4) beds and four (4) occupied beds room [ROOM NUMBER] - 289.5.sq ft with four (4) beds and four (4) occupied beds room [ROOM NUMBER] - 292. 4 sq ft with four (4) beds and four (4) occupied beds room [ROOM NUMBER] - 286.5 sq ft with four (4) beds and four (4) occupied beds room [ROOM NUMBER] - 286.1 sq ft with four (4) beds and four (4) occupied beds room [ROOM NUMBER] - 291.9 sq ft with four (4) beds and four (4) occupied beds During a concurrent observation and interview on 1/8/2026 at 8:30 AM with Resident 40, in Resident 40' s room (room [ROOM NUMBER]), Resident 40 in her wheelchair, able to propel self in her room. Resident 40 stated, she had no issues with the room, she was able to move around, and nurses can care for her without any concern. During an Interview on 1/8/2026 at 8:40 AM with Resident 16, in Resident 16's room (room [ROOM NUMBER]), Resident 16 stated, she did not have any concern about her room size, the nurses are able to care for just fine. During an Interview on 1/8/2026 at 8:45 AM with Resident 10, in Resident 10's room (room [ROOM NUMBER]), Resident 10 stated, he is fine with his room size. During an Interview on 1/8/2026 at 9:30 AM with Certified Nurse Assistant (CNA) 2, CNA 2 stated, she was able to do her work , and she had enough space to care residents in the above-mentioned room, even with wheelchairs. During an Interview on 1/8/2026 at 9:40 AM with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, she had no concerns with above-mentioned room size, she was able to do her residents care and treatments as needed. During a concurrent observation and interview on 1/8/2026 at 9:57 AM with the Maintenance Supervisor (MS), MS measured sampled rooms [ROOM NUMBER]. MS stated, room [ROOM NUMBER] was 155 sq. ft for two beds, room [ROOM NUMBER] was 292 sq. ft for four beds, and room [ROOM NUMBER] was 292 sq. ft for four beds. MS stated, he did not hear any concern about the room size with residents. During the re-certification survey between 1/6/2026 until 1/9/2026, the above listed rooms had sufficient space for the residents ' freedom of movement. Each resident in the rooms listed above had Individual bedside tables and over the bed tables. The rooms 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 present any adverse effect on the residents' personal space, nursing care, and comfort. During a review of the facility's Room Waiver Request, dated 1/6/2026, the request indicated the Administrator (ADM), and the Director of Nursing (DON) will screen admissions, and complete room rounds to ensure only the allowed capacity of residents were allowed in the rooms listed above. The Room Waiver Request Indicated, the MS and the ADM Inspected the rooms listed above to ensure that required medical equipment such as wheelchairs, guest chairs, and the Hoyer lift (a mechanical device used to lift and/or transfer a person) did not impact the delivery of care in the residents residing in the listed rooms.

Based on interview and record review, the facility failed to prevent and immediately report and/or no later than two hours the alleged allegation of abuse (an action that intetionally cause harm to another person) that involves verbal and physical abuse altercation of two of two sampled residents (Resident 2 and Resident 3) on 6/5/2025 before 10 AM when Resident 2 kicked Resident 3 ' s wheelchair and both residents had a verbal altercation. Resident 2 with history of abusive behavior hit License Vocational Nurse (LVN) 1 on the cheek on 6/2/2025 around 9 PM (prior medication pass) and was not supervised and monitored for his abusive behavior to prevent recurrent abuse as indicated in the facility's policy and procedure. This deficient practice resulted in Resident 2 hitting Resident 1 on the cheek while in the activity room on 6/5/2025 around 2:30 PM (four and a half hours after the first alleged abuse incident) during an altercation. Findings: A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included depressive episodes (persistent feeling of sadness and loss of interest), dementia (a decline in mental ability, severe enough to interfere with daily life), mood disturbance (a mental health condition that primarily affects your emotional state), and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 1 ' s History and Physical Examination (HPE), dated 2/15/2025, indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment screening tool), dated 5/21/2025, indicated the Resident 1 ' s cognitively status (ability to think, remember, and reason) moderately impaired. The MDS indicated Resident 1 was independent (resident completes the activity by themselves with no assistance with helper) with eating, toileting, dressing, personal hygeine, and required Setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with bathing. A review of Resident 2 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations (sensory experiences that appear real but are not, meaning someone might see, hear, feel, smell, or taste something that isn't actually there) and delusions (a false belief or judgment about external reality) and mood disorder symptoms, such as depression, mania), bipolar disorder (a mental health condition that causes extreme mood swings), and anxiety disorder. A review of Resident 2 ' s HPE, dated 3/6/2025, indicated Resident 2 does not have the capacity to understand and make decisions. A review of Resident 2 ' s MDS, dated [DATE], indicated the Resident 2 ' s cognitively status was moderately impaired. The MDS indicated Resident 2 required Setup and clean-up assistance with eating, personal hygeine, bathing, dressing and required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with toileting. A review of Resident 3 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, psychotic disturbance (a condition where a person experiences a significant loss of contact with reality), and anxiety. A review of Resident 3 ' s HPE, dated 1/23/2025, indicated Resident 3 was cooperative, appropriate affect, and normal judgment. A review of Resident 3 ' s MDS, dated [DATE], indicated the Resident 3 ' s cognitively status was moderately impaired. The MDS indicated Resident 3 required supervision or touching assistance with eating, personal hygeine, required partial/moderate assistance (helper does less than half the effort) with toileting and dressing, and substantial/maximal assistance (helper does more than half the effort) with bathing. A review of an SBAR (Situation, Background, Assessment, and Recommendation, a communication framework used to structure conversations, especially in healthcare, to ensure clear and concise information exchange, particularly in urgent situations) Communication Form and progress note dated 6/2/2025 timed at 9:25 PM, indicated Resident 2 punched LVN 1 on her right jaw in Resident 2 ' s room prior to medication administration. A review of SBAR Communication Form and progress note dated 6/5/2025 timed at 10AM, indicated Resident 2 had a physical and verbal aggressiveness towards a Resident (Resident 3) and was noted to have kicked Resident 3 ' s (while in his wheelchair) wheelchair in the hallway. A review of Resident 2 ' s facility document titled, SBAR Communication Form and progress note dated 6/5/2025 timed at 2:50 PM, indicated while playing BINGO in the activity room Resident 2 punched the other Resident (Resident 1) on the right side of the face. A review of Resident 2 ' s care plan (CP) for diagnosis of schizophrenia manifested by outburst of anger, revised on 6/5/2025, indicated Resident 2 had episode physical aggression towards staff on 6/2/2025, kicking wheelchair of another resident on 6/5/2025, and hitting another resident unprovoked on 6/5/2025. The CP did not have any intervention how resiudent will be supervised and monitored for aggressive behavior. During an interview on 6/16/2025 at 9:45 AM with Activity Staff (AS) (Witness of Resident-to-Resident abuse between Resident 1and Resident 2). AS stated, on 6/5/2025 in the afternoon, while in the activity room during a game of BINGO, Resident 1 was reaching for Resident 2 ' s chips (small disc use as currency), Resident 2 then hit Resident 1 on the chin. During an interview on 6/16/2025 at 9:50 AM with Activity Director (AD), AD stated the altercation between Resident 1 and Resident 2 happened on 6/5/2025 around 2 PM. AD stated, AS reported to her that Resident 2 hit Resident 1 on the chin during a BINGO game, and she reported it immediately to the DON (Director of Nurses). AD stated, Resident 2 was not on 1 to 1 monitoring ( one staff monitoring one resident) or on frequent monitoring prior to the incident. During an interview on 6/16/2025 at 10:00 AM with the DON, DON stated the incident between Resident 1 and Resident 2 happened on 6/5/2025 around 2 PM, both residents were separated, and Resident 2 was transferred to General Acute Care Hospital (GACH) 1 for evaluation. DON stated, Resident 2 was not placed on frequent monitoring, or 1 to 1 sitter prior to the abuse incident with Resident 1. During an interview on 6/16/2025 at 10:50 AM with the LVN 1 (LVN whom Resident 2 hit on the chin on 6/2/2025), LVN 1 stated, the incident happened on 6/2/2025 around 9 PM. LVN 1 stated, Resident 2 approached her for his medication while she was passing medications for another resident, she then told Resident 2 she could go to his room to give his medication. LVN 1 stated, when she went to Resident 2's room and about to turn on the overhead light to give him his medication, Resident 2 turned around and punched her on her right jaw. During a concurrent interview and record review on 6/16/2025 at 10:55 AM with the DON, facility document titled SBAR Communication Form and progress note (PN), dated 6/5/2025 timed at 10:00 AM was reviewed. The document indicated, Resident 2 was noted to have kicked a Residents wheelchair in the hallway. DON stated, the incident happened on 6/5/2025 before 10:00 AM, Resident 2 kicked Resident 3 ' s wheelchair and had a verbal altercation as they passed by each other in the hallway. During an interview on 6/16/2025 at 11 AM with the Director of Rehab (DOR), and MDS Nurse (MDSN) (Witnesses of alleged physical and verbal altercation between Resident 2 and Resident 3 on 6/5/2025 before 10 AM). DOR stated, the incident happened on 6/5/2025 before 10 AM. DOR stated, she was taking Resident 2 to the rehab room, Resident 2 was ahead of her in the hallway, when she turned around because MDSN called her, she heard a loud sound and observed Resident 2 and Resident 3 was having a loud verbal altercation. DOR stated, Resident 2 told her he kicked Resident 3 ' s wheelchair. MDSN stated, he with DOR intervened to prevent further altercation. DOR and MDSN both stated, they both reported the incident to the DON and ADM right away. DOR and MDSN both stated, the policy for alleged abuse was no report the incident immediately within 2 hours to the Ombudsman, Police, and California Department of Public Health (CDPH), MDSN stated, they should have followed up with the DON and the ADM, if it was reported to the proper agencies because they mandated reporter. During an interview on 6/16/2025 at 11:23 AM with LVN 2, LVN 2 stated she was the primary nurse for Resident 2 on 6/5/2025. LVN 2 stated, she learned about the incident between Resident 2 and Resident 3 ' s physical and verbal altercation from the DON, DOR and MDSN in the morning. LVN 2 stated, she was not aware that the incident was not reported timely within 2 hours to the proper agencies. LVN 2 stated, incident of alleged abuse allegation needs to be reported immediately to have an intervention and to prevent reoccurrence of aggression, its policy. During an interview on 6/16/2025 at 12:10 PM with the DON, DON stated, the physical and verbal altercation between Resident 2 and Resident 3 that happened on 6/5/2025 before 10 AM was reported to him. DON stated, there was no physical injury, that ' s why he did not report the incident to the appropriate agencies. DON stated, looking back he should have reported the incident to the proper agencies within two hours, to protect other residents and staff in the facility by more frequent monitoring of Resident 2 ' s behavior. DON stated, not reporting the physical and verbal altercation between Resident 2 and Resident 3 timely within 2 hours had the potential for reoccurrence of Resident 2 abusive behavior that could affect other residents ' and staff safety and potentially could have prevented the resident-to-resident abuse between Resident 2 and Resident 1. A review of the facility ' s policy and procedure (P&P) titled, Abuse and Neglect Prohibition Policy, dated 06/2022, the P&P indicated: a)the facillity policy prohibit abuse, mistreatment through; prevention of occurrence, identification of possible incidents or allegations, reporting of incidents and protection of residents, b) the facility staff are doing that is within their control to prevent occurrence of abuse and mistreatment, and c) under reporting of incidents; upon receiving information concerning a report of suspected or alleged abuse and mistreatment the administrator or designee will report all alleged violations -immediately but no later than 2 hours if alleged violation involves abuse.

Based on observation, interview, and record review, the facility failed to ensure bedside curtains for one (1) of two sampled residents (Resident 2) was fully closed, when Resident 2 tested positive for influenza (a severe lung infection) and required to be on droplet precaution (a set of infection control measures used to prevent the spread of respiratory infections from a patient to others) in accordance to public health guidelines on influenza outbreak taking place in the facility. This deficient practice had the potential to result in wide spread influenza infectiion spreading to other residents and staffs in the facility. Findings: During an observation on 1/28/25 at 2:15pm in Room A, the curtain for Resident 2 was partially open, two other beds were occupied with other residents, a certified Nurse Assistant (CNA 3) was observed wearing simple face mask in the room. During a review of Resident 2's Admission Record, Resident 2 was admitted on [DATE] with medical diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and Chronic Kidney Disease (CKD-moderate to severe loss of kidney function). During a review of Resident 2's Minimum Data Sheet (MDS- a Federal mandated resident assessment tool) dated 10/24/24, indicated that Resident 2 was cognitively intact (able to think, learn, and remember clearly). During a review of Resident 2's Nursing Progress note dated 1/28/25 at 8:15 am, indicated that Resident 2's tested positive for Influenza, physician was notified, and Tamiflu (prescription medicine used to treat the flu) 30mg BID (twice daily) for five (5) days was prescribed. During a concurrent observation and interview on 1/28/25 at 2:15pm with CNA 3 at room [ROOM NUMBER], CNA 3 stated she ' s aware that Resident 2 has Influenza, CNA 3 stated bedside curtain got stuck sometimes and released easily sometimes, she did not notice how long since the curtain for Resident 2 got stuck, CNA 3 verified curtain was not fully closed today. During a concurrent interview and record review on 1/28/25 at 2:40pm with Infection Preventionist (IP), document titled General Control Recommendations for outbreak emailed by Public Health Nurse, IP stated the recommendation indicated that Place ill residents in a private room. If a private room is not available, place ill residents with one room. If symptomatic residents are cohorted, maintain a spatial separation of at least 6 feet between residents and a curtain between resident beds. IP stated per guidelines the curtain for Resident 2 should have been always closed for droplet precaution. During an interview on 1/28/25 at 3:20 pm with Director of Nursing (DON) stated no single room available for Resident 2 at this time, there ' s droplet precaution and PPE supplies for the room but curtain should have been fully closed for resident that has tested influenza positive. Staffs and the other residents in the same room would be at higher risk for getting flu if the curtain can't be fully closed.

Based on observation, interview, and record review, the facility failed to provide the necessary care and interventions to prevent pressure injury (PI-damage to an area of the skin caused by constant pressure on the area for a long time) for one (1) of three (3) sampled residents (Resident 1) by failing to turn, reposition and to off-offload (release pressure) from an area of the body every two hours while in bed, keep clean and dry after a bowel movement or wetness from urine due to incontinence (unwanted passage of urine or stool that you can ' t control). These deficient practices resulted in: 1. Resident 1 developed a facility-acquired Stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) PI on sacrococcyx (tailbone) area on 10/15/24, and proceeded to Stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible) with drainage on 10/22/24. 2. A sacrococcyx PI reopened on 12/18/24 after MASD (Moisture Associated Skin Damage) developed on 12/8/24, and on 12/26/24 Sacrococcyx PI proceeded to Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included Parkinson ' s Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), spondylosis (degeneration of the bones and disks), dementia (a progressive state of decline in mental abilities). During a review of Resident 1 ' s Minimum Data Sheet (MDS- a Federal mandated resident assessment tool) dated 9/19/24, indicated Resident 1 ' s was assessed to be dependent and required helper does all of the effort in Activities of Daily Living (ADL- activities such as bathing, dressing and toileting a person performs daily) which included bed mobility, roll to left and right, transfer, dressing, and personal hygiene. toilet hygiene with two or more helper to perform activity. During a record review and concurrent interview with the Treatment Nurse (TN) on 1/29/25 at 10:15 am of Resident 1 ' s clinical record indicated the following: - Resident 1 ' s Braden Score Assessment (a tool to evaluate a patient's risk for developing pressure injuries) dated 9/19/24, indicated Resident 1 was at high risk for developing PI due to skin often moist, very limited mobility, makes occasional slight changes in body or extremity position and requires moderate to maximum assistance in moving. - Resident 1 ' s admission skin assessment dated [DATE] indicated Resident 1 was admitted with the following skin breakdown: Left heel with suspected Deep Tissue Injury (DTI -a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) measured 0.5 (centimeter) cm Left buttock Pressure injury measured 4 cm x 4 cm Right buttock pressure injury measured 5 cm x 5 cm -Resident 1 ' s care plan initiated on 9/28/24 indicated Resident 1 had a left heel pressure injury and potential for pressure ulcer development related to fragile skin, immobility, disease process; dementia, diabetes mellitus (condition of having high blood sugar). The interventions included offloading and repositioning the resident every 2 hours. - Resident 1 ' s Licensed Nurses Notes, dated 10/1/24, indicated resident was seen by the wound consultant (medical professional specialized in wound care) and ordered to discontinue current treatments to the left buttock pressure injury, due to site resolved and to continue current treatment to right buttock and left heel DTI by offloading and repositioning the resident. - The SBAR (Situation, Background, Assessment, and Recommendation- a structured method of communication that helps teams share information about a patient's condition) dated 10/15/2024 timed at 10 am, indicated during the wound consultant, Resident 1 was noted with new sacrococcyx pressure injury Stage 2 measuring 3.5 cm x1.0 cm x 0.1 cm, and with upper mid back Stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) measuring 2.0 cm x 2.0 cm x 0.1cm, with new treatment to continue to offload and reposition the resident and provide a Low Air Loss mattress (LAL-an air mattress with tiny holes designed to let out air very slowly to keep the skin dry and redistribute pressure). - Resident 1 ' s Weekly Skin assessment dated [DATE] indicated the wound consultant documented Resident 1 had Stage 3 PI on sacrococcyx area, measuring 4.0 cm x 2.0 cm x 0.2 cm, with serosanguinous drainage (fluid from a wound that appears thin, slightly yellow with a light pink tinge moderate amount) 20% slough(dead tissue that is usually yellow, tan, gray, or green in color, usually moist and stringy in texture, that may be found in wounds), 70% granulation (red, bumpy tissue in the wound bed) 10% epiletheal (superficial pink/ white tissue that migrates across the wound from the wound margin). - Licensed Nurses Notes, dated 10/23/24, indicated Resident 1 was seen and examined by wound consultant, change treatment order to left heel and sacrococcyx pressure injury and to continue off load and reposition. - Resident 1 ' s care plan, dated 10/30/24 indicated the resident was at risks for clinical/exacerbation (worsened) of skin condition due to non-compliance, non-adherence, or refusal of turning, repositioning. The interventions included to provide Low air loss mattress for skin management, respect resident ' s wishes, turn and reposition as needed, provide education regarding benefits of compliance and risks associated with non-compliance. -Resident 1 ' s care plan, dated 11/13/24 and resolved on 12/9/24 indicated potential/actual impairment to skin integrity. The intervention included to provide treatment wash with soap and water pat dry, apply barrier cream for skin maintenance every on maintenance after pressure injury resolved on 12/9/24. -- Resident 1 ' s Licensed Nurses Notes on 12/17/24 at 3 pm, indicated the resident was seen and examined by wound consultant and ordered to continue treatment to the left heel and continue to offload and reposition. Resident 1 ' s SBAR dated 12/18/24 indicated Resident 1 was observed a MASD was identified on sacrococcyx area, there was no documentation describing the color, drainage and extent of the skin area with breakdown related to MASD. - Resident 1 ' s Weekly Skin assessment dated [DATE], indicated a sacrococcyx PI was identified, measuring 4.0 cm x 3.0 cm x 0 cm, with scant (small amount) serous drainage. - Licensed Nurses Notes, dated 12/18/24 timed at 1pm, indicated Resident 1 ' s sacrococcyx MASD was reclassified to Stage 2 pressure ulcer, and the intervention included to change brief as needed, keep clean and dry. Continue turning and repositioning and the LAL mattress keep in place. Resident 1 ' s care plan, dated 12/18/24 indicated the resident had a potential/actual impairment to skin integrity of the sacrococcyx MASD. The interventions included provide treatment as ordered by the physician, wash with soap and water pat dry, apply barrier cream every shift for 21 days and provide LAL mattress. - Licensed Nurses Notes on 12/22/2024 timed at 12:23 pm indicated Resident 1 refused all medications and Resident 1 ' s sacrococcyx pressure injury Stage 2, was reclassified to unstageable pressure injury (pressure injury with wound bed covered by a thick layer of dead tissue [eschar] and slough [yellow, gray, or green debris]) due to 100% slough. - Licensed Nurses Notes on 12/26/24 at 11:36 pm, indicated Resident 1 was seen by the wound consultant and ordered to administer antibiotic (medication used to treat infection) therapy prophylaxis (preventive care) for the sacrococcyx PI after, debridement (removal of dead tissue of the wound). The wound consultant reclassified sacrococcyx wound from unstageable PI to Stage 4 PI measuring 9.1cm x 6,5 cm x 2.5 cm with moderate exudate, new treatment ordered. The note indicated Resident 1 was at risk for delayed wound healing and deterioration secondary to incontinent of bowel and bladder, old age, skin thin and fragile, needs extensive assist in bed mobility and transfer. - Licensed Nurses Notes, dated 1/17/25, indicated Resident 1 was transferred to the General Acute Care Hospital on 1/17/25 due to tachycardia (abnormally fast heart rate), diaphoresis (excessive sweating due to an underlying health condition). During an interview on 1/29/25 at 10:15 am, TN stated Resident 1 was high risk for skin integrity impairment, and the care plan included providing Low Air Loss Mattress, frequent incontinent brief change, and monitor any change in skin condition. TN stated she relied on staffs reporting to her. TN stated she did not follow up with staffs or keep track on a daily basis if Resident 1 was kept clean and dry or repositioned every 2 hours. During an interview with Director of Staff Development (DSD) on 1/29/25 at 11:55 am, DSD stated he aware that Resident 1 developed PI at the facility. DSD stated he was responsible for training and supervising CNAs. DSD stated he has no daily logs about supervising staffs, no rounding logs or in-service provided to the CNA ' s specifically after Resident 1 developed PI in the facility. During an interview with Director of Nursing (DON) on 1/29/25 at 2:40 pm, DON stated a system of tracking to ensure residents were repositioned around the clock and incontinence management should had been established for Resident 1 to receive quality of care and prevention of facility acquired PI. DON also stated, Resident 1 with the PI reopened on 12/18 was not evaluated by wound consultant until 12/26/24 (8 days after the PI reopened) due to last wound consultant routine visit to the facility was scheduled on 12/17/24. The DON stated there was no documented evidence the wound consultant was notified that the wound reopened on 12/18/2025. During a record revies and interview with treatment nurse (TN) on 1/29/25 at 11:35 am, TN stated Resident 1 was incontinent for bowel and bladder, and was bedfast, TN stated nursing care intervention for incontinence was to provide frequent gentle cleansing and frequent diaper change, and staffs to report to TN for any skin condition change. TN stated the # sign indicating number of changes on bowel and bladder on CNA Flowsheet was to be documented per every eight-hour shift. TN stated she relies on CNAs to inform her about resident ' s skin issues, overseeing but not tracking resident ' s skin moisture or diaper change. During an interview with Director of Staff Development (DSD) 1/29/25 at 12 pm, DSD stated he didn ' t keep a log of surveillance on daily rounding to ensure the CNA repositioned, offloaded and changed Resident 1 ' s incontinent brief timely. During an interview with Director of Nursing (DON) on 1/29/25 at 1:50 pm, the DON stated Resident 1 was incontinent for bowel and bladder and the care plan for incontinence was to provide frequent incontinent brief change. DON stated he was not sure if CNA provided frequent incontinence care and incontinent brief change. During a review of the facility ' s Policy and procedure, title Skin Breakdown, Prevention and Management dated 12/2017, indicated the following: -When a resident is identified to have a pressure ulcer, the licensed nurse will contact the attending independent licensed practitioner. -When a resident is identified to have a pressure ulcer, the licensed nurse will contact the attending independent licensed practitioner. The licensed nurse will notify the independent licensed practitioner for any sites or area that requires any form of treatment. -The Staff Developer will conduct and provide educational training upon hire and yearly thereafter and/or as needed to the staff. Risk reduction strategies included: Skin Inspections: All residents should be inspected at least daily. This can be done with dressing, toileting, bathing, peri-care, etc. Pay particular attention to bony prominences. Minimize exposure to low humidity. Moisture dry skin. Ensure weekly skin checks are completed. Turning and Repositioning: Keep bony prominences from direct contact using systematic turning and repositioning, and positioning devices such as pillows or foam wedges. Avoid positioning directly on the trochanter. Determine tissue tolerance. Manage Incontinence: Initiate incontinent care every two hours, incontinent barriers, briefs, absorbent under pads (made with materials that absorb moisture& present a quick drying surface to the skin). Avoid hot water and use a mild cleansing agent that minimizes irritation and dryness. Written plan of care: Each resident ' s care plan should be unique, including specific turning and repositioning plans. Identify and address each factor noted in the risk assessment. Staff Education: Target prevention at all levels of health care, from providers to residents and families. Identify the role each plays in pressure ulcer prevention. Implement a comprehensive pressure ulcer prevention program.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse (food waste, scraps) properly by not covering one of one metal dumpsters (large trash container designed to be emptied into a truck) due to overflowing trash bags filled with garbage, and leaving additional trash bags, boxes, and an old mattress on the ground by the garbage area. This deficient practice had a potential to attract birds, flies, insects, pest, rodents, and possibly spread infection to residents and staffs in the facility. Findings: During a concurrent observation and interview on 11/18/2024 at 10:55 AM with the Maintenance Supervisor (MS) in the facility's garbage area, one metal dumpster was observed with the lid open due to overflowing trash bags filled with garbage, and additional trash bags, boxes, and an old mattress on the ground by the garbage area next to the bin. The MS stated, the housekeeping supervisor was responsible of making sure the trash bin was empty, and the garbage area was clean. The MS stated, we were also responsible in making sure this area was clean, because these could lead to infestation of rodents, insects, and other pest that can negatively affect everyone in the facility. During an interview on 11/18/2024 at 10:58 AM with Dietary Service Supervisor (DSS), the DSS stated, the kitchen uses the same trash bin as the rest of the facility, it should be kept clean to prevent infestation of pest and rodents that could possibly get in the facility premises and negatively affect the health of the residents and staff. During an interview on 11/18/2024 at 11:00 AM with the Administrator (ADM), the ADM stated, the housekeeper was responsible to making sure the garbage area was clean, and she was not aware of the overflowing trash bin, with surrounding garbage and boxes. The ADM stated, she will address the trash in the garbage area immediately because it was a potential for pest and other insects ' infestation and can affect the residents and staff ' s health. During an interview on 11/18/2024 at 1:06 PM with the housekeeping supervisor (HS), the HS stated, she was responsible in making sure the garbage area was clean. The HS stated, she will request for an additional pickup date, and in-service all the staff to notify her and the administrator to request for a pickup when the trash bin is half full. The HS stated it was an infection control issue that could affect the health of everyone in the facility. During an interview on 11/19/2024 at 8:10 AM with the Director of Nursing (DON), the DON stated, it was not good to have an overflowing trash bin and garbage on the ground because it could attract pest, insects, and rodents, that could get inside the facility and cause infection to residents and staff. During a review of the facility ' s policies and procedures (P&P) titled Dispose of Garbage and Refuse, dated 8/2017, indicated: a)all garbage and refuse will be collected and disposed of in a safe and efficient manner, b)ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris.

Based on observation, interview, and record review, the facility failed to implement the facility 's policy and procedure on infection control to prevent the spread of infection for 3 of 6 sampled residents (Resident 101, Resident 5, and Resident 39) by failing ensure Certified Nurse Assistant (CNA) 6 practice proper hand hygiene and wear gloves or gowns in Resident 5's contact precaution (a set of measures to prevent the spread of infectious agents through direct or indirect contact with individuals or an environment) room. These deficient practices had the potential to result in the spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm). Findings: During a review of Resident 5's Admission Record, the facility admitted Resident 5 on 3/5/2021 and readmitted her on 10/4/2024 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing), muscle weakness, and metabolic encephalopathy (a chemical imbalance in the blood that affects the brain). During a review of Resident 5's Minimal Data Set (MDS, a resident assessment tool), dated 8/6/2024, the MDS indicated Resident 5's cognition (a person ' s mental process of thinking, learning, remembering, and using judgement) was moderately impaired and required maximal assistance (helper does more than half of the effort) or dependent (the helper does all of the effort) for activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) such as toileting hygiene, personal hygiene, dressing, and transferring from lying to sitting or from the bed to the chair. During a review of Resident 5's History and Physical (H&P, a comprehensive physician's note regarding the assessment of a resident ' s health status), dated 10/4/2024, the H&P indicated Resident 5 does not have the capacity to understand and make decisions. During a review of Resident 5's care plan, revised on 11/14/2024, the care plan indicated Resident 5 required contact precaution related to multi-drug-resistant organism (MDRO, a microorganism that was resistant to one or more classes of antibiotic or antifungal medications) infection. The care plan ' s interventions included providing education to Resident 5 that the providers and staff must follow contact precautions that included washing hands before and after entering and leaving the room, wearing gloves and gown during care activities. During a review of Resident 42's Admission Record, the facility admitted Resident 42 on 1/31/2024 and readmitted him on 10/14/2024 with diagnoses that included metabolic encephalopathy and an artificial opening of the urinary tract. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42 ' s cognition was moderately impaired. During a review of Resident 42's Order Summary Report, order start date on 10/25/2024, the report indicated Resident 42 had enhanced barrier precautions where the providers and staff must clean their hands, including before entering and when leaving the room. During an observation on 11/18/2024 at 11:03AM in front of Resident 5's room, there was a contact precaution sign posted by the doorway. During an observation on 11/18/2024 at 12:54PM in Resident 5's room, CNA 6 was inside Resident 5's room setting up her food tray and water cups without wearing a gown or gloves. CNA 6 was observed walking out of Resident 5's room without using alcohol-based hand rub or washing hands with soap and water and entered Resident 42 ' s room without using alcohol-based hand rub or washing her hands. During an interview on 11/18/2024 at 1:03 PM with CNA 6, CNA 6 stated, she walked into Resident ' s 5 room to deliver her lunch tray. CNA 6 stated, she did not recall seeing the contact precaution sign outside the door. CNA 6 stated, she did not use alcohol-based hand rub or was her hands with soap and water, and she did not wear a gown or gloves when walking into Resident 5 ' s room. CNA 6 stated, she did not recall practicing hand hygiene when she left Resident 5 ' s room to walk into Resident 42 ' s room. CNA 6 stated she should have worn gloves and gown before walking into Resident 16 ' s room and to practice hand hygiene before and after leaving a resident ' s room for patient safety as to not spread infections to other residents. During a review of the facility ' s policies and procedures (P&P) titled, Transmission Based Standard, dated 6/2022, indicated the facility staff place signage that included instructions for the specific use of personal protective equipment (PPE, protective equipment that consists of gown, gloves, and masks to protect an individual from hazardous material) in a visible area outside the resident ' s room. The P&P indicated the staff wears the appropriate PPE before entry into a resident ' s room placed on transmission-based precautions. The P&P indicated for residents placed on contact precautions, staff should wear a gown and gloves for all interactions that may involve contact with the resident and the resident ' s environment. During a review of the facility ' s P&P titled, Hand Hygiene, dated 8/2017, the P&P indicated all employees who have direct resident contact will sanitize their hands between contacts with residents.

Based on observation and interview and record review the facility did not follow policy and procedure for Food Storage Principle, on food storage, and in accordance with professional standards for food service safety by failing to: 1. Discard 15 ham sandwiches in a steel pan in the refrigerator with an expired used by date of [DATE]. 2. Label and date an open plastic bag with two hotdog buns in the refrigerator. 3. Discard six breaded fish in an open plastic bag in the freezer with an expired used by date of [DATE]. 4. Label and date a pitcher of prune juice in the refrigerator. 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. Findings: During a concurrent observation and interview on [DATE] at 8:30 AM with the Dietary Service Supervisor (DSS) during an initial kitchen tour, observed: a) 15 ham sandwiches in a steel pan in the refrigerator with an expired used by date of [DATE]. b) Two hotdog buns in a clear plastic bag in the refrigerator without a label and use by date. c) Six breaded fish in an open plastic bag in the freezer with an expired used by date of [DATE]. d) A pitcher of prune juice in the refrigerator without a label and use by date. During the same interview, the DSS stated, foods in the kitchen should be labeled and with a use by date, also expired use by date food should be discarded immediately, not having label on the food and/or having an expired used by date foods, had the potential for foods to be old and/or contaminated and can negatively affect residents ' health who consumed it. During an interview on [DATE] at 8:05 AM with the Director of Nurses (DON), the DON stated, food in the kitchen should be labeled and with a current used by date as per policy, it was important so the kitchen staff would know when to get rid of it and not to be serve to the residents. The DON stated, it was important to follow these practices because, if not, it can cause food contamination, and cause food borne illnesses that can affect residents ' health. During a review of the facility ' s policy and procedure (P&P) titled, Food Storage Principle, dated ,d+[DATE], indicated; a) purpose is to preserve food quality before and after food is prepared, b)label each package, box, can etc. with the expiration date, date of receipt, or when the item was stored after preparation, c) discard foods that have exceeded their expiration date, and d) discard leftover foods that have not been used within 48 hours of preparation. During a review of the Food Code 2022, indicated ,d+[DATE].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 5 C (41 F) 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 accommodate the needs of three of three sampled residents (Resident 1, 9, and 45) by failing to ensure residents call light (a device used by residents to signal his or her needs for assistance) was within reach. These deficient practices had the potential for Resident 1, 9, and 45 not able to call the facility staff to ask for help or assistance. Findings: 1. During a review of Resident 9's Admission Record indicated the facility admitted Resident 9 on 1/23/2024 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and blindness of left eye. During a review of Resident 9's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/9/2024, indicated Resident 9 had severely impaired memory and cognition (ability to think and reason). The MDS indicated Resident 9 was dependent with oral hygiene, shower/bathe self, toilet hygiene, personal hygiene, and chair/bed-to-chair transfer. During a concurrent observation and interview on 11/18/2024 at 10:18 AM, with Certified Nursing Assistant (CNA) 4, observed Resident 9 lying in bed. The resident's touch pad call light (a touch pad call light enables individuals with limited movement to call for help) was observed tucked between the mattress and bed rail. CNA 4 stated Resident 9 was blind on the left eye and weak on both hands. CNA 4 stated Resident 9 would not be able to locate the call light and use the call light to call for assistance from facility staff. 2. During a review of Resident 45's Admission Record indicated the facility admitted Resident 45 on 9/19/2024 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Parkinson ' s disease (a chronic brain disorder that affects movement, balance, and coordination). During a review of Resident 45's Initial History and Physical, dated 9/21/2024, indicated Resident 45 has the capacity to understand and make decisions. During a review of Resident 45's MDS, dated [DATE], indicated Resident 45 required substantial/maximal assistance with eating, oral hygiene, and personal hygiene, and was dependent with shower/bathe self, toilet hygiene, and chair/bed-to-chair transfer. During a review of Resident 45's Care Plan, dated 10/1/2024, indicated the Care Plan addressed assistance with activities of daily living and its intervention including placing call light always thing reach. During a concurrent observation and interview on 11/18/2024 at 10:25 AM, with Resident 45, the resident was observed lying in bed with the touch pad call light placed at the top of the bed over the pillow. Resident 45 was observed with tremors (involuntary movement of one or more parts of the body) with his hands, and the resident was unable to lift arms over his head. Resident 45 stated he did not know where his call light button was. During a concurrent observation and interview on 11/18/2024 at 10:26 AM, the CNA 4, CNA 4 stated Resident 45's call light button was on top of the bed over his pillow and Resident 45 could not reach the call light button. CNA 4 stated call light should be within residents' reach so they could use it and asked for help for their needs and safety. During an interview on 11/21/2024 at 1:07 PM, with the Director of Nursing (DON), the DON stated the staff should put call light within residents' reach at all times to meet their needs and ensure their safety, especially emergent situation. 47882 3. During a review of Resident 1's Admission Record indicated the facility originally admitted Resident 1 on 3/24/2023 and readmitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - lung diseases that make it hard to breathe), anxiety disorder (a mental health condition that involves excessive and persistent feelings of fear, dread, and uneasiness), and generalized muscle weakness. During a review of Resident 1's MDS, dated [DATE], indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with personal hygiene, dressing, and roll left and right, and dependent (helper does all the effort) with bathing and toileting. A review of Resident 1's Care Plan for risk for fall due to poor balance, weakness and poor safety awareness dated 3/27/2023, the care plan interventions included to keep the resident's call light within reach and answered promptly. A review of Resident 1's facility document titled Fall Risk Assessment, dated, 7/3/2024, and 9/27/2024, the document indicated Resident 1 was a high risk for fall. During a concurrent observation and interview on 11/18/2024 at 9:26 AM with Licensed Vocational Nurse (LVN) 3 in Resident 1's room, Resident 1 was in bed laying facing the left side of the bed with the resident ' s call light hanging on the right side of the bed the button pointing towards the floor, unreachable to Resident 1. LVN 3 stated, Resident 1 is able to use a call light, however, the call light needed to be reachable and not placed behind the resident. LVN 3 stated, as per policy, the call light should be within reach to call for assistance, especially for any type of emergency. During an interview on 11/19/2024 at 8:05 AM with the DON, the DON stated, residents call light should always be within reach as per policy. The DON stated, it is important for the call light to be within reach in order for residents to call for assistance and for any type of emergency such as a fall. During review of the facility's policy and procedure (P&P) titled, Answering Call Lights, dated 8/2017, indicated the call light will be placed within easy reach of the resident. During a review of the facility's P&P titled, Answering Call Lights, dated 8/2017, the P&P indicated; a) the purpose is to respond to the residents requests and needs when call lights are used, b) ensure when resident is in bed the call light will be placed within easy reach of the resident, and residents call light will be answered as soon as possible.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for two of two sampled residents (Residents 4 and 23) when: 1. Resident 4, who was a high risk for fall, was observed in bed reaching for his drinks by the bedside table, without a floor mat as per plan of care to prevent injury from fall. 2. Resident 23, who was a high risk for fall, and had a fall incident on 11/18/2024 in Room B (RB-not Resident 23's room) witnessed by a Resident in Room B (RRB), was not frequently monitored, or supervised as per plan of care. These deficient practices had the potential for to cause major injury from a fall and negatively affect Residents 4's and 23's quality of life. Findings: 1. During a review of Resident 4 ' s admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included psychosis (symptoms that cause a person to lose touch with reality, or have a break in their thoughts and perceptions), anxiety disorder (a condition that causes excessive feelings of fear, dread, and worry that can interfere with daily life), and history of fall. During a review of Resident 4 ' s History and Physical, dated 7/30/2024, indicated Resident 4 does not have the capacity to understand and make decisions. During a review of Minimum Data Set (MDS, a resident assessment tool), dated 10/18/2024, indicated Resident 4 ' s cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with eating, substantial/maximal assist (helper does more than half the effort) personal hygiene and toileting, and dependent (helper does all the effort) with dressing and bathing. During a review of Resident 4 ' s facility document titled Fall Risk Assessment, dated 4/25/2024, 7/19/2024, and 10/21/2024, indicated Resident 4 was a high risk for fall. During a review of Resident 4 ' s care plan (CP) for risk for falls, injuries from falls related to history of falls, impaired safety awareness, revised 10/24/2024, the CP indicated Resident 4 had falls on 6/28/2023, 1/8/2024, and 3/11/2024, intervention included the use of left floor mat. During a concurrent observation and interview on 10/19/2024 at 10:20 AM with Licensed Vocational Nurse (LVN) 1 in Resident 4 ' s room, Resident 4 was lying in bed moving and reaching for his drinks on a bedside table left side of the bed, there was no floor mat next to the bed as per plan of care. LVN 1 stated, she was not aware Resident 4 was a fall risk and needed to have a floor mat next to the bed. LVN 1 stated, it was important to have a floor mat next to Resident 4 ' s bed in case of a fall it can minimize the potential for a major injury. During an interview on 11/19/2024 at 10:45 AM with Director of Nursing (DON), the DON stated, the facility did not implement the plan of care for Resident 4 to ensure there was a floor mat next to the bed. The DON stated, not having a floor mat next to the bed, for a high risk for fall resident, had the potential to cause major injury from a fall. 2. During a review of Resident 23 ' s admission record indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included psychotic disorder, anxiety disorder, abnormalities of gait and mobility (having problems with the way you walk or move around) and muscle weakness. During a review of Resident 23 ' s History and Physical, dated 10/4/2024, indicated Resident 4 does not have the capacity to understand and make decisions. During a review of the MDS, dated [DATE], indicated Resident 23 ' s cognitive skills was severely impaired. The MDS indicated Resident 23 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) personal hygiene, substantial/maximal assistance with dressing and toileting and dependent with showering/bathing. During a review of Resident 23 ' s CP for actual falls related to balance deficit, cognitive impairment, poor safety awareness, initiated 10/6/2024 and revised on 11/18/2024, indicated Resident 23 had a fall incident on 10/6/2024 in his room, 10/17/2024 in his room, and 11/18/2024 in Room B (RB) not his room. The CP indicated intervention initiated 10/6/2024 was frequent visual monitoring. During a review of Resident 23 ' s facility document titled SBAR Communication Form and Progress Note, dated 11/18/2024 timed at 6:45 PM, the document indicated Resident 23 had an unwitnessed fall in Room B at 5:40 PM out of his wheelchair and sustained a skin tear 1.5 cm x 1.5 cm on the right elbow and 1 cm x 0.8 cm on the right parietal area. During a review of Resident 23 ' s facility document titled Fall Risk Assessment, dated 10/6/2024, 10/17/2024, and 11/18/2024, indicated Resident 23 was a high risk for fall. During an observation on 11/19/2024 at 3:05 PM in front of the nurse ' s station by Resident 23 ' s room, Resident 23 on his wheelchair observed a small superficial skin tear on the forehead and the right elbow, Resident 23 was non-interview-able. During an interview on 11/19/2024 at 3:10 PM with Treatment Nurse (TN) 1, TN 1 stated, she was working the day of the fall incident on 11/18/2024, she was called to room B by the DON to do the skin treatment on Resident 23 ' s forehead and elbow, Resident 23 was already back on his wheelchair. TN 1 stated, she does not know who was monitoring Resident 23 and why Resident 23 was in another room. During an interview on 11/19/2024 at 3:20 PM with Registered Nurse (RN) 1, RN 1 stated, she was working the day of the fall incident on 11/18/2024, she was called to room B by the DON to help with the assessment, Resident 23 was already up on the chair. RN 1 stated, she does not know who was monitoring Resident 23 and why Resident 23 was in another room. During an interview on 11/19/2024 at 3:30 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated, he was working the day of the fall incident on 11/18/2024, he was called to room B by the DON, Resident 23 was already on the floor. CNA stated, the DON and himself assisted Resident 23 back in his wheelchair. CNA 1 stated, he does not know who was monitoring Resident 23, and added he was busy passing trays. CNA 1 stated, he does not know why Resident 23 was in room B, it is not his room. During an interview on 11/19/2024 at 3:40 PM with the DON, the DON stated, a family member in room B called that Resident 23 fell . DON stated, when he got there Resident 23 was on the floor lying on his right side and noted a skin tear on the forehead and the right elbow, he was the first nurse in the room. The DON stated, he does not know who was supposed to monitor Resident 23 and why Resident 23 was in room B. During a concurrent interview and record review, on 11/19/2024, at 3:50 PM, with the DON, Resident 23 ' s Electronic Health Records for the month of October and November was reviewed. The records did not indicate any type of documentation for frequent visual monitoring due to Resident 23 being high risk for fall. The DON stated, he cannot find any type of documentation of frequent visual monitoring for Resident 23, but he will initiate every hour monitoring and start a log. DON stated, no one seemed to be monitoring Resident 23 when had the fall, since a visitor was the one who saw him. During an interview on 11/20/2024 at 11:05 AM with Resident in Room B (RRB), RRB stated, she remembered Resident 23 ' s fall incident on 11/18/2024, a man in a wheelchair came in the room and tried to reach something on the floor and fell . RRB stated, there was no nurses/staff in the room. During an interview on 11/21/2024 at 8:15 AM with the DON, the DON stated, the facility does not have a policy for supervision, but residents should be supervised at least every hour especially for high fall risk residents to make sure they were safe and comfortable. The DON stated, not supervising high fall risk Residents had the potential to cause major injury from a fall. During a review of the facility ' s policy and procedure (P&P) titled, Comprehensive Care Plan, dated 12/2016, indicated; a) comprehensive plan of care will include interventions to attempt to manage risk factors., b) comprehensive plan of care will address the Resident ' s individual needs, and c) develop goals and approaches for each problem and /or condition that are realistic, specific, measurable, and include interventions/approaches that relate to each stated long and short term goal. During a review of the facility ' s P&P titled, Fall Prevention Program, dated 12/2016, indicated; a) the facility will identify interventions related to the resident ' s specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling, b) if a resident is at risk for falls, it will be identified on the care plan, all precautions will be implemented to protect the resident according to the fall prevention and reduction program, and c) the care plan should include close observation and increased supervision.

Based on observation, interview, and record review, the facility failed to ensure certified nurse assistant (CNA) 3 was seated when assisting one of eight sampled Residents (Resident 2) during mealtime. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Residents 2. Findings: During a review of Resident 2's Admission Record indicated the facility originally admitted Resident 2 on 5/18/2016 and readmitted her on 9/10/2024 with diagnoses that included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and hemiplegia (a condition that causes partial or complete paralysis on one side of the body). During a review of Resident 2's Initial History and Physical, dated 9/13/2024, indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/2024, indicated Resident 2 was dependent with eating, oral hygiene, shower/bathe self, toilet hygiene, and chair/bed-to-chair transfer. During an observation on 11/18/24 at 12:43 PM, Resident 2 was observed seated on her bed in her room. CNA 3 was standing next to the head of the bed and facing the foot of the bed, on Resident 2 ' s right side. CNA 3 placed Resident 2 ' s meal tray onto the bedside table, located to the right of CNA 3. CNA 3 was observed standing and looking down at Resident 2 while feeding Resident 2. During an interview on 11/18/2024 at 12:44 PM, with CNA 3, CNA 3 stated standing over and feeding Resident 2. CNA 3 stated she should have obtained a chair and sat down next to Resident 2 so she could be at eye level with Resident 2 while providing feeding assistance. During an interview on 11/21/2024 at 1:06 PM, with the Director of Nursing (DON), the DON stated that staff should not stand over the resident while providing feeding assistance to preserve the resident's dignity. During a review of the facility's policy and procedure titled, Assistance with Meals, dated 4/2018, indicated Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals.

Based on interview and record review, the facility failed to ensure an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and Physician Orders for Life Sustaining Treatment (POLST, a medical order form that tell medical staff what to do if you have a medical emergency and are unable to speak for yourself) was accessible in residents medical records (physical paper chart) for one of eight sampled residents (Resident 41). Resident 41's paper chart did not have a copy of the Advance Directive Acknowledgement and the original POLST. This deficient practice had the potential for Resident 41's medical treatment, provisions, to be delayed and/or not be carried out, according to the Resident 41's and/or Responsible Party's request during an emergency, which can negatively affect Resident 41's quality of care. Findings: During a review of Resident 41 ' s Admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), seizures (a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person's behavior, movements, feelings, and level of consciousness) , and urinary tract infections (UTIs) are common infections that affect the bladder, the kidneys and the tubes connected to them. During a review of Resident 41's History and Physical Examination (H&P), dated 7/19/2024, indicated Resident 41 does not have the capacity to understand and make decisions. The H&P indicated prognosis is from fair to serious. During a review Minimum Data Set (MDS, a resident assessment tool), dated 9/6/2024, indicated Resident 41's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 41 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating and required substantial/maximal assist (helper does more than half the effort) with personal hygiene, dressing, toileting, and bathing/showering. During a concurrent interview and record review, on 11/18/2024, at 12:01 PM, with Licensed Vocational Nurse (LVN) 4, Resident 41 ' s medical paper chart (Resident 41's medical records), (undated) was reviewed, the chart did not have a copy of Resident 41's advance directive and POLST. LVN 4 stated, it was the practice of the facility to ensure the advance directive and the POLST were in the physical paper chart, he did not know why it was not in Resident 41's chart. LVN 4 stated, it was important to have it in the chart so the nurses would know the care needed to provide in case of emergency, otherwise, it had the potential to delay the care. During a concurrent interview and record review, on 11/18/2024, at 12:10 PM, with Registered Nurse (RN) 2, Resident 41's medical paper chart (Resident 41's medical records), (undated) was reviewed, the chart did not have a copy of Resident 41's advance directive and POLST. RN 2 stated, Resident 41's advance directive and the POLST should be in Resident 41's physical paper chart, it was the facility's protocol (rules or guidelines that everyone needs to follow to communicate or interact effectively). RN 2 stated, it was important that the advance directive and the POLST were in the physical paper chart so nurses can adhere to what care Resident 41 and/or the responsible party wanted in case of emergency, it was the first thing nurses checked during an emergency. RN 2 stated, not having the advance directive and the POLST in the physical paper chart can delay the process and/or affect Resident 41's quality of care. During an interview on 11/19/2024 at 8:05 AM with the Director of Nursing (DON), the DON stated, he expected resident's advance directive and POLST be in the resident's physical paper chart, it was the first item the nurses checked in case of emergency. DON stated, not having residents advance directive and POLST in the resident's physical paper chart had the potential to delay and/or negatively affect the resident ' s quality of care. During a review of the facility's policy and procedure (P&P) titled, Advance Directive, dated 2/2017, indicated; a) the facility ' s copy of the advance directive must be filed in the resident ' s clinical record, b) the facility must document in a prominent part of the resident ' s clinical record whether the resident has issued an advance directive, and c) the facility will document provision of information for advance directive and will be maintained in the clinical record. During a review of the facility's P&P titled, Physician Orders for Life Sustaining Treatment (POLST), dated 12/2016, indicated; a) a completed, fully executed POLST is a legal physician order, and is immediately actionable, b) once reviewed, the POLST should be copied, and the current original form placed in the front of the resident ' s chart, along with the resident ' s advance directive if he/she has one.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnosis of dementia (the loss of cognitive process) with combative behavior (aggressiveness/eagerness to fight) was free from physical restraints (any manual method, physical or mechanical device/equipment or material that limits a resident's freedom of movement and cannot be removed by the resident) for purposes of discipline or convenience, by failing to: 1. Protect Resident 1 from physical injury on 8/20/2024, when Licensed Vocational Nurse (LVN) 1 restrained Resident 1's right and left arms by crossing Resident 1's arms across the chest and above the head and pull/drag the resident from the resident's room to the Nursing Station when Resident 1 exhibited episodes of mood swings [a sudden or intense change in a person's emotional state]. 2. Implement Resident 1's care plan interventions on Dementia, and Communication Problem related to Language Barrier [a difficulty for people communicating because they speak different languages] by establishing rapport and eye contact with the resident, use appropriate words and gestures, listen carefully and attend to verbal/nonverbal expressions when LVN 1 physically restrained Resident 1's left and right arms with both of her hands, while the resident was exhibiting episodes of mood swings, anxiety and agitation on 8/20/2024. 3. Ensure the facility's Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals for residents) develop a comprehensive care plan when Resident 1 exhibited (showed) new behaviors manifested by combativeness, punching, scratching, and kicking, chasing staff, including touching the roommate (Resident 2) on 6/9/2024, 7/7/2024, and 8/18/2024, in accordance with the facility's policy and procedure [P&P] titled Person Centered Plan of Care. 4. Develop care plan interventions on 8/22/2024, to address Resident 1's combative behavior and agitation and identify the root cause (the fundamental reason for the occurrence of a problem) of the resident's behavior symptoms (combativeness and agitation) to prevent further injury to Resident 1. 5. Prohibit the use of physical restraints, in accordance with the facility's policy and procedure titled Physical Restraint Management, when LVN 1 held Resident 1 down with both hands to prevent LVN 1 from being hit, kicked and spit on by Resident 1 and restrained Resident 1's right and left arms by crossing Resident 1's arms across the chest and above the head and pull/drag the resident from the resident's room to the Nursing Station, on 8/20/2024. As a result, LVN 1 restrained Resident 1's freedom of movement and the resident sustained (continued over time) redness/bruising to the back of the left hand and verbalized pain to both hands and shoulders on 8/20/2024. On the same day, on 8/20/2024 timed at 7:48 PM, during a telemedicine (the use of electronic information and communications technologies to provide and support) visit with Psychiatrist 1, Resident 1 verbalized being scared. Resident 1 was unable to verbalize the reason for being scared. These deficient practices placed other residents with behavioral issues (acting in a way that causes harm) residing at the facility [24 residents], at risk for staff abuse and restraints and cause psychosocial (covers a person's mental, emotional, social, and spiritual health) decline, physical (relating to the body) injuries, hospitalization , and death. On 8/26/2024 at 6:22 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 of unnecessary physical restraint for a resident (Resident 1) who had behavioral issues which included combativeness. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of the IJ situation on 8/26/2024 at 6:22 PM, due to the facility's unnecessary use of physical restraint for Resident 1, while in an agitated state. On 8/28/2024 at 1:46 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On 8/28/2024 at 5:15 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 dated 8/28/2024, included the following: o The facility interviewed 30 interviewable residents on 08/26/2024 and screened for any incidents of being physically restrained during care by the Social Services Designee (SSD) and 12 non-interviewable residents received body check (examine the body) on 08/26/2024, to determine any unexplained bruising (blood pooling under the skin) or redness by licensed nurses and the DON. o The facility started Training and Education on 8/26/24 headed by the Nurse Consultant Director of Staff Education and the DON, regarding abuse (the act of causing harm) and physical restraints. The training on Managing Behavior and Care plan will be completed by 08/28/2024. o The facility started ln-service (continuous) training for staff nurses on 8/26/24, regarding updating comprehensive care plans for residents that exhibit combative behaviors to be completed and to include on the care plan not to use any type of restraints. o The facility started an In-service training for staff and nurses on 8/26/24, on managing residents that exhibit combative behaviors. Staff from nursing department (Registered Nurse (RN), LVN, Certified Nurse Assistants [CNA], Restorative Nurse Assistants [RNA]) Dietary Department, Housekeeping, Maintenance and Department Managers (Social Service, Medical Records staff, Rehabilitation Department, Minimum Data Set (MDS), DON, DSD, IPN, Business Office Manager [BOM]), have been trained and will continue training until all staff have attended. o The facility conducted an In-service training for staff (RN, LVN, CNA, RNA, Housekeeping, Dietary Department, Maintenance and Department Managers) on 8/26/24, on what constitutes a physical restraint and its definition. o The nurse consultant conducted an In-service to all RNs, LVNs, CNAs, and RNAs, Housekeeping, Maintenance staff, Dietary staff, and Department Managers on 08/28/2024, regarding Behavior Management, Abuse and Physical Restraints. o The SSD, DON and Activity Director (AD) will conduct interviews of alert residents to determine if they have been physically restrained during care at least daily for the next 3 days and weekly for two weeks and monthly thereafter. o CNAs will continue to conduct body checks for all residents to identify any unexplained redness or bruising during showers and will be reported to the Charge nurse/Treatment nurse (TN) 1 and/or to DON for further intervention and reporting. Findings: During a review of Resident 1's Admission Record [AR], the AR indicated the facility admitted the resident on 6/6/2024, with diagnoses that included dementia and encephalopathy (damage or disease that affects the brain). During a review of Resident 1's History and Physical Examination (HPE, a comprehensive physician's note regarding the assessment of the resident's health status) signed by the attending physician (Physician 1) on 6/7/2024, the HPE indicated Resident 1 had fluctuating (changing frequently) capacity to understand and make decisions. During a review of Resident 1's Post COC [Change in Condition]/SBAR [Situation, Background, Assessment, Recommendation] notes dated 6/9/2024 timed at 1:20 PM, the Post COC indicated Resident 1 became combative towards the end of the shift and was brought back to bed several times. During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) dated 6/12/2024, the MDS indicated the resident had moderately impaired cognition (thought process). During a review of Resident 1's Interdisciplinary Team [IDT] Conference Record dated 6/12/2024, indicated that Resident 1 did not present with any behavioral issues, needs encouragement to join activities of choice and enjoys music. The IDT Record indicated the facility did not use physical restraints and restraints were not recommended at this time for Resident 1. During a review of Resident 1's care plans initiated in June 2024, the care plans indicated the following information: -On 6/12/2024, the facility developed a care plan titled [Resident 1] has a communication problem related to language barrier. The care plan interventions included allowing adequate time to respond, face the resident when speaking, making eye contact and reducing environmental noise, and monitoring for physical/nonverbal indicators of discomfort or distress. -On 6/12/2024, the facility developed a care plan titled [Resident 1] has diagnosis of dementia, at risk for decline in communication and activity participation . The care plan interventions included establishing rapport and eye contact with the resident, use appropriate words and gestures, listen carefully and attend to verbal/nonverbal expressions, reducing environmental noise, and maintaining a calm, unhurried manner. During a review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note dated 7/7/2024 timed at 12:47 PM, indicated that on 7/7/2024 at about 8 AM, Resident 1 began to swing fist (refers strictly to the action of throwing one's fist) at the CNA when Resident 1 was reoriented by the CNA not to pull on her roommates' (Resident 2) gown. The SBAR indicated Physician 1 ordered Ativan (medication for anxiety) 0.5 milligrams [mg- unit of measurement) by mouth every 12 hours as needed for agitation for 14 days on 7/7/2024. During a review of Resident 1's care plans, for July 2024, the care plan did not indicate documented evidence that a care plan for Resident 1's agitation was developed on 7/7/2024, to specify the goals and care plan interventions the facility staff needed to implement to manage the resident's agitation. During a review of Resident 1's Telephone Order (TO) dated 8/5/2024, indicated a physician's telephone order to administer Depakote (medication to treat episodes of mania [extreme changes in mood]) oral tablet to 125 mg, one tablet by mouth one time a day for mood swings manifested by outbursts (uncontrolled feelings) of anger. During a review of Resident 1's SBAR Communication Form and Progress Note dated 8/18/2024, timed at 3:22 PM, authored by LVN 3, the SBAR Form indicated Resident 1 attempted to touch Resident 2 and when Resident 1 was redirected, the resident shook her head in denial and punched LVN 3. The SBAR form indicated Resident 1 began to chase facility staff down the facility hallway attempting to punch and kick staff. The SBAR Form indicated Resident 1 was combative, punching, scratching, and kicking staff. The SBAR Form indicated that LVN 3 called 911 emergency services, and a police officer spoke to Resident 1 in her primary/native language and the police officer was able to redirect the resident to calm down and go back to her room. During a review of Resident 1's Progress Notes New dated 8/19/2024, timed at 5:52 PM, the Progress Notes indicated the physician ordered to increase the resident's medication [Depakote] 120 mg from once a day to two times a day as a result of the behavior manifested by the resident on 8/18/2024. During a review of Resident 1's TO dated 8/19/2024, the TO indicated to administer Ativan oral tablet 0.5 mg, one tablet by mouth, every 12 hours to the resident as needed for 14 days manifested by verbalization of nervousness. During a review of Resident 1's Medication Administration Record [MAR], the MAR indicated to give the resident one tablet of Ativan 0.5 mg starting 8/19/2024, by mouth every 12 hours for 14 days, as needed for anxiety manifested by verbalization of nervousness. The MAR did not indicate Ativan was administered as needed for anxiety, from 8/19/2024 or 8/20/2024. The MAR indicated an order to monitor behavior for anti-anxiety manifested by verbalization of nervousness and tally by hashmarks (a way to count and record count numerically), starting on 8/19/2024. The MAR did not indicate Resident 1's anxiety manifested by verbalization of nervousness was monitored and counted by the licensed nurses from 8/19/2024 through 8/27/2024. During a review of Resident 1's TO dated 8/19/2024, indicated Depakote oral tablets dosage was increased from the original dose that was ordered on 8/5/2024 from 125 mg, one tablet once a day to 125 mg, one tablet two times a day, for mood swings manifested by outbursts (uncontrolled feelings) of anger. During a review of Resident 1's MAR in August 2024, the MAR indicated for the Depakote medication, Resident 1's behavior issues of outbursts of anger was monitored and documented 16 days after the original order of the Depakote oral tablets was ordered on 8/5/2024 starting 8/21/2024. During a review of a Short Message Service [SMS - a text messaging service that allows users to send short text messages between mobile devices] sent via text message [TM] from LVN 1 to the Director of Nursing (DON) dated 8/20/2024 timed at 6:48 AM, the TM indicated Resident 1 keeps hitting other residents and LVN 1 was unable to physically control the resident. The TM indicated Resident 1 was very aggressive and LVN 1 had to hold Resident 1 to prevent Resident 1 from going back to Resident 1 and 2's room and from hitting and kicking LVN 1. The TM indicated the DON asking LVN 1 What prompted crossing her arms? Or dragging her [Resident 1] to the station with both arms/hands held? LVN 1's response indicated She [Resident 1] did not want to stop. Where else should she go if not the station. Holding her hands so she [Resident 1] doesn't hit me. The TM indicated the DON stating that Resident 2 denied being hit by Resident 1 and Resident 1 sustained injuries/bruising to both the right and left hand. During a review of Resident 1's SBAR Communication Form and Progress Note dated 8/20/2024 timed at 12:27 PM, the SBAR indicated Resident 1 was allegedly hitting the roommate, Resident 2 on 8/20/2024. The SBAR indicated the charge nurse, LVN 1, reported that Resident 1 hit Resident 2. The SBAR indicated that upon interview of Resident 1, Resident 1 denied hitting Resident 2. The SBAR indicated Physician 1 was made aware of the allegation that Resident 1 hit Resident 2, but no new orders were given by Physician 1, as a result of the allegation. During a review of Resident 2's SBAR Communication Form and Progress Note dated 8/20/2024, indicated Resident 2 was allegedly hit by the roommate (Resident 1). The SBAR Form indicated Resident 2 was interviewed and Resident 2 stated she was not hit by Resident 1. The SBAR Form indicated Resident 2 did not have any injuries or bruising upon body assessment of the licensed nurse. During a review of Resident 2's Progress Notes, dated 8/20/2024 and timed at 9:32 AM, the Progress Notes indicated Resident 2 was discharged back to home on 8/20/2024. During a review of Resident 1's Skin Observation Tool dated 8/20/2024, timed at 1:48 PM, the tool indicated that 2 centimeters (cm- unit of measurement) by 2 cm bluish discoloration was observed on the back of Resident 1's left hand. During a review of Resident 1's IDT Conference Record dated 8/20/2024, the IDT Record indicated the IDT team met with Resident 1 with the aid of translator services and asked Resident 1 if her injury (bruising to the left hand) caused by LVN 1 was hurting, Resident 1 did not respond. The IDT record further indicated that Resident 1 denied hitting Resident 2. During a review of Resident 1's care plan, titled [Resident 1] was involved with an alleged abuse, initiated on 8/20/2024, indicated a goal that Resident 1 would not display any further behavior (no specific behavior indicated) for one month. The care plan interventions developed on 8/20/2024, included visual monitoring hourly and a STAT (immediately) X-ray of Resident 1's bilateral (both) hands and shoulders due to pain. During a review of Resident 1's care plan titled [Resident 1] has a new behavior of punching, kicking, and scratching staff, attempting to touch and grab other residents indicated the care plan was initiated on 8/18/2024 and revised on 8/22/2024. The care plan interventions dated 8/18/2024, indicated to notify attending physician of significant changes in behavior, notify responsible party, and provide psychosocial support. The care plan did not indicate the care plan interventions added, when the facility revised the care plan on 8/22/2024. The revised care plan dated 8/22/2024, did not include resident specific interventions to address Resident 1's behavior symptoms of combativeness with staff, agitation, and outbursts of anger. During a review of Resident 1's Psychology [the scientific study of the human mind and its functions, especially those affecting behavior] Note, dated 8/20/2024, the Psychology Note indicated Resident 1 verbalized being scared. The Psychology Note indicated that when Resident 1 was asked why or what happened, Resident 1 was unable to reply. During a review of CNA 2's handwritten Investigation Statement dated 8/19/2024 (corrected by DON as 8/20/2024), indicated CNA 2 heard LVN 1 calling to get Resident 1 out of the room because Resident 1 was hitting Resident 2. CNA 2 wrote witnessing Resident 1 walking out of the room heading by the facility hallway towards the Nurses Station, at around 6 AM, CNA 2 wrote that before Resident 1 reached the Nurses Station, LVN 1 stopped Resident 1 and spoke with the resident through the translator services using the phone, however Resident 1 got mad when LVN 1 confronted her and was about to kick and spit on LVN 1. CNA 2 further wrote that to avoid the assault, [LVN 1] restrained Resident 1 by holding the [resident's] hands while [the resident] was still trying to kick and spit on LVN 1. CNA 2 wrote that Resident 1 was screaming and kept talking in her language while LVN 1 tried to sit the resident on a wheelchair. CNA 2 wrote that LVN 1 held Resident 1's hand hard that it left a red mark at the back of Resident 1's hand. During a review of CNA 4's Investigation Statement dated 8/20/2024, indicated CNA 4 (night shift CNA) stated she witnessed Resident 1, inside her room, tapped Resident 2's foot with an open hand trying to wake her (Resident 2) up, on 8/20/2024 at around 6:20 AM. The Investigation Statement indicated CNA 4 told Resident 1 to stop tapping Resident 2's foot and Resident 1 started talking in her primary/native language as Resident 2 woke up . During a review of CNA 3's (night shift CNA) Investigation Statement dated 8/20/2024, indicated CNA 3 heard yelling coming from Resident 1's room and when she entered the room, CNA 3 observed Resident 1 yelling and standing by Resident 2's bed. The Investigation Statement indicated CNA 3 left the room and reported Resident 1 to LVN 1. The Investigation Statement indicated CNA 3 stated that LVN 1 was trying to calm down Resident 1 in the facility hallway and held Resident 1's hands to prevent LVN 1 from getting hit. The Investigation Statement indicated CNA 3 got a wheelchair and sat Resident 1 down while another CNA (CNA 1) arrived from the morning shift and started to talk to Resident 1 to calm her down. During an interview on 8/26/2024 at 10:34 AM with Housekeeper (HK) 1, HK 1 stated that on 8/20/2024 at around 6:40 AM, he heard arguing by the hallway, across the Nurses Station. HK 1 stated witnessing Resident 1 standing by the Nursing Station while LVN 1 was behind Resident 1 restraining Resident 1's left and right arms with both of her hands. HK 1 stated that Resident 1 right and left arms and hands were crossed and restrained for about 5 minutes. HK 1 stated while LVN 1 was restraining the resident, Resident 1 was screaming, yelling, and kicking. HK 1 stated LVN 1 was calling for someone to get a wheelchair, while LVN 1 was physically restraining Resident 1. HK 1 stated that CNA 1 from the 7 AM to 3 PM shift, came to help calm down Resident 1. HK 1 stated Resident 1 had calmed down when CNA 1 had spoken to her. HK 1 stated that Resident 1 was pointing and complaining of left-hand pain to CNA 1. HK 1 stated that CNA 1 applied an ice pack to Resident 1's left hand. During an interview on 8/26/2024 at 10:47 AM, CNA 1 stated she arrived at the facility at around 6:45 AM. CNA 1 stated that she witnessed Resident 1 screaming in front of the Nurses Station, sitting on the wheelchair while LVN 1 physically restrained Resident 1 by holding Resident 1's left and right hand and Resident 1's arms were crossed above her head. CNA 1 stated she was able to calm down Resident 1, so LVN 1 had stopped restraining Resident 1. CNA 1 stated she noticed Resident 1 had redness on the back of the left hand. CNA 1 stated after she applied an icepack on Resident 1's left hand, CNA 1 took Resident 1 back to her room. During an observation and interview on 8/26/2024 at 11:06 AM, in Resident 1's room, in the presence of another employee [Translator 1] translating for Resident 1, Translator 1 stated that according to Resident 1, it was hard to remember what happened on 8/20/2024, during the early morning, because it happened a while back. Resident 1 stated she did not have any pain anymore. Resident 1 had pointed to the back of her left hand with yellowish discoloration. During an interview on 8/26/2024 at 11:21 AM, the Treatment Nurse (TN 1) stated that Registered Nurse (RN) 2 reported to her that Resident 1 needed treatment on her left dorsal hand bruising, on 8/20/24. TN 1 stated that Resident 1 was pointing to her left hand when she went to assess the resident. TN 1 stated that Resident 1 had a 2 cm by 2 cm bluish discoloration to the resident's left dorsal (back of the hand) hand, with no swelling, on 8/20/2024. TN 1 stated that Resident 1's bruising to the left hand had now changed to yellowish discoloration with no pain or swelling. During an interview on 8/26/2024 at 11:36 AM, the ADM stated when she arrived at the facility on 8/20/2024 at 7:30 AM, HK 1 reported that he observed LVN 1 had physically restrained Resident 1 on 8/202024 at around 6:40 AM, at the Nurses Station. The ADM stated she had immediately started the abuse investigation. The ADM stated during the course of her investigation, LVN 1 physically restrained Resident 1 by holding Resident 1's left and right hands while inside her room and was forcefully pulled by holding both of her hands in a strong manner towards the Nurses Station. The ADM stated Resident 1 sustained bruising to the back of her left hand. The ADM stated CNA 4 reported to LVN 1 that Resident 1 had allegedly abused her roommate [Resident 2] by tapping her foot on 8/20/24 at around 6:20 AM, when CNA 4 was walking by Resident 1's room. The ADM stated that LVN 1 had communicated with the DON via TM regarding the incident with Resident 1. The ADM stated that LVN 1 texted to the DON the reason why she physically restrained Resident 1 was because she assumed that Resident 1 would hit Resident 2 while in the resident's room. The ADM stated LVN 1 restrained Resident 1's hands because she did not want to get hit by the resident. The ADM stated LVN 1 forcefully pulled Resident 1's left and right hand out of the room and pulled the resident to the Nursing Station. The ADM stated the DON requested LVN 1 to submit a written statement, but LVN 1 did not submit and respond to any further communication with the ADM or the DON. The ADM stated LVN 1 was suspended on 8/20/2024 and was later terminated on 8/23/2024. During an interview, on 8/26/2024 at 12:08 PM, the DON stated LVN 1 stopped communicating via text messages and LVN 1 did not call back or respond to her for a written statement of what occurred on 8/20/2024. The DON further stated that LVN 1 forcefully pulled Resident 1's right and left hand on 8/20/2024 towards the Nursing Station. The DON stated LVN 1 did not follow the facility policy on Restraint Management and did not use good nursing judgement to deescalate [to decrease difficulty of a situation] Resident 1's agitated state. The DON stated the physical force used by LVN 1 caused injury (bruising) to Resident 1's left and right hand and may have caused psychosocial distress (unpleasant emotions which negatively impacts quality of life) by making Resident 1 feel helpless. The DON stated LVN 1 should have talked to Resident 1 in a calm voice or walked away, and just monitor Resident 1 until she calmed down. During an interview on 8/26/2024 at 2:05 PM with LVN 2, LVN 2 stated she arrived at the facility around 6:50 AM, on 8/20/2024, and observed LVN 1 restrained Resident 1's left and right hands and crossed the resident's arms across the resident's abdomen/chest area with LVN 1's right hand. LVN 1 used her left hand to hold her cell phone while trying to call the translator services to communicate with Resident 1. LVN 2 stated Resident 1 had been restrained for about two minutes. During the same observation, on 8/26/2024 at 2:05 PM, LVN 2 stated Resident 1 was not agitated or combative. LVN 2 stated CNA 1 came to Resident 1 and started to speak with her to comfort her. LVN 2 stated after CNA 1 talked to Resident 1, LVN 1 released her hand from Resident 1. LVN 2 stated CNA 1 took Resident 1 back to her room and reported to LVN 1 about Resident 1's injury (bruising) to the left hand and CNA 1 placed an ice pack to Resident 1 left and right hand. LVN 2 stated that LVN 1 should have not physically restrained Resident 1. LVN 2 stated LVN 1 caused physical and psychological harm to Resident 1 because LVN 1 used force which led to Resident 1 getting injured physically. During a telephone interview on 8/26/2024 at 2:29 PM, Resident 2 was interviewed and stated that Resident 1 would wake up at night and just walk up and down the hallway. Resident 2 stated that Resident 1 never hit her and did not bother her. During a concurrent interview and record reviews on 8/26/2024 at 3:10 PM, Resident 1's Nursing Progress Notes titled Post [COC] dated 6/9/2024 timed at 1:20 PM and SBAR Communication Form and Progress Note dated 7/7/2024 timed at 12:47 PM were reviewed with the DON. During the concurrent interview, the DON stated he was unaware of Resident 1's Post COC on 6/9/2024 that indicated Resident 1's combative behavior. The DON further stated that he was unaware of Resident 1's combative behavior exhibited on 7/7/2024, as indicated in the SBAR Form. The DON stated there was no resident specific care plan developed for Resident 1's combative behaviors prior to 8/18/2024, because there was no IDT conference conducted to address Resident 1's aggressive behavior since the resident's behavior symptoms were not reported to him [DON]. The DON stated the SBAR Form dated 7/7/2024, indicated the physician ordered Ativan 0.5 mg every 12 hours as needed for agitation. The DON stated Resident 1's aggressive behavior and the physician order for the use of Ativan should have been communicated and addressed to identify and manage Resident 1's behavioral issues to avoid abuse or physical restraints. During a concurrent interview on 8/26/2024 at 3:34 PM and record review of Resident 1's care plan titled [Resident 1] has a new behavior of punching, kicking, and scratching staff, attempting to touch and grab other residents, dated 8/18/2024 and revised on 8/22/2024 with the DON, the DON stated that Resident 1's care plan interventions for Resident 1's new behavior of punching, kicking and scratching staff were not specific to the Resident 1's behavioral needs. The DON stated the licensed nurses only developed three care plan interventions which included to notify the physician, notify Resident 1's family, and provide psychosocial support. The DON stated the care plan did not indicate how the staff would provide psychosocial support such as to talk to the resident so she could voice any concerns. The DON stated the care plan did not address triggers or root cause that may have been causing Resident 1 to touch other residents especially Resident 2, including punching, kicking, and scratching staff. The DON stated because the care plan on 8/18/2024 did indicate addressing the root cause of Resident 1's aggressive behavior, LVN 1 led to escalating Resident 1's aggressive behavior by physically restraining Resident 1 on 8/20/2024. The DON stated restraining Resident 1 was not the appropriate action to protect the resident and calm her down. The DON stated LVN 1 used physical force (on 8/20/2024) and led to Resident 1's increase in aggression. During the same interview, on 8/26/2024 at 3:34 PM, the DON stated the facility's IDT conference should have been conducted the next day, on 8/19/2024, when resident 1 had an episode of combativeness on 8/18/2024. The DON stated the IDT conference was not conducted the next day, 8/19/2024, because it was a weekend (Sunday). The DON stated the next incident happened on 8/20/2024, early morning, and should had been prevented if Resident 1's combative behaviors was addressed by the IDT on 8/19/2024. During a phone interview on 8/26/2024 at 4:40 PM, LVN 3 stated he worked on 8/17/2024 from 11 PM to 7 AM shift. LVN 3 stated he had cared for Resident 1 in the past and Resident 1 previously had behaviors of agitation when Resident 1 would get startled. LVN 3 stated after Resident 1 had been redirected back to her room, Resident 1 became aggressive and began making threatening gestures with her fist. LVN 3 stated Resident 1 slapped him across the face while trying to calm her down. LVN 3 stated after several attempts to redirect Resident 1, the resident began chasing staff in the hallway. LVN 3 stated when Resident 1 began chasing staff, he called 911 emergency services. LVN 3 stated police officers arrived in the early morning of 8/18/2024 at around 1 AM. LVN 3 stated there was an officer who speaks Resident 1's native language and was able to calm her down. LVN 3 stated Resident 1 went back to her room and told the police officer she was tired. During an interview on 8/27/2024 at 4:18 PM, with RN 1 stated she worked on 8/17/2024 from 3 PM to 11 PM shift and she did not see Resident 1 in an agitated state and was not chasing, yelling, and kicking staff but noticed the resident with episodes of anxiously pacing up and down the hallway. RN 1 stated Resident 1 would pace up and down the hallway but return to her room. RN 1 stated she did not know if Resident 1's behaviors (verbalization of nervousness and outburst of anger) was being monitored or counted in the resident's records. During a review of the facility's P&P titled Physical Restraint Management dated 3/2017, the P&P indicated physical restraints are not used for purposes of discipline or convenience, but only as required to treat the resident's medical symptoms. The P&P indicated physical restraints are defined as any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The P&P indicated physical restraints include, but are not limited to, leg restraints, arm restraints, hand mitts, soft ties, or vests, lap cushions, and lap trays the resident cannot move easily. During a review of the facility's P&P titled Person Centered Plan of Care dated 12/2016 indicated It is the policy of this facility to provide each resident with a person-centered plan of care developed that includes goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs identified during comprehensive assessment and preferences of residents as

Based on observation, interview. and record review, the facility failed to ensure residents were free from involuntary seclusion (separation of a resident from other residents) for two of 4 sampled residents by failing to: 1. On [DATE], Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1 confined (keep someone in a closed space by force) a resident (Resident 1) who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 being secluded (hidden or isolated) against her will and resulting in psychosocial harm to Resident 1. Resident 1 verbalized crying, yelling, and calling out for help, scared when doors were closed or being in dark/closed spaces, unable to sleep at night, and feeling terrified. 2. Resident 2, (Resident 1's roommate) who required total dependence on staff with transferring from bed to chair, witnessed Resident 1's involuntary seclusion while inside the same room, on [DATE]. This deficient practice resulted in Resident 2 verbalizing how the incident that happened to Resident 1 made her feel uncomfortable and anxious and thought that it could happen to her too, especially that she is bed bound and could not walk. On [DATE] at 3:26 PM, during the investigation of a complaint, the Department of Public Health (DPH) called 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) in the presence of the Administrator (ADM) and Director of Nursing (DON), in regard to one (1) resident in the facility (Resident 1) that was involuntarily secluded in the bathroom by LVN 1 and CNA 1. On [DATE] at 7:21 PM, the Department of Public Health removed the IJ while onsite after the surveyor verified the facility implemented the facility's IJ Removal Plan (a detailed plan to address the IJ findings) given by the ADM which included: 1. The assigned licensed nurse conducted a change of condition assessment for Resident 1 on [DATE] related to the possible emotional trauma or post-traumatic stress (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident) related to the involuntary seclusion. 2. The physician was notified on [DATE] . The Social Service Designee re-interviewed Resident 1 on [DATE] to allow resident to express her feelings and concerns to further identify triggers and develop a comprehensive plan of care to minimize any emotional distress. 3. The IDT will conduct a meeting on [DATE] to update Resident 1's plan of care to address the resident's potential emotional trauma related to the involuntary seclusion. Resident 1's behavior will be observed, and the Social Service Designee will complete a new trauma informed assessment by [DATE] to determine event triggers. The evening shift Licensed Nurses and Certified Nursing Assistants will be responsible to provide emotional support to the resident and on the night shift. Resident 1 currently has a hard time sleeping at night, so the nursing staff will comfort her with a bedtime routine (such as soft music, room lighting), and offer medication as ordered by the physician. 4. The assigned licensed nurse conducted a change of condition assessment for Resident 2 on [DATE] related to the possible emotional trauma or post-traumatic stress related to witnessing the involuntary seclusion that occurred with her roommate on [DATE]. The physician was notified on [DATE], and no new orders given. Social Service Designee re-interviewed resident on [DATE] to allow resident to express her feelings and concerns to further identify triggers and develop a comprehensive plan of care to minimize any emotional distress. 5. The DON, Social Services Designee (SSD), Director of Staff Development (DSD), and ADM will conduct an Interdisciplinary Team (IDT) meeting on [DATE] to update Resident 1's plan of care to address the resident's potential emotional trauma related to the involuntary seclusion. The facility's Medical Director and the Responsible Party will be invited to attend via phone as well. Resident 2's behavior will be observed, and a new trauma informed assessment will be completed by the SSD as of [DATE] to determine event triggers. 4. Based on resident interviews, the facility will update Resident 1's care plan to eliminate triggers by providing more lighting in the room, leaving doors open in the room, and providing an alternative for privacy in the room (such as shower poncho, privacy screens). The interventions to be initiated as of [DATE]. 5. The facility will initiate in-services for all staff providing direct patient care as of [DATE] regarding the revised care plan for Resident 1. The care plan information will also be disseminated to staff during each shift huddle, and department managers during stand-up meeting . 6. A trauma informed assessment will be initiated as of [DATE] for Resident 1 and Resident 2 . by social service designee. 7. As of [DATE], the SSD and/or Activity Director to conduct room visits to Resident 1 and Resident 2. The goal will be to allow to verbally vent feelings, provide activity of choice, verbally ensure they are feeling comfortable, and provide verbal reassurance to make them feel safe. These visits will occur daily at minimum of 1 a day for the next 90 days. The facility will implement a log to track the daily visits for the next 90 days as well. 8. Resident 1 was seen by the psychologist (a person who specializes in the study of mind and behavior or in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], the SSD and ADM requested the psychologist to make a visit for Resident 1 and Resident 2. The facility scheduled the psychology visit for both residents to be seen on [DATE] by the psychologist for additional emotional support. The plan is to see Resident 1 two times a week in person and/or via facetime, and for Resident 2, once a week. The DON and/or will ensure a follow-up call is made to the psychologist to ensure the scheduled visits resume. 9. Inservice training of staff will be conducted on the following topics: -Abuse Prevention Policy - [DATE], [DATE], to be completed by [DATE] -Managing Residents with Difficult Behaviors - Initiated [DATE] and will be completed by [DATE] by Psychology Group/DSD (Director of Staff Development) -Involuntary Seclusion - Initiated on [DATE] and will be completed by [DATE] -Signs and Symptoms of Mental Abuse - Initiated [DATE] and on-going -Care Planning - Initiated [DATE] and will be completed by [DATE] -Plan of Care for Resident 1 and Resident 2 - Initiated [DATE] and will be completed by [DATE] -Trauma Informed Care - to be initiated on [DATE] and completed by [DATE]. -Diversity Training / Cultural Competency to be initiated [DATE] and completed by [DATE] 10. All interviewable residents potentially affected by the deficient practice of CNA 1, CNA 2 and LVN 1's action of involuntary seclusion was interviewed on [DATE], and not affected by this deficient practice. 11. All non-interviewable residents' representatives were interviewed on [DATE], and no other resident were affected by the deficient practice. 12. Yearly all staff will be provided training on trauma, involuntary seclusion and abuse prevention and will be completed beginning [DATE]. Cross referenced to F742 Findings: 1. A review of Resident 1's 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 [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Assessment (MDS; a care assessment tool) dated [DATE], indicated Resident 1's cognition (thought process) was intact. The MDS indicated Resident 1 required extensive (means when a resident requires weight bearing support while performing part of an activity), one person assistance during transfers, toilet use, dressing, locomotion in the unit, and personal hygiene. A review of Resident 1's telephone physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's late entry Psychosocial Note dated [DATE] timed at 9:00 AM, indicated the social worker received a call from Resident 1's responsible party about Resident 1's family member's death. The Note indicated the funeral service would be on [DATE] at 2 PM. The Note indicated Resident 1 expressed sadness and episodes of crying. The Note indicated Resident 1 would be referred to a follow up psychology consult. A review of Resident 1's Licensed Nurses Notes indicated the following information: a. On [DATE] at 8:03 PM- indicated Physician 1 ordered for Resident 1 to be transferred to the acute hospital for evaluation due to sadness. The Progress Notes indicated Resident 1 would be transferred to the acute hospital the next day ([DATE]). b. On [DATE] at 8:20 PM- indicated Resident 1 came back at 4:30 PM from attending the family member's funeral. The note indicated Resident 1 looked sad. A review of the facility's Final Investigation Report Conclusion, dated [DATE], indicated the following information: On [DATE], at approximately 7:07 am, Resident 1 reported to the Director of Staff Development (DSD) she was locked (confined) in her closet last night by a staff member. The DSD inquired to clarify the incident, then immediately reported the allegation to both the ADM and Director of Nursing. He (DSD) reported Resident 1 alleged her charge nurse, LVN 1 locked her in the closet last night. She (Resident 1) stated she was locked in a dark room and was not able to get out. Per LVN 1 and CNA 1, the resident had been very restless, and agitated throughout the 11 pm to 7 am shift. Further stated she (Resident 1) did not sleep at night and was wandering throughout the facility the entire shift (11 pm to 7 am). At one point, the resident attempted to elope out (walk out without notice) of the facility, and it was at that point LVN 1 and CNA 1 took her (Resident 1) to her room. Resident 1, because she would not stay in her room, she (Resident 1) alleged LVN 1 locked her inside a closet. Several interviews were conducted with Resident 1, and her story remained consistent. Resident 1, she stated she was locked in the closet and was unable to get out. Resident 1 stated she (Resident 1) tried to get out for a while, but she was not able to. Resident 1 stated I know it was LVN 1 who did this to me, that bastard. Resident 1 was not able to tell how she eventually got out of the closet, nor the approximate time this alleged incident occurred. The same review of the Final Investigation Report Conclusion dated [DATE] above, further indicated, Resident 2 (Resident 1's roommate) stated Resident 1 was locked in the bathroom. She (Resident 2) stated she witnessed staff place the bed up against the bathroom door, and she (Resident 2) believes the resident (Resident 1) was in there. She (Resident 2) stated she heard noises coming from the bathroom as if someone was trying to get out. Resident 2 showed me (Administrator) where she claimed two (facility) staff members placed a bed against the bathroom door. She (Resident 2) stated the resident (Resident 1) had disappeared while the bed was against the door. CNA 2 stated she entered the room and witnessed LVN 1 and CNA 1, placing the bed against the bathroom door with the resident (Resident 1) already in the bathroom. She (CNA 2) stated they told her to turn her head and act like she did not see anything. A review of Resident 1's acute hospital's records indicated Resident 1 was admitted to the acute psychiatric hospital on [DATE] timed at 2:49 PM, with chief complaints of [CONDITION(S)] (used to describe conditions that affect the mind, where there has been some loss of contact with reality), acute (sudden onset) anxiety (the mind and body's reaction to stressful, dangerous, or unfamiliar situations), depression, and agitation (a state of excitement, disturbance, or worry). The acute hospital record's Psychiatric Evaluation dated [DATE], indicated Resident 1 was placed on 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness) for DTO (danger to others) and transferred to the acute hospital for inpatient psychiatric treatment. The evaluation stated Resident 1 was irritable and guarded. On [DATE] at 9:25 AM, during an interview with the Director of Nursing (DON), the DON stated during the interviews with CNA 2 and Resident 2, both stated that LVN 1 and CNA 1 locked (confined) Resident 1 in the bathroom on [DATE], by pushing the bed in front of the bathroom door. The DON stated that the incident was witnessed by CNA 2 and Resident 1's roommate, Resident 2. The DON stated involuntary seclusion is not right because it is a form of abuse and can cause emotional stress, trauma, and the incident can occur in the victim's mind, time and again. The DON stated if staff were unable to redirect residents from leaving the facility, the appropriate intervention for staff to do is to place the resident on one-to-one supervision (closely monitor), provide as needed medications such as [MEDICATION(S)] (anti-anxiety medication) as ordered by the physician, inform the attending physician (Physician 1), and the resident's responsible party, complete an SBAR (Situation, Background, Assessment and Recommendation. The DON stated if any of the implemented interventions did not work, the facility staff should call [DATE] emergency services. An Observation of the facility's surveillance video on [DATE] at 10:20 AM, in the presence of the ADM indicated the following information dated [DATE]: a. Timestamped at 5: 21 AM: Resident 1 attempted to exit the facility's front door (wheeling herself). b. Timestamped at 5:23 AM: LVN 1, accompanied by CNA 1 was seen wheeling Resident 1 in her wheelchair back to her room. c. Timestamped at 5:24 AM: CNA 2 was seen walking towards Resident 1's room and went inside the room. d. Timestamped at 5:26 AM: LVN 1, CNA 1, and CNA 2 was seen going out of Resident 1's room. e. Timestamped at 6 AM: CNA 1 and CNA 2 was seen walking back towards Resident 1's room and went back inside Resident 1's room. f. Timestamped at 6:02 AM: LVN 1 was seen walking towards Resident 1's room and entered Resident 1's room. g. Timestamped at 6:03 AM: LVN 1, CNA 1, and CNA 2 was seen exiting Resident 1's room together (40 minutes from 5:23 AM when LVN 1 and CNA 1 was seen wheeling Resident 1 to her room). h. Timestamped at 6:10 AM: Resident 1 was seen wheeling herself out of the room. On [DATE] at 10:35 AM, during the observation of the facility's surveillance video and concurrent interview of the ADM, the ADM stated that the incident of Resident 1 being confined in the bathroom inside Resident 1's room happened on [DATE] between the hours of 5:23 AM and 6:03 AM. On [DATE] at 11:05 AM, during an interview with Resident 1, Resident 1 stated one of her family members died and she was going to a funeral on that day ([DATE]). Resident 1 stated before going to her family member's funeral, during the early morning of [DATE], LVN 1 locked her in the bathroom, inside her room. Resident 1 stated, It was dark, very dark. Resident 1 stated she was inside the bathroom for a long time. Resident 1 stated she was scared while inside the bathroom and was banging on the door several times. Resident 1 stated she was crying while she was yelling and calling for help to get out, inside the bathroom. Resident 1 stated she could not remember who opened the door and when the door opened Resident 1 stated she was scared. Resident 1 stated ever since LVN 1 locked her in the bathroom, she did not like to see any doors being closed and did not like to be inside dark places. Resident 1 stated she could not sleep at night because it was very dark, It's terrifying. 2. A review of Resident 2'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 2's MDS indicated dated [DATE], indicated Resident 2 had intact cognition and memory recall. The MDS indicated Resident 2 required extensive assistance for bed mobility, totally dependent on staff for locomotion on and off units and could not walk. On [DATE] at 11:25 AM, during an interview with Resident 2, Resident 2 stated she remembered approximately two weeks ago, during the early morning (unable to recall exact date) she woke up to the noise of two people (LVN 1 and CNA 1) inside her room. Resident 2 stated she saw LVN 1 and CNA 1 pushed the bed (pointed to Resident 1's bed) in front of the bathroom door and blocked the bathroom door with the bed. Resident 2 stated that Resident 1 was not in her bed during that time. Resident 2 stated she recalled hearing a noise coming from the inside of the bathroom and Resident 2 thought she heard that someone was banging on the door, yelling, and crying. Resident 2 stated the yelling, crying and the banging on the door would stop for a while, and then continue again. Resident 2 stated that she was still awake when in about an hour, the two CNAs (CNA 1 and CNA 2) came back inside the room and pushed the bed back towards the wall. Resident 2 stated after that, she saw Resident 1 coming out of the bathroom in her wheelchair and wheeled herself to bed. Resident 2 stated the incident that happened to Resident 1 made her feel uncomfortable and anxious and thought that it could happen to her too, especially that she is bed bound and could not walk. On [DATE] at 12:13 PM, during an interview with the Social Services Director (SSD), the SSD stated prior to the incident, she informed Resident 1 that the resident's family member passed away and that she would accompany the resident to the funeral that was scheduled to be held on [DATE] in the afternoon. The SSD stated she came to the facility early that morning ([DATE]) to get Resident 1 ready for the family member's funeral when Resident 1 informed her that LVN 1 and CNA 1 locked her in the bathroom earlier that same day ([DATE]). The SSD stated she informed the DSD and the police. During the same interview with the SSD and concurrent interview of the SSD's psychosocial notes, on [DATE] at 12:13 PM, indicated no documented evidence addressing the resident's fears from being confined and secluded in the bathroom by facility staff. The SSD stated she did not ask questions or talked to Resident 1 about the incident that happened on [DATE] or offered additional psychosocial support because the resident was more focused on the death of the family member. The SSD stated that after the resident's family member's death, the Psychologist she had referred Resident 1 to was not able to come and visit. The SSD stated that Physician 1 had ordered for Resident 1 to be transferred to the acute psychiatric hospital for further evaluation due to sadness. The SSD stated Resident 1 was transferred on [DATE] to the acute psychiatric hospital. On [DATE] at 12:58 PM, during an interview with the DSD, the DSD stated Resident 1 is alert and oriented to person, time, and place. The DSD stated that sometimes Resident 1 would go to other residents' room, but Resident 1 can be easily redirected back to her room. The DSD stated that on [DATE], at 7:09 AM, Resident 1 informed him that LVN 1 confined her in a dark room for a long time and Resident 1 stated she was trying and trying to get out, but she could not get out. On [DATE] at 1:35 PM, during another interview with the SSD, the SSD stated that confining Resident 1 in the bathroom was not acceptable because it is a form of abuse. The SSD stated it can negatively affect and cause trauma to Resident 1. The SSD stated Resident 1 was having some anxiety issues. The SSD stated that she had noticed since Resident 1 was readmitted back to the facility (on [DATE]), Resident 1 had showed fear of closed doors and the lights in her room being off or dark. On [DATE] at 2 PM, during an interview with LVN 2, LVN 2 stated Resident 1 tends to go to other residents' room but can be easily redirected back to her room. LVN 2 stated that confining Resident 1 in bathroom is a type of abuse that could lead to serious mental and physical injuries, even dying. LVN 2 stated that involuntary seclusion can lead to [CONDITION(S)] (post-traumatic stress disorder- a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). On [DATE] at 2:14 PM, during an interview with CNA 3, CNA 3 stated that she was assigned to Resident 1 on [DATE], during the morning shift (7 AM to 3 PM shift). CNA 3 stated that on [DATE], during the morning shift, she assisted Resident 1 in getting ready for the family member's funeral. CNA 3 stated Resident 1 attempts to go to other resident's rooms but can easily be redirected back to her room. CNA 3 stated she had observed Resident 1 sad and crying that day ([DATE]). On [DATE] at 2:43 PM, during an interview with ADM, the ADM stated involuntary seclusion is against residents' rights, and it is a form of abuse. The ADM stated it can result in fear and can be viewed as a form of punishment physically and mentally. On [DATE] at 1:30 PM, during an observation in the resident's room, CNA 3 was assisting Resident 1 during toileting inside the bathroom with the door wide open. During a subsequent interview with CNA 3, CNA 3 stated Resident 1 told her a week ago that she did not want the bathroom door to be closed because it makes her anxious. CNA 3 stated she respected the request of Resident 1 to keep the bathroom door open during toileting. On [DATE] at 2:38 PM, during an interview with Registered Nurse (RN) 1, RN 1 stated involuntary seclusion is a form of abuse that can cause mental, physical harm, and stress to the resident. On [DATE] at 11:02 AM, during a telephone interview with CNA 1, CNA 1 stated she was familiar with Resident 1, and most of the time Resident 1 was assigned to her during the night shift (11 PM to 7 AM). CNA 1 stated she was assigned to Resident 1 on [DATE], during the 11 PM to 7 AM shift. CNA 1 stated Resident 1 was wheeling around the facility more than usual on [DATE] from 11 PM to 5AM ([DATE]). CNA 1 stated Resident 1 was restless and going to other residents' rooms. CNA 1 stated she did not know about Resident 1's family member's recent death. CNA 1 stated Resident 1 told CNA 1 she was going to miss the family member's funeral. CNA 1 stated she did not call Resident 1's responsible party and did not offer any activities to redirect Resident 1. CNA 1 declined to comment regarding the alleged incident of confining Resident 1 in the bathroom the morning of [DATE]. On [DATE] at 12:28 PM, during a telephone interview with CNA 2, CNA 2 stated that on [DATE] at around 5:20 AM, when she walked into Resident 1's room, she observed LVN 1 and CNA 1 pushing Resident 1's bed against the bathroom door. Resident 1 was unable to come out of the bathroom. CNA 2 stated she heard Resident 1's wheelchair hitting the door and Resident 1 screaming and banging on the door. CNA 2 stated that LVN 1 and CNA 1 told CNA 2 that she (CNA 2) did not see anything, as they walk out of the resident's room. CNA 2 stated she could hear Resident 1 screaming for help. CNA 2 stated that around 6:10 AM, she and CNA 1 went back to Resident 1's room. CNA 1 stated she saw Resident 2's (Resident 1's roommate) bed on a high fowler's (seated upright with their spine in straight position), wide awake with eyes wide and with shocked look on her face. CNA 2 stated that Resident 2 was looking at CNA 1 and CNA 2. CNA 2 stated she and CNA 1 moved the bed back towards the wall. CNA 2 stated when CNA 1 opened the bathroom door, Resident 1 was still sitting on her wheelchair, and that it was very dark in the bathroom because the light was off in the bathroom. CNA 2 stated she saw Resident 1's face was red, very angry, and at the same time very upset. CNA 2 stated Resident 1's hands were on the wheelchair as she wheeled herself out of the bathroom. CNA 2 stated CNA 1 told Resident 1 to lie down in bed. CNA 2 stated that she should have intervened and not let LVN 1 and CNA 1 confine Resident 1 in the bathroom and call [DATE]. On [DATE] at 1:15 PM, during a telephone interview with Resident 1's responsible party (RP1), RP 1 stated Resident 1 informed her that LVN 1 confined her in the bathroom. Resident 1 told RP1 that after the incident, Resident 1 was terrified being in the dark and did not want the bathroom door to be closed. RP 1 stated that their family member passed away on [DATE] and Resident 1 was informed about it and the funeral was scheduled on [DATE] in the afternoon. On [DATE] at 5:02 PM, during a telephone interview with LVN 1, LVN 1 stated he was assigned to Resident 1 on [DATE] during the 11 PM to 7 AM shift. LVN 1 stated Resident 1 told him she wants to go to the family member's funeral. LVN 1 stated Resident 1 was restless during the whole night shift, wheeling around the facility and going to other resident's rooms. LVN 1 stated that around 5 AM, they found Resident 1 outside of the facility. LVN 1 stated he wheeled Resident 1 back to her room with CNA 1 and left Resident 1 sitting on the wheelchair. LVN 1 denied all allegations of confining Resident 1 in the bathroom in the early morning of [DATE]. A review of the facility's policy and procedure titled Abuse and Neglect Prohibition Policy updated in [DATE], indicated It is the facility's policy to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all residents . The policy indicated The purpose of the policy is to ensure that facility staff are doing all that is within their control to prevent occurrences of abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all residents . Abuse is defined as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health including the following: Involuntary seclusion is defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident's legal representative.

Based on interview and record review, the facility failed to follow its policies for Fall and Change of Condition by failing to notify the physician for one of three sampled residents (Resident 1) when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] On 2/2/20 at 6 a.m., Certified Nurse Assistant 1 (CNA 1) found Resident 1 on the floor next to the resident's bed with her legs bent to the right. CNA 1 and Housekeeper 1 (HK 1) transferred Resident 1 from the floor to the resident's bed without reporting the fall. As a result, Resident 1 experienced severe pain (pain that prevent the resident from performing daily living activities), and the resident did not receive timely treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross Reference: F697 S/S D Findings: A review of Resident 1's Admission Record, indicated the facility admitted the resident on 11/26/17, and readmitted the resident on 10/22/19, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Care Plan for Dementia dated 10/22/19, indicated the resident was at high risk for further decline. The approached intervention was to notify the resident's physician on any significant changes in Resident 1's conditions. A review of Resident 1's History and Physical dated 10/23/19, indicated the resident had a fluctuating (continually change) capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 1/26/20, indicated the resident had severe impairment in cognitive skills (brain uses to think, read, learn, remember, reason, and pay attention) for daily decisions making. Resident 1 required extensive assistance for transfers and bed mobility with two-persons assist. The MDS indicated the resident did not have limitations that interfered with daily functions to her lower extremities (hip, knee, ankle, and foot). A review of Resident 1's Fall Reduction Care Plan Fall dated 2/3/20, indicated the resident had a suspected fall. The care plan indicated that on 2/2/20, CNA 1 found Resident 1 on the floor. The care plan indicated CNA 1 and HK 1 transferred Resident 1 back to bed and CNA 1 did not communicate with a Licensed Nurse (unidentified) regarding Resident 1's fall. A review of Resident 1's Change of Condition Notes dated 2/3/20, timed at 7:40 a.m., indicated Resident 1 complained of pain (no pain level indicated on the notes), had discoloration on her right hip, and was unable to move her legs due to pain. The notes indicated a facility's staff (unidentified) notified Resident 1's physician on 2/3/20 at 9:26 a.m. (more than 27 hours after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 1's Physician Telephone Orders dated 2/3/20, and timed at 11:27 a.m., indicated for the resident to receive an X-ray (a photographic/digital image of the internal part of the body) to the right hip due to right hip pain and discoloration. A review of Resident 1's Physician Telephone Orders dated 2/3/20, and timed at 10:41 p.m., indicated to transfer the resident to a General Acute Care Hospital (GACH) in the morning for further evaluation and treatment due to right hip pain and severe [CONDITION(S)]. A review of Resident 1's Radiology Patient Report from the facility dated 2/3/20, and timed at 11:47 p.m., indicated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Physician Order, dated 2/3/20 indicated for the resident to receive [MEDICATION(S)] (medication used to treat fever, swelling and pain) 200 milligrams (mg) 3 tablets by mouth every 12 hours as needed for mild to moderate pain. A Review of Resident 1's Right Hip Pain and Discoloration Change of Condition Notes, dated 2/4/20, untimed, indicated the resident complained of pain 6/10 (moderate pain) to her hip (unidentified side) and the resident received a warm compress for pain. The notes did not indicate Resident 1 receive the [MEDICATION(S)] to reduce her pain. A review of Resident 1's Nurses Progress Notes dated 2/4/20, timed at 8:30 a.m., (two days after the unwitnessed fall) indicated two paramedics transferred the resident to a GACH. A review of the facility's Final Investigation Report dated 2/9/20 indicated Resident 1's right [CONDITION(S)] was a result of an unwitnessed fall that occurred on 2/2/20 at 6 a.m. The report indicated CNA 1 noted Resident 1 was sitting on the floor next to the bed with her legs bent and leaning on the right side. The report indicated CNA 1 and HK 1 transferred Resident 1 from the floor back to the bed and did not report the fall incident to the charge nurse. A review of Resident 1's GACH records, titled Discharge Summary, with a discharge date of [DATE], indicated the GACH admitted the resident secondary to a right [CONDITION(S)] after sustaining a fall and [CONDITION(S)]. The discharge summary indicated the resident described her hip pain as aching, rated as 8/10 (severe pain-unable to perform daily living activities) and her symptoms were aggravated with movement. Resident 1 received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge summary indicated a two-view hip X-ray was done on 2/4/20, and revealed a fracture within the base of the right femur (thigh bone) with intertrochanteric extension ([CONDITION(S)]) suspected. Resident 1 received orthopedics (a branch of medicine dealing with the correction of deformities of bones or muscles) consultation and was referred to Physical Therapist (movement experts who improve quality of life through prescribed exercise, hands-on care, and patient education). During a telephone interview on 4/16/20, at 2:30 p.m., HK 1 stated that on 2/2/20 at 6 a.m., Resident 1 was on the floor with her right knee bent and CNA 1 asked him to assist her (CNA 1) to move Resident 1 to the bed. HK 1 stated they (CNA 1 and HK 1) transferred Resident 1 from the floor back onto the resident's bed by holding the resident's armpits. During two telephone interviews on 4/16/20, at 3:22 p.m. and at 3:45 p.m., CNA 1 stated she was busy and discontinued the phone interviews. During a telephone interview on 6/4/20 at 10:44 a.m., the facility's Director of Staff Development (DSD) stated on 2/2/20, CNA 1 did not follow the facility's Fall policy and procedure. The DSD stated CNA 1 failed to notify Licensed Vocational Nurse 1 (LVN 1) after finding Resident 1 on the floor so LVN 1 could assess the resident and call the physician for further orders. The DSD stated CNA 1 and HK 1 did not need to transfer Resident 1 back to bed. A review of the facility's undated policy and procedure, titled Falls, indicated for the first staff member who arrived at the scene when a resident has fallen to not move the resident unless directed by a licensed nurse or a physician. A review of the facility's undated policy and procedure, titled Change of Condition, indicated for staff to notify the attending physician promptly when there was an accident involving residents, which resulted in injury and had the potential for requiring medical intervention. The policy indicated in emergency situations such as a fall with a possible fracture, the Registered Nurse would assess the resident and immediately call the attending physician.

Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread of infections during the Coronavirus ((COVID-19) an illness caused by [MEDICAL CONDITION] that can spread from person to person) crisis for 32 of 37 Non-COVID-19 residents, staff members, and visitors by failing to ensure: 1. Staff and/or visitor did not pass by the clean area (Non-COVID-19) after going to the dirty area (COVID-19). 2. There was a physical barrier separating the COVID-19 area from the Non-COVID-19 area. 3. Staff correctly donning and doffing Personal Protective Equipment (PPE). 4. Dedicated staff assigned to work only in the COVID-19 area. 5. The doors of the residents in isolation room remained close. 6. Areas for breakroom, restroom and charting areas were designated for the staff taking care of residents that are COVID-19 positive. 7. Dedicated entrance and exit for the COVID-19. These deficient practices caused an increased risk in the development and transmission of communicable disease and infections which could result in death due to COVID-19 crisis. On 5/24/19 at 10:34 a.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and the facility Director of Nursing (DON) for the facility's failure to implement measures to prevent infections that threatened the health and safety of 32 residents, all staff and all visitors. On 5/27/20 at 12:30 p.m., after the facility submitted an acceptable plan of action (POA), the survey team verified on on-site the implementation of the POA by observation, interviews, and record review and confirmed the removal of the immediate jeopardy in the presence of the Administrator. The Administrator provided an acceptable POA as follows: A. Location of the residents that are currently affected were consolidated to rooms 1 & 2 which is isolated to a specific wing of the facility 5/24/2020. B. rooms [ROOM NUMBERS] doors are kept closed since 5/24/2020. C. A zipper wall barrier will be installed diagonally to accommodate and include room [ROOM NUMBER] which will separate the COVID-19 area on 5/25/2020. D. room [ROOM NUMBER] will be used by assigned staff for area lunch and charting area to prevent mingling of assigned staff from Non-CoViD19 area. E. CNA 1 and all nursing staff were provided in-service training by DON re: infection control, handwashing, donning and doffing and how to remove N95 masks with gloves starting 5/24/2020 and completed by 5/25/2020. F. Dedicated staff has been assigned for COVID and Non-COVID area separately. COVID staff can enter and exit thru section of COVID area. G. All CoViD19+ patients were moved to consolidate the area for which COVID-19 patients will be cared for and was completed on 5/24/2020. H. All nursing staff were provided inservice training by DON re: infection control, handwashing, donning and doffing and how to remove N95 masks with gloves starting 5/24/2020 and completed by 5/25/2020. I. The facility will continue to use room [ROOM NUMBER] as a dedicated area for COVID19 staff charting and lunch area. J. The Director of Nursing Service (DON) and DSD Infection Preventionist (IP) Nurse will conduct daily checks of the compliance of the COVID-19 unit and staffing to ensure continuation of separation of staff assigned for the COVID and Non-COVID Unit. Any non-compliance will be brought up to DSD IPNurse for further follow up and training needs. K. Hand hygiene, donning and doffing competencies will be completed at least once a week by the DON/DSD IPNurse to ensure that staff is compliant with practices. L. Staff will no longer use the lab coats, instead going to the COVID unit, staff will use the washable gown, then going inside the patient's room using the disposable gown. (330 in house and 150 at the Corporate). In-service will be done by the DSD IP Nurse on 5/26/2020, completed on 5/27/2020 for staff regarding using the disposable gowns when entering the residents room to provide care. M. The Staff working in the COVID Positive area will be provided a new N95 mask daily at the beginning of the shift. The DSD IP Nurse will in-service the staff to get a new N95 mask each day at the beginning of their shift on 4/26/2020, completed on 5/27/2020. The N95 mask will be available at the entrance of the COVID area at all times. Findings: A review of the facility's census, dated 5/24/20, indicated the facility had 37 residents residing in the facility. A review of facility's document indicated the facility had 5 COVID-19 positive residents and 32 COVID-19 negative residents. 1. During an observation on 5/24/20 at 10:50 a.m., the COVID-19 isolation area (rooms for COVID positive residents) had no barrier (a device used to differentiate a hallway area) or separation from the Non -COVID area (rooms for COVID negative residents). When the staff/visitors entering and exiting the facility, they will pass the COVID-19 area before going to the non-COVID-19 area. Two of three rooms in the isolation area (room [ROOM NUMBER] and room [ROOM NUMBER]) were observed with the door open. During an interview, on 5/24/20 at 10:50 a.m., Registered Nurse 1 (RN 1) stated that everyone uses the front door to come in the facility and passing through the COVID-19 area in order to get to the Non-COVID-19 area. RN 1 said the isolation room doors were supposed to be close. RN 1 also stated the facility had limited supply for gowns and they used washable long sleeve lab coats. 2. During an observation on 5/24/20 at 11:35 a.m., the staff who worked in the green zone (Non-COVID-19) and the red zone (COVID-19) were having meals in the same breakroom. During an interview on 5/24/20 at 11:35 a.m., RN2 stated the staff, who are assigned to green zone duties, should not eat in the red zone breakroom. RN 2 did not know why the staff did not follow this rule. During an interview on 5/24/20 at 11:35 a.m., Certified Nursing Assistant (CNA) 1 stated the facility has designated green and red zone breakrooms, but the refrigerator for the employees is in the COVID-19 area breakroom. CNA 1 further stated all staff members enter the COVID-19 breakroom to get food from the refrigerator and sometimes stay and eat in that break room. CNA1 also stated there is only one charting area for both COVID-19 and non-COVID-19 staff members. 3. During an observation on 5/24/20 at 11:40 a.m., CNA 2 entered isolation room, (room [ROOM NUMBER]), with no gown and no face shield. CNA 2 was exiting the room with her mask N95 still on and then removed it without gloves. During an interview on 5/24/20 at 11:45 a.m., CNA2 stated she was assigned to both COVID-19 (rooms 2, 3, 4) and Non-COVID-19 (room [ROOM NUMBER]) residents. CNA2 stated she was not wearing an isolation gown because she had a lab coat that she hangs inside the residents' door and she dons inside the room. She said some of the lab coats are too small for her and will not close, but that she still wears it. When asked if she could get a coat that would fit her, she said that sometimes they are not washed or ready for her to wear. She said that the coats are not disinfected after each use, are used for one shift, and then disposes it in the dirty clothes hamper for cleaning. She said sometimes the N95s are too small for her and they do not fit her. She said she has not had an N95 fit test. 4. During an interview on 5/24/20 at 2:45 p.m., the Director of Nursing stated she tries to assign staff for COVID-19 only but if not, then they need to start caring for the residents in the green zone (Non-COVID-19) first, then the red zone (COVID-19). She said the staff put on the lab coat inside the resident's rooms. During an interview, on 5/25/20 at 10:33 a.m., Licensed Vocational Nurse 1 stated that she administers medication to the non-COVID-19 residents first and then goes to the COVID-19 area to administer medication to the residents with COVID-19 positive. 5. During an observation on 5/24/20 at 2:46 p.m., Visitor 1 walked inside the facility pass through the COVID-19 isolation area into the Non-COVID-19 area. Resident 1, who was wearing a surgical mask that was not covering her nose, passed the isolations (rooms [ROOM NUMBERS]) with open doors. During an interview, on 5/25/20 at 11:21 a.m., the Director of Staff Development stated that he in-serviced the staff to Don (to put on) isolation gear inside the residents' rooms so long as they didn't touch anything. He stated that he told them to reuse the lab coats because they were short on PPE, and he told them to have one lab coat per room and dispose it at the end of the shift. On 5/25/20, the facility did not submit an acceptable plan of action (POA) to the Department. The Department informed the ADM the IJ was not lifted. On 5/25/20 at 3:45 pm, the DON and Nurse Consultant were notified that the POA was not accepted. During an observation on 5/26/20 at 2:45 p.m., the barrier for the COVID-19 isolation unit was not sealed along the top and bottom edge of the barrier. During an interview on 5/26/20 at 2:45 p.m., the DON stated she could see the gaps in the barrier on the top and bottom edges. She said the barrier should be reinforced and sealed. During an interview on 5/26/20 at 2:15 p.m., LVN2 stated that she uses reusable gowns when entering the isolations rooms. She said that she puts one on top of the gown she is wearing and then takes the top gown off when exiting the room. She said she puts in in the hamper in the corridor and if she has to go back into the room she gets new, reusable gown. She said she does not have access to disposable gowns. When asked about N95 mask, she stated that she gets one N95 mask for three days use. She said she stores in it in a plastic bag and reuses it for three days unless it is visibly dirty or wet. When asked about what the direction for extended us of N95, she said she didn't know, but she just puts in it a plastic bag until the next shift. During an interview, on 5/26/20 at 2:30 p.m., CNA3 stated that she uses one N95 mask for three days and puts it in a plastic bag. She stated that she gets a new one every three days. When asked about procedure to extend the use of N95, she said she did not know. A review of the facility's Mitigation Management Plan dated 5/28/20 indicated the following: The facility has a dedicated space within the facility to ensure separation of infected patients and for eliminating movement of health care practitioner (HCP) among those spaces to minimize transmission risk. All residents with COVID-19 infection confirmed by testing, or those residents who are recovering from COVID-19 infection, will be separated from residents who are not infected or have unknown infection status are placed in dedicated COVID-19 positive wings. Residents that are COVID-19 positive will be placed and cohorted either using in single-occupancy rooms or cohorted into a multi-occupancy room with other confirmed cases. Symptomatic residents with suspected COVID-19 infection may remain in their room (if multi-occupancy room, with 6 feet, or as far as possible, between beds and curtains closed) while testing is pending. The facility has implemented a staffing plan to limit transmission which includes: Dedicated, consistent staffing teams who directly interact with residents that are COVID-19 positive. Limiting clinical and other staff who have direct resident contact to specific floors or wings. There should be no rotation of staff between floors or wings during the period they are working each day. An established policy to minimize the number of staff interacting with each resident. The SNF has policies in place to address HCP shortages, including contingency and crisis capacity strategies. The facility has personal protective equipment (PPE) plan for adequate provision of PPE, including types that will be kept in stock, duration the stock is expected to last. Signs are posted immediately outside of resident rooms indicating appropriate infection control and prevention precautions and required PPE in accordance with CDPH guidance. Necessary PPE is immediately available outside of the resident room when there are units with separate cohorted spaces for both COVID-19 positive and negative residents or in the corridor near rooms in dedicated COVID-19 units and in other areas where resident care is provided. Trash disposal bins are positioned as near as possible to the exit inside of the resident room to make it easy for staff to discard PPE after removal, prior to exiting the room, or before providing care for another resident in the same room when there are units with separate cohorted spaces for both COVID-19 positive and negative residents. PPE are also available for all visitors and are provided upon screening.