Every finding on record at Golden Haven Care Center

Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan to address the resident's medical and physical needs for one of six sampled residents (Resident 6), who had a history of seizure and was non-compliant in using her soft-shell helmet when out of bed, as per physician's order. This deficient practice had the potential to compromise the facility's ability to provide consistent care specific to Resident 6's needs.Findings: During a review of Resident 6's admission Record (AR), the AR indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included epilepsy (a brain disorder that causes unprovoked seizures { a sudden, uncontrolled burst of electrical activity in the brain}), intellectual disabilities (a person has significantly more difficulty learning, problem-solving, and understanding complex ideas) and anxiety disorder ( feelings of fear, dread, and tension are persistent, excessive, and disproportionate to the actual situation). During a review of Resident 6's History and Physical Examination (HPE), dated 1/6/2026, the HPE indicated Resident 6 does not have the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 6/12/2026, the MDS indicated Resident 6's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 6 required partial/moderate assistance (helper does less than half the effort) with personal hygeine and substantial/maximal assistance (helper does more than half the effort) with eating, toileting, bathing and dressing. During a review of Resident 6's facility document titled SBAR Communication Form (written communication tool that helps provide essential, concise information, usually during crucial situations) dated 2/21/2026, the Form indicated Resident 6 had a self-resolve seizure activity. During a review of Resident 6's facility document titled SBAR Communication Form dated 5/17/2026, indicated Resident 6 had a self-resolve seizure activity. During a review of Resident 6's facility document titled Order Summary Report (OSR) dated 7/9/2026, the OSR indicated Resident 6 may wear soft shell (helmet lightweight, flexible protective headgear used by individuals with seizure disorders) when out bed for seizure precaution- ordered 1/4/2026. During a concurrent observation and interview on 7/9/2026 at 4:10 PM with the Director of Nurses (DON) in the activity room, Resident 6 was observed sitting in her wheelchair but was not wearing her soft-shell helmet. DON stated, Resident 6 was always non-compliant in wearing her helmet. During a concurrent interview and record review on 7/9/2026 at 4:20 PM with the DON, Resident 6's electronic health record (EHR) from readmission 1/4/2026 up to 7/9/2026 was reviewed. Resident 6's EHR did not indicate a person-centered care plan was developed for Resident 6's non-compliance in wearing her soft-shell helmet. DON stated, a care plan should have been initiated for noncompliance for Resident 6 not wearing the soft-shell helmet. The DON stated the non-compliance should be care planned since it was specific to Resident 6's care needs and to ensure facility staff were aware and could provide consistent care. During an interview on 7/9/2026 at 4:40 PM with Certified Nurse Assistant (CNA) 1, CNA 1 stated when she attempted to place Resident 6's soft-shell helmet onto Resident 6's head, Resident 6 refused and would become agitated. During an interview on 7/9/2026 at 4:45 PM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 6 refused to wear her soft-shell helmet sometimes and would become agitated and then take of the soft-shell helmet. LVN 1 stated it was important to ensure a specific care plan for resident non-compliance was initiated , to ensure the facility's staff were on the same page in implementing alternative plans to address the non-compliance, such as frequent monitoring, or placing the resident close to the station. During an interview on 7/9/2026 at 4:55 PM with the DON, DON stated Resident 6 did not have a specific care plan for non-compliance in wearing her soft-shell helmet. DON stated, it is important to have a specific care plan for Resident 6's non-compliance, so staff would have consistent care and alternative measures to address the noncompliance, such as close monitoring. DON stated, not having a consistent plan of care from Resident 6's noncompliance, had the potential for major head injury during a seizure activity. A review of the facility's policy and procedure (P&P) titled, Seizure Precautions, dated 1/1/2026, indicated, the facility will provide preventative measures prior to and during seizure activity to prevent resident injury to the extent possible, precautions are planned using information obtained from resident's history. A review of the facility's P&P titled, Care Planning, dated 1/1/2026, indicated; a) comprehensive person-centered care plan is developed for each resident based on their individual assessed needs, and b) each resident's comprehensive care plan will describe interventions that are to be furnished to attain and maintain the resident's practicable physical mental and psychosocial well-being, and interventions and services that would be required but are not provided due to resident's exercise of rights, which include rights to refuse treatment.

Based on interview and record review, the facility failed to monitor three of three sample residents (Resident 7, 67, and 82) reviewed for pharmacy services for the adverse side effects (unwanted, uncomfortable, or dangerous reactions caused by medication or medical treatments) in their drug regimen to prevent unnecessary drug use by failing to: 1. Monitor Resident 7 for the adverse side effect of Tramadol HCL (powerful pain-relieving medication for moderate to severe pain) oral tablet 50 milligrams (mg, unit of mass) that the resident received for pain. 2.Monitor Resident 67 and 82's for the adverse side effect of Hydrocodone-Acetaminophen (Norco, powerful pain-reliving medication for moderate to severe pain) that the residents received for pain. 3. Implement interventions for Resident 7's Tramadol use and Resident 67 and 82's Hydrocodone-Acetaminophen use to indicate the adverse side effects to monitor while receiving the pain medications such as respiratory depression, nausea, and increased drowsiness, lethargy (decreased alertness) and sedation (sleepiness). These failures had the potential to result in Resident 7, Resident 67, and Resident 82 not to receive immediate care or not receive any care when the resident develops an adverse side effects such may include excessive sedation and lead to coma and death related to Tramadol and Hydrocodone-Acetaminophen. Findings: 1.During a review of Resident 7's admission Record (AR), the facility admitted Resident 7 on 4/17/2025 and readmitted Resident 7 on 12/20/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and polyneuropathy (multiple damaged peripheral nerves that causes weakness, numbness, tingling, and pain). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills were intact. The MDS indicated Resident 7 was dependent (helper does all the effort) for ADLs such as toileting and showering and was dependent on staff when repositioning herself in bed. The MDS indicated Resident 7 was on a scheduled pain medication regimen and received as needed pain medication, and the MDS indicated Resident 7 did experience frequent pain. The MDS indicated that Resident 7 was taking an opioid (powerful pain-relieving medication). During a review of Resident 7's Order Summary Report, the order, start date 12/20/2025, indicated Resident 7 was ordered to receive Tramadol HCL with instructions to give 1 tablet by mouth every 12 hours as needed for moderate to severe pain, which included a pain severity of 4 to 10 out of 10 pain severity on the numerical pain scale (tool used to measure severity of form 0 to 10/10; 0 = no pain, 10 = worst pain imaginable). 2.During a review of Resident 67's AR, the facility admitted Resident 67 on 8/21/2025 and readmitted Resident 67 on 9/15/2025 with diagnoses that included COPD, osteoporosis (weak and brittle bones due to lack of calcium and vitamin D), and polyneuropathy (a disease or damage affecting multiple peripheral nerves throughout the body simultaneously, often resulting in symmetrical numbness, tingling, and weakness, typically starting in the feet and hands. During a review of Resident 67's MDS, dated [DATE], the MDS indicated Resident 67's cognitive skills were moderately impaired. The MDS indicated Resident 67 had a pain medication regimen, and the MDS indicated Resident 67 denied pain at that time. The MDS indicated that Resident 7 did not use an opioid. During a review of Resident 67's Order Summary Report, the order, start date 9/16/2025, indicated Resident 67 had Hydrocodone-Acetaminophen tablet 5-325mg with instructions to give 1 tablet by mouth every 6 hours as needed for severe pain such as 7 to 10 out of 10 pain severity on the numerical pain scale. 3.During a review of Resident 82's AR, the facility admitted Resident 82 on 1/23/2025 and readmitted Resident 82 on 2/15/2025 with diagnoses that included acute and chronic respiratory failure (RF, a condition where there is not enough oxygen or too much carbon dioxide [a colorless and odorless gas that is a waste product when mammals breathe out] in the body) with hypoxia (low levels of oxygen in blood), age- related osteoporosis, and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the left elbow and hand. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 87's cognitive skills were moderately impaired. The MDS indicated Resident 82 was on a scheduled pain medication regimen and received as needed pain medication, and the MDS indicated Resident 82 did experience frequent pain. The MDS indicated that Resident 82 was taking an opioid. During a review of Resident 82's Order Summary Report, an order, dated 3/3/2025, indicated Resident 82 had Hydrocodone-Acetaminophen tablet 5-325mg with instructions to give 1 tablet by mouth every 6 hours as needed for severe pain such as 8 to 10 out of 10 pain severity on the numerical pain scale. During a concurrent interview and record review on 1/16/2026 at 10:47 AM with Licensed Vocational Nurse (LVN) 3, Resident 7's Order Summary Report was reviewed. LVN 3 stated Resident 7's Tramadol order was considered an opioid. LVN 3 stated that there was no physician's order to monitor the adverse effects of Tramadol. During the same concurrent interview and record review on 1/16/2026 at 10:50 AM with LVN 3, Resident 7's care plans were reviewed. LVN 3 stated Resident 7's Tramadol care plan and did not indicate to monitor the resident for the specific adverse side effects of Tramadol use. During the same concurrent interview and record review on 1/16/2026 at 10:55 AM with LVN 3, Resident 67's Order Summary Report and care plans were reviewed. LVN 3 stated Resident 67's order for Hydrocodone-Acetaminophen was considered an opioid. LVN 3 stated, there was no physician order to monitor for the adverse effects of Hydrocodone-Acetaminophen use. LVN 3 stated, Resident 67's care plan for Hydrocodone-Acetaminophen did not indicate to monitor the resident for adverse effects of Hydrocodone-Acetaminophen use. During the same concurrent interview and record review on 1/16/2026 at 11 AM with LVN 3, Resident 82's Order Summary Report and care plans were reviewed. LVN 3 stated, Resident 82's order for Hydrocodone-Acetaminophen physician order to monitor the side effects of Tramadol use. LVN 3 stated, Resident 67's care plan for Hydrocodone-Acetaminophen did not indicate to monitor the specific adverse side effects of Hydrocodone-Acetaminophen use. During the same interview on 1/16/2026 at 11:05 AM with LVN 3, LVN 3 stated that it was important to monitor the side effects of opioids because the adverse side effects of excessive opioid use may cause decrease respirations and decrease oxygen levels which may lead to excessive sedation and eventually coma or death. During an interview on 1/16/2026 at 1:40 PM with the Director of Nursing (DON), the DON stated, it was important to monitor the side effects of opioid medications such as the respiratory effort, respirations, oxygen levels, and lethargy (feeling sluggish and unusually tired or sleepy) because these adverse side effects may lead to excessive sedation that could result in a coma or death. During the same concurrent interview and record review on 1/16/2026 at 1:45 PM with the DON, Resident 7's, 67's, and 82's Order Summary Report were reviewed. The DON stated that Resident 67 and Resident 82 did not have a current active order to monitor for adverse side effects of Hydrocodone-Acetaminophen. During the same concurrent interview and record review on 1/16/2026 at 1:55 PM with the DON, Resident 7's, 67's, and 82's care plans were reviewed. The DON stated that Resident 7 had a care plan for Tramadol, but the care plan did not indicate monitoring the specific adverse side effects of Tramadol that may affect Resident 7. The DON stated that Residents 67 and 82 had a care plan for Hydrocodone-Acetaminophen, but the care plan did not indicate to monitor for the specific adverse side effects Hydrocodone-Acetaminophen that may affect Resident 67 or 82. During the same interview on 1/16/2026 at 2:05 PM with the DON, the DON stated it was important to indicate what adverse side effects the opioid medication may have on a resident to ensure the licensed nurses became aware of what adverse side effects to monitor and to report to the physician. During a review of the facility's policies and procedures titled Medication Administration - General Guidelines, dated December 2019, the P&P indicated that the staff should be monitoring side effects or other mediation-related problems continually. During a review of the facility's P&P titled, Administration Procedures for All Medications, dated December 2019, the P&P indicated to monitor for side effects or adverse drug reactions immediately after administration and throughout each shift.

Based on observation and interview the facility failed to ensure foods were properly stored and sealed in accordance with the Policy and Procedure titled, Food storage, preparation, distribution and serving food. This deficient practice 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 organisms that cause illness such as bacteria, viruses, or parasites) and toxins. Findings: During a concurrent initial kitchen observation and interview with the Dietary Supervisor (DS) on 1/13/2026 at 9:20 AM, the dry food storage was observed. A plastic food container which contained dehydrated bread pudding was open, with the lid not on. The DS stated the container that contained the dehydrated banana pudding was not properly closed and was exposed to air which would contaminate the food contents.DS stated that if the pudding was contaminated and served to the residents, it could result in foodborne illness. During a review of the facility's policy and procedures (P&P) titled, Food Storage revised 1/1/2026, indicated that food items will be stored, thawed, and prepared in accordance with good sanitary practice. The P&P indicated any opened products should be place in storage containers with tight fitting lids.

Based on observation and interview the facility failed to ensure one of five sampled residents' (Resident 30) call light were within reach and easily accessible for use. This deficient practice had the potential for Resident 30 not to be able to call for assistance when needed especially during emergency and not to receive care or receive delayed care. Findings: During a review of Resident 30's admission Record (AR), the AR indicated that Resident 30 was admitted to the facility on [DATE] with diagnoses including hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (known as CVA/stroke- loss of blood flow to a part of the brain) affecting left dominant side, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified visual loss. During a review of Resident 30's Minimum Data Set (MDS, a resident assessment tool) dated 12/25/2025, the MDS indicated Resident 30 had moderately impaired cognitive skills for daily decision making. The MDS also indicated that Resident 30 required substantial/maximal assistance (helper does more than half the effort) on oral hygiene, personal hygiene, and upper body dressing. During a concurrent observation and an interview on 1/13/2026 at 9:39 AM with Resident 30, Resident 30 was observed lying in bed. Resident 30 stated that she needed assistance to be placed in a comfortable position and to reposition her left arm. Resident 30 stated she could not see well and could not locate her call light. During a concurrent observation and an interview on 1/13/2026 at 9:50 AM with certified nurse assistant (CNA) 1, CNA 1 stated Resident 30's call light was not within reach. CNA 1 stated that Resident 30 could not move her left arm on her own so it was important to keep Resident 30's call light within reach at all times. During an interview on 1/13/2026 at 9:59 AM with the licensed vocational nurse (LVN) 1, LVN 1 stated Resident 30 required maximum assistance for most of her activities of daily living (ADL's, basic self-care tasks essential for independent living ) and it was important to ensure residents' call lights were within reach so when a resident needed assistance, the resident could call for help by pressing the call light. LVN 1 further stated the call light cord should not be wrapped around multiple times onto a residents' bed since the cord would be shortened and tight and could prevent the resident from reaching the call light. supposed not to be wrapped multiple times because the cord would be too tight and short to be accessible for Resident 30. During an interview on 1/15/2026 at 12:00 PM with the Director of Staff Development (DSD), DSD stated that a call light is a system that enables resident to call nursing staff from their bed or restroom, and a call light should always be accessible for residents. During a review of the facility's policy and procedures (P&P) titled Communication- Call System revised on 10/24/2022, the P&P indicated that the call cord will be placed within the resident's reach in the resident's room.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 11) was provided a written notice of Bed-hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy upon transfer to the General Acute Care Hospital (GACH) on 1/4/2026. This deficient practice resulted in Resident 11 and/or their representatives not being informed of their rights regarding bed reservation during hospitalization, which could lead to confusion and disruption in continuity of care. Findings: During a review of Resident 11's admission Record (AR), the AR indicated the facility admitted the resident to the facility on 9/7/2024, with diagnoses including dementia (a general term for a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life) with behavioral disturbance (loss of memory and thinking ability with agitation and physical aggression) and hypertension (HTN - high blood pressure). During a review of Resident 11's History and Physical (H&P) dated 10/18/2025, the H&P indicated Resident 11 did not have the capacity to understand and make decisions. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool) dated 12/8/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 11's Physician Discharge summary dated [DATE], the summary indicated that Resident 11 was transferred to the general acute care hospital (GACH) on 1/4/2026 for abnormal vital signs with a documented heat rate of 110 beats per minute (bpm). During a review of Resident 11's medical records Hard Chart on 01/15/2026 at 8:26 AM, Resident 11's records were reviewed for bed hold documentation. The hard chart did not indicate any documentation for a bed hold. During a concurrent interview and record review on 1/15/2026 at 8:38 AM with the Director of Nursing (DON), Resident 11's medical record Hard Chart under the admission records tab documents were reviewed. The DON stated that there was no bed hold document signed or present in Residents 11's medical record hard chart and it was unknown if the responsible party (RP) or conservator was notified regarding the bed hold. The DON stated that the absence of the bed hold document indicated the facility was noncompliant with state & federal regulations, and that if not appropriately documented Resident 11's RP would get billed incorrectly. During a review of the facility's policy and procedure (P&P) titled Bed Hold revised on 9/1/2023, the P&P indicated that the facility advises residents or the resident's representative in writing that the Facility has a bed hold policy and will hold the resident's bed for up to seven (7) days if the resident is transferred to a general acute care hospital.

Based on interview and record review, the facility failed to develop a comprehensive care plan to indicate interventions in the management of dementia (a general term for a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life) for one of three sampled residents (Resident 3). This deficient practice had the potential for Resident 3's not to received or receive delayed care that is individualized care to the resident's needs. Findings: During a review of Resident 3's admission Record (AR), the AR indicated the facility admitted the resident to the facility on [DATE], with diagnoses including dementia (a general term for a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life) and unspecified psychosis (loses of touch with reality) experiencing symptoms like hallucinations (seeing/hearing things not there). During a review of Resident 3's History and Physical (H&P) dated 5/24/2025, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 12/10/2025, the MDS indicated that Resident 3 had a severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 3's Care Plan titled Resident 3 has impaired cognitive functions/impaired thought processes related to dementia initiated on 3/13/2025, the care plan indicated interventions that included statements such as keep the resident's routine consistent, monitor and report as needed (PRN) changes, and reminisce with photos, without identifying resident-specific behaviors, triggers, communication needs, safety risks, or individualized approaches required to meet the resident's dementia-related needs. During an interview on 1/15/2026 at 1:10 PM with Certified Nursing Assistant (CNA), CNA 4 stated that Resident 3 could not verbally communicate her needs but used eye gestures and hand movements. CNA 4 stated that Resident 3 gets frustrated and agitated 2 to 3 times a week and that Resident 3 would wave her hands around and grunt when Resident needed something. CNA 4 stated once Resident 3's needs were met; Resident 3 would calm down. During a concurrent interview and record review on 1/15/2026 at 1:45 PM, with Licensed Vocational Nurse (LVN) 2, Resident 3's Care Plan on Dementia care was reviewed. LVN 2 stated that Resident 3's dementia care plan lacked specific, individualized treatments and interventions to address the resident's dementia-related behaviors and care needs. LVN 2 stated that the care plan did not address when Resident 3 was frustrated and agitated and how to respond to treat the behavior. During a concurrent interview and record review on 1/15/2026 at 2:11 PM, with Director of Staff Development (DSD) Resident 3's Care Plan on Dementia care was reviewed. DSD stated Resident 3's dementia care plan was not resident-specific and lacked individualized interventions based on the resident's assessed needs, behaviors, and preferences. DSD stated that Resident 3's care plan contained generic interventions and did not clearly guide staff on how to respond to Resident 3's specific behaviors or triggers when Resident 3 was frustrated or agitated. During a concurrent interview and record review on 1/15/2026 at 2:30 PM, with the Director of Nursing (DON), Resident 3's Care Plan on Dementia care was reviewed. DON stated that Resident 3's care plan contained generic interventions and did not clearly guide staff on how to respond to the resident's specific behaviors or triggers. DON stated that this practice had the potential to result in inconsistent or ineffective care for residents with dementia. During a review of the facility Policy and Procedure (P&P) titled Care Planning revised on 6/12/2025, the P&P indicated that each resident's Comprehensive Care Plan will describe the following: Interventions and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 30), who was unable to carry out activities of daily living (ADLs) by failing to: 1. Ensure that Resident 30 received services to maintain good oral hygiene as indicated in the care plan by Certified Nurse Assistant (CNA) 3 after Resident 30 finished with her meal. 2. Ensure that Resident 30 was assisted to be properly positioned for her meal. Specifically, on 1/14/2026 Resident 30 was observed in high Fowler's position leaning to her right side when CNA 2 set up tray and cued the resident to start eating. These deficient practices had the potential to place Resident 30 at risk for diseases of the mouth, gums, and teeth, and aspiration (something other than air gets into the airways) of the food pieces in the mouth could further lead to pneumonia (an infection/inflammation in the lungs). Findings: During a review of Resident 30's admission Record (AR), the AR indicated that the facility admitted Resident 30 on 3/15/2022 with diagnoses including hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (known as CVA/stroke- loss of blood flow to a part of the brain) affecting left dominant side, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and unspecified visual loss. During a review of Resident 30's Care Plan dated 6/21/2024, the Care Plan indicated that Resident 30 had self-care deficits due to decreased strength and endurance, and Impaired physical mobility related to limitation of joint mobility. The Care Plans also indicated that Resident 30 required assistance with ADLs functions. The Care Plan interventions indicated to provide oral care to keep teeth and mouth free of odor and debris. The Care Plans did not indicate interventions including proper positioning of Resident 30. During a review of Resident 30's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/25/2025, the MDS indicated Resident 30 had moderately impaired cognitive skills for daily decision making. The MDS also indicated that Resident 30 required substantial/maximal assistance (helper does more than half the effort) on oral hygiene, personal hygiene, and rolling left and right. During a review of Resident 30's Physician Orders dated 12/30/2025, the Orders indicated to provide Regular diet, Soft & Bite Sized-SB6 texture (Foods are soft and fork-tender; they are moist, but there is no separate thin liquid present), Thin-0 consistency (Thin liquids are also called level 0, they are unchanged). During a review of Resident 30's Flowchart for Activities of Daily Living (ADLs Flowchart) dated from 1/1/2026 to 1/15/2026, the ADLs Flowchart indicated that Resident 30 required partial/moderate assistance (helper does less than half the effort) on eating. During a concurrent observation and interview on 1/14/2026 at 12:38 PM in the resident room, CNA 2 was observed assisting Resident 30 to high Fowler's position (semi-sitting posture where the head of the bed is elevated 60 to 90 degrees). CNA 2 was then observed setting up meal tray and about to leave the resident room while Resident 30 was sitting in the center of the bed with upper body leaning to right upper bed rail. CNA 2 stated Resident 30 was only able to feed herself with the right arm. CNA 2 also stated she was supposed to help and make sure the resident was in the correct position for meal. During a concurrent observation and interview on 1/15/2026 at 9:30 AM, Resident 30 was observed sleeping in bed in a semi-Fowler_position (a position in which the individual lies on their back on a bed with the head of the bed elevated at 30-45 degrees), mouth open with visible traces of food on Resident 30's gums. CNA 3 stated Resident 30 was not provided with oral care after breakfast that morning, 1/15/2026. CNA 3 stated she was supposed to provide oral care to Resident 30 after the resident had her breakfast and it was one of her responsibilities to maintain residents in good hygiene. During a concurrent record review and an interview on 1/15/2026 at 9:59 AM with the Licensed Vocational Nurse (LVN) 1, Resident 30's MDS was reviewed. LVN 1 stated Resident 30 required maximal assistance on majority of ADLs including oral hygiene. LVN 1 stated Resident 30's dental health will be at risk if not done. During an interview on 1/15/2026 at 12:05 PM with the Director of Staff Development (DSD), the DSD stated she was responsible for supervising CNAs and ensuring the CNAs provide proper care and assistance to residents. The DSD stated that any CNA delivering the meal tray to a resident should also provide assistance as needed and ensure that the resident was positioned and supported properly for eating. The DSD stated improper position could cause the resident to have spine problems, or aspirate (something other than air gets into airways). The DSD further stated if the CNA was not familiar with the level of assistance of the resident whom they served meal to; he or she should seek recommendations from their charge nurse. The DSD stated oral hygiene was important and the assigned CNA for Resident 30 should have provided oral care once Resident 30 was done with her meal. The DSD further stated by not having oral hygiene maintained, the resident could be at risk for bad mouth odor or even aspirate on anything remaining from the gum and that can lead to pneumonia. During a review of the facility's Policy and Procedures (P&P) titled Grooming dated 1/1/2026, the P&P indicated that the facility would work with residents to promote hygiene, comfort, and dignity. The P&P also indicated that residents who have teeth should brush them twice daily, and residents who do not have teeth or who have dentures should perform mouth care twice daily. During a review of the facility's policy and procedures (P&P) titled Eating and Swallowing dated 1/1/2026, the P&P indicated the following: 1. Body positioning is a critical component in addressing self-feeding and swallowing skills. Posture affects the resident's ability to use the upper extremities during self-feeding and also plays significant role in safe swallowing. 2. The resident's weight should be evenly distributed on the buttocks and thighs to prevent weight shift and leaning to one side. 3.The resident's trunk, neck and head should be supported in midline.

Based on observation, interview, and record review, the facility staff failed to ensure one of three sampled residents (Resident 13) received appropriate services ensuring Restorative Nursing Assistant (RNA) demonstrated proper hand placement while providing passive range of motion (PROM). This deficient practice placed Resident 13 at risk for pain, injury, and compromised joint integrity. Findings: During a review of Resident 13's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included spondylosis (spinal osteoarthritis, where the protective cartilage cushioning the ends of your bones gradually break down over time causing bones to rub together, leading to join pain, stiffness, and reduced mobility), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to restricted joint mobility) of left and right knee, and difficulty in walking. During a review of Resident 13's History and Physical (H&P) dated 9/8/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 13's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 12/24/2025, the MDS indicated the resident had severe cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated the resident was dependent (helper did all of the effort and the resident did none) from facility staff for all self-care areas and functional abilities. The MDS indicated the resident received restorative nursing programs. During a review of Resident 13's Order Summary Report dated 9/8/2025, the Order Summary Report indicated RNA for active-assistive range of motion (AAROM, when the resident partially moved a body part themself but received extra help from a therapist to move further and more safely) to left upper extremity, every day, five times a week, ongoing as tolerated. During a review of Resident 13's Order Summary Report dated 9/8/2025, the Order Summary Report indicated RNA for active-assistive range of motion (AAROM, when the resident partially moved a body part themself but received extra help from a therapist to move further and more safely) to right upper extremity, every day, five times a week, ongoing as tolerated. During a review of Resident 13's Order Summary Report dated 11/21/2025, the Order Summary Report indicated Restorative Nursing Assistant (RNA, helped resident's get stronger and more independent after illness or injury focusing on regaining daily skills like walking, eating, and bathing) program for PROM exercise to left lower extremities, every day, seven days a week, as tolerated. During a review of Resident 13's Order Summary Report dated 11/21/2025, the Order Summary Report indicated RNA program for PROM exercise to right lower extremities, every day, seven days a week, as tolerated. During an observation in Resident 13's room on 1/15/2026 at 2:55 PM, RNA 1 was observed providing flexion/extension (simple movements that involved bending [flexion] and straightening [extension] the joints) PROM exercises to the resident's left and right lower extremity. RNA 1 placed her left hand under the resident's lower right thigh and placed her right hand over the resident's right toes holding the resident's toes in her hand. Upon completion, RNA 1 moved to the resident's left leg and placed her right hand under Resident 13's lower left thigh and placed her left hand under the ball of the food (the padded, fleshy area on the sole of your foot located between the arch and the toes) of the resident's left foot. During an interview on 1/15/2026 at 3:14 PM, RNA 1 stated when providing flexion and extension exercise, the hands should have been under the resident's thigh and under the ankle. RNA 1 stated if the proper technique was not used the resident could be uncomfortable, be in pain, or might get hurt. During an interview on 1/15/2026 at 3:30 PM, Physical Therapist (PT) 1 stated proper hand placement when providing PROM exercises during flexion and extension of the leg would be to have one hand under the ankle and the other one at the resident's lower thigh to support the entire leg. PT 1 stated if facility staff were not using proper hand placement, the resident could be uncomfortable, could cause skin breakdown or even a fracture if a resident had brittle bones. During a review of the facility's P&P titled, Restorative Nursing Program Guidelines dated 1/1/2026, the P&P indicated The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning. The P&P indicated, The basic restorative nursing categories include active range of motion (AROM) and passive range of motion (PROM). During a review of the facility's policy and procedure (P&P) titled Performing Range of Motion Exercises dated 1/1/2026, the P&P indicated When assisting the resident, hold the part of the body being exercised securely, but gently above and below the joint, not on the joint. Begin ROM exercises at the larger joints and work outward toward the smaller, finer joints. The P&P indicated ROM exercises are performed with caution to prevent injury or pain. During a review of the facility's undated P&P titled, Range of Motion Exercises, the P&P indicated for flexion/extension for the hip and knees Support the leg at the knee and ankle joints and keep the knee straight. Raise and lower the leg. Bend the knee and move toward the chest; slowly straighten the knee.

Based on observation, interview, and record review, the facility failed to provide respiratory care in accordance with professional standards of practice and the facility's policy and procedures for one of three sampled residents (Resident 7) by failing to ensure: 1.Resident 7 was evaluated for the refusal to use Bilevel Positive Airway Pressure (BiPAP, a noninvasive mask-based device used to help residents breathe easier by pushing air into the lungs) machine and implement interventions to ensure the resident received adequate oxygenation. 2. Resident 7 had a physician order was received before the administration of oxygen delivered via nasal cannula (a tubing that connects to the oxygen concentrator machine used to deliver oxygen into the nares) when the resident refused to use the BiPAP. 3. Implement interventions for Resident 7's who uses oxygen delivered via NC and indicate what are the negative outcomes to monitor related to the use or refusal to use BiPAP machine as specified in the care plan to prevent shortness of breath and respiratory failure (failure of the lungs to meet the oxygen demand of the body). These failures had the potential for Resident 7 to receive inadequate oxygen and result in recurrent hospitalization due to respiratory failure and a potential to result in shortness of breath, discomfort from difficulty breathing and death. Findings: During a review of Resident 7's admission Record (AR), the facility admitted Resident 7 on 4/17/2025 and readmitted Resident 7 on 12/20/2025 with diagnoses that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), respiratory failure and asthma (a chronic condition where the airways narrow and swell making it difficult to breathe). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills were intact. The MDS indicated Resident 7 was dependent (helper does all the effort) for ADLs such as toileting and showering and was dependent on staff when repositioning herself in bed. The MDS indicated Resident 7 used continuous oxygen therapy and used a BiPAP machine as her non-invasive mechanical ventilator. During a review of Resident 7's Nursing Progress Notes (PN), dated 12/13/2025 timed at 11 AM, the PN indicated that Resident 7 had a change in mental status and appear to look tired. The PN indicated PCP 1 was notified and recommended Resident 7 to be transferred to GACH 1. During a review of Resident 7's Weight and Vitals Summary, the following were reviewed: 12/13/2025 at 2:03 AM - 18 breaths per minute, 82 beats per minute, 93% oxygen levels via nasal cannula, 2. 12/13/2025 at 9:49 AM - 19 breaths per minute, 98 beats per minute, 93% oxygen level via nasal cannula During a review of Resident 7's GACH 1 Records, Physician 3's (GACH Family Medicine Physician) History and Physical (HP), dated 12/13/2025, the PN indicated that Resident 7 had been hypoxemic (low levels of oxygen in blood) oxygen saturation in the upper 80's while on oxygen therapy. The PN indicated that Resident 7 had chronic hypercapnic (too much carbon dioxide in the blood) and hypoxemic respiratory failure. During a review of Resident 7's Order Sheet, dated 12/15/2025 ordered by Physician 2 (a pulmonologist or a physician that treats lung disorders and diseases), the order indicated tto continue BiPAP on and off during the daytime and continuous at night and to titrate (adjust) Resident 7's oxygen therapy level to keep her oxygen saturation (amount of oxygen in the blood, normal levels are 94 - 100%) levels around 92%. During a review of Resident 7's GACH Records, Physician 2's PN, dated 12/19/2025, the PN indicated to continue Resident 7's oxygen therapy to keep her oxygen saturations above 92% and to alternate the oxygen therapy between the nasal cannula (NC, a lightweight flexible tube with two prongs that sit just inside the nares used to deliver supplement oxygen therapy) and the BiPAP machine. Physician 2 indicated that Resident 7 will wear the BiPAP machine on and off during the daytime and continuously during the nighttime. During a review of Resident 7's Order Summary Report, an order, dated 12/22/2025, indicated Resident 7 would wear the BiPAP machine at bedtime continuously and as needed during the daytime. During a review of Resident 7's care plan, initiated on 1/6/2025 and revised on 1/13/2026, the care plan indicated Resident 7 was noncompliant and refused to use the BiPAP machine as ordered. The care plan's interventions included to monitor and report any negative outcomes from noncompliance to physician and to educate consequences of non-compliance. During an observation and interview on 1/13/2025 at 10:52 AM with Resident 7 in Resident 7's room, Resident 7 was observed lying in bed receiving oxygen via NC connected to the oxygen concentrator (a medical device that used the air in the atmosphere to filter and provide oxygen) on the left side of the head of her bed. The oxygen concentrator gauge was set at 4 liters per minute (LPM) of oxygen. The BiPAP machine was on the right bedside table. Resident 7 stated, she has always used oxygen therapy through the nasal cannula and it was hard for her to breathe without it. Resident 7 stated, she did not like using the BiPAP machine at night because it felt like it was suffocating her. During an observation on 1/14/2026 at 8:30 AM in Resident 7's room, Resident 7 was observed sleeping in bed receiving oxygen via NC connected to an oxygen concentrator gauge was at 4 LPM of oxygen. During an observation on 1/15/2026 at 9:25 AM in Resident 7's room, Resident 7 was observed sleeping in bed receiving oxygen via NC Connected to an oxygen concentrator gauge was at 4 LPM of oxygen. During an interview on 1/15/2026 at 2:20 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 7continuously used oxygen therapy via her NC because she feels more comfortable using the NC than the BiPAP machine. LVN 2 stated, Resident 7 rarely used the BiPAP at night because she does not get enough oxygen with the BiPAP machine. During a concurrent observation and interview on 1/15/2026 at 2:28 PM in Resident 7's room with LVN 2, Resident 7 was observed lying in bed with oxygen delivered via NC the oxygen concentrator was set at 2 LPM of oxygen. LVN 2 stated, Resident 7's oxygen concentrator was at 2 LPM and he turned it down because he saw [the surveyor] in Resident 7's room looking at the oxygen concentrator. LVN 2 stated, this morning (1/15/2026), Resident 7's oxygen concentrator was between 3 to 4 LPM and yesterday (1/14/2026), Resident 7's oxygen concentrator was at 4 LPM. During a concurrent interview and record review on 1/15/2026 at 2:45 PM with LVN 2, Resident 7's Order Summary Report was reviewed. LVN 2 stated that there was no physician's order active order for Resident 7 to received oxygen therapy via NC. During the same concurrent interview and record review on 1/15/2026 at 2:50 PM with LVN 2, Resident 7's care plans were reviewed. LVN 2 stated that there was no documented evidence of a care plan was developed for Resident 7 who uses oxygen delivered via NC. LVN 2 stated it was important to indicate the type of care and interventions needed by the resident while receiving oxygen therapy the included specific respiratory status, oxygen saturations level to monitor etc. During the same concurrent interview and record review on 1/15/2026 at 2:55 PM with LVN 2, Resident 7's care plans were reviewed. LVN 2 stated, Resident 7's care plan for noncompliance with the use of BiPAP noncompliance was not resident specific. The care plan did not indicate what specific behavior to monitor and what are the negative outcomes to monitor. During a concurrent interview and record review on 1/15/2026 at 3:06 PM with the Director of Nursing (DON), Resident 7's Order Summary Report was reviewed. The DON stated Resident 7 was a well-known oxygen therapy user. The DON stated that Resident 7 had an order for BiPAP use but did not have an order to receive oxygen therapy via NC. The DON stated, without the right amount of oxygen therapy order for oxygen delivered via NC, Resident 7 could be getting unnecessary oxygen which is considered a medication. During the same concurrent interview and record review on 1/15/2026 at 3:10 PM with the DON, Resident 7's care plans were reviewed. The DON stated, there was no documented evidence of a care plan for Resident 7 to received oxygen therapy via NC. The DON stated there was no resident-specific care plan and interventions to help monitor the staff monitor and management Resident 7's COPD and oxygen therapy to monitor the effectiveness of the therapy. During the same concurrent interview and record review on 1/15/2026 at 3:15 PM with the DON, Resident 7's care plans were reviewed. The DON stated that Resident 7's BiPAP compliance care plan was not resident specific and did not have resident-specific interventions to monitor for negative outcomes. During a review of the facility's policies and procedures (P&P) titled Oxygen Administration, dated 5/7/2025, the P&P indicated all resident's receiving oxygen must have oxygen orders. During a review of the facility's P&P titled, Care Planning, dated 6/12/2025, the P&P indicated each resident's comprehensive care plan should describe the interventions and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial [NAME].

Based on observation, interview, and record review, the facility failed to ensure proper use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for two of five sampled residents (Resident 4 and 6) by failing to: 1. Attempt to use nonrestrictive measures and other appropriate alternatives prior to installing bed rails. 2. Complete the resident assessment for Resident 6's risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or above the bed rail). 3. Implement intervention to monitor the residents for the use of bed rails. These deficient practices had the potential to result in Resident 4 and 6 to be at risk for accident and entrapment that could lead to injuries. Findings: a. During a review of Resident 4's admission Record (AR), the AR indicated that Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy (a group of conditions that cause brain dysfunction), morbid obesity (a severe form of obesity characterized by a body mass index [BMI] of 40 or higher), and acquired absence of left leg below knee (loss of the left leg below the knee, typically due to medical intervention such as surgery following severe injury or disease). During a review of Resident 4's Care Conference IDT (IDT- An interdisciplinary team is defined as a group of professionals who collaborate interdependently to achieve goals) Meeting dated 10/30/2025, there was no documented evidence indicating any review of bed rails use. During a review of Resident 4's Order Summary Report (OSR) dated 12/16/2025, the OSR indicated to put a bilateral full side rails up as enabler (support) to enhance bed mobility/ repositioning/ transferring/ ADL (activities of daily living) care and safety. During a review of Resident 4's Nursing admission Assessment (NAA) dated 12/16/2025, the NAA indicated that Resident 4 needed a siderail (known as bed rail), and frequent monitoring was selected as initiated among 19 alternative measure options. The NAA also indicated that Resident 4 was alert, confused, cannot follow commands or remember the use and purpose of bed rails. During a review of Resident 4's Nursing Progress Notes (NPN) dated from 12/16/2025~1/12/2026, there was no documented evidence indicating alternative measures were attempted prior to the use of bed rails. There was also no documented evidence of monitoring proper placement and function of bilateral full side rails. During an observation and a concurrent interview on 1/13/2026 at 10:15 AM, Resident 4 was sleeping in bed, and both full side rails were up. Licensed Vocational Nurse (LVN 1) stated that Resident 4's had full bed rails up because the resident requested it. During a concurrent record review and an interview on 1/15/2026 at 4 PM with LVN 1, Resident 4's clinical records were reviewed. LVN 1 stated Resident 4's bed rails were ordered to grant the Resident 4's request. LVN 1 stated there was no documentation of discussion with Resident 4 or his responsible party (RP) regarding feasible alternative methods. LVN 1 also stated there was no documentation about attempted alternative measures or monitoring for the safe use of bed rails for Resident 6 in the nursing progress notes. During a concurrent record review and an interview on 1/16/2026 at 3:15 PM with MDSN, Resident 4's clinical records were reviewed. MDSN stated the date of physician's order for bed rails and the date Resident 4's readmission was the same day, 12/16/2025. MDSN stated there was supposed to have more alternatives initiated or attempted prior to the use of bed rails. MDSN further stated the documentation on MAR was only to ensure side rails were up but should have required the nurses to monitor and ensure resident's safety during use of bed rails due to potential risks. MDSN also stated Resident 4's Care plans were supposed to include IDT for initial and quarterly review. b. During a review of Resident 6's AR, the AR indicated that Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including asthma (is a condition in which the airways narrow and swell and may produce extra mucus), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and dementia (a progressive state of decline in mental abilities). During a review of Resident 6's Order Summary Report (OSR) dated 10/27/2025, the OSR indicated to have bilateral padded full side rails up as enabler to enhance bed mobility and provide safety from potential seizure. During a review of Resident 6's CCIDT Meeting dated 10/30/2025, there was no documented evidence indicating any review prior to the use of bed rails. During a review of Resident 6's Nursing Quarterly Assessment (NQA) dated 10/30/2025, the NQA indicated that Resident 6 needed a siderail (known as bed rail), frequent monitoring and reminder to use call light were selected among 19 initiated alternative measure options. The NQA indicated that Resident 6 was alert, confused, cannot follow commands or remember the use and purpose of bedside rails, and could not use call alarms. The Resident Measurement for head, neck, and chest breath in the NQA as part of entrapment risk assessment was left blank. During a review of Resident 6's Nursing Progress Notes (NPN) dated from 10/27/2025~1/12/2026, there was no documented evidence indicating alternatives were attempted prior to the use of bed rails. There was also no documented evidence of monitoring the resident for proper placement and function of bilateral padded full side rails. During an observation and a concurrent interview on 1/13/2026 at 3:11 PM in the resident's room, Resident 6 was lying in bed and both side rails were up. Certified Nursing Assistant (CNA) 5 stated that Resident 6's bed rails needed to be up when in bed for fall precaution. During a concurrent record review and an interview on 1/15/2026 at 3:39 PM with LVN 1, Resident 6's clinical records were reviewed. LVN 1 stated Resident 6's bed rails were ordered to prevent injury and for seizure precautions. LVN 1 stated there was no documentation of attempted alternative measures or monitoring safe use of bed rails for Resident 6 in the nursing progress notes. During a concurrent record review and an interview on 1/15/2026 at 1:10 PM with MDSN, Resident 6's clinical records were reviewed. MDSN stated the Device/ Restraint Assessment in NQA dated 10/30/2025 should have been completed and evaluated by IDT team. MDSN also stated there was no documentation in Resident 6's medical record indicating all appropriate alternatives initiated or attempted prior to the use of bed rails. MDSN further stated the current documentation on MAR dated from 11/1/2025 to 1/12/2025 was only to ensure side rails were up but should have required the nurses to monitor and ensure resident's safety during use of bed rails due to potential risks. During a review of the facility's Policy and Procedures (P&P) Bed Rails dated 1/1/2026, the P&P indicated the following: Decisions to use or to discontinue the use of a bed rail will be made in the context of an individualized resident assessment using an Interdisciplinary Team (IDT) with input from the resident or resident representative and will take into account the resident's medical needs. The Assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs. For bed with rails that are incorporated or pre-installed, the facility must determine whether or not disabling the bed rail poses a risk to the resident. The plan of care should also include documentation of the type of specific direct monitoring and supervision provided during the use of the bed rails and the identification of how needs will be met during the use of bed rails (e.g., repositioning, hydration, etc.) assessed needs.

Based on interview and record review the licensed nursing staff and physician failed to act upon the pharmacist's recommendations documented in the Medication Regimen Review (MRR, a comprehensive evaluation of a resident's medication regimen intended to promote positive outcomes and minimize adverse effects) to assess the resident's pain condition and add respiratory monitoring to the Physician's Order for the use Morphine Sulfate (Morphine, a potent opioid analgesic, used to treat severe pain) for one of two sampled residents (Resident 5). This deficient practice had the potential for delayed identification of clinical changes, ineffective medication administration, and adverse effects that could lead to acute medical events requiring emergency care or hospitalization. Findings: During a review of Resident 5's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities), and anxiety disorder (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). During a review of Resident 5's History and Physical (H&P) dated 9/11/2025, indicated the resident had the capacity to understand and make decisions. During a review of Resident 5's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 11/8/2025, indicated the resident's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated the resident's active diagnoses included anxiety, depression, and bipolar disorder. The MDS indicated the resident was receiving antipsychotic (psychiatric medications that manage psychosis [hallucinations (sensory experiences that seem real but were caused by brain changes), delusions (fixed, false beliefs strongly held despite evidence to the contrary), disordered thinking] in conditions like bipolar disorder and severe depression), antianxiety (reduce symptoms like excessive worry and panic), and antidepressant (prescription drug used to primarily for depression and anxiety) medication. During a review of Resident 5's Pharmacist's Medication Regimen Review (MRR) dated 11/29/2025 and 11/30/2025, the MRR indicated the resident was on a schedule pain management regimen that could increase the risk of respiratory depression. The MRR indicated recommendations to assess the resident's pain condition and consider adding respiratory monitoring (watching and measuring how often and how well someone was breathing) to the order. During a review of Resident 5's Physician's Order dated 12/17/2025 at 6:15 PM, the Physician's Order indicated to administer morphine sulfate extended release (ER) oral tablet extended release 30 milligrams (mg, unit of measurement) one tablet by mouth every 12 hours for severe pain (7-10, from a 0 out of 10 pain scale where 0 was no pain and 10 signified the worse pain imaginable). During a concurrent interview and record review of Resident 5's MRR on 1/16/2026 at 2:17 PM, the Director of Nursing (DON) stated the facility staff was not following the Pharmacist's recommendations of assessing the resident's pain condition and adding respiratory monitoring to the Physician's Order. The DON stated Resident 5 could have been at risk for adverse effects. During a review of the facility's policy and procedure (P&P) titled Drug Regimen Review dated 1/1/2026, the P&P indicated The intent is that the facility maintains the resident's highest practicable level of physical, mental, and psychosocial well-being and prevents or minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing (DON). The P&P indicated, The pharmacist will report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. The P&P indicated The Medical Director and DON will also review the pharmacist's report if any irregularities are identified. The DON is responsible for following up with the Attending Physician, as indicated. The P&P indicated a definition for Irregularity, refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcomes of pharmaceutical services. An irregularity also includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy.

Based on interview and record review, the facility failed to obtain laboratory test as ordered by the physician for one of three sampled residents (Resident 67) who was ordered by Physician (Attending Physician) 1 to obtain urinalysis (urine test to determine presence of infection or other kidney disorder) urine culture (a urine test to identify if bacteria was growing in the urine) after Resident 67 complained of dysuria (painful, burning, or discomfort when urinating) on 1/7/2026. The urinalysis and urine culture test were obtained eight (8) days since the physician ordered the laboratory test after the facility was informed that there was no laboratory test obtained for Resident 67. As a result of this deficient practice Resident 67 did not receive the antibiotic (medication used to treat infection) resulting in continued to experience of burning sensation and a potential to have worsened UTI, permanent kidney damage, hospitalization, and death. Findings: During a review of Resident 67's admission Record (AR), the facility admitted Resident 67 8/21/2025 and readmitted on 9/15/2025 with diagnoses that included UTI, chronic obstructive pulmonary disease (COPD, chronic lung disease causing difficulty in breathing), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 67's Minimal Data Set (MDS, a resident's assessment), dated 11/29/2025, the MDS indicated Resident 67's cognitive (a resident's thought process) skills were moderately impaired. During a review of Resident 67's care plan (CP), dated 12/19/2025, Resident 67 had a UTI. The CP's goal indicated Resident 67's UTI will resolve without complications by 12/15/2025. The CP's interventions included for the staff to check Resident 67 every 2 hours for incontinence, monitor and report signs and symptoms of UTI such as dysuria, flank (lateral sides of the body between the ribs and hip) pain, and altered mental status, to obtain and monitor lab or diagnostic work as ordered, and to report results to MD and follow up as indicated. During a review of Resident 67's SBAR Communication Form (situation, background assessment recommendation, communication tool used by healthcare workers when there is a change of condition among the residents) dated 1/7/2026, the SBAR form indicated Resident 67 verbalized having burning sensation upon urination. Physician 1 recommended collecting Resident 67's urine for a urinalysis and urine culture. The SBAR indicated Physician 1 ordered to start Resident 67 on Macrobid (antibiotic medication used to treat UTI) 100 milligrams (mg, unit of weight) twice a day for five (5) days after the urine was collected. During a review of Resident 67's Order Summary Report, the physician order, dated 1/7/2026, indicated the urinalysis and urine culture were uncollected 1/7/2026 for one time only related to UTI infections. During an observation and interview on 1/14/2026 at 9:18 AM with Resident 67 room, was observed lying in bed watching television. Resident 67 stated, she recently told the nurses It burns when she urinates that started sometime last week, and she was supposed to start medication for the burning sensation which she had not received yet. Resident 67 stated she was still experiencing a burning sensation when urinating even this morning (1/14/2026). During a concurrent interview and record review on 1/15/2026 at 2:55PM with Licensed Vocational Nurse (LVN) 2, Resident 67's Change of Condition (CoC) record, dated 1/7/2026, was reviewed. LVN 2 stated the CoC indicated Resident 67 complained of a burning sensation when urinating and Physician 1 recommended to start Resident 67 on a Macrobid, an antibiotic, for five (5) days after urinalysis and urine culture was collected. During a concurrent interview and record review on 1/15/2026 at 3 PM with LVN 2, Resident 67's laboratory test results from 12/2025 to 1/2026 were reviewed. LVN 2 stated there was no documented evidence Resident 67's urine for urinalysis and urine culture were collected or Macrobid antibiotics was administered. During a concurrent interview and record review on 1/15/2026 at 3:30 PM with the DON, Resident 67's Nursing Progress Notes, dated 1/7/2026 to 1/9/2026, were reviewed. The DON stated there was no documented evidence that Resident 67's urine tests were collected on 1/7/2026. The DON stated, there was no documented evidence Resident 67 was started on an antibiotic on or after 1/7/2026. The DON stated, there was no documented evidence Resident 67 was started on an antibiotic on or after 1/7/2026 to this day (1/15/2026), which was a total of eight (8) days. During the same interview on 1/15/2026 at 3:38 PM with the DON, the DON stated, it was important to implement the physician order for a urinalysis and urine culture to determine what was causing Resident 67's discomfort and dysuria because there may be some infection happening in her body that the facility was unaware of. During an interview on 1/16/2026 at 4:25 PM with the Infectious Preventionist (IP), the IP stated, Resident 67's CoC record on 1/7/2026 was not followed up. The IP stated, if the physician order was missed on one shift, then the following shift should follow up on physician order. During a review of Resident 67's Lab Results Report Urine Culture record, collected on 1/16/2026 and reported on 1/18/2026, the report indicated Resident 67's urine grew greater than 100,000 colony forming units per milliliter (cfu/mL) of Klebsiella Pneumoniae (bacterial infection of urinary tract that often causes burning or painful urine). During a review of the facility's policies and procedures (P&P) titled Laboratory, Diagnostic and Radiology Services, dated 6/1/2027, the P&P indicated laboratory, diagnostic, and radiology services will be coordinated pursuant to an order by the physician. The P&P indicated the facility is responsible for the quality and timeliness of services provided by the laboratory, diagnostic, or radiology provider.

Based on observations, interviews, and record reviews, the facility failed to develop a resident centered care plan for one of three sampled residents (Resident 1) after the facility identified a safety concern in which Resident 1's Responsible Party (RP) 1 was observed utilizing the Hoyer lift (a mechanical device used to lift and/or transfer a person) without calling staff for assistance to transfer Resident 1 from the bed to the chair. This deficient practice had the potential for Resident 1's specific care needs and treatment to not be addressed and had the potential for Resident 1 to sustain falls due to unsafe transfers in and out of bed. During a record review of the admission record (AR) dated 12/7/2025, the AR indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses that included muscle wasting (weakening, shrinking, and loss of muscle), Abnormal posture (involuntary/rigid body positioning), unspecified dementia (a progressive state of decline in mental abilities). During a record review of Resident 1's History and Physical (H & P) dated 10/7/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 12/18/2025, the MDS indicated that Resident 1's cognitive skills (related to thinking, reasoning, decision-making and problem solving) were moderately impaired. The MDS further indicated Resident 1 required substantial/maximal assistance on staff for personal hygiene, lower body dressing, shower/bathe self, toileting hygiene, and dependent (helper does all of the effort) on toilet transfers, chair/bed-to-chair. During a review of Resident 1's Care Plan for High Risk for Fall and Injury, revised on 12/19/25, the Care Plan indicated interventions for frequent reminder regarding safety. During a review of Resident 1's Care Plan for at Risk for Falls, revised on 12/19/25, the Care Plan interventions indicated to educate the resident/family/caregivers about safety reminders and to alter remove any potential causes. During a record review of Resident 1's Progress Notes dated 11/17/2025 at 2:58 PM, the Notes indicated that the Interdisciplinary team (IDT - a team of staff, resident or their representative that meet to discuss needed care and treatments of the residents) met with Resident 1's daughters regarding a safety issue in which staff had observed the family transferring Resident 1 from the chair to the bed without the staff assistance. During an interview on 12/29/2025 at 10:41 AM with Resident 1's representative (RP 1), RP 1 stated that RP 1 assists Resident 1 with care at times and that Resident 1 prefers to be suspended up on the Hoyer lift (a mechanical device used to lift and/or transfer a person) when having a bowel movement. RP 1 stated that a couple of weeks ago RP 1 used the Hoyer lift without staff assistance to transfer Resident 1 from the chair to the bed. During a concurrent observation and interview on 12/29/2025 at 1:14 PM inside Resident 1's room, the Hoyer lift was observed next to Resident's 1 bed. Certified Nurse Assistant (CNA 1) stated that Resident 1 required the Hoyer lift for transfers and that CNA 1 had used the Hoyer lift for a transfer for Resident 1 with the assistance from another staff a Restorative Nurse Assistant (RNA 1). During an observation on 12/29/2025 at 2:33 PM the Hoyer lift was observed inside Resident 1's room at the foot of Resident 1's bed. During a concurrent interview and record review on 12/29/2025 at 3:45 PM with the Director of Nurses (DON) Resident 1 Progress Notes dated 11/17/2025 at 2:58 PM was reviewed. The progress notes indicated the IDT had a meeting with Resident's 1 family members with the safety concern of family transferring Resident 1 with the use of the Hoyer lift without staff assistance. DON stated the care plan for non-compliance or lack of knowledge was not initiated for Resident 1 to indicate that the Hoyer lift should not to be stored inside Resident 1's room. During a review of the facility's policy and procedure titled, Care Planning, dated 6/12/2025, indicated, that is the facility's policy to ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The facility's policy also indicated that the IDT and or a licensed nurse will initiate the care plan, and the care plan will be finalized and updated as indicated for change in condition, onset of new problems, resolution of current problems, and as deemed appropriate by clinical assessment and judgment on an as needed basis. The facility's policy also indicated that the IDT will review the comprehensive care plan as needed at the following intervals including to address changes in behavior and care and other times as appropriate or as necessary.

Based on observation, interview, and record review the facility failed to ensure one out of seven sampled residents ( Resident 7) was provided a funtioning call light. This deficient practice had the potential to result in a delay in care and untimely response for Resident 7. Findings: A review of Resident 7 ' s Admission Record indicated the resident was admitted to the facility on [DATE], with a diagnosis that included Dysphagia (difficulty with verbal communication) and Anxiety ( feelings of being worried or nervous). A review of Resident 7 ' s Minimum Data Set ( MDS, a resident assessment tool) dated 05/13/2025, indicates resident has moderate cognitive impairment ( decline in memory, attention, language, function) and requires moderate assistance ( helper does more that half the effort ) for activities of daily living such as oral hygiene, toileting hygiene, and dressing. A review of Resident 7 ' s Care Plan Titled Ophthalmology Consult, dated 05/07/2025, indicated a goal for Resident 7 to not have any falls or bruising related to impaired vision. The Care Plan indicated an intervention to have call lights within reach. A review of Resident 7 ' s Care Plan Titled Resident 7 has a communication problem related to impaired ability to understand and be understood sometimes, dated 05/14/2025, indicated to ensure and provide a safe environment with call light within reach, adequate low glare light, bed in lowest position and wheels locked and to avoid isolation. A review of Resident 7 ' s Care Plan Titled Resident 7 is at risk for falls related to adverse reactions from medications dated 05/08/25, indicated to ensure Resident 7 ' s call light was within reach and to encourage the resident to use the call light for assistance as needed. During an observation on 5/21/2025 at 10:40AM in resident 7 ' s room, Resident 7 ' s call light was observed on the floor and not within Resident 7 ' s reach. During an interview on 5/21/2025 at 10:40 AM with Resident 7, Resident 7 stated the call light did not work. During a concurrent observation and interview on 05/21/2025 AM, with certified nursing assistant ( CNA)1 in resident 7 ' s room , Resident 7 ' s call light was observed on the floor. CNA 1 pressed Resident 7 ' s call light, but the call light did not work. There was not light observed or sound heard when CNA 1 pressed Resident 7 ' s call light. CNA1 stated the button on the call light was not functional and could not be pressed. CNA1 stated it was important that the resident ' call lights were functional since that was how the resident called for assistance when staff were not in residents ' rooms. CNA 1 stated the call light alerted staff when a resident required assistance. During a concurrent observation and interview on 05/21/2025 at 10:50AM, with Registered Nurse (RN)1, in resident 7 ' s room, Resident 7 ' s call light was observed. RN 1 stated Resident 7 ' call light button was not functional since the button was stuck and could not be pressed. RN 1 stated it was crucial to have a working call light so that residents could alert facility staff when assistance was needed. During an interview with Maintenance Supervisor ( MS) on 05/21/2025 at 11:37 AM , stated he conducted weekly inspections to ensure all residents ' call lights were functioning properly. MS stated he maintained a binder to document any issues, including malfunctioning call lights, and that the binders were located in nursing station 1 and station 2, where staff ccoul report maintenance needs. The Maintenance Supervisor reported that the last documented check of Resident 7 ' s call light was conducted on 05/15/2025, with no issues. MS stated he had not received any reports or notifications regarding Resident 7 ' s non functioning call light. A review of the facility ' s policy and procedure titled, Communication Call System, revised October 24, 2022, the policy stated the purpose was to provide a mechanism for residents to promptly communicate with nursing staff. The Policy further indicated that should the primary call system become inoperable for any reason, the facility shall provide an alternative call system to enable residents to alert nursing staff from their beds and toileting/ bath facilities. Additionally, the policy required that defective call bells be reported immediately to maintenance and replaced immediately , and that hourly resident safety checks be conducted and documented until the primary call system is restored.

Based on interview and record review, the facility failed to ensure one of three residents reviewed (Resident 1), who was receiving Quetiapine (a medication used to treat bipolar disorder [a mental disorder that results in severe sadness and manic or extreme joy or elated behavior) was monitored for the specific behavior of paranoid delusions (false beliefs that someone is being threatened or mistreated) as indicated for use of the medication. This deficient practice placed Resident 1 at risk unnecessary use of medication and for mismanagement of her mental disorder and expose her to potential side effects associated with taking Quetiapine, such as drowsiness that could lead to accidents and falls. Findings: A review of Resident 1 ' s Admission Record indicated the resident was admitted on [DATE] with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), mood disorders, and dementia (a progressive state of decline in mental abilities). A review of Resident 1 ' s History and Physical (H&P), dated 1/24/2025, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/27/2025, indicated the resident had moderately impaired cognition (the ability to think and process thoughts). A review of Resident ' s Order Summary Report, dated 2/14/2025, indicated a physician ' s ordered for the resident to take Quetiapine Fumarate Oral Tablet 25 MG (MG, milligram, a unit of measuring weight) give 1 tablet by mouth at bedtime for schizophrenia manifested by (m/b) paranoid delusions. A review of Resident ' s Medication Administration Report (MAR) for the months of 1/2025 and 2/2025, indicated the resident was being administered Quetiapine Fumarate. The MAR did not indicate that Resident 1 ' s behavior of paranoid delusions was being monitored by staff. A review of Resident 1 ' s nursing progress notes for the months of 1/2025 and 2/2025, did not indicate documented evidence that the resident ' s specific behavior of paranoid delusions was identified and monitored. A review of Resident 1 ' s care plan for the use of Quetiapine, initiated on 1/26/2025, indicated the resident ' s behavior was to be monitored for effectiveness every shift. The care plan also indicated for the resident to be monitored for adverse reactions associated with taking Quetiapine. During a concurrent interview and record review on 2/18/2025 at 1:41 PM, Licensed Vocational Nurse (LVN) 1 stated,Resident 1 ' s entire medical records were reviewed, including the MAR and nursing progress notes. LVN 1 stated Resident 1 ' s records did not have documented evidence that Resident 1 ' s behavior of paranoid delusions was monitored. LVN 1 stated Resident 1 ' s behavior should have been monitored to ensure the medication is effective and Resident 1 ' s behavior is being treated. During an interview on 2/18/2025 at 3:45 PM with Director of Nursing (DON), DON stated Quetiapine is considered a psychotropic medication and its use must be monitored. DON stated psychotropic medications (medication that affects mood and behavior) must be monitored to ensure they are working. DON stated monitoring the behavior aids in determining if the medication needs to be discontinued or reduced in dose. DON stated not monitoring the medication could lead to mismanagement of Resident 1 ' s mental disease. DON further stated if the medication is not effective, taking the medication still exposes the resident to side effects that could be dangerous, such as drowsiness that could lead to falls or tremors (involuntary quivering movement). A review of the facility ' s policy and procedure (P&P) titled, Psychotherapeutic Drug Management, revised 10/24/2022, indicated nurses will monitor psychotropic drug use daily. The P&P also indicated nurses will monitor the presence of target behaviors. The P&P also indicated the weekly nursing summary will include as assessment of the psychotherapeutic drugs administered including manifestations.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and implement interventions in accordance with the resident's needs, care plan, facility policy and professional standards of practice and the physician's order for one of three sampled residents (Resident 77) who had a diagnoses of chronic obstructive pulmonary disease exacerbation (COPD, sudden severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath (SOB), difficulty breathing and respiratory distress (a condition that occurs when the body needs more oxygen, resulting in difficulty breathing, rapid breathing, and low blood oxygen levels) and a history of pneumonia (a severe respiratory infection that results in shortness of breath and difficulty breathing) by failing to: 1. Monitor and evaluate if the oxygen provided was effective to relieve the resident's respiratory distress and oxygenation in accordance with the resident's care plan for COPD and physician's orders, when Resident 77 experienced shortness of breath (SOB), labored breathing (taking more effort to breath than usual), and an oxygen saturation (blood oxygen level) decreased to 72% (normal range ,d+[DATE]%) while receiving oxygen via nasal cannula (NC- a plastic flexible tubing used to deliver oxygen into the nose) at 2 liters per minute (L/min) on [DATE] at 11:05 PM. 2. Follow physician orders to titrate (adjust) Resident 77's oxygen therapy at ,d+[DATE] L/min to maintain oxygen blood levels of 92% when Resident 77's oxygen saturation decreased to 72% on [DATE] at 12:10 AM, while receiving 2 L/min of oxygen via NC. 3. Ensure Licensed Vocational Nurse (LVN) 6 monitored and documented Resident 77's respiratory distress, treatments rendered (given), and report Resident 77's change in respiratory condition to the physician, in accordance with the physician orders and the facility's policy and procedure. 4. Ensure to notify the physician and 911 (an emergency number) emergency services immediately, when Resident 77 complained of not being able to breathe and exhibited signs and symptoms of respiratory distress as manifested by labored breathing and oxygen saturation of 72% on [DATE] at 12:10 AM. 5. Ensure the physician was aware that Resident 77 was refusing to go to the hospital while complaining of not being able to breath and exhibited signs and symptoms of respiratory distress as manifested by labored breathing and oxygen saturation of 72% on [DATE] at 12:10 AM. As a result of these deficient practices Resident 77 did not receive immediate respiratory care and interventions on [DATE] from 11:05 PM when the resident was initially observed with respiratory distress, labored breathing, decreased level of oxygenation, until [DATE] at 2:29 AM when the paramedics pronounced Resident 77 dead after providing unsuccessful CPR (cardiopulmonary resuscitation, an emergency treatment for someone who stopped breathing or heartbeat has stopped by providing chest compression [pressing on the chest over the heart] and rescue breathing [mouth-to-mouth resuscitation]) was provided. On [DATE] at 2:02 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 with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to notify the physician regarding significant changes in Resident 77's respiratory conditions and provide the necessary respiratory care and monitoring. On [DATE] at 11:17 AM, the IJ was removed in the presence of the Administrator (ADM) and the Director of Nurses (DON) after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and while onsite at the facility, the surveyors verified/confirmed the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The IJ Removal Plan dated [DATE], included the following: 1. On [DATE], the Director of Nursing (DON) conducted a full house audit to identify all residents with a diagnosis of COPD, those on continuous and, PRN (as needed) oxygen. The audit identified 10 residents with COPD and 18 residents receiving oxygen therapy. The DON reviewed the care plans and physician's orders for these residents to ensure appropriate interventions such as following MD (Medical Doctor/physician) orders, oxygen therapy orders, repositioning of patients, checking oxygen saturation, assessment of signs and symptoms of hypoxia (low blood oxygen in the body tissues) respiratory failure (failure of the lungs to meet the body's demand for oxygen) for effectiveness of the intervention and monitoring for signs and symptoms of respiratory distress, verifying respiratory status using objective data such as oxygen saturation were in place. The DON will also review the communication to the Primary Care MD, if no response, the medical director and or emergency services will be called immediately. No additional residents were found to be at immediate risk. 2. On [DATE] a one to one in-service regarding MD notification, Medical Director notification, and emergency services was provided to the Night Shift Licensed Nurse assigned to Resident 77 on [DATE], by the facility's DON. The Licensed Nurse was also suspended pending the facility's investigation. 3. On [DATE] and [DATE] the Pharmacy Consultant initiated Medication Regimen Reviews (review of the medications the residents are receiving) for all residents receiving Oxygen Therapy and with COPD/SOB. 4. On [DATE], the facility conducted a root cause analysis (RCA) which included interviews with involved staff. The RCA revealed the following contributing factors: Lack of staff education on monitoring and reporting changes in respiratory status, and inadequate communication between nursing staff and physicians regarding significant changes in condition. 5. On [DATE] the Certified Nursing Assistant (CNA) assigned to Resident 77 on [DATE] during the night shift was provided a one-to-one in-service regarding Emergency Care Policy and Procedure. 6. On [DATE], the Director of Nursing/ Staff Development Coordinator (DSD) started to provide in- services to all Licensed Nursing staff for all shifts including CNAs, LVNS, RNs on Emergency Medical Response: A. Monitoring and reporting changes in respiratory status B. Following physician orders for oxygen titration and maintaining target oxygen saturation levels, and C. Facility policy and procedure for responding to respiratory distress, including immediate notification of the primary physician, emergency services, and medical director. 7. By [DATE], the DON reviewed the facility's policy and procedure for responding to respiratory distress to ensure clarity and consistency with current standards of practice. 8. By [DATE], the DON created a monitoring tool related to COPD and Oxygen Therapy to ensure clarity and consistency with current standards of practice. Findings: During a review of Resident 77's Admission Record (AR), the AR indicated the facility admitted Resident 77 on [DATE] and readmitted on [DATE] with diagnoses that included COPD with exacerbation (worsened symptoms), pneumonia, hypertensive heart disease (high blood pressure), and type 2 diabetes mellitus (condition of having high blood sugar). During a review of Resident 77's Physician Orders for Life-Sustaining Treatment (POLST- a medical order that documents a patient's preferences for end-of-life care), dated [DATE], indicated if the resident was found with a pulse and/or was breathing, full treatment was ordered for medical interventions including intubation (a tube placed in the mouth to the airway to provide oxygenation), advanced airway interventions (a tube place in the airway), mechanical ventilation (assisted breathing provided with the use of a machine), and cardioversion (a medical procedure that restores a normal heart rhythm by using electricity or medication to treat an abnormal heart rhythm). During a review of Resident 77's Order Summary Report (OSR), indicated on [DATE], Resident 77 had physician orders to monitor for sign and symptoms of respiratory distress that included monitoring for pulse oximetry (a device used to monitor oxygen blood level), lethargy (a state of unusual drowsiness, fatigue, and lack of energy and mental alertness), accessory muscle usage (breathing using muscles other than those typically used for breathing to take in and expel air) and to document with hashmarks (or tally marks, a numerical system used to keep track of things by number) in the clinical record of the resident if present and report to the physician. The physician also ordered to titrate (adjust) oxygen at ,d+[DATE] L/min via NC continuously to maintain oxygen saturation at 92 % or above, and to notify the physician if oxygen saturation was below 92% for SOB. The OSR indicated in the event of an emergency, the Medical Director may be called if the attending physician or alternate physician are not available. During a review of Resident 77's History and Physical Examinations, dated [DATE], indicated Resident 77 had the capacity to understand and make decisions. During a review of Resident 77's OSR, indicated on [DATE], Resident 77 had a physician order for Full Code (a medical order that instructs the health care team to perform all possible life-saving measures if the resident goes into cardiac or respiratory arrest [when the heart stopped beating or the resident stopped breathing]). During a review of Resident 77's Physician Progress Note, dated [DATE], indicated Resident 77 exhibited alertness and cognitive ability to effectively communicate needs and his language comprehension and response during assessments were appropriate. The notes indicated Resident 77 continued under monitoring for anemia (a condition of not having enough healthy red blood cells to carry oxygen to the body's tissues) and has declined hospitalization despite the recommendation, understanding the associated risks and benefits. During a review of Resident 77's Physician Progress Note, dated [DATE], indicated when confronted with acute medical symptoms or conditions necessitating immediate attention for Resident 77, the staff has received explicit instructions to promptly trigger emergency medical services (EMS- a system that provides emergency medical care to residents after an incident of serious illness or injury) via 911 and direct the resident to the emergency department. These symptoms and conditions encompass, though are not confined to exacerbation (severe symptoms) of asthma (a respiratory disorder that makes it difficult to breath). The note indicated, the data mentioned above is based on information available during the encounter and may change as other data becomes available. During a review of Resident 77's Care plan, dated [DATE], indicated Resident 77 had exacerbation (worsened symptoms) of COPD manifested by wheezing (a high-pitched, whistling sound that occur during breathing when the airways in the lungs become narrowed or blocked) with the goal that the resident would display optimal breathing patterns daily. The care plan interventions included to give aerosol (a substance released in very fine mist) or bronchodilations (a medication that make breathing easier by relaxing the muscles in the lungs and widening the airways [bronchi])as ordered by the physician and monitor/document any side effects and effectiveness, to monitor for difficulty breathing on exertion, and to administer oxygen via nasal cannula at 2 L/min. During a review of Resident 77's OSR, indicated on [DATE], Resident 77 had a physician order for Ipratropium-Albuterol (a medication used to prevent wheezing, difficulty breathing, chest tightness, and coughing) 3 ml (milliliter, unit of volume) inhale (breathing in) orally (by mouth) every 6 hours as needed for SOB/wheezing for 14 days. During a review of Resident 77's Progress Notes, dated [DATE], indicated on [DATE] at 11:05 PM, during an initial assessment Licensed Vocational Nurse (LVN) 6 noted Resident 77 was in bed asleep but responsive to verbal stimuli with no complaint of pain or discomfort. The note indicated on [DATE] at 12:10 AM, Resident 77 was sitting on his bed and verbalized I can't breathe, I need a breathing treatment, breathing was labored with oxygen saturation was at 72%. The note indicated LVN 6 administered a breathing treatment and offered to transfer the resident to the hospital of which Resident 77 declined and on [DATE] at 12:30 AM, Resident 77 verbalized thank you, I'm feeling better. The note indicated at on [DATE] at 1 AM, Resident 77 was asleep with eyes closed and receiving continuous oxygen at 2 L/min, then at 1:55 AM, LVN 6 was alerted to Resident 77's room by Certified Nurse Assistant (CNA) 4, that Resident 77 was unresponsive with no chest movement and no pulse, CPR (cardiopulmonary resuscitation, is an emergency treatment that's done when someone's breathing or heartbeat has stopped by chest compression [pressing on the chest over the heart] and rescue breathing [mouth-to-mouth resuscitation]) was initiated and 911 was called. The notes indicated on [DATE] at 2:10 AM, the paramedics arrived and took over the CPR and Resident 77 was pronounced dead at 2:29 AM and Resident 77's physician was notified via text on [DATE] at 3:16 AM. During a review of Resident 77's Medication Administration Record (MAR) for [DATE], indicated on [DATE] at 12:10 AM, Ipratropium-Albuterol Inhalation Solution medication was given to Resident 77 for SOB/wheezing. During a review of Resident 77's Physician's Discharge Summary, dated [DATE], indicated Resident 77 was discharged from the facility due to resident expired. During a review of Paramedic Run Report, dated [DATE], indicated Resident 77 presented warm, pupils were fixed (indication of no brain activity), in asystole (no heart rhythm) and for the duration of CPR. The report indicated, Resident 77 remained in asystole with no changes after given 3 Epinephrine (the primary drug administered during CPR to reverse cardiac arrest) doses and was pronounced dead at 2:29 AM after 20 minutes of high-quality CPR. The report indicated, staff stated the patient (Resident 77) is being seen at this facility for COPD and possible pneumonia. Pt was advised to go to the hospital by staff numerous times for better care and treatment but declined for a week. Pt was given a breathing treatment by staff at midnight with no improvement and was found not breathing at around on [DATE] at 2 AM. Staff immediately began CPR and called 911. CPR taken over by EMS on [DATE] at 2:09 AM. During an interview on [DATE] at 4:37 PM with CNA 4, CNA 4 stated, when she came to work on [DATE] at around 11:06 PM, Resident 77 did not respond when she tried to greet him, his eyes were closed, and he was breathing very fast. CNA 4 stated, Resident 77 was receiving oxygen supplement with a tube in his nose. CNA 4 stated, LVN 6 told her that Resident 77 was not feeling well and that she should keep an eye on the resident. CNA 4 stated, she checked Resident 77 several times and observed Resident 77's breathing was getting loose and loose to the point of no breathing anymore, and his facial expression was flat. CNA 4 stated, she did not monitor for Resident 77's vital signs (measurement of the blood pressure, heart rate, respiratory rate, and body temperature) or oxygen saturation because it was the charge nurse's responsibility. CNA 4 stated, she asked LVN 6 to Please come and check on Resident 77 because she had to attend another resident. CNA 4 stated, LVN 6 went to see Resident 77 and she went to another resident's room to give care. CNA 4 stated, when she came out of the other resident's room, she saw LVN 4 bringing in a big oxygen tank to Resident 77's room. When she peeked in Resident 77's room, LVN 4 told her that the resident was dead. CNA 4 stated, she recalled LVN 4 was performing CPR on Resident 77, but she did not come to help in Resident 77's room because she was busy with the other resident. During an interview on [DATE] at 5:09 PM with LVN 6, LVN 6 stated, when he first checked on Resident 77 at the start of his shift on [DATE] at around 11 PM, Resident 77's vital signs including the oxygen saturation was around ,d+[DATE]% while Resident 77 was receiving 2 L/min oxygen via NC. LVN 6 stated, Resident 77 was breathing heavily, and very labored. LVN 6 stated, about an hour later, Resident 77 told him I can't breathe, I want my breathing treatment. LVN 6 stated he checked Resident 77's oxygen saturation and it was at 72%. LVN 6 stated, he asked Resident 77 if he wanted to be transferred to the hospital, but Resident 77 stated No, meaning he didn't want to go the hospital, so LVN 6 gave Resident 77 Albuterol breathing treatment as ordered by the physician. LVN 6 stated, after the treatment, Resident 77's oxygen saturation went up, but not that high, to ,d+[DATE]%. LVN 6 stated, he asked Resident 77 again if Resident 77 wanted to be transferred to the hospital, Resident 77 stated No. LVN 6 stated, after the breathing treatment was given, he put Resident 77 back to continuous oxygen at 3 L/min via NC. LVN 6 stated, he did not recheck Resident 77's vital signs when Resident 77 had an episode of decreased oxygen saturation of 72%, and he did not recheck and monitor Resident 77's oxygen saturation after giving Resident 77's breathing treatment when the oxygen saturation increased to ,d+[DATE]%. LVN 6 stated, when communicating with the physicians at the facility, the staffs only text the doctors during the night, the staffs do not call the doctors if they need to report the resident's condition. LVN 6 stated, he did not document Resident 77's (Change of Condition) COC, notify the doctor via text or call, or call 911 regarding Resident 77's labored breathing, low oxygen level, changes in the respiratory and refusal to go to the hospital because Resident 77 had a behavior of refusing to be transferred to the hospital and because LVN 6 believed that Resident 77's breathing was better given that the oxygen saturation went up from 72 % to ,d+[DATE]%. LVN 6 also stated, he was busy with other residents. LVN 6 stated, he told CNA 4 to keep an eye on Resident 77 for his movement in case Resident 77 was not breathing. LVN 6 stated, when CNA 4 came and told him to come to see Resident 77, he rushed in Resident 77's room, tapped on Resident 77's shoulder but the resident was not responding. LVN 6 stated, Resident 77's chest was not moving up and down, so he ran out of the room to call for help and brought in the bigger oxygen tank. LVN 6 stated, LVN 7 was helping him to call 911 while he went back to Resident 77's room and started CPR. LVN 6 stated, the resident's room did not have any button to activate Code Blue (a code announced through an overhead audio system to alert the staffs in the facility about a medical emergency). LVN 6 stated, he did not call for a Code Blue overhead because he did not want to panic other residents during the nighttime. During an interview on [DATE] at 6:06 PM with LVN 7, LVN 7 stated, he was at his nursing station when he heard LVN 6 running in the hallway, telling him, My patient is not responding. LVN 7 stated, he helped LVN 6 to call 911 at his station, when he finished his call with 911, he walked over to Resident 77's room and believed that there were two to three people in the room and recalled one of them was doing CPR. LVN 7 stated, he did not come in to help because the EMS already came in by that time. During a concurrent record review and interview on [DATE] at 9:14 AM with the Regional Medical Record (RMR), Resident 77's Change of Condition/MD notification and orders for the month of [DATE] were reviewed. The RMR stated, there was no documented evidence that a COC was completed, no indication that the physician was notified, and no physician order to address Resident 77's respiratory distress and decreased oxygenation on [DATE]. The RMR stated, there was no care plan for Resident 77's refusal to go to the hospital and no documented evidence that alternative interventions were discussed with Resident 77 regarding his refusal. There was also no documentation that the DON, Administrator or the facility's Medical Director was informed about Resident 77's change in respiratory condition. During an interview on [DATE] at 10:04 AM with the MDS Nurse (MDSN), the MDSN stated, when Resident 77 desaturated (a drop in blood oxygen level) and was having SOB, LVN 6 should follow the doctor's order to notify the doctor right away about the situation and the resident's low saturation even when the resident refused to be transferred to the hospital. The MDSN stated, the doctor should be notified about the resident's refusal because if the resident was alert enough, the doctor could explain to the resident that if he refused care, it could lead to death. The MDSN stated, it was important to notify the doctor right away so the LVN could have orders for immediate interventions and treatment. The MDSN stated, the doctor might also ask the nurse to just call 911. During an interview on [DATE] at 11:16 AM with the Director of Nurses (DON), the DON stated, at nighttime, the facility doesn't have any registered nurse, only LVNs. The DON stated, depending on the severity of the situation, the doctor could be contacted via calls or text messages. The DON stated, if the primary physician didn't respond, the medical director could be notified. The DON stated, he (DON) was also available ,d+[DATE] in case of emergency for guidance. The DON stated, in a situation when the resident's saturation went down to 72% and was having SOB and there was order for breathing treatment, the nurse could send the doctor a text to notify the doctor about the situation. The DON stated, while waiting for the doctor's response, the LVN should monitor for the resident's vital signs including oxygen saturation, put the resident on oxygen and titrate to the maximum oxygen level as ordered, give breathing treatment, and continue to monitor the resident for how the resident was doing with vital signs and document them in the resident's medical record. The DON stated, if the oxygen saturation was at ,d+[DATE]% after treatment, the treatment was not effective. The DON stated, if the resident refused to be transferred to the hospital, the nurse should notify the doctor right away to report the situation that the oxygen and breathing treatment was given as ordered but the oxygen saturation level did not increase as expected and that the resident refused transferring to the hospital. The DON stated, LVN 6 should have reported Resident 77's desaturation episode and his refusal to the doctor even if LVN 6 respected Resident 77's right and have the doctor decide what to do. The DON stated, 911 should have been called to manage the situation. During an interview on [DATE] at 4:50 PM with Resident 77's primary physician (PMP 1), the PMP 1 stated, on the night of [DATE], he did not receive any text or call from the facility staff regarding Resident 77's desaturation and SOB. PMP 1 stated, he only got a text to notify him that his patient (Resident 77) had passed away early morning of [DATE] because of unresponsiveness and not breathing. PMP 1 stated, when the oxygen saturation went down to 72% and Resident 77 was having SOB, LVN 6 should give breathing treatment and notify him at least via text messages. PMP 1 stated, after breathing treatment, when the oxygen saturation went up to ,d+[DATE]%, the saturation was still too low, and Resident 77 should have been transferred out to the hospital for higher level of care. PMP 1 stated, even when Resident 77 refused, LVN 6 should have let him know. PMP 1 stated, he would have asked LVN 6 to transfer or call 911. PMP 1 stated, the facility's practice is very aggressive with transferring out in cases of emergency that the patient was not able to be stabilized. PMP 1 stated, if he was aware of the patient's repeated refusal to care, he would consider hospice or discuss with him of changing in code status if Resident 77 was alert able to decide for himself. PMP 1 stated, LVN 6 should not decide by himself without informing the physician whether to not transfer Resident 77 to the hospital or not due to respecting the resident's right because Resident 77 was still a full code. During a review of the facility's Policies and Procedures (P&P) titled, Change of Condition (COC) Notification, revised [DATE], indicated the following: a. An acute COC is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinical important means a deviation that, without intervention, may result in compilations or death. b. The Licensed nurse will notify the resident's Attending Physician when there is a significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, life threatening conditions or clinical complications; a need to alter treatment signification; and a decision to transfer or discharge the resident from the facility. c. The Licensed Nurse will assess the resident's COC and document the observations and symptoms. d. The Attending Physician will be notified timely with the residents' COC. Notification to the Attending Physician will include a summary of the condition change, and an assessment of the resident's vital signs. e. In emergency situations (e.g., a resident is experiencing unexpected SOB), the Licensed Nurse will: immediately call the Attending Physician. f. If the Licensed Nurse is unable to reach the Attending Physician or the Physician on call during emergency situations, he/she will notify the Facility's Medical Director. If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital. g. Notify the Nursing Supervisor of emergency. During a review of the facility's P&P titled, Emergency Care - General, revised [DATE], indicated, emergency - Life threatening is the situation that requires prompt intervening actions to maintain physical, mental, and/or emotional health. Summon help and immediately call 911 for medical emergency assistance. These emergency situations would include but are not limited to: cessation (stop) of breathing and document the resident's vital signs including blood pressure, pulse, respirations and temperature. During a review of the facility's P&P titled, Pulse Oximetry (Assessing Oxygen Saturation), revised [DATE], indicated: a. For the safety and comfort of residents, the Facility will utilize pulse oximetry to measure levels of oxygen in the resident's blood when such measurement is ordered by the resident's Attending Physician or as indicated by the resident's condition. b. A normal oxygen saturation is between 90 to 100 percent. Anything below 90 percent should be closely monitored, including the maintenance of a flow chart or documentation record for oxygen saturation level. c. Residents with respiratory distress will have a respiratory assessment completed that may include the use of a pulse oximeter to noninvasively measure the resident's blood oxygen saturation. d. If oxygen saturation is less than 90 percent, if oxygen saturation is at less than an acceptable level fo the resident's condition, notify the Attending Physician. During a review of the facility's P&P titled, Oxygen Administration, dated [DATE], indicated to prevent or reverse hypoxia and provide oxygen to the tissues, the facility will, in an emergency situation or when a physician's order cannot be immediately obtained, oxygen may be initiated by a Licensed Nurse in the presence of acute chest pain or any other acute situation in which hypoxia is suspected. A physician is to be contacted as soon as possible after initiation of oxygen therapy in emergency situations, for verification and documentation of the order for oxygen therapy consultation, and further orders. Oxygen saturations will be measured and documented at a minimum of daily for resident's receiving oxygen therapy.

Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 19, 1, and 20) had that their medical records updated to show documentations that: 1. Resident 19, Resident 20, or their Responsible Party (RP) were offered and explained on how to execute an Advance Directive (a written statement of a person ' s wishes regarding medical treatment made to ensure those wishes were carried out should the resident be unable to communicate them to the doctor). 2. Resident 1 and 20 ' s had a Physician Order Life Treatment (POLST, a portable medical order form that records the resident ' s treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency) had a physician ' s signature. These failures had the potential to cause conflict with the resident ' s wishes regarding the alternatives in the provision of health care and the failure to convert the resident ' s wishes regarding life-sustaining treatment and resuscitation (the act of reviving someone who has stopped breathing or is unconscious) into physician orders. Findings: 1. During a review of Resident 19 ' s Admission Record, the facility admitted Resident 19 on 12/16/2014 and readmitted Resident 19 on 5/20/2020 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing), parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and muscle weakness. During a review of Resident 19 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the resident ' s health status), dated 10/10/2023, the H&P indicated Resident 19 had the capacity to understand and make decisions. During a review of Resident 19 ' s Advance Directive Acknowledgement form, dated 7/6/2024, there was no documented evidence whether the option of an advance directive was informed or offered to Resident 19 and their RP. During a review of Resident 19 ' s Minimum Data Set (MDS, a resident assessment tool), dated 9/29/2024, the MDS indicated that Resident 19 was moderately cognitively (a person ' s mental process of thinking, learning, remembering, and using judgement) impaired. The MDS indicated Resident 19 required substantial to dependent assistant for all ADLs. 2. During a review of Resident 20 ' s Admission Record, the facility admitted Resident 20 on 10/25/2024 and readmitted Resident 20 on 11/18/2024 with diagnoses that included a displaced intertrochanteric fracture of the right femur (fracture of the right upper thigh bone), cellulitis (a bacterial skin infection) of the right lower limb, and paranoid schizophrenia (a mental illness where someone experiences intense paranoia characterized by hallucinations [perceptual experiences in the absence of real external sensory stimuli] and delusions [misconceptions or beliefs that were firmly held, contrary to reality]). During a review of Resident 20 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the assessment of the resident ' s health status), dated 10/26/2024, the H&P indicated that Resident 20 had the ability to make her needs known but does not have the capacity to consent. During a review of Resident 20 ' s MDS, dated [DATE], the MDS indicated Resident 20 ' s cognitive status was severely impaired. The MDS indicated Resident 20 was dependent on all ADLs and required substantial assistance when moving from sitting on the side of the bed to lying down and when turning side to side in bed. The MDS indicated Resident 20 did not hallucinate or have delusions. During a review of Resident 20 ' s POLST form, dated 10/26/2024, the POLST did not have a physician ' s signature. During a review of Resident 20 ' s Advance Directive Acknowledgement form, dated 10/26/2024, there was no documented evidence whether the option of an advance directive was informed or offered to Resident 20 and her RP. 3. During a review of Resident 1 ' s Admission Record, the facility admitted Resident 1 on 11/17/2023 and readmitted Resident 1 on 9/7/2024 with diagnoses that included muscle wasting and atrophy (wasting away of muscle mass), unspecified dementia (a progressive state of decline in mental abilities), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) malfunction. During a review of Resident 1 ' s H&P, dated 9/10/2024, the H&P indicated Resident 1 did not have the capacity to understand or make decisions. During a review of Resident 1 ' s MDS, dated [DATE], the MDS indicated that Resident 1 rarely or never made any daily decision makings. The MDS indicated that Resident 1 was dependent (a helper does all the effort or required the assistance of two or more helpers to complete the activity) for all activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily). The MDS indicated that Resident 1 required substantial assistance (helper does more than half the effort) when turning side to side in bed and from sitting to lying in bed. During a review of Resident 1 ' s POLST form, dated 3/27/2024, Physician ' s 1 ' s signature was not documented. During a concurrent record review and interview on 12/4/2024 at 2:03PM with Registered Nurse (RN) 1, Resident 1, 19, and 20 ' s POLST and advance directive were reviewed. RN 1 stated, Resident 1 ' s POLST was not signed by the Physician 1. RN 1 stated, Resident 19 ' s advance directive was not filled out completely and did not indicate whether the advance directive was explained to Resident 19 ' s RP. RN 1 stated, Resident 20 ' s POLST was not signed by the physician (unable to identify) and the advance directive was not filled out completely and did not indicate whether the advance directive was explained to Resident 19 ' s RP. RN 1 stated, nursing initiated and completed the POLST upon admission, and the Social Services Director (SSD) follows up on the POLST the following day. RN 1 stated, the SSD reviews the POLST to ensure it was filled out, which included making sure a physician ' s signature was present. RN 1 stated, if the POLST was missing a physician ' s signature, the physician had 72 hours to come in the facility to sign the POLST. RN 1 stated, the POLST was a set list of physician ' s orders that required a physician ' s signature because it was important that the physician confirms that all the orders on the POLST were correct. RN 1 stated, the advance directive should be filled out to ensure the advance directive was thoroughly explained to the resident or the RP. RN 1 stated, if there was an advance directive, the advance directive should be followed because it was the resident ' s wishes in case of an emergency. During a concurrent record review and interview on 12/4/2024 at 2:35PM with the SSD, Resident 1, 19, and 20 ' s POLST and advance directive were reviewed. The SSD stated, she forgot to check the POLST and advance directive for completeness. The SSD stated, it was her responsibility to ensure the POLST and advance directive were explained to the resident and resident ' s RP and ensure the forms were filled out completely. The SSD stated, she and the Director of Nursing (DON) reviewed all POLST and advance directive forms to ensure completion, which included checking for physician and RP signatures. The SSD stated, the Medical Records Director (MRD), conducted a third audit to ensure the POLST and advance directive were filled out completely before uploading into the resident ' s medical chart. The SSD stated, the physician ' s signature should be on the POLST in 1-2 days upon admission because the physician needs to agree to the POLST. The SSD stated, it was important to explain what an advance directive was and what options the resident or resident ' s RP had. During a concurrent record review and interview on 12/4/2024 at 2:35PM with the MRD, Resident 1, 19, and 20 ' s POLST and advance directive were reviewed. The MRD stated, she audited the resident ' s medical records, which included checking that all sections of the POLST and advance directive. The MRD stated, she did not check Resident 1, 19, and 20 ' s POLST and advance directive for completeness. The MRD stated, if there was an incomplete section or a signature missing on the POLST or advance directive, she should have followed up with the SSD and with the physician. During a review of the facility ' s policies and procedures (P&P), Physician Orders for Life Sustaining Treatment (POLST), dated 6/1/2017, the P&P indicated a completed and signed POLST form is a legal physician order that was immediately actionable. The P&P indicated the physician will review the order after admission and consult with the resident to ensure that the order was consistent with the resident ' s goals. The P&P indicated that a licensed nurse or Social Services Designee will explain the POLST form to the resident or the resident ' s responsible party and will notify the physician, nurse practitioner or physician assistant. During a review of the facility ' s P&P, Advance Directives, revised on 6/1/2021, the P&P indicated, the facility will inform the resident of their right to execute an Advance Directive Form, if one does not already exist. The P&P indicated, if a resident does not have the capacity to understand the information about an advance directive, the facility may give advance directive information to the resident ' s representative in accordance with state law. The P&P indicated, each resident is informed of their choice to complete the advance directive, and the choice not to complete the advance directive Form is recorded in the resident ' s medical record.

Based on observation, interview, and record review, the facility failed to follow and implement the facility ' s Policies and Procedures (P&P) titled, Change of Condition Notification, revised [DATE], for one of three sampled residents (Resident 77) with diagnoses of chronic obstructive pulmonary disease exacerbation (COPD, worsened and severe symptoms of a lung disease characterized by poor airflow to the lungs that results in shortness of breath, and respiratory distress (a condition that occurs when the body needs more oxygen than it's getting, leading to difficulty breathing, rapid breathing, and low blood oxygen levels) and a history of pneumonia (a severe respiratory infection that results in shortness of breath and difficulty breathing) by failing to: 1. Ensure to notify the physician and 911 (an emergency number) emergency services immediately, when Resident 77 complained of not being able to breath and exhibited signs and symptoms of respiratory distress, labored breathing (take more efforts to breath) and oxygen saturation of 72% (normal range 90 to 100 percent) on [DATE] at 12:10 AM. 2. Ensure the physician was informed that Resident 77 was refusing to go to the hospital while complaining of not being able to breath and exhibited signs and symptoms of respiratory distress, labored breathing, and oxygen saturation of 72% on [DATE] at 12:10 AM. As a result of these deficient practices Resident 77 did not receive immediate respiratory care and interventions on [DATE] from 11:06 PM when the resident was initially observed with respiratory distress, labored breathing, decreased level of oxygenation, until [DATE] at 2:29 AM when the paramedics pronounced Resident 77 dead after unsuccessful CPR (cardiopulmonary resuscitation, an emergency treatment for someone who stopped breathing or heartbeat has stopped by providing chest compression [pressing on the chest over the heart] and rescue breathing [mouth-to-mouth resuscitation]) was provided. Cross reference to F695 and F867 Findings: During a review of Resident 77's Admission Record (AR), the AR indicated the facility admitted Resident 77 on [DATE] and readmitted on [DATE] with diagnoses that included COPD with exacerbation (worsened symptoms), pneumonia, hypertensive heart disease (high blood pressure), and type 2 diabetes mellitus (condition of having high blood sugar). During a review of Resident 77 ' s Physician Orders for Life-Sustaining Treatment (POLST- a medical order that documents a patient's preferences for end-of-life care), dated [DATE], indicated if the resident was found with a pulse and/or was breathing, full treatment was ordered for medical interventions including intubation (a tube placed in the mouth to the airway to provide oxygenation), advanced airway interventions (a tube place in the airway), mechanical ventilation (assisted breathing provided with the use of a machine), and cardioversion (a medical procedure that restores a normal heart rhythm by using electricity or medication to treat an abnormal heart rhythm). During a review of Resident 77 ' s Order Summary Report (OSR), indicated on [DATE], Resident 77 had physician orders to monitor for sign and symptoms of respiratory distress that included monitoring for pulse oximetry (a device used to monitor oxygen blood level), lethargy (a state of unusual drowsiness, fatigue, and lack of energy and mental alertness), accessory muscle usage (breathing using muscles other than those typically used for breathing to take in and expel air) and to document with hashmarks (or tally marks, a numerical system used to keep track of things by number) in the clinical record of the resident if present and report to the physician. The physician also ordered to titrate (adjust) oxygen at ,d+[DATE] L/min via NC continuously to maintain oxygen saturation at 92 % or above, and to notify the physician if oxygen saturation was below 92% for SOB. The OSR indicated in the event of an emergency, the Medical Director may be called if the attending physician or alternate physician are not available. During a review of Resident 77 ' s History and Physical Examinations, dated [DATE], indicated Resident 77 had the capacity to understand and make decisions. During a review of Resident 77 ' s OSR, indicated on [DATE], Resident 77 had a physician order for Full Code [a medical order that instructs the health care team to perform all possible life-saving measures if the resident goes into cardiac or respiratory arrest (when the heart stopped beating or the resident stopped breathing)]. During a review of Resident 77 ' s Physician Progress Note, dated [DATE], indicated Resident 77 exhibited alertness and cognitive ability to effectively communicate needs and his language comprehension and response during assessments were appropriate. The notes indicated Resident 77 continued under monitoring for anemia (a condition of not having enough healthy red blood cells to carry oxygen to the body's tissues) and has declined hospitalization despite the recommendation, understanding the associated risks and benefits. During a review of Resident 77 ' s Physician Progress Note, dated [DATE], indicated when confronted with acute medical symptoms or conditions necessitating immediate attention for Resident 77, the staff has received explicit instructions to promptly trigger emergency medical services (EMS) via 911 and direct the resident to the emergency department. These symptoms and conditions encompass, though are not confined to exacerbation (severe symptoms) of asthma (a respiratory disorder that makes it difficult to breath). The note indicated, the data mentioned above is based on information available during the encounter and may change as other data becomes available. During a review of Resident 77 ' s Progress Notes, dated [DATE], indicated on [DATE] at 11:05 PM, during an initial assessment Licensed Vocational Nurse (LVN) 6 noted Resident 77 was in bed asleep but responsive to verbal stimuli with no complaint of pain or discomfort. The note indicated on [DATE] at 12:10 AM, Resident 77 was sitting on his bed and verbalized I can ' t breathe, I need a breathing treatment, breathing was labored with oxygen saturation was at 72%. The note indicated LVN 6 administered a breathing treatment and offered to transfer the resident to the hospital of which Resident 77 declined and on [DATE] at 12:30 AM, Resident 77 verbalized thank you, I ' m feeling better. The note indicated at on [DATE] at 1 AM, Resident 77 was asleep with eyes closed and receiving continuous oxygen at 2 L/min, then at 1:55 AM, LVN 6 was alerted to Resident 77 ' s room by Certified Nurse Assistant (CNA) 4, that Resident 77 was unresponsive with no chest movement and no pulse, CPR was initiated and 911 was called. The notes indicated on [DATE] at 2:10 AM, the paramedics arrived and took over the CPR and Resident 77 was pronounced dead at 2:29 AM and Resident 77 ' s physician was notified via text on [DATE] at 3:16 AM. During a review of Resident 77 ' s Physician ' s Discharge Summary, dated [DATE], indicated Resident 77 was discharged from the facility due to resident expired. During a review of Paramedic Run Report, dated [DATE], indicated Resident 77 presented warm, pupils were fixed (indication of no brain activity), in asystole (no heart rhythm) and for the duration of CPR. The report indicated, Resident 77 remained in asystole with no changes after given 3 Epinephrine (the primary drug administered during CPR to reverse cardiac arrest) doses and was pronounced dead at 2:29 AM after 20 minutes of high-quality CPR. The report indicated, staff stated the patient Resident 77) is being seen at this facility for COPD and possible pneumonia. Pt was advised to go to the hospital by staff numerous times for better care and treatment but declined for a week. Pt was given a breathing treatment by staff at midnight with no improvement and was found not breathing at around on [DATE] at 2 AM. Staff immediately began CPR and called 911. CPR taken over by EMS on [DATE] at 2:09 AM. During an interview on [DATE] at 4:37 PM with CNA 4, CNA 4 stated, when she came to work on [DATE] at around 11:06 PM, Resident 77 did not respond when she tried to greet him, his eyes were closed, and he was breathing very fast. CNA 4 stated, Resident 77 was receiving oxygen supplement with a tube in his nose. CNA 4 stated, LVN 6 told her that Resident 77 was not feeling well and that she should keep an eye on the resident. CNA 4 stated, she checked Resident 77 several times and observed Resident 77 ' s breathing was getting loose and loose to the point of no breathing anymore, and his facial expression was flat. CNA 4 stated, she asked LVN 6 to Please come and check on Resident 77 because she had to attend another resident. CNA 4 stated, LVN 6 went to see Resident 77 and she went to another resident's room to give care. CNA 4 stated, when she came out of the other resident's room, she saw LVN 4 bringing in a big oxygen tank to Resident 77 ' s room. CNA 4 stated, when she looked into Resident 77 ' s room, LVN 4 told her that the resident was dead. CNA 4 stated, she recalled LVN 4 was performing CPR on Resident 77, but she did not come to help in Resident 77 ' s room because she was busy with the other resident. During an interview on [DATE] at 5:09 PM with LVN 6, LVN 6 stated, when he first checked on Resident 77 at the start of his shift on [DATE] at around 11 PM, Resident 77 ' s vital signs including the oxygen saturation was around ,d+[DATE]% while Resident 77 was receiving 2 L/min oxygen via NC. LVN 6 stated, Resident 77 was breathing heavily, and very labored. LVN 6 stated, about an hour later, Resident 77 told him I can ' t breathe, I want my breathing treatment. LVN 6 stated he checked Resident 77 ' s oxygen saturation and it was at 72%. LVN 6 stated, he asked Resident 77 if he wanted to be transferred to the hospital, but Resident 77 stated No, meaning he didn't want to go the hospital, so LVN 6 gave Resident 77 Albuterol breathing treatment as ordered by the physician. LVN 6 stated, after the treatment, Resident 77 ' s oxygen saturation went up, but not that high, to ,d+[DATE]%. LVN 6 stated, he asked Resident 77 again if Resident 77 wanted to be transferred to the hospital, Resident 77 stated No. LVN 6 stated, after the breathing treatment was given, he put Resident 77 back to continuous oxygen at 3 L/min via NC. LVN 6 stated, he did not recheck Resident 77 ' s vital signs when Resident 77 had an episode of decreased oxygen saturation of 72%, and he did not recheck and monitor Resident 77 ' s oxygen saturation after giving Resident 77 ' s breathing treatment when the oxygen saturation increased to ,d+[DATE]%. LVN 6 stated, when communicating with the physicians at the facility, the staffs only text the doctors during the night, the staffs do not call the doctors if they need to report the resident ' s condition. LVN 6 stated, he did not document Resident 77 ' s COC, notify the doctor via text or call, or call 911 regarding Resident 77 ' s labored breathing, low oxygen level, changes in the respiratory and refusal to go to the hospital because Resident 77 had a behavior of refusing to be transferred to the hospital and because LVN 6 believed that Resident 77 ' s breathing was better given that the oxygen saturation went up from 72 % to ,d+[DATE]%. LVN 6 also stated, he was busy with other residents. LVN 6 stated, he told CNA 4 to keep an eye on Resident 77 for his movement in case Resident 77 was not breathing. LVN 6 stated, when CNA 4 came and told him to come to see Resident 77, he rushed in Resident 77 ' s room, tapped on Resident 77 ' s shoulder but the resident was not responding. LVN 6 stated, Resident 77 ' s chest was not moving up and down, so he ran out of the room to call for help and brought in the bigger oxygen tank. LVN 6 stated, LVN 7 was helping him to call 911 while he went back to Resident 77 ' s room and started CPR. LVN 6 stated, the resident ' s room did not have any button to activate Code Blue. LVN 6 stated, he did not call for a Code Blude overhead because he did not want to panic other residents during the nighttime. During a concurrent record review and interview on [DATE] at 9:14 AM with the Regional Medical Record (RMR), Resident 77 ' s Change of Condition/MD notification and orders for the month of [DATE] were reviewed. The RMR stated, there was no documented evidence that a COC was completed, no indication that the physician was notified, and no physician order to address Resident 77 ' s respiratory distress and decreased oxygenation on [DATE]. The RMR stated, there was no care plan for Resident 77 ' s refusal to go to the hospital and no documented evidence that alternative interventions were discussed with Resident 77 regarding his refusal. There was also no documentation that the DON, Administrator or the facility ' s Medical Director was informed about Resident 77 ' s change in respiratory condition. During an interview on [DATE] at 10:04 AM with the MDS Nurse (MDSN), the MDSN stated, when Resident 77 desaturated (a drop in blood oxygen level) and was having SOB, LVN 6 should follow the doctor ' s order to notify the doctor right away about the situation and the resident's low saturation even when the resident refused to be transferred to the hospital. The MDSN stated, the doctor should be notified about the resident ' s refusal because if the resident was alert enough, the doctor could explain to the resident that if he refused care, it could lead to death. The MDSN stated, it was important to notify the doctor right away so the LVN could have orders for immediate interventions and treatment. The MDSN stated, the doctor might also ask the nurse to just call 911. During an interview on [DATE] at 11:16 AM with the Director of Nurses (DON), the DON stated, at nighttime, the facility doesn't have any registered nurse, only LVNs. The DON stated, depending on the severity of the situation, the doctor could be contacted via calls or text messages. The DON stated, if the primary physician didn ' t respond, the medical director could be notified. The DON stated, he was also available ,d+[DATE] in case of emergency for guidance. The DON stated, in a situation when the resident's saturation went down to 72% and was having SOB and there was order for breathing treatment, the nurse could send the doctor a text to notify the doctor about the situation. The DON stated, while waiting for the doctor ' s response, the LVN should monitor for the resident ' s vital signs including oxygen saturation, put the resident on oxygen and titrate to the max oxygen level as ordered, give breathing treatment and continue to monitor the resident for how the resident was doing with vital signs and document them in the resident ' s medical record. The DON stated, if the oxygen saturation was at ,d+[DATE]% after treatment, the treatment was not effective. The DON stated, if the resident refused to be transferred to the hospital, the nurse should notify the doctor right away to report the situation that the oxygen and breathing treatment was given as ordered but the oxygen saturation level did not increase as expected and that the resident refused transferring to the hospital. The DON stated, LVN 6 should have reported Resident 77 ' s desaturation episode and his refusal to the doctor even if LVN 6 respected Resident 77 ' s right and have the doctor decide what to do. The DON stated, 911 should have been called to manage the situation. During an interview on [DATE] at 4:50 PM with Resident 77 ' s primary physician (PMP 1), the PMP 1 stated, on the night of [DATE], he did not receive any text or call from the facility staff regarding Resident 77 ' s desaturation and SOB. PMP 1 stated, he only got a text to notify him that his patient (Resident 77) had passed away early morning of [DATE] because of unresponsiveness and not breathing. PMP 1 stated, when the oxygen saturation went down to 72% and Resident 77 was having SOB, LVN 6 should give breathing treatment and notify him at least via text messages. PMP 1 stated, after breathing treatment, when the oxygen saturation went up to ,d+[DATE]%, the saturation was still too low, and Resident 77 should have been transferred out to the hospital for higher level of care. PMP 1 stated, even when Resident 77 refused, LVN 6 should have let him know. PMP 1 stated, he would have asked LVN 6 to transfer or call 911. PMP 1 stated, their practice is very aggressive with transferring out in cases of emergency that the patient was not able to be stabilized. PMP 1 stated, if he was aware of the patient's repeated refusal to care, he would consider hospice or discuss with him of changing in code status if Resident 77 was alert able to decide for himself. PMP 1 stated, LVN 6 should not decide by himself without informing the physician whether to not transfer Resident 77 to the hospital or not due to respecting the resident ' s right because Resident 77 was still a full code. During a review of the facility ' s Policies and Procedures (P&P) titled, Change of Condition Notification, revised [DATE], indicated the following: a. An acute COC is a sudden, clinically important deviation from a patient ' s baseline in physical, cognitive, behavioral, or functional domains. Clinical important means a deviation that, without intervention, may result in compilations or death. b. The Licensed nurse will notify the resident ' s Attending Physician when there is a significant change in the resident's physical, mental or psychosocial status, e.g., deterioration in health, life threatening conditions or clinical complications; a need to alter treatment signification; and a decision to transfer or discharge the resident from the facility. c. The Licensed Nurse will assess the resident's COC and document the observations and symptoms. d. The Attending Physician will be notified timely with the residents ' COC. Notification to the Attending Physician will include a summary of the condition change, and an assessment of the resident ' s vital signs. e. In emergency situations (e.g., a resident is experiencing unexpected SOB), the Licensed Nurse will: immediately call the Attending Physician. f. If the Licensed Nurse is unable to reach the Attending Physician or the Physician on call during emergency situations, he/she will notify the Facility ' s Medical Director. If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital. g. Notify the Nursing Supervisor of emergency situation. During a review of the facility ' s P&P titled, Emergency Care - General, revised [DATE], indicated, emergency - Life threatening is the situation that requires prompt intervening actions to maintain physical, mental, and/or emotional health. Summon help and immediately call 911 for medical emergency assistance. These emergency situations would include but are not limited to: cessation (stop) of breathing and document the resident ' s vital signs including blood pressure, pulse, respirations and temperature. During a review of the facility ' s P&P titled, Pulse Oximetry (Assessing Oxygen Saturation), revised [DATE], indicated: a. A normal oxygen saturation is between 90 to 100 percent. Anything below 90 percent should be closely monitored, including the maintenance of a flow chart or documentation record for oxygen saturation level. b. If oxygen saturation is less than 90 percent, if oxygen saturation is at less than an acceptable level fo the resident ' s condition, notify the Attending Physician. During a review of the facility ' s P&P titled, Oxygen Administration, dated [DATE], indicated to prevent or reverse hypoxia and provide oxygen to the tissues, the facility will, in an emergency situation or when a physician's order cannot be immediately obtained, oxygen may be initiated by a Licensed Nurse in the presence of acute chest pain or any other acute situation in which hypoxia is suspected. A physician is to be contacted as soon as possible after initiation of oxygen therapy in emergency situations, for verification and documentation of the order for oxygen therapy consultation, and further orders. Oxygen saturations will be measured and documented at a minimum of daily for resident's receiving oxygen therapy.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to care for two of three sampled residents (Resident 65 and Resident 36) with indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine and left in place for a set amount of time). Resident 65 and 36 with indwelling catheter was observed with presence of sediments (particles free floating in urine that could be sign of infection) in the urine that was not assessed, documented and reported to the physician. These failures had the potential to result in a delay in treatments, interventions, and services to treat a possible UTI (an infection in the urinary tract- urethra, bladder, utterer and kidney), which could lead to a resident ' s increased confusion, sepsis (a life-threatening blood infection), hospitalization , and possibly death. Findings: 1. During a review of Resident 65 ' s Admission Record, the facility admitted Resident 65 on 2/2/2024 and readmitted Resident 65 on 6/7/2024 with diagnoses that included metabolic encephalopathy (a brain disorder that occurred when a chemical imbalance in the blood affects the brain) and acute kidney failure (kidneys suddenly stop working). During a review of Resident 65 ' s History and Physical (H&P, a comprehensive physician ' s note regarding the resident ' s health status), dated 6/17/2024, Resident 65 did not have the capacity to understand and make decisions. During a review of Resident 65 ' s Minimum Data Set (MDS, a resident assessment tool) dated 11/11/2024, the MDS indicated Resident 65 has severely impaired cognition (a person ' s mental process of thinking, learning, remembering, and using judgement). The MDS indicated Resident 65 was dependent (helper does all the effort. Resident does none of the effort to complete an activity) for all activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) and functional mobility (a person ' s ability to move safely and independently within their environment). The MDS indicated Resident 65 had an indwelling catheter. During a review of Resident 65 ' s Order Summary Report (a physician ' s order) dated 2/3/2024, indicated Resident 65 ' s indwelling catheter needed to be monitored and documented for sediments, foul odor, hematuria (blood in urine), or bladder distention (the bladder was stretched beyond its normal capacity due to blockage in the urinary tract). The physician order indicated to document (Y) if noted and to notify the physician, and to document (N) if none noted. During a review of Resident 65 ' s Order Summary Report, dated 2/3/2024, Resident 65 ' s indwelling catheter may be flushed with 60 milliliters (mL, unit of measure) of normal saline solution (NS) as needed for increased sediments. During a review of Resident 65 ' s care plan, revised on 11/13/2024, Resident 65 had an indwelling catheter with interventions that included monitoring for signs and symptoms for UTI such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased heart rate, increased temperature, foul smelling urine, and a change in behavior. During a review of Resident 65 ' s Treatment Administration Record (TAR, a record of a resident ' s treatment in the resident ' s medical record), for the month December 2024, was reviewed. The TAR indicated Resident 65 ' s indwelling catheter was assessment for 12/3/2024 but did not indicate whether the indwelling catheter had sediments, foul odor, hematuria, or bladder distention. During a review of Resident 65 ' s TAR, for the month of December 2024, indicated Resident 65 ' s indwelling catheter was not flushed with 60 mL of NS on 12/3/2024. 2. During a review of Resident 36 ' s Admission Records, the facility admitted Resident 36 on 2/3/2024 and readmitted Resident 36 on 8/1/2024 with diagnoses that included encephalopathy (a change in a resident ' s brain function), generalized osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), and an overactive bladder (increased urge to urinate that may be hard to control). During a review of Resident 36 ' s H&P, dated 9/10/2024, the H&P indicated Resident 36 did not have the capacity to understand and make decisions. During a review of Resident 36 ' s MDS, dated [DATE], the MDS indicated that Resident 36 ' s cognition was severely impaired. The MDS indicated Resident 36 required dependent assistance for all ADLs and functional mobility. The MDS indicated Resident 36 had an indwelling catheter. During a review of Resident 36 ' s Order Summary Report, dated /2/2024, indicated Resident 36 ' s indwelling catheter needed to be monitored and documented for sediments, foul odor, hematuria, or bladder distention. The order indicated to document (Y) if noted and to notify the physician, and to document (N) if none noted. During a review of Resident 36 ' s Order Summary Report, with an order start date of 8/2/2024, Resident 36 ' s indwelling catheter may be flushed with 60 mL of NS as needed for increased sediments. During a review of Resident 36 ' s care plan, revised on 11/12/2024, Resident 36 had an indwelling catheter and was at risk for development of complications such as developing a UTI with interventions that included monitoring for signs and symptoms of UTIs such as pain, burning, blood-tinged urine, cloudiness, deepening of urine color, increase heart rate, increase temperature, foul smelling urine, and a change in behavior. During a review of Resident 36 ' s TAR, for the month of December 2024, was reviewed. The TAR indicated Resident 36 did not have sediments in the indwelling catheter for 12/3/2024. During a review of Resident 36 ' s TAR, for the month of December 2024, was reviewed. The TAR indicated Resident 36 ' s indwelling catheter was not flushed with 60mL of NS for 12/3/2024. During an observation on 12/3/2024 at 9:05AM in Resident 36 ' s room, Resident 36 ' s indwelling catheter had sediments in the tubing. During an observation on 12/3/2024 at 9:30AM in Resident 65 ' s room, Resident 65 ' s indwelling catheter had sediments in the tubing. During a concurrent observation and interview on 12/4/2024 at 4:21PM with Licensed Vocational Nurse (LVN) 9, in Resident 36 ' s room, Resident 36 ' s indwelling catheter had sediment urine draining into the tubing. LVN 9 stated, there was a bit of sediment present in the indwelling catheter tubing. During a concurrent observation and interview on 12/4/2024 at 4:25PM with LVN 9, in Resident 65 ' s room, Resident 65 ' s indwelling catheter had sediment in the tubing. LVN 9 stated, there was some sediment present in the indwelling catheter tubing. During an interview on 12/4/2024 at 4:30PM with LVN 9, LVN 9 stated, he was unaware of the sediment in Resident 36 ' s and Resident 65 ' s urine. LVN 9 stated, Resident 36 and 65 ' s urine should be clear, and there should not be any cloudiness or sediment in the urine. LVN 9 stated, part of indwelling catheter care included following the physician ' s order for flushing the indwelling catheter for irrigation (a procedure that used NS to clear a blocked catheter and remove debris from the bladder) and monitoring the urine for cloudiness, sediments, urine color, or foul odor. During a concurrent interview and record review on 12/4/2024 at 4:45PM with LVN 9, Resident 36 and Resident 65 ' s Change of Condition Evaluation (CoC, a document used to record a resident ' s change of condition, required notifications to physicians and responsible parties, care plan updates, and physician orders), Nursing Progress Notes (a written record that a nurse keeps about a resident ' s health status), and TAR were reviewed. LVN 9 stated, the physician was not notified of Resident 36 and Resident 65 ' s sediment in the indwelling catheter because there was no CoC or nursing progress notes documented. LVN 9 stated, there was a place to document sediment in the urine in the TAR, and it was not documented. LVN 9 stated, the LVNs would document the sediment in the indwelling catheter in the TAR, document a progress note, create a CoC to notify the physician, and create a care plan. LVN 9 stated, sediment in the urine could lead to a UTI, and if the UTI was not properly treated, the resident could become hospitalized . During an interview on 12/6/2024 at 7:30PM with the Director of Nursing (DON), the DON stated, if there was hematuria, sediment, or foul odor noted in a resident ' s indwelling catheter, the physician should be notified. The DON stated, there was a place in the TAR for the licensed nurses to document any abnormal assessments of the indwelling catheter. The DON stated, it was important to assess the urine in the indwelling catheter because if there was sediment in the tubing, it could lead to blockage of the indwelling catheter tubing. The DON stated, this blockage could lead the urine to be backed up in the urinary tract and this could become a UTI. During a review of the facility ' s policies and procedures (P&P), Catheter - Care of, revised on 6/1/2017, the P&P indicated, a resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. The P&P indicated, to report signs and symptoms of UTI to the attending physician such as fever, changes in urine such as foul odor or bloody/cloudy appearance. During a review of the facility ' s P&P, Change of Condition Notification, revised on 6/1/2017, the P&P indicated the facility will notify the resident ' s attending physician when the resident has a significant change in the resident ' s physical, cognitive, behavioral, or functional status. The P&P indicated a Licensed Nurse will document the date, time, and details of the incident and the assessment in the nursing notes, the time the physician was notified, and their recommendations.

Based on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted in a highly visible and prominent place that was readily accessible to residents, staff, and visitors daily. This failure had the potential to result in residents and visitors not being able to access full view the facility's staffing information to ensure safe staffing sufficient staffing were implemented. Findings: During an observation on 12/3/2024 at 8:30AM in the front lobby, there was no nurse staffing information posted by the receptionist's desk. During an observation on 12/3/2024 at 9:00AM in Nursing Station 1, 2, and 3, there was no nurse staffing information posted with each Nursing Station. During a concurrent observation and interview on 12/6/2024 at 6:50 PM with the Director of Staff Development (DSD), the facility's nurse staffing information was posted next to the facility's shadow box frame by the main entrance that contained important facility documents not limited to the facility's business license and administrator's license, not easily visible to residents and visitors. The DSD stated, the nurse staffing information should be posted in a highly visible area so the residents and visitors could see the projected numbers of Certified Nurse Assistants (CNAs) would be working that day and how many CNAs will be caring for the facility's residents. During an interview on 12/6/2024 at 7:30PM with the Director of Nursing (DON), the DON stated, nurse staffing information was not posted in a highly visible area such as the nursing station or by the front lobby. The DON stated, it was important to have the nurse staffing information posted in a prominent place so all the residents and family members can see and have the assurance that there was enough staff taking care of their loved one on any day in the facility. During a review of the facility's policies and procedures (P&P), Nursing Department - Staffing, Scheduling, & Posting, revised on 10/24/2022, the P&P indicated the nurse staffing data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors.

Based on interviews and record reviews, the facility failed to ensure the attending physician (Medical Doctor [MD] 1) included blood sugar monitoring [an intervention that is essential for managing diabetes that involves checking blood sugar levels using a device] and medications to manage Diabetes Mellitus [DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body) normally] for one of three sampled residents (Resident 1) who was diabetic (a person with diagnosis of diabetes) by failing to: 1. Ensure the licensed staff reviewed Resident 1's general acute care hospital (GACH 1) records for all appropriate discharge orders and ensure admission orders from the facility and continuity of care for DM was verified with MD 1, upon admission to the facility, on [DATE]. 2. Ensure the licensed staff verified Resident 1's admission orders from the facility, by reviewing Resident 1's medical history from GACH 1 and addressed the resident's diagnoses of DM. There was no documented evidence diabetes management that included blood sugar monitoring, insulin administration and monitoring to prevent hyperglycemia (high blood sugar level) and hypoglycemia (low blood sugar level) was implemented while the resident resided in the facility from [DATE] to [DATE]. 3. Inform the physician that Resident 1 with DM did not have admission orders from the facility to monitor the resident's blood sugar and if the physician wanted to continue the orders for the resident to receive insulin to manage the resident's diabetes according to GACH 1's Discharge Documentation and in accordance with the facility's policy and procedure titled Admission Assessment. 4. Ensure the plan of care for Resident 1's DM was implemented by monitoring the resident for hypoglycemia and hyperglycemia while residing in the facility from [DATE] to [DATE] (a total of 61 days). As a result, Resident 1 was transferred to GACH 2 via 911 emergency services on [DATE] due to altered level of consciousness (a change in a patient's state of awareness [ability to relate to self and the environment]), oxygen desaturation (a decrease in the amount of oxygen in the blood) of 77% (blood oxygen levels drop below a normal range [normal levels are 96 to100 %]) and a blood sugar level of 500 (normal blood sugar levels are between 70 to 100). Resident 1 arrived at GACH 2 Emergency Department (ED) with a blood sugar level of 810 (normal blood sugar levels are between 70 to 100) on [DATE]. Resident 1 was transferred to the Intensive Care Unit (ICU, a specialized unit in a hospital that caters to patients that are critically ill) for management of Diabetic Ketoacidosis (DKA - a serious complication of diabetes that happens when the body does not have enough of a hormone called insulin) and died on [DATE]. According to Resident 1's Certificate of Death (a legal document used by the state and federal government to prove someone has died ), Resident 1's immediate cause of death (final disease or condition resulting in death) was Diabetic Ketoacidosis and the underlying cause of death (disease or injury that initiated the events resulting in death) was DM Type 2. On [DATE] at 7:33 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to ensure a resident with a diagnosis of DM Type 2 received the appropriate admission orders from the facility or diabetes care and management provided by a physician. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of an IJ situation on [DATE] at 7:33 PM, due to the facility's failure to ensure Resident 1 received the appropriate facility admission orders for diabetes care and management provided by a physician. On [DATE] at 3:02 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 3:19 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 [DATE], included the following: - On [DATE], the DON provided an in-service (training program while staff are employed) with Licensed Vocational Nurse (LVN) 1 on diabetic medication order clarifications, facility admission orders, implementation of care plans, verification of physician orders, and signs and symptoms of hyperglycemia (high blood sugar levels) and hypoglycemia (low blood sugar levels). - LVN 1 was provided with additional in-service on Diabetic Care Policy and Procedure, diabetic patient management, order clarification, and care planning on escalation (to involve someone of higher position) of interventions if medication list is not provided for residents upon admission. - Starting [DATE], the Director of Nurses (DON)/Designee initiated monthly in-services for three months to reinforce best practices in the admission process, to review all inquiries for newly admitted residents. Registered Nurse [RN]/DON will input all medication orders for newly admitted residents. RN/DON will complete all admission assessments for newly admitted residents. RN/ DON will contact the transferring acute care hospital and primary care provider to clarify all medication orders and compare to the patient's diagnosis/medical condition to ensure that all of the correct medications are ordered for each resident upon admission to the facility and correct any potentially missed medication orders in real time. - On [DATE] and [DATE], the DON provided all licensed nurses with an in-service regarding Diabetes Management including the review of facility admission diagnosis, diabetic medication order clarification, implementation of care plans, verification of physician orders, and proper documentation to ensure that all staff are updated on the current diabetic care policy and procedure. - On [DATE], the Pharmacist Consultant (provides facilities with expert advice and recommendations about resident's medications by performing medication reviews) completed a Medication Regimen Review (MRR, a process conducted by a pharmacist, to review a resident's medications) for all residents with diagnosis of DM at the facility and made recommendations. - On [DATE], the DON and Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool) Nurse reviewed records for all current residents with the diagnosis of DM using a Diabetes Audit Log to identify other residents. All residents with diagnosis of DM were physically assessed, admission orders/documentation were reviewed, monitoring for signs and symptoms of hypoglycemia and hyperglycemia were reviewed, and care plans were reviewed/updated to address DM management. - On [DATE], the DON/MDS Nurse and the Medical Records Director (MRD), conducted an audit of medication administration records and treatment protocols for residents with a diagnosis of DM to ensure adherence to prescribed treatments. - Starting [DATE], the MDS Nurse will conduct an admission chart review audits for newly admitted residents the next day, after their admission to the facility to monitor compliance with diabetes management protocols, physician orders, blood sugar monitoring, and identify areas requiring corrective action. - Starting [DATE], the Interdisciplinary Team [IDT] will develop and implement comprehensive care plans for residents with DM, including regular monitoring, and preventive measures for complications. Care plans will be reviewed by IDT and updated during weekly meetings and as required by changes in the resident's condition by a licensed nurse. - Starting [DATE], the RN or DON will oversee documentation of care plans, assessments, medication orders, monitoring, and physician orders, ensuring that all interventions are properly recorded and that any issues or clarifications are addressed the same day that the residents are admitted . - On [DATE], the Medical Director provided an in-service with Resident 1's attending physician regarding admission orders, DM medication management, medication orders, order for blood sugar checks and monitoring for signs and symptoms of hypoglycemia and hyperglycemia. - On [DATE], the Medical Director provided an in service with the Pharmacist Consultant that reviewed Resident 1's medication regimen during the month of February 2024 to educate the consultant on reconciliation of all resident's diagnosis with medication orders concurrently. - On [DATE], the Medical Director educated the Pharmacist Consultant regarding medication recommendations regarding DM medication management, medication orders, and order for blood sugar checks and monitoring for signs and symptoms of hypoglycemia and hyperglycemia. - Starting [DATE], the DON/Designee will oversee the administration of diabetes-related medications and ensure that physician recommendations are followed daily. - Starting [DATE], the Medical Director will initiate an in-service of the facility's Primary Care Physicians, Nurse Practitioners, and Physicians Assistants on admission orders, DM medication management, medication orders, and order for blood sugar checks. Cross reference with F684, F711, F756 Findings: During a review of Resident 1's GACH 1 record, titled, Inpatient Progress Notes, dated [DATE], indicated Resident 1 had a diagnosis of DM . The GACH 1 record indicated a plan to continue Resident 1's insulin medication to maintain a blood sugar goal of less than 180. During a review of Resident 1's GACH 1 record titled Discharge Documentation dated [DATE], timed at 11:07 AM, indicated Issues to Address on Outpatient Follow Up/Discharge Action Plan which included Resident 1 to have continued diabetes management upon admission in the facility. The Discharge Documentation record indicated Resident 1 received insulin in GACH 1 and will need physician [follow up] for DM care. Further review of the Discharge Documentation indicated Resident 1's last blood sugar result in GACH 1 on [DATE] was 157. During a review of Resident 1's Facility Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included DM, encephalopathy (damage or disease that affects the brain), dementia (a syndrome that causes a decline in cognitive [thought process] abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), and hypertension (high blood pressure). During a review of Resident 1's Facility Nursing Admission Assessment, dated [DATE], timed at 6:03 PM, signed by LVN 1 and LVN 3, indicated the resident was admitted to the facility on [DATE] at around 5:10 P.M. The Nursing Admission Assessment indicated Resident 1 had a diagnosis of DM Type 2. During a review of Resident 1's care plan titled, The resident [Resident 1] has DM, initiated on [DATE] and revised on [DATE], indicated a goal for the resident is to not have complications related to diabetes. The care plan interventions included to monitor, document, and report signs and symptoms of hyperglycemia and hypoglycemia. During a review of Resident 1's Order Summary Report (OSR) for all orders during Resident 1's stay at the facility from [DATE] to [DATE], included a physician order to administer Insulin Lispro [a class of insulin hormone] Injection Solution 100 Unit/ML [Unit per milliliter, a unit of measure] Inject as per sliding scale (a guide use to determine how much insulin to give to correct an elevated blood sugar) on [DATE]. The OSR indicated the order for Insulin Lispro sliding scale was discontinued the same date, [DATE]. During a review of Resident 1's facility records titled, Discontinue Order, dated [DATE], timed at 11:17 PM, signed by LVN 1, indicated a telephone order from MD 1 for Insulin Lispro Sliding Scale to be discontinued on [DATE], timed at 11:16 PM. The record indicated the reason for discontinuing was Clarification of Order. During the review of the resident's physician orders, there was no additional orders or justification for Lispro insulin after it had been discontinued. During a review of Resident 1's History and Physical (H&P), dated [DATE], signed by MD 1, indicated the resident did not have the capacity to understand and make decisions. The H&P indicated Resident 1 had a diagnosis of DM. During a review of Resident 1's Admission MDS, dated [DATE], indicated the resident had severely impaired [a condition that significantly limits an individual's physical or mental abilities] cognition (ability to remember and process information). The Admission MDS indicated Resident 1 did not have an order for insulin and did not include resident's diagnosis of DM. During a review of Resident 1's Change in Condition Evaluation (CIC), dated [DATE], timed at 7:04 PM, the CIC indicated Resident 1 was found to have labored breathing (a non-medical term used to describe when breathing is difficult or impaired) and with a blood sugar level of 500. The CIC indicated Resident 1 had signs and symptoms that included altered mental status, oxygen desaturation, and hyperglycemia. The CIC indicated MD 1 and Resident 1's family were notified. The CIC indicated Resident 1 was transferred via 911 emergency services to GACH 2 on [DATE]. During a review of Resident 1's Transfer Form, dated [DATE], the Transfer Form indicated Resident 1 was transferred to GACH 2 on [DATE]. The Transfer Form indicated the reason for the transfer was due to altered mental status. During a review of Resident 1's GACH 2 Emergency Department [ED] Reports dated [DATE], indicated the resident was admitted to the ED on [DATE] at 6:48 PM with a chief complaint of altered mental status and having a blood sugar of High [a glucometer (a portable device used to measure blood sugar levels) reading that means a very high blood sugar level above 600]. The GACH 2 ED Report indicated At around 5:50 PM, [Resident 1] refused her dinner and threw her juice on the floor and refused to eat. When [Resident 1] was reevaluated they [facility staff], noted that she [Resident 1] was breathing heavily [difficulty breathing] and not speaking. The GACH 2 ED Report indicated the facility staff tried to measure [Resident 1's] [blood] sugar, and the glucometer read as high. The GACH 2 ED Report indicated Resident 1's blood sugar level taken at the GACH 2 upon arrival to the ED was 810. During the same review of Resident 1's GACH 2 ED Report dated [DATE], indicated a diagnosis of DKA. The GACH 2 ED Report indicated the resident was started on insulin drip (insulin that is administered directly through a person's vein) and was admitted to the ICU for management of the DKA. During a review of Resident 1's GACH 2 Medication Administration Record [MAR], the GACH 2 MAR indicated GACH 2 started Resident 1 on insulin drip (insulin given through an intravenous [IV-thorough the vein] to get into the body more quickly to bring down high blood sugar) on [DATE]. During a review of Resident 1's GACH 2 records titled Discharge [DC] Summaries Notes, dated [DATE], timed at 3:11 PM, indicated Resident 1 coded [a medical term which means a person's heart stopped and basic life support was provided] and expired on [DATE] while in the ICU. The GACH 2 DC Summary indicated Resident 1's final diagnoses included DM Type 2, hyperosmolar hyperglycemic state (a serious complication of diabetes that happens when blood sugar levels are very high for a long period of time), DKA, sepsis (a serious condition in which the body responds improperly to an infection), and altered mental status . During a review of Resident 1's Certificate of Death indicated Resident 1 expired on [DATE] in GACH 2. The Certificate of Death indicated the immediate cause of death (final disease or condition resulting in death) as Diabetic Ketoacidosis and underlying cause of death (disease or injury that initiated the events resulting in death) indicated Diabetes Mellitus Type 2. During a concurrent interview on [DATE] at 1:28 PM with the MDS Nurse and record review of Resident 1's clinical records and physician orders provided by the facility from [DATE] to [DATE], the MDS Nurse stated there were no documented evidence that the facility licensed staff called MD 1 to verify the reason for the Clarification of Order for Resident 1's Insulin Lispro Sliding Scale that was discontinued on [DATE]. The MDS Nurse stated there was no additional orders or justification for discontinuing the resident's order for Lispro insulin after it had been discontinued on ,d+[DATE].2024. The MDS Nurse stated there was no documented evidence that licensed staff notified MD 1 or other physicians that Resident 1 was receiving insulin while at GACH 1. The MDS Nurse stated there was no documented evidence that licensed staff verified if MD 1 would continue the order for insulin and blood sugar monitoring as a diabetic regimen [course of treatment] for Resident 1. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored. The MDS Nurse stated discontinuing a medication should have a valid reason. The MDS Nurse stated the reason indicated by LVN 1 on [DATE], which read clarification of order, was not a valid reason for discontinuing the Insulin Lispro Sliding Scale on [DATE]. The MDS Nurse stated she did not call or clarify with MD 1 to verify the insulin medication order and blood sugar monitoring, upon completion of the resident's Admission MDS [on [DATE]]. The MDS nurse stated there was no documented evidence that Resident 1 was monitored for signs and symptoms of hyperglycemia and hypoglycemia, as indicated in the resident care plan for DM developed on [DATE] and revised on [DATE]. During the same interview, on [DATE], at 1:28 PM, the MDS Nurse stated that she had reviewed the GACH 1 records provided to the facility upon Resident 1's admission on [DATE]. The MDS Nurse stated the GACH 1 records indicated Resident 1 was receiving insulin while at GACH 1. The MDS Nurse stated the facility should have continued Resident 1's blood sugar monitoring and insulin because it was the GACH 1's discharge plans for Resident 1, prior to facility admission. During a concurrent interview and record review of Resident 1's entire facility records, from [DATE] to [DATE], and the facility's policy and procedures on Admission Assessment and Admission and Orientation of Residents on [DATE] at 2:48 PM, LVN 2 stated there was no documented evidence that another licensed nurse, reviewed Resident 1's medication orders the next day after the resident's admission to the facility. LVN 2 reviewed the policy and procedures on Admission and Orientation of Residents, that indicated a registered nurse will conduct the initial assessment of the resident. LVN 2 stated when a resident is admitted during the evening or night shift by an LVN, an RN must re-assess the resident again the next day, which should include the verification of the resident's medication orders. LVN 2 stated there was no documented evidence that another licensed staff (RN or another LVN) conducted a drug review of Resident 1's medication orders and re-assess Resident 1 the next day, which should include verification of the resident's medication orders, as indicated in the facility's policy titled Admission Assessment and Admission and Orientation of Residents to ensure all the required orders were included. During a phone interview on [DATE] at 4:25 PM with LVN 1, LVN 1 stated when a resident is admitted to the facility, the admitting nurse calls the physician and asks if the attending physician would like to continue everything [medication orders from the GACH]. LVN 1 stated she does not verbally read over the resident's entire medication list to the physician. LVN 1 stated she could not remember if she spoke to MD 1 on [DATE], when she admitted Resident 1 to the facility. LVN 1 stated she could not remember discontinuing any insulin medications or blood sugar monitoring for Resident 1 on [DATE]. LVN 1 stated discontinuing an insulin order required a valid reason such as supporting the discontinuation with laboratory results such as a Hemoglobin [Hb] A1C [a common blood test used to diagnose type 1 (pancreas does not make insulin) and type 2 (the pancreas make less insulin) diabetes] laboratory result. LVN 1 stated the facility practice was for the MDS Nurse to review a newly admitted resident's GACH records and for the RN supervisor to review the admission orders for accuracy. LVN 1 stated she did not know if another licensed staff or an RN reviewed Resident 1's admission orders the next day following admission on [DATE]. During an interview on [DATE] at 6:45 PM with the DON, the DON stated when a resident is newly admitted to the facility, the licensed nurse should verify all the resident's medications with the physician. The DON stated it is the licensed nurse's responsibility to notify the physician if a resident's medical diagnosis was not addressed, such as not having medications for a resident's diagnosis of DM. The DON stated for a resident with a diagnosis of DM, the expectation is for the licensed nurse to ask the physician to add an order for blood sugar monitoring. The DON stated discontinuing insulin must be supported by enough justification such as blood sugar trends or laboratory values like the Hemoglobin A1C. During a review of the facility's P&P titled, Admission and Orientation of Residents, revised [DATE], indicated the following: 1. The resident's physician will provide medical orders, including a medical condition or problem associated with each medication. 2. The resident's physician will provide routine care orders to maintain or improve the resident's function. 3. A registered nurse will conduct the initial assessment of the resident. During a review of the facility's P&P titled, Admission Assessment, [DATE], indicated the licensed nurse will complete a drug regimen review upon admission or as close to the actual time of admission as possible to identify any potential or actual clinically significant medication issues. During a review of the facility's policy and procedure titled Care Planning dated [DATE], indicated each resident should have a comprehensive person-centered care plan developed and implemented based on individual assessed needs.

Based on interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) who had a diagnosis of Diabetes Mellitus [DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin (a hormone made by the pancreas- an organ in the body) received treatment and services, in accordance with professional standards of practice, the care plan, physician orders, and the facility ' s policies and procedures, for the treatment and care of DM. The facility failed to: 1. Ensure a licensed staff reviewed Resident 1 ' s medical history of DM and discharge orders from GACH 1 that indicated Resident 1 was receiving insulin and blood sugar monitoring, prior to admission to the facility and verify with MD 1 if blood sugar monitoring and/or insulin should be continued while residing at the facility from [DATE] to [DATE]. 2. Implement the facility ' s policy and procedure titled Admission Assessment, when another licensed nurse did not complete a drug regimen review on or after Resident 1 ' s admission at the facility to identify any potential or actual clinically significant medication issues. 3. Implement the facility ' s policy and procedure titled Diabetic Care and Resident 1 ' s plan of care for DM, which indicated the facility ' s licensed nurses would monitor Resident 1 for signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), and document in the resident ' s records, from the date of facility admission on [DATE]- [DATE] (a total of 61 days). 4. Ensure the facility ' s Interdisciplinary Team (IDT- a group of professionals with different areas of expertise who work together to achieve a common goal), that included the Director of Nursing (DON) was aware of Resident 1 ' s care plan for DM and reviewed the resident ' s records to ensure the care plan are being followed, in accordance with the DON ' s written job description. 5. Ensure that the facility ' s Pharmacist Consultant (PH) 1 have documented evidence in the facility ' s Medication Regimen Review (MRR, a process conducted by a pharmacist, to review a resident ' s medications) that pharmacy recommendations were provided to address concerns related to Resident 1 ' s diagnosis of DM, in accordance with the Pharmacist Consultant job description. The MRR did not indicate recommendations for blood sugar monitoring or insulin regimen to manage Resident 1 ' s DM. As a result, Resident 1 had a change in condition on [DATE], manifested by altered level of consciousness (a change in a patient's state of awareness [ability to relate to self and the environment]), oxygen desaturation (blood oxygen levels drop below a normal range [normal levels are 96 to100 %]) of 77% and a blood sugar of 500 (normal blood sugar levels are between 70 to 100). Resident 1 was transferred to the general acute care hospital (GACH) 2 via 911 emergency services. Resident 1 ' s blood sugar result from the GACH 2 indicated a blood sugar of 810 on [DATE]. Resident 1 died at the GACH 2 due to Diabetic Ketoacidosis (DKA - a serious complication of diabetes that happens when the body does not have enough of a hormone called insulin [a hormone made by the pancreas- an organ in the body)]) on [DATE]. Resident 1 ' s Certificate of Death (a legal document used by the state and federal government to prove someone has died ) indicated the immediate cause of death (final disease or condition resulting in death) as Diabetic Ketoacidosis and underlying cause of death (disease or injury that initiated the events resulting in death) indicated DM Type 2 (a type of DM [chronic condition caused by not producing enough insulin in the body]) . On [DATE] at 7:43 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 with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility ' s failure to ensure a resident with a diagnosis of Diabetes Mellitus (DM, a chronic disease where a person has high blood sugar levels because the body does not produce insulin normally and required blood sugar monitoring and/or medications to lower blood sugar levels]) Type 2 received treatment and services for diabetes. The survey team notified the Administrator (ADM) and the Director of Nursing (DON) of an IJ situation on [DATE] at 7:43 PM, due to the facility ' s failure to ensure Resident 1 received the appropriate admission orders for diabetes care and management provided by a physician. On [DATE] at 3:02 PM, the Administrator (ADM) provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). On [DATE] at 3:19 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 [DATE], included the following: On [DATE], the DON provided an in-service (training program while staff are employed) with Licensed Vocational Nurse (LVN) 1 on diabetic medication order clarifications, admission orders, implementation of care plans, verification of physician orders, and signs and symptoms of hyperglycemia (high blood sugar levels) and hypoglycemia (low blood sugar levels). LVN 1 was provided with additional in-service on Diabetic Care Policy and Procedure, diabetic patient management, order clarification, and care planning on escalation (to involve someone of higher position) of interventions if medication list is not provided for residents upon admission. Starting [DATE], the Director of Nurses (DON)/Designee initiated monthly in-services for three months to reinforce best practices in the admission process, to review all inquiries for newly admitted residents. Registered Nurse [RN]/DON will input all medication orders for newly admitted residents. RN/DON will complete all admission assessments for newly admitted residents. RN/ DON will contact the transferring acute care hospital and primary care provider to clarify all medication orders and compare to the patient's diagnosis/medical condition to ensure that all of the correct medications are ordered for each resident upon admission and correct any potentially missed medication orders in real time. On [DATE] and [DATE], the DON provided all licensed nurses with an in-service regarding Diabetes Management including the review of admission diagnosis, diabetic medication order clarification, implementation of care plans, verification of physician orders, and proper documentation to ensure that all staff are updated on the current diabetic care policy and procedure. On [DATE], the Pharmacist Consultant (provides facilities with expert advice and recommendations about resident ' s medications by performing medication reviews) completed a Medication Regimen Review for all residents with diagnosis of DM at the facility and made recommendations. On [DATE], the DON and Minimum Data Set (MDS- a comprehensive standardized assessment and screening tool) Nurse reviewed records for all current residents with the diagnosis of DM using a Diabetes Audit Log to identify other residents. All residents with diagnosis of DM were physically assessed, admission orders/documentation were reviewed, monitoring for signs and symptoms of hypoglycemia and hyperglycemia were reviewed, and care plans were reviewed/updated to address DM management. On [DATE], the DON/MDS Nurse and the Medical Records Director (MRD), conducted an audit of medication administration records and treatment protocols (system of rules) for residents with a diagnosis of DM to ensure adherence to prescribed treatments. Starting [DATE], the MDS Nurse will conduct an admission chart review audits for newly admitted residents the next day, after their admission to the facility to monitor compliance with diabetes management protocols, physician orders, blood sugar monitoring, and identify areas requiring corrective action. Starting [DATE], the IDT will develop and implement comprehensive care plans for residents with DM, including regular monitoring, and preventive measures for complications. Care plans will be reviewed by IDT and updated during weekly meetings and as required by changes in the resident's condition by a licensed nurse. Starting [DATE], the RN or DON will oversee documentation of care plans, assessments, medication orders, monitoring, and physician orders, ensuring that all interventions are properly recorded and that any issues or clarifications are addressed the same day that the residents are admitted . On [DATE], the Medical Director provided an in-service with Resident 1 ' s attending physician regarding admission orders, DM medication management, medication orders, order for blood sugar checks and monitoring for signs and symptoms of hypoglycemia and hyperglycemia. On [DATE], the Medical Director provided an in service with the Pharmacist Consultant that reviewed Resident 1's medication regimen during the month of February 2024 to educate the consultant on reconciliation of all resident's diagnosis with medication orders concurrently. On [DATE], the Medical Director educated the Pharmacist Consultant regarding medication recommendations regarding DM medication management, medication orders, and order for blood sugar checks and monitoring for signs and symptoms of hypoglycemia and hyperglycemia. Starting [DATE], the DON/Designee will oversee the administration of diabetes-related medications and ensure that physician recommendations are followed daily. Starting [DATE], the Medical Director will initiate an in-service of the facility's Primary Care Physicians, Nurse Practitioners, and Physicians Assistants on admission orders, DM medication management, medication orders, and order for blood sugar checks. Cross reference to F635, F711, F756 Findings: During a review of Resident 1 ' s GACH 1 record, titled, Inpatient Progress Notes, dated [DATE], indicated Resident 1 had a diagnosis of DM . The GACH 1 record indicated a plan to continue Resident 1 ' s insulin medication to maintain a blood sugar goal of less than 180. During a review of Resident 1 ' s GACH 1 record titled Discharge Documentation dated [DATE], timed at 11:07 AM, indicated Issues to Address on Outpatient Follow Up/Discharge Action Plan which included Resident 1 to have continued diabetes management in the facility. The Discharge Documentation record indicated Resident 1 received insulin in GACH 1 and will need physician [follow up] for DM care. Further review of the Discharge Documentation indicated Resident 1 ' s last blood sugar result in GACH 1 on [DATE] was 157. During a review of Resident 1 ' s Admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included DM, encephalopathy (damage or disease that affects the brain), dementia (a syndrome that causes a decline in cognitive [thought process]) abilities, such as thinking, remembering, and making decisions, that can interfere with daily activities), and hypertension (high blood pressure). During a review of Resident 1 ' s Nursing Admission Assessment, dated [DATE], timed at 6:03 PM, signed by LVN 1 and LVN 3, indicated the resident was admitted to the facility on [DATE] at around 5:10 P.M. The Nursing Admission Assessment indicated Resident 1 had a diagnosis of DM Type 2. During a review of Resident 1 ' s care plan titled, The resident [Resident 1] has DM, initiated on [DATE] and revised on [DATE], indicated a goal for the resident to not have complications related to diabetes. The care plan interventions included to monitor, document, and report signs and symptoms of hyperglycemia and hypoglycemia. During a review of Resident 1 ' s Order Summary Report (OSR) for all orders during Resident 1 ' s stay at the facility from [DATE] to [DATE], included a physician order to administer Insulin Lispro [a class of insulin hormone] Injection Solution 100 Unit/ML [Unit per milliliter, a unit of measure] Inject as per sliding scale (a guide use to determine how much insulin to give to correct an elevated blood sugar) on [DATE]. The OSR indicated the order for Insulin Lispro sliding scale was discontinued the same date, [DATE]. During a review of Resident 1 ' s facility records titled, Discontinue Order, dated [DATE], timed at 11:17 PM, signed by LVN 1, indicated a telephone order from MD 1, for Insulin Lispro Sliding Scale to discontinue on [DATE], timed at 11:16 PM. The record indicated the reason for discontinuing was Clarification of Order. During a review of Resident 1 ' s Admission MDS, dated [DATE], indicated the resident had severely impaired [a condition that significantly limits an individual's physical or mental abilities] cognition (ability to remember and process information). The Admission MDS indicated Resident 1 did not have an order for insulin and did not include resident ' s diagnosis of DM. During a review of Resident 1 ' s Admission MDS, dated [DATE], indicated the resident had severely impaired cognition (ability to remember and process information). The Admission MDS indicated Resident 1 did not have an order for insulin and did not include resident ' s diagnosis of DM. During a review of Resident 1 ' s IDT Conference Record, dated [DATE], signed by different members of the facility ' s IDT from the Nursing Department, Activities Department, and Social Services, participated by Resident 1 ' s family member (FM 1), the IDT Record indicated Resident 1 had a diagnosis that included dementia and DM Type 2. The IDT Record indicated Resident 1 ' s plan of care to receive physical therapy (a healthcare profession that helps an individual ' s body improve and perform physical movements) and occupational therapy (therapy based on engagement in meaningful activities of daily life) while residing at the facility and the discharge goals to go home with FM 1. The IDT Conference Record did not indicate information that IDT addressed Resident 1 ' s plan of care for management of DM. During a review of Resident 1 ' s Change in Condition Evaluation (CIC), dated [DATE], timed at 7:04 PM, the CIC indicated Resident 1 was found to have labored breathing (a non-medical term used to describe when breathing is difficult or impaired) and with a blood sugar level of 500. The CIC indicated Resident 1 had signs and symptoms that included altered mental status, oxygen desaturation, and hyperglycemia. The CIC indicated MD 1 and Resident 1 ' s family were notified. The CIC indicated Resident 1 was transferred via 911 emergency services to GACH 2 on [DATE]. During a review of Resident 1 ' s Transfer Form, dated [DATE], the Transfer Form indicated Resident 1 was transferred to GACH 2 on [DATE]. The Transfer Form indicated the reason for the transfer was due to altered mental status. During a review of Resident 1 ' s GACH 2 Emergency Department [ED] Reports dated [DATE], indicated the resident was admitted to the ED on [DATE] at 6:48 PM with a chief complaint of altered mental status and having a blood sugar of High [a glucometer (a portable device used to measure blood sugar levels) reading that means a very high blood sugar level above 600]. The GACH 2 ED Report indicated At around 5:50 PM, [Resident 1] refused her dinner and threw her juice on the floor and refused to eat. When [Resident 1] was reevaluated they [facility staff], noted that she [Resident 1] was breathing heavily [difficulty breathing] and not speaking. The GACH 2 ED Report indicated the facility staff tried to measure [Resident 1 ' s] [blood] sugar, and the glucometer read as high. The GACH 2 ED Report indicated Resident 1 ' s blood sugar level taken at the GACH 2 upon arrival to the ED was 810. During the same review of Resident 1 ' s GACH 2 ED Report dated [DATE], indicated a diagnosis of DKA. The GACH 2 ED Report indicated the resident was started on insulin drip (insulin that is administered directly through a person ' s vein) and was admitted to the ICU for management of the DKA. During a review of Resident 1 ' s GACH 2 Medication Administration Records (MAR), the GACH 2 MAR indicated GACH 2 started Resident 1 on insulin drip (insulin given through an intravenous [IV-through the vein] to get into the body more quickly to bring down high blood sugar) on [DATE]. During a review of Resident 1 ' s GACH 2 records titled Discharge [DC] Summaries Notes, dated [DATE], timed at 3:11 PM, indicated Resident 1 coded [a medical term which means a person ' s heart stopped and basic life support was provided] and expired on [DATE] while in the ICU. The GACH 2 DC Summary indicated Resident 1 ' s final diagnoses included DM Type 2, hyperosmolar hyperglycemic state (a serious complication of diabetes that happens when blood sugar levels are very high for a long period of time), DKA, sepsis (a serious condition in which the body responds improperly to an infection), and altered mental status . During a review of Resident 1 ' s Certificate of Death indicated Resident 1 expired on [DATE] in GACH 2. The Certificate of Death indicated the immediate cause of death (final disease or condition resulting in death) as Diabetic Ketoacidosis and underlying cause of death (disease or injury that initiated the events resulting in death) indicated Diabetes Mellitus Type 2. During a concurrent interview on [DATE] at 1:28 PM with the MDS Nurse and record review of Resident 1 ' s clinical records provided by the facility from [DATE] to [DATE], the MDS Nurse stated there were no documented evidence that any licensed staff called MD 1 to verify the reason for the Clarification of Order for Resident 1 ' s Insulin Lispro Sliding Scale that was discontinued on [DATE]. The MDS Nurse stated there was no documented evidence that licensed staff notified MD 1 or other physicians that Resident 1 was receiving insulin from GACH 1. The MDS Nurses stated there was no documented evidence that licensed staff verified if MD 1 would continue the order for insulin and blood sugar monitoring as a diabetic regimen [course of treatment] for Resident 1. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored. The MDS Nurse stated discontinuing a medication should have a valid reason. The MDS Nurse stated the reason indicated by LVN 1 on [DATE], which read clarification of order, was not a valid reason for discontinuing the Insulin Lispro Sliding Scale on [DATE]. The MDS Nurse stated she did not call or clarify with MD 1 to verify the insulin medication order and blood sugar monitoring, upon completion of the resident ' s Admission MDS [on [DATE]]. The MDS nurse stated there was no documented evidence that Resident 1 was monitored for signs and symptoms of hyperglycemia and hypoglycemia, as indicated in the resident care plan for DM developed on [DATE] and revised on [DATE]. During a concurrent interview on [DATE] at 1:28 PM with the MDS Nurse and record review of Resident 1 ' s clinical records provided by the facility from [DATE] to [DATE], the MDS Nurse stated there were no documented evidence that any licensed staff called MD 1 to verify the reason for the Clarification of Order for Resident 1 ' s Insulin Lispro Sliding Scale that was discontinued on [DATE]. The MDS Nurse stated there was no documented evidence that licensed staff notified MD 1 or other physicians that Resident 1 was receiving insulin from GACH 1. The MDS Nurses stated there was no documented evidence that licensed staff verified if MD 1 would continue the order for insulin and blood sugar monitoring as a diabetic regimen [course of treatment] for Resident 1. The MDS Nurse stated residents that have a diagnosis of DM should have an order to have their blood sugar monitored. The MDS Nurse stated discontinuing a medication should have a valid reason. The MDS Nurse stated the reason indicated by LVN 1 on [DATE], which read clarification of order, was not a valid reason for discontinuing the Insulin Lispro Sliding Scale on [DATE]. The MDS Nurse stated she did not call or clarify with MD 1 to verify the insulin medication order and blood sugar monitoring, upon completion of the resident ' s Admission MDS [on [DATE]]. The MDS nurse stated there was no documented evidence that Resident 1 was monitored for signs and symptoms of hyperglycemia and hypoglycemia, as indicated in the resident care plan for DM developed on [DATE] and revised on [DATE]. During the same interview, on [DATE], at 1:28 PM, the MDS Nurse stated that she had reviewed the GACH 1 records, provided to the facility upon Resident 1 ' s admission on [DATE]. The MDS Nurse stated the GACH 1 records indicated Resident 1 was receiving insulin from the GACH. The MDS Nurse stated the facility should have continued Resident 1 ' s blood sugar monitoring and insulin because it was the GACH 1 ' s discharge plans for Resident 1, prior to facility admission. The MDS Nurse stated there was no documented evidence the facility ' s licensed nurses monitored Resident ' s blood sugar from [DATE] to [DATE]. The MDS Nurse stated the only blood sugar result she found for Resident 1 was taken on [DATE], with a blood sugar result of 500. During a concurrent interview and record review of Resident 1 ' s entire facility records, from [DATE] to [DATE], and the facility ' s policy and procedure on Admission Assessment and Admission and Orientation of Residents on [DATE] at 2:48 PM, LVN 2 stated there was no documented evidence that another licensed nurse, reviewed Resident 1 ' s medication orders the next day after the resident ' s admission to the facility. LVN 2 reviewed the policy and procedures on Admission and Orientation of Residents, that indicated a registered nurse will conduct the initial assessment of the resident. LVN 2 stated when a resident is admitted during the evening or night shift by an LVN, an RN must re-assess the resident again the next day, which should include the verification of the resident ' s medication orders. LVN 2 stated there was no documented evidence that another licensed staff (RN or another LVN) conducted a drug review of Resident 1 ' s medication orders and re-assess Resident 1 the next day, which should include verification of the resident ' s medication orders, as indicated in the facility ' s policy titled Admission Assessment and Admission and Orientation of Residents to ensure all the required orders were included. During a phone interview on [DATE] at 4:25 PM with LVN 1, LVN 1 stated when a resident is admitted to the facility, the admitting nurse calls the physician and asks if the attending physician would like to continue everything [medication orders from the GACH]. LVN 1 stated she does not verbally read over the resident ' s entire medication list to the physician. LVN 1 stated she could not remember if she spoke to MD 1 on [DATE], when she admitted Resident 1 to the facility. LVN 1 stated she could not remember discontinuing any insulin medications or blood sugar monitoring for Resident 1 on [DATE]. LVN 1 stated discontinuing an insulin order required a valid reason such as supporting the discontinuation with laboratory results such as a Hemoglobin [Hb] A1C (a common blood test used to diagnose type 1 and type 2 diabetes) laboratory result. LVN 1 stated the facility practice was for the MDS Nurse to review a newly admitted resident ' s GACH records and for the RN supervisor to review the admission orders for accuracy. During an interview on [DATE] at 6:45 PM with the DON, the DON stated it is the licensed nurse ' s responsibility to notify the physician if a resident ' s medical diagnosis was not addressed, such as not having medications for a resident ' s diagnosis of DM. The DON stated for a resident with a diagnosis of DM, the expectation is for the licensed nurse to ask the physician to add an order for blood sugar monitoring. The DON stated discontinuing insulin must be supported by enough justification such as blood sugar trends or laboratory values like the Hemoglobin A1C. During a concurrent interview and record review of Resident 1 ' s IDT Conference Record dated [DATE], and the resident ' s entire records from [DATE] to [DATE], on [DATE] at 9:55 AM with the DON, the DON stated the IDT Record did not show evidence that Resident 1 ' s DM was addressed. The DON stated the IDT record did not indicate a plan for Resident 1 ' s DM such as adding an order for insulin or blood sugar monitoring. The DON stated he could not find documented evidence the facility ' s IDT addressed Resident 1 ' s DM plan of care interventions on [DATE], to meet care plan goals to prevent complications related to diabetes that included monitoring, documenting, and reporting signs and symptoms of hyperglycemia and hypoglycemia. The DON stated the standard of practice for residents with DM should include blood sugar monitoring or a Hemoglobin A1C result and visual monitoring of signs and symptoms of DM. The DON stated there was no evidence in Resident 1 ' s records that the facility ' s licensed nurses monitored the resident for signs and symptoms of hypoglycemia, hyperglycemia and other signs and symptoms of DM such as frequent urination or increased thirst. The DON stated there was no laboratory order made by the physician (MD 1) that included Hb A1c during the resident ' s stay in the facility from [DATE] to [DATE]. The DON stated that Resident 1 ' s MAR from [DATE] to [DATE] did not indicate Resident 1 was monitored for blood sugar levels and DM signs and symptoms. During a review of the facility ' s MRR for the months of ,d+[DATE], ,d+[DATE], and ,d+[DATE], the MRR did not have documented evidence that Pharmacist Consultant (PH) 1 addressed or provided pharmacy recommendations related to Resident 1 ' s diagnosis of DM. The MRR did not indicate recommendations for blood sugar monitoring or insulin regimen to manage Resident 1 ' s DM. During an interview, on [DATE] at 11:45 AM, PH 1 stated she comes to the facility on ce a month to review the facility residents ' medications. PH 1 stated she reviews the residents ' current medications only and does not look at a resident ' s diagnoses when making her recommendations. PH 1 stated, she was not part of the medication review when a resident gets admitted to the facility. PH 1 stated, she does not look at admission orders that were not current or had been discontinued. PH 1 stated she would only be able to recommend insulin medication for a resident, if the resident was getting their blood sugars checked and would base her recommendations on the results of the blood sugar checks. PH 1 stated she could not remember Resident 1 and did not check the resident ' s medication records why Resident 1 ' s insulin and blood sugar checks were discontinued on admission ([DATE]). PH 1 stated that if she knew Resident 1 had diabetes and did not have any blood sugar checks, she would have recommended for blood sugar checks or a Hemoglobin A1C laboratory test to be done and would have recommended insulin or oral diabetes medications (medications taken by mouth to manage blood sugar levels). During an interview on [DATE] at 1:19 PM, MD 1 stated that normally the current medications from the acute hospital are continued when a resident is admitted to the facility. MD 1 stated he could not remember Resident 1, but he signed and performed the resident ' s History and Physical assessment on [DATE]. MD 1 stated, generally, unless the discharging physician in the GACH discontinued the GACH medications, the expectation is for current medications to be continued at the facility. MD 1 stated, he reviewed the medications of Resident 1 from GACH 1 and stated that all current medications was supposed to be continued. MD 1 stated Resident 1 ' s insulin medications should not have been discontinued. MD 1 stated Resident 1 ' s insulin should have been continued at the upon admission to the facility on [DATE]. MD 1 stated, he does not discontinue insulin medications, once admitted to the facility, but would review for any dosage changes. MD 1 stated, he was not aware Resident 1 ' s insulin was not continued in the facility and that there was no blood sugar monitoring ordered for the resident. MD 1 stated, if insulin is discontinued, the resident could get hyperglycemic [increase blood sugar levels]. MD 1 stated, Resident 1 should have received insulin while in the facility. MD 1 stated, Resident 1's blood sugar levels could go high if not monitored and complication such as DKA could happen and result in death. MD 1 stated, he was not aware Resident 1 did not have an order for blood sugar monitoring, and if he knew that Resident 1 had a diagnosis of diabetes, he would have placed an order for blood sugar monitoring. MD 1 stated he expected the facility ' s licensed nurses to let him know that Resident 1 did not have blood sugar monitoring for the management of DM. MD 1 stated, discontinuing insulin needs documented justification and could not recall if the facility ' s licensed nurses informed him of Resident 1 ' s blood sugar monitoring. During an interview on [DATE] at 5:25 PM, the DON stated that PH 1 did not have any pharmacy recommendations for Resident 1 for the months of ,d+[DATE], ,d+[DATE], and ,d+[DATE]. During a review of the facility ' s policy and procedure (P&P) titled, Diabetic Care, revised [DATE], indicated the following: 1. The purpose of the P&P is to provide a protocol for the immediate treatment of hypoglycemia in residents diagnosed with diabetes. 2. The Licensed Nurse will monitor residents for signs and symptoms (of) hypoglycemia and hyperglycemia. Signs and symptoms will be documented in the resident ' s medical record and the Attending Physician will be notified. 3. Notify the Attending Physician of treatment and results and for any possible changes in insulin or oral diabetes medications. During a review of the facility ' s P&P titled, Admission and Orientation of Residents, revised [DATE], indicated the following: 1. The resident ' s physician will provide medical orders, including a medical condition or problem associated with each medication. 2. The resident ' s physician will provide routine care orders to maintain or improve the resident ' s function. 3. A registered nurse will conduct the initial assessment of the resident. During a review of the facility ' s P&P titled, Admission Assessment, [DATE], indicated the the licensed nurse will complete a drug regimen review upon admission or as close to the actual time of admission as possible to identify any potential or actual clinically significant medication issues. During a review of the facility ' s policy and procedure titled Care Planning dated [DATE], indicated each resident should have a comprehensive person-centered care plan developed and implemented based on individual assessed needs. During a review of the facility ' s job description titled, Consultant Pharmacist, (undated) indicated the pharmacist is to: 1. Provide physicians, nurses, and patients with therapeutic recommendations and/or medication information. 2. Report any drug regimen irregularities to the attending physician and Director of Nursing. During a review of the facility ' s job description titled, Charge Nurse (oversee the operations of their specific nursing unit) dated Year 2003, indicated the Charge Nurse ' s duties and responsibilities include: 1. Report all discrepancies noted concerning physician ' s orders, diet change, charting error, etc. to the Nurse Supervisor. 2. Consult with the resident ' s physician in providing resident ' s care, treatment, rehabilitation etc, as necessary. 3. Review the resident ' s chart for specific treatments, medication orders, diet,[TRUNCATED]

Based on interview and record review, the facility failed to prevent one of two sampled residents (Resident 1), who was a high risk for falls, history of seizures [a sudden, uncontrolled burst of electrical activity in the brain], which can cause changes in behavior, movements, feelings and levels of consciousness), and needed two persons, moderate assistance for transferring, from falling and sustaining injuries by failing to: 1. Develop a care plan and place Resident 1 on seizure monitoring and seizure precautions, upon admission to the facility on [DATE], that included the use of seizure pads and floor mats as indicated in the facility's policy and procedures titled Seizure Precautions and Fall Management Program, and bilateral side rails up, in accordance with the physician's order on 3/2/24. 2. Conduct an IDT-Falls Committee meeting within 72 hours when Resident 1 had a fall and sustained physical injuries from the fall and update the resident's care plan interventions, on 3/7/24 and 3/18/24, to prevent further falls that can result to an injury, in accordance with the facility's policy and procedure titled Fall Management Program. Resident 1 sustained a laceration (skin wound) on the left eyebrow after the fall on 3/7/24 and a small skin tear to the right lateral top side of the pinky finger (little finger) after the fall on 3/18/24. As a result, on 5/2/24, Resident 1 was found on the floor bleeding from the head with seizure activity and foaming of the mouth, as witnessed by Certified Nurse Assistant (CNA) 1 for three to five seconds. Resident 1 was transferred to the general acute care hospital (GACH 3) via 911 emergency services for head injury evaluation and surgical incisions to the head. In GACH 3, Resident 1's trauma to the posterior (located behind or toward the back) scalp required laceration repair by skin staples (a surgical procedure to close an open wound) on the scalp that measured 5 centimeters (cm- unit of measurement) long. Findings: A review of Resident 1's GACH 1 records, titled History and Physical (H&P), dated 1/24/24 timed at 9:25 a.m., and GACH 1 Progress Notes, dated 2/14/24 timed at 12:35 p.m., indicated Resident 1 had a history of head injury (due to an assault), cardiac arrest (a condition when the heart stops beating suddenly), and seizure. A review of Resident 1's facility record titled, Admission Record indicated Resident 1 was admitted to the facility from GACH 1 on 3/2/24 and readmitted on [DATE] with diagnosis that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), anoxic brain damage (caused by a complete lack of oxygen to the brain, with symptoms that included problems with thinking and focus, seizures, muscle wasting (a weakening, and loss of muscle caused by disease or lack of use) and atrophy (progressive decline of a body part), difficulty walking, and injury of the head. A review of Resident 1's facility records, titled Order Summary Report, for March 2024, indicated a physician order dated 3/2/24, that indicated the resident may have bilateral side rails up as enabler to assist with bed mobility, transfers, and repositioning. A review of Resident 1's record titled, Fall Risk Assessment, dated 3/3/24 timed at 9:09 a.m., indicated Resident 1 was at high risk for falling due to impaired gait (difficulty rising from chair, uses chair arms to get up, bounces to rise; keeps head down when walking, watches the ground; grasps furniture, person, or aid when ambulating; cannot walk unassisted). A review of Resident 1's facility Care plan, dated 3/3/24 indicated, Resident 1 was at risk for falls and/or injuries related to balance deficit, cognitive impairment (a condition when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), and history of falls. The care plan interventions indicated to attach call light within reach and encourage resident to use it, developing an activity program to refocus resident, educate/remind resident to ask for assistance, frequent visual checks, keep bed in low position, keep resident up in wheelchair in a supervised area, and postural devices as needed. A review of Resident 1's facility Care plan, dated 3/7/24 and revised on 3/8/24 indicated, Resident 1 had an actual fall with left eyebrow laceration with poor balance and unsteady gait. The care plan interventions included to continue interventions on the At risk plan, to determine and address the causative factors of the fall, neuro-checks, and physical therapy consult. A review of Resident 1's Progress Notes New, dated 3/7/24 timed at 2:26 p.m. indicated Resident 1 had an unwitnessed fall around 8:40 a.m. when the resident was found on the floor in the Activity Room, which resulted in laceration on left eyebrow and a transfer to GACH 2. A review of Resident 1's Order Summary Report, for the month of March, 2024 indicated, Resident 1 had a physician order on 3/7/24 to be transferred to GACH 2 via ambulance for further evaluation and treatment. A review of Resident 1's GACH 2 records titled Physician H&P, dated 3/8/24 at 7:50 a.m. indicated Resident 1 was referred to urgent care for evaluation from the facility for evaluation of a head injury that he sustained when he had unwitnessed fall on 3/7/24 and was admitted to GACH 2 for syncope (fainting or passing out), laceration from fall, and bradycardia (abnormal low heart rate). The GACH 2 Physician H&P indicated Resident 1 was bleeding from the left eyebrow. The GACH 2 Physician H&P indicated [Resident 1] had a history of unstable gait that could have led to the fall, but it is possible the patient (Resident 1) may have had a syncopal episode (fainting or passing out). A review of Resident 1's facility record, titled Progress Notes New, dated 3/13/24 timed at 6:54 p.m., indicated the resident was readmitted back from the facility in stable condition. A review of Resident 1's facility record indicated the Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 3/17/24, the MDS indicated, Resident 1's cognitive skills for daily decision making was severe impairment (difficulty with or unable to make decisions, learn, remember things). The MDS indicated Resident 1 needed moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limb, but provides less than half the effort) to transfer to and from a bed to a chair/wheelchair, and walk at least ten (10) feet in a room, corridor, or similar space. The MDS indicated due to medical conditions or safety concerns, walking 50 feet with two turns had not been attempted for Resident 1. The MDS under Fall History, indicated Resident 1 had an episode of fall within the last month of the MDS assessment date of 3/17/24. A review of Resident 1's facility records, titled Progress Notes New, dated 3/18/24 at 3:20 p.m. indicated Resident 1 had another unwitnessed fall when the resident was found lying on the right side on 3/18/24 timed at 2:40 p.m. The Progress Note indicated Resident 1's fall on 3/18/24 resulted in a small skin tear noted to the right lateral top side of the pinky finger. A review of Resident 1's facility record indicated a Physician Order, dated 5/2/24 at 5:06 p.m. indicated Resident 1 had an order to be transferred out via 911 emergency services to GACH 3 related to status post (an event that a person experienced previously) unwitnessed fall with seizure activity. A review of Resident 1's facility records, titled Progress Notes New, dated 5/2/24 timed at 5:12 p.m. indicated Resident 1 had an unwitnessed fall at 4:50 p.m. when he was found on the floor bleeding from the head with seizure activity noted from three to five seconds. The Progress Note indicated Resident 1 was transferred to GACH 3 via 911 emergency services on 5/2/24. A review of Resident 1's GACH 3 Emergency Department (ED) Notes dated 5/2/24 timed at 7:20 p.m., indicated the resident was resting in bed . with eyes open. The ED Note indicated Resident 1 was Unable to recall what happened, where he lives but knows he's in the hospital . Patient complains of left hip/leg knee pain, appears uncomfortable. Moving back in fourth in bed [sic] . Patient requires frequent redirection to lay still but forgets and rolls around in bed . A review of Resident 1's GACH 3 records, titled Trauma Surgery History and Physical, dated 5/2/24 at 6:56 p.m. indicated Resident 1 arrived at the GACH 1 ED, status post witnessed seizure and fall. The GACH 3 record indicated, The patient (Resident 1) was found on the ground in a convalescent home following an unwitnessed event that was described as seizure-like. The event lasted for approximately 3-5 seconds and involved the patient foaming at the mouth. The patient was reportedly altered during the entirety of the event. Patient reportedly recently had a cardiac arrest. Staples applied to posterior scalp laceration . A review of Resident 1's GACH 3 records, titled Laceration Repair Procedure Note, dated 5/2/24 timed at 7:06 p.m. indicated, Resident 1 was admitted for trauma to the posterior scalp, which required laceration repair by skin staples on the scalp measuring 5 cm long. A review of Resident 1's GACH 3 records, titled Computed Tomography [CT] ( uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) Brain without contrast, dated 5/2/24 indicated critical finding of Small focus of acute posttraumatic subarachnoid hemorrhage (bleeding in the brain) in the left medial frontal region (area just behind the forehead). A review of Resident 1's GACH 3 records, titled Neurology Consult Note, dated 5/3/24 at 10:16 a.m. indicated Patient had a scalp laceration for which he received staples. A review of Resident 1's facility records, titled Progress Notes New, dated 5/8/24 timed at 7:57 p.m., indicated the resident was readmitted back to the facility from GACH 3 with diagnosis of head injury. A review of Resident 1's facility records, titled Skin Observation Checks, dated 5/9/24 indicated Resident 1 had surgical incision with four (4) staples in the back of the head, which measured at 4 x 0.1 centimeters (a unit of length). During an interview on 5/17/24 at 11 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 was known in the facility to be high risk for falls due to forgetfulness and confusion. CNA 1 stated, on 5/2/24, at around 4 p.m., CNA 1 helped Resident 1 back to bed after sitting on the wheelchair located on the right side of his bed. CNA 1 stated, after putting Resident 1 to bed, while helping CNA 2 with another resident in a different room, CNA 1 heard a sound that indicated somebody had fallen. CNA 1 stated they found Resident 1 on the floor on the right side of his bed, with the resident's head bleeding. CNA 1 stated, that on 5/2/24, CNA 1 observed that there was no floor mat on the right side of Resident 1's bed and the side rails for both sides were down and she did not know why. When asked if CNA 1 had put the bed siderails up for Resident 1 on 5/2/24 at around 4 p.m., CNA 1 stated, she could not recall if she put the side rails up after putting Resident 1 back to bed. CNA 1 stated Resident 1 was not strong enough to put the bed side rails down by himself if the side rails were up. CNA 1 stated, she believed that Resident 1 was trying to go to the bathroom, which was located toward the right side of the bed because going to the bathroom was what Resident 1 frequently requested. CNA 1 stated that Resident 1's stronger side was on the right side where he usually gets up from the bed. CNA 1 stated Resident 1 had a fall a few times in the facility before and needed assistance with walking because his walk was not steady. During an interview on 5/17/24 at 11:40 a.m. with CNA 2, CNA 2 stated she was the first one that saw Resident 1 on the floor, on 5/2/24 at around 4:45 to 4:50 p.m. CNA 2 stated, Resident 1 was in bed when she asked CNA 1 for help in another room around 4:30 p.m. CNA 2 stated, while CNA 1 was helping CNA 2 with one of her assigned residents, they heard a boom sound so CNA 2 went to check each resident's rooms until she went to Resident 1's room and found him lying face up on the floor bleeding from his head. CNA 2 stated the area that they (CNA 1 and 2) were assigned had a lot of residents that were high risk for falls. CNA 2 stated, Resident 1 should be on one-to-one monitoring because Resident 1 was very unpredictable, forgetful, confused and not compliant with nurse's recommendation to call for help before getting up on his own. During an interview on 5/17/24 at 12:15 p.m. with Registered Nurse (RN) 1, RN 1 stated on 5/2/24 in the afternoon, she heard a commotion and went to Resident 1's room. RN 1 stated she saw Resident 1 on the floor with a lot of blood, and there was no floor mat on the right side where Resident 1 was lying. RN 1 stated, Resident 1 was a high fall risk because of his unsteady balance. RN 1 stated, Resident 1 was known for forgetfulness and never listened to the nurse's reminder to call for help before getting up. RN 1 stated, there should be a non-compliance care plan for Resident 1 because he had fallen in the facility before. RN 1 stated Resident 1 had a history of seizures so there should also be seizure care plan initiated upon admission for Resident 1. During an interview on 5/17/24 at 12:47 p.m. with LVN 1, LVN 1 stated she was called by CNA 1 and CNA 2 on 5/2/24 and asked for help. LVN 1 stated, when she came, Resident 1 was lying on the floor on the right side of the bed facing up. LVN 1 stated, there was one floor mat that was placed on the left side of Resident 1's bed but Resident 1 fell on the right side of the bed where there was no floor mat. LVN 1 stated, blood was everywhere, and Resident 1 was Shaking really bad for three to five seconds. LVN 1 stated, Resident 1 did not have any bed side rails up and was not on one-to-one monitoring. LVN 1 stated, Resident 1 had history of falls in the facility prior to the fall on 5/2/24 and was restless, non-compliant when nurses asked him to call before getting up. LVN 1 stated, she did not know if the physician was made aware of Resident 1's noncompliance. During an interview on 5/17/24 at 1:06 p.m. with the Director of Nurses (DON), the DON stated, on 5/2/24 at around 5 p.m., he responded to a call for assistance in Resident 1's room. The DON stated, Resident 1 was lying on the floor and his head was bleeding. The DON stated, Resident 1 was having seizures and foaming from his mouth for about three to five seconds. The DON stated, there was no floor mat on the side that Resident 1 fell in, and the side rails were not up. The DON stated, he did not know for sure if the seizure triggered Resident 1's fall or his noncompliant behavior triggered the fall. The DON stated, for fall risk residents, interventions should be initiated that included frequent monitoring, and use of the floor mats. On 5/17/24 at 2:45 p.m., during a concurrent record review of Resident 1's Nursing Admission Assessment, dated 3/2/24 timed at 8:29 p.m., and interview with the Infection Prevention Nurse (IPN), Resident 1's diagnoses included localization related idiopathic epilepsy [partial seizures that originate from a localized region of the brain that process and register incoming sensory information (data received through our senses such as sight, smell, touch, taste, and hearing) and make possible the conscious awareness of the world] and epileptic syndrome. The IPN stated, the term was the same as seizure. The IPN stated, if the resident was admitted with history of seizure, a care plan for seizure monitoring and intervention should be initiated. The IPN stated, he could not find documented evidence that a care plan was developed to address seizure precautions for Resident 1 since facility admission on 3/2/24. The IPN stated, seizure precaution care plan was initiated on 5/9/24, after Resident 1 was found on the floor with seizure activity on 5/2/24. During a concurrent record review and interview on 5/17/24 at 3 p.m. with the IPN, Resident 1's GACH 1 record titled History and Physical, dated 1/24/24 timed at 9:25 a.m. and GACH 1 Progress Notes, dated 2/14/24, timed at 12:35 p.m. were reviewed, the IPN stated that GACH 1 was the acute hospital where Resident 1 was originally admitted from on 3/2/24. During a concurrent record review and interview on 5/17/24 at 3:15 p.m., Resident 1's History and Physical (H&P) dated 3/7/24 and Resident 1's GACH 2's Physician H&P dated 3/8/24 at 7:50 a.m. were reviewed with the IPN. The IPN stated, GACH 2 was the acute hospital where Resident 1 was sent to after his first fall on 3/7/24. The IPN stated, the records indicated that Resident 1 had history of dementia or Parkinson's disease dementia. The IPN stated, dementia should be listed in Resident 1's admission record and a care plan to address dementia should be initiated on 3/8/24. The IPN stated, he could not find any care plan for dementia. During a concurrent record review and interview on 5/17/24 at 3:45 p.m., with the IPN, Resident 1's Progress Notes, dated from 3/2/24 to 5/17/24 were reviewed, the IPN stated, the records indicated Resident 1 had recurrent falls in the facility that happened on 3/7/24, 3/18/24, and 5/2/24. During a concurrent record review and interview on 5/17/24 at 4:20 p.m. with the IPN, Resident 1's Care Plan since 3/2/24 was reviewed. The IPN stated, Resident 1 had his first fall on 3/7/24 with a care plan created. The IPN stated, when Resident 1 had his second fall on 3/18/24, there should be a revised care plan to evaluate the interventions and make changes as needed to prevent another incident. The IPN stated, he could not find any revised care plan to address the incident on 3/18/24. During the same concurrent record review and interview with the IPN, on 5/17/24 at 4:20 p.m., the IPN stated, if a resident had non-compliant behaviors with recommendations, it should have been addressed in the care plan. The IPN stated, he could not find any care plan that addressed Resident 1's non-compliant behaviors. During an observation on 5/17/24 at 4:55 p.m. with Resident 1, Resident 1's back of the head was observed with stitches. During an interview on 5/17/24 at 5:05 p.m. with CNA 3, CNA 3 stated Resident 1 was known for trying to get up by himself if no staff was available to watch him and had history of several falls. During a concurrent interview and record review on 5/17/24 at 5:20 p.m., Resident 1's care plans since 3/2/24 was reviewed with the DON, the DON stated, if the same fall incidents happened again, the resident's fall risks needed to be reassessed to see the gap in behaviors and root cause so that the interventions could be adjusted. The DON stated, the physician should be notified. The DON stated, prior to the actual fall, if the resident was identified as non-compliant, trying to get out of bed, high risk for falls, the behaviors should be addressed in the care plan. The DON stated, in Resident 1's records, there were no care plan that indicated specific behaviors from Resident 1 had that could increase the resident's risk for falls. The DON stated it was very important to address Resident 1's non-compliant behavior so that all care providers could be aware and know how to take care of the resident. During a concurrent record review and interview on 5/17/24 at 5:40 p.m., Resident 1's Nursing Admission Assessment, dated 3/2/24 timed at 8:29 p.m. and Resident 1's Order Summary Report dated 3/2/24 were reviewed, the DON stated that Resident 1 had history of seizure and had order for Levetiracetam (a type of drug that is used to control/prevent seizures or convulsions) 1000 mg (unit of weight) by mouth two times a day for anticonvulsant since 3/2/24. The DON stated, if a resident had history of seizure and was taking any anticonvulsant medication, he would expect to have a care plan developed and seizure precautions added in the care plan interventions from 3/2/24 facility admission, that included padded side rails up, seizure monitoring and floor mats. The DON stated, he could not find the diagnosis of seizure in Resident 1's medical record. The DON stated, seizure precautions, monitoring order, and care plan were put in place on 5/9/24, after Resident 1 had a fall incident with seizure activity on 5/2/24, 61 days from facility admission on 3/2/24. During a concurrent record review and interview on 5/17/24 at 6 p.m., Resident 1's H&P dated 3/7/24 and Resident 1's GACH 2's Physician H&P dated 3/8/24 at 7:50 a.m. were reviewed with the DON, the DON stated, Resident 1 had dementia as indicated in the records. The DON stated, dementia could be at risk for fall because by nature, the resident's thinking process was impaired. The DON stated, if the resident had a history of dementia, care plan should be initiated to make sure all care providers know how to take care the resident. The DON stated, he could not find any dementia care plan for Resident 1. During a concurrent interview and record review on 5/17/24 at 6:15 p.m., Resident 1's clinical records since admitted [DATE] were reviewed with the DON, the DON stated there was no documented evidence that the facility's IDT Falls committee addressed the resident's falls and identify interventions to prevent recurrence of falls to prevent injuries for 3/7/24 and 3/18/24. The DON stated that the IDT meeting should be conducted to identify a root cause of resident's recurrent falls, develop a care plan to identify interventions and revise as needed to prevent future fall incidents. The DON stated, he could only find one IDT Falls committee meeting on 5/9/24, that addressed Resident 1's fall on 5/2/24. The DON stated, there was supposed to be IDT meetings performed on 3/7/24 and 3/18/24 that could have prevented another fall with injury on 5/2/24. During an interview on 5/17/24 at 6:30 p.m., the DON stated, to prevent physical injury when a high-risk resident falls on the floor, the facility utilizes floor mats. The DON stated, floor mats could be placed on both sides of the bed or only one side of the bed. The DON stated, the floor mat should be placed on the side that resident tends to get up to or his strong side. The DON stated that Resident 1's CNAs reported that Resident 1 normally tried getting up from the right side of the bed, then the floor mat should have been placed on the right side of Resident 1's bed to prevent injury from fall. During an interview on 5/17/24 at 6:50 p.m. with the Administrator (ADM), the ADM stated that she could not find Resident 1's diagnosis of seizure and dementia in his admission record. The ADM confirmed that if Resident 1's seizure and dementia was addressed and monitored in the care plan and an IDT meeting was held within 72 hours after the fall to conduct a root cause analysis and further interventions, on 3/7/24 and 3/18/24, Resident 1's fall incident which resulted in bleeding from his head and a transfer to GACH 1 on 5/2/24 could have been prevented. A review of the facility's policy and procedure (P&P) titled, Seizure Precautions, dated 6/1/17, indicated that residents considered at high risk for seizure activity would have seizure precautions initiated, seizure pads will be placed on the resident's side rails. Floor mats may be used. A review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated 6/1/17 indicated: -The Nursing Staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls. -The Interdisciplinary Team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. Interventions will be implemented or changed based on the resident's condition and response. -Suggested measures that can be used in the prevention of falls included determine the safest use of side rails. -Post Fall: The IDT-Falls Committee will meet within 72 hours of a fall. The IDT-Falls Committee will review and document: Summary of event following a fall; root cause analysis; Referrals, as necessary; and Interventions to prevent future falls. The resident's Care Plan will be updated as necessary.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was alert, oriented to name, place, time and person, and able to make needs known was free from sexual abuse (non-nonconsensual touching of one person for the sexual gratification of another) by failing to ensure: 1. Resident 1 was not sexually abused by the Laundry Staff from 8/30/23 to 9/1/23. 2. Resident 1 was protected from sexual abuse from the Laundry Staff. The Licensed Vocational Nurse (LVN 1) and the Director of Nursing (DON) was aware of Resident 1's allegation of sexual abuse when it was reported by Resident 1 on 9/2/23. The Laundry Staff continued to work in the facility until 9/5/23. These deficient practices resulted in Resident 1 experiencing sexual abuse, verbalized feeling unhappy, uncomfortable, disgusted, shocked, and violated (failing to respect someone ' s peace or privacy) from the action and abuse of the Laundry Staff. This deficient practice also had the potential to affect other vulnerable residents in the facility to experience sexual abuse. On 9/12/23 at 2:39 pm, the California Department of Public Health (CDPH) called and was notified of an Immediate Jeopardy situation (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) with regards to the facility ' s failure to protect the residents from sexual abuse, allowing Laundry Staff back to the facility and went into Resident 1 ' s room talking to her. The facility submitted an acceptable IJ Removal Plan (action to correct the deficient practices), to CDPH on 9/13/23 at 5:07 PM. The IJ was removed on 9/13/23, after the surveyors verified and confirmed the facility implemented the facility ' s IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of Administrator (ADM) and the Director of Nursing (DON). The acceptable IJ Removal Plan included the following information: 1. Administrator provided a 1:1 (one on one) in-service regarding Abuse Prevention and Prohibition and immediately. 2. Terminated Laundry Staff on 9/13/23. 3. DON and Treatment Nurse proceeded to assessed Resident 1 and conduct a body assessment on 9/5/23 at 11:10 AM. Resident body check was noted to be clear and skin intact. 4. Resident was assessed as alert, oriented and no complaint of any pain, discomfort, was noted to be calm and cheerful and no signs and symptoms of any emotional distress such as crying, sadness or being emotional, denied feeling of fear and anxiety. 5. Change of Condition/SBAR (stands for 'Situation, Background, Assessment, Recommendation a communication tool communication between members of the health care team about a patient's condition) was initiated by the DON on 9/5/23 at 11:30 AM, Primary MD (Medical Doctor) and Family 1 made aware of the alleged abuse allegation of Resident 1. Primary MD ordered refers to psychiatrist and continue monitor for signs and symptoms of emotional distress times 14 days. Care plan for Risks for emotional distress and discomfort related to Alleged Abuse allegation by a male laundry employee was initiated on 9/5/23. 6. IDT (Interdisciplinary Team-team of facility staff that work together to develop the plan care of the residents) team met with Resident 1 on 9/5/23 at 12:00 PM to discuss her alleged allegation of abuse regarding the laundry male staff. Resident was informed regarding the Laundry Staff being suspended this morning to provide reassurance and ensure her safety. Resident 1 was informed to report any concern or issues regarding any facility staff to licensed nurses immediately to ensure her safety. 7. On 9/5/23 at 12:30 PM, Regional Clinical Director (RCD) provided in-service training to Administrator and DON regarding Abuse Prohibition and Management specifically on timely reporting of alleged resident abuse and protection of resident who made the allegation of abuse. 8. A physician order for monitoring of Resident 1 for signs and symptoms of emotional distress by the licensed nurse each shift was initiated on 9/5/23 at 1:30 PM and will be ongoing indefinitely to ensure that any resident issue be communicated to primary MD and psychiatrist timely. RCD provide in-services regarding Abuse Prohibition and Management including reporting and prevention to Dietary staff, Housekeeping and nursing staff on 9/5/23 at 1:00 PM. Administrator continued to provide Abuse Prohibition and Management in-service to facility on 9/5/23 3-11 shift and DON provided Abuse Management to nursing staff on 9/6/23 11-7 shift. All facility staff were made aware of Resident 1 allegation of abuse regarding the male Laundry Staff during the abuse in-services. Cross Reference F607 Findings: A review of Resident 1 ' s Admission Record indicated the Resident 1 was admitted the facility on 12/11/18 with diagnoses that included unspecified Epilepsy (neurological disorder in which a person has two or more unprovoked seizures that occur more than 24 hours apart), myocardial infarction (partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle), and, muscle weakness (when full effort doesn't produce a normal muscle contraction or movement). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 8/17/23, indicated Resident 1 had the capacity to make needs known and understand others, and with moderate cognitive impairment (ability to understand and make decisions). During an interview on 9/7/23 at 11:20 am, the DON stated she was informed by LVN 1 on 9/3/23 around 2:30 pm on Sunday of Resident 1 ' s sexual abuse allegation. The DON stated Resident 1 ' s allegation was not considered an allegation of abuse since she has dementia (progressive or persistent loss of intellectual functioning). The DON stated she told LVN 1 she will come back tomorrow (9/4/23) to assess the sexual allegation. The DON stated Resident 1 informed her about the allegation of sexual abuse on 9/4/23 at around 6:35 pm. The DON stated she did not report Resident 1 ' s allegation of sexual abuse to the adult protective services, the state survey agency, ombudsman, and the local law enforcement, and did not investigate the allegation of sexual abuse because Resident 1 has dementia. The DON stated the facility ' s Abuse policy indicated the facility ' s abuse coordinator was the ADM who should report any allegation of abuse to the Department, Ombudsman, and local law enforcement within two hours. DON admitted it was her fault she did not inform the ADM and suspend the Laundry Staff when she was informed by LVN 1 about the sexual abuse allegation on 9/3/23. The DON denied that she was informed of the allegation of sexual abuse on 9/2/23 as reported by Resident 1 to the law enforcement and the surveyor. During an interview on 9/7/23 at 11:50 am, the ADM stated he was not informed of Resident 1 ' s sexual abuse allegation on 9/2/2023 as reported by Resident 1. The ADM stated he was notified of the alleged sexual abuse on 9/5/23 around 9 am. The ADM stated DON and LVN 1 did not report Resident 1 ' s allegation of sexual abuse to the adult protective services, the state survey agency, ombudsman, and the local law enforcement. The ADM stated the facility ' s Abuse policy indicated the facility should report any allegation of abuse to the Department, Ombudsman, and local law enforcement within two hours of alleged sexual abuse. During an observation and interview with Resident 1 on 9/7/23 at 12:30 PM, Resident 1 was observed sitting on the bed. In an interview, Resident 1 was alert and oriented to name, place, time and date. Resident 1 stated on 8/30/23 while she was sitting on the bed, the Laundry Staff stood in front of her and said something to her that she could not understand. The Laundry Staff then grabbed her left hand and put her hand under his buckle belt and had her rub his penis five to six times back and forth. Resident 1 stated the Laundry Staff was smiling and kept looking behind him to see if there was anyone watching. Resident 1 stated before the Laundry Staff left her room, he said he was coming back. Resident 1 stated, the next day on 8/31/23, the Laundry Staff went in her room between 10 AM to 11 AM, and again grabbed her hand and rubbed her hand on penis about five to six times and he kept watching the door to see if someone was coming. Resident 1 stated on 9/1/23, the Laundry Staff came into her room again, grabbed and rubbed her hand against his penis. Resident 1 stated she pulled back her left hand and told Laundry Staff Not to do that ever again. Resident 1 stated she felt unhappy, uncomfortable, disgusted, and shocked with the incident. Resident 1 stated she did not know what to do and who to tell. Resident 1 stated she talked to Family 1 (FAM1) about the sexual abuse. Resident 1 stated FAM 1 informed the Licensed Vocational Nurse (LVN 1) about the sexual abuse by the Laundry Staff on 9/2/23. A review of Police Report (PR) from Police Department (PD1) reported dated on 9/5/23 at 11:52 am. PD1 conducted an interview with Resident 1 and the PR indicated the following: 1. Resident 1 stated on 8/30/23 around 1 pm, Laundry Staff went into her room and approached her bedside. Resident 1 was in a sitting position on her bed and Laundry Staff stood on left side of her bed, grabbed her left hand, and pulled towards the bottom portion of his belt buckle. Resident 1 stated the Laundry Staff rubbed the back of her hand approximately five to six times back and forth between his belt-buckle and his penis. Laundry Staff placed her hand over his paints and not under his clothes. Laundry Staff was looking back toward the bedroom door to see if anyone was approaching her bedroom. Resident 1 said Laundry Staff looked at her, touched her face with his other hand. Laundry Staff released her left hand and put his finger to his mouth and said Shh, shh shh, I ' ll be back. 2. Resident 1 stated on 8/31/23 between 10 am to 11 am, Laundry Staff went into her room and approached her left side of bed. Resident 1 was in a sitting position on her bed and Laundry Staff stood on the left side. Laundry Staff grabbed her left hand and pulled it toward his groin area. Resident 1 stated in the manner the Laundry Staff grabbed her hand form a fist position. Resident 1 said Laundry Staff rubbed the back of her hand below his belt buckle over his pants approximately six times back and forth between his belt-buckle and his penis. Laundry Staff was looking back toward the bedroom door to see if anyone was approaching her bedroom. Laundry Staff released her left hand and put his finger to his mouth and said Shh . shh shh, I ' ll be back. 3. Resident 1 stated on 9/1/23 between 10 am to 11 am, Laundry Staff went into her room and approached her left side of bed. Resident 1 was in a sitting position on her bed and Laundry Staff stood on the left side. Laundry Staff grabbed her left hand and pulled it toward his groin area. Resident 1 stated the manner in which the Laundry Staff grabbed her hand form a fist position. Resident 1 said Laundry Staff rubbed the back of her hand below his belt buckle over his pants two times. Resident 1 hand was rubbed back and forth between his belt-buckle and his penis. Resident said she was in shocked the other two times that Laundry Staff assaulted her and now she was angry and pulled her hand away. Resident 1 recalled saying No don ' t ever do that again, Laundry Staff walked away and never returned. 4. Resident 1 stated she notified LVN 1 on 9/2/23. 5. Resident 1 stated on 9/5/23 at around 9 am the Laundry Staff walked in her room and said, Momma, momma, momma, please don ' t. I have a sick daughter in college. Please momma, please don ' t get me fired. I won ' t be able to get work. 6. The report indicated the Resident 1 was coherent and provided detailed statements of the answer to the question and the allegation appeared credible. During an interview on 9/12/23 at 10:35 am LVN 1 stated Resident 1 ' s Family (FAM 1) called him around noon time on 9/3/23 and told him about Resident 1 was sexual abuse by the Laundry Staff on 8/30/23, 8/31/23 and 9/1/23. LVN 1 went to Resident 1 ' s room to gather information from Resident 1. LVN 1 stated at the beginning, on 9/3/23 Resident 1 she was in shocked and hesitated to tell the whole story. LVN 1 stated Resident 1 reported that feeling anxious and afraid to go to nursing station to look for him. LVN 1 stated Resident 1 was able to give detailed information of the sexual abuse incident clearly and was not confused. LVN 1 stated he reported Resident 1 ' s allegation of sexual abuse to DON around 2 pm on 9/3/23. LVN 1 denied that he received Resident 1 ' s allegation of sexual abuse on 9/2/23 as reported by Resident 1 to the police the surveyor. During an interview on 9/12/23 at 12:10 pm with Maintenance and Laundry supervisor (MLS), stated that he was informed by LVN 1 on 9/3/23 about the Resident 1 ' s alleged sexual abuse by the Laundry Staff. Laundry Staff was off on 9/3/23 and 9/4/23. MLS stated Laundry Staff returned to work on 9/5/23. During an interview on 9/13/23 at 3:20 pm with the DON, stated that she talked to the Laundry Staff on 9/5/23 not to go to Resident 1 ' s room. A review of Resident 1 ' s progress note titled Psych evaluation following an alleged sexual abuse, dated 9/8/23, indicated Resident 1 was sexually violated by a facility staff on 8/30/23, 8/31/23 and 9/1/23. The evaluation indicated, on 8/30/23 the Laundry Staff came into to her room and stoked her face with his hand; on 8/31/23 Resident 1 stated the Laundry Staff came to her room and stoked her arms; Resident 1 stated she felt uncomfortable and unhappy by the action of the Laundry Staff; and on 9/1/23 Resident 1 stated Laundry Staff came to her room and held her left hand to rub his groin. Resident 1 reported she felt violated and disgusted by the action of the Laundry Staff. A review of the facility ' s policy and procedure, titled Abuse Prevention and Prohibition Program revised on 10/24/22, indicated the residents had the right to be free from abuse and the facility had zero-tolerance for abuse, neglect, and mistreatment of each resident. The policy indicated the facility was committed to protecting residents from abuse by anyone, including from the facility staff; shall thoroughly investigate; and report resident allegation of abuse no later than two hours after forming the allegation to the ombudsman, law enforcement: adult protective services and state survey agency; protect resident from any harm that could result from investigation; and the facility staff member accused of committing abuse against a resident is suspended until the investigation is complete, and the findings had been reviewed by the Administrator.

Based on observation, interview and record review, the facility staff failed to implement the facility's policy and procedure, titled Abuse Prevention and Prohibition Program Policy for one of three sampled residents (Resident 1) by not protecting, preventing, reporting, investigating an allegation of sexual abuse (non-consensual touching of one person for the sexual gratification of another) from the facility's male Laundry Staff. The facility failed to: 1. Prevent Resident 1 from sexual abuse when the facility's male Laundry Staff grabbed and rubbed Resident 1's hand between his belt buckle and his penis five to six times back and forth while in the Resident 1's room on 8/30/23 and 8/31/23. 2. Protect Resident 1 from sexual abuse on 9/1/23, when the Laundry Staff continued to go into Resident 1's room putting the resident's hand above his penis. Resident 1 pulled away and told the Laundry Staff Not to do that ever again. 3. Protect Resident 1 from sexual abuse when the Laundry Staff remained employed at the facility from 9/2/23 to 9/5/23, for four days after reported to the Licensed Vocational Nurse (LVN 1) 1 and the Director of Nursing (DON) on 9/2/23 by Resident 1 and Family 1 (FAM1). 4. Report Resident 1's allegation of sexual abuse to the Department of Public Health (State Survey Agency), local law enforcement, Ombudsman (state agency that advocates for the residents) and Adult Protective Services (agency that protects the adults and elderly) on 9/2/23 by Resident 1 and FAM 1 to LVN 1 and the DON. 5. Investigate an allegation of sexual abuse when the sexual abuse was reported by Resident 1 to the Licensed LVN 1 and the DON on 9/2/23. The allegation was investigated on 9/5/23 (four days after the alleged abuse occurred). These deficient practices resulted in Resident 1 experiencing sexual abuse, verbalized feeling unhappy, uncomfortable, disgusted, shocked, and violated (failing to respect someone's peace or privacy) from the action and abuse of the facility Laundry Staff. This deficient practice also had the potential to affect other vulnerable residents in the facility to experience sexual abuse. On 9/12/23 at 2:39 pm, the California Department of Public Health (CDPH) notified the facility of an Immediate Jeopardy situation (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 DON and the Administrator (ADM) with regards to the facility's the failure to implement the facility's Abuse prevention and prohibition program. The facility submitted an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) to CDPH on 9/13/23 at 5:07 pm. The IJ was removed on 9/13/23, after the surveyors verified and confirmed that the facility implemented the facility's IJ Removal Plan while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable IJ Removal Plan included the following information: 1. Facility Administrator provided a 1:1 (one on one or one person providing in service to one staff) in-service regarding Abuse Prevention and Prohibition and immediately and suspended the Laundry Staff on 9/5/23 on 10:30 am. 2. Facility Administrator reported Resident 1's alleged sexual abuse allegation to Department of Public Health on 9/5/23 at 11:00 am by telephone. 3. The DON reported Resident 1's allegation of sexual abuse of via telephone to the police on 9/5/23 at 11:40 am. 4. The Administrator called the ombudsman (a state agent that advocates for the residents) on 9/5/23 at 12:00 pm and left message regarding Resident 1 alleged sexual abuse allegation. 5. Facility Administrator completed the SOC (State of California) 314 (form used by the facility to report suspected adult or elderly abuse to the stated survey agency) was faxed to CDPH on 9/5/23 at 4:07 pm and the Ombudsman office on 9/5/23 at 4:09 pm. 6. The local police came to the facility on [DATE] at 12:20 pm and interviewed Resident 1 via telephone. 7. On 9/5/23 at 12:00 pm, Regional Clinical Director provided a 1:1 in-service training to the DON regarding timely reporting of abuse to the abuse coordinator (Administrator) and timely initiation of investigation upon knowledge of Resident 1 alleged sexual abuse allegation to ensure Resident 1 safety and prevent psychological (mental) and emotional trauma (traumatizing experiences that leave you feeling unsafe or helpless). 8. On 9/5/23 at 12:30 pm, Regional Clinical Director (RCD) provided in-service training to Administrator and DON regarding Abuse Prohibition and Management specifically on timely reporting of alleged resident abuse and protection of resident who made the allegation of abuse. 9. RCD provided in-services regarding Abuse Prohibition and Management including reporting and prevention to Dietary staff, Housekeeping and nursing staff on 9/5/23 at 1:00 pm. The Administrator continued to provide Abuse Prohibition and Management in-service to facility on 9/5/23 during 3pm-11pm shift, and the DON provided Abuse Management to nursing staff on 9/6/23 11pm-7am shift. All facility staff was made aware of Resident 1 allegation of abuse regarding the male Laundry Staff during the abuse in-services. 10. Abuse binder on each station was initiated by the DON on 9/12/23 at 8:15 pm and provided in-service to the licensed nurses regarding the Abuse binder contents and information on the 3pm-11pm shift and will be ongoing till all licensed nurses will be in-service by 9/13/23. The Abuse binder will contain the following information: 1.) Contact number and fax number for CDPH, Contact Number and Fax number for Ombudsman and contact number for the police district. 2.) Name and Title of the Abuse Coordinator and DON 3.) Copies of SOC 341 form 4.) Facility policy and Procedure for Abuse Prohibition and Management. 11. Facility will continue to provide staff education regarding Abuse Prevention, Investigation and Reporting monthly for the next 6 months starting in the month of October 2023 to ensure facility compliance with facility's policy and procedure on Abuse Prohibition and Management. 12. Facility initiated QAPI (Quality Assurance Program Improvement-program to improve the quality of care at the facility) for Abuse Management on 9/5/23 to prevent recurrence of any late reporting, prevention of abuse and protection of resident including timely investigation of any alleged abuse resident report. Cross Reference to F600 Findings: A review of Resident 1's Admission Record indicated the Resident 1 was admitted to the facility on [DATE] with diagnoses that included unspecified epilepsy (a disorder due to disturbed activity in the brain), myocardial infarction (partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle) and, muscle weakness (when full effort doesn't produce a normal muscle contraction or movement). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 8/17/23, indicated Resident 1 had the capacity to make needs known and understand others, and with moderate cognitive impairment (ability to understand and make decisions) that required extensive assistance (resident involved in activity, staff provide weight bearing support) with one-person physical assistance on bed mobility and transfer. A review of Police Report (PR) from Police Department (PD1) report dated, 9/5/23 at 11:52 am. PD1 conducted an interview with Resident 1 and the PR that indicated the following: 1. Resident 1 stated on 8/30/23 around 1 pm, Laundry Staff went into her room and approached her bedside. Resident 1 was in a sitting position on her bed and Laundry Staff stood on left side of Resident 1's bed, grabbed her left hand and pulled towards the bottom portion of his belt buckle. Resident 1 stated the Laundry Staff rubbed the back of her hand approximately five to six times back and forth between his belt-buckle and his penis. Laundry Staff placed her hand over his pants and not under his clothes. Laundry Staff was looking back toward the bedroom door to see if anyone was approaching the resident's bedroom. Resident 1 said Laundry Staff looked at her, touched her face with his other hand. The Laundry Staff released her left hand and put his finger to his mouth and said Shh, shh shh, I'll be back. 2. Resident 1 stated on 8/31/23 between 10 am to 11 am, the male Laundry Staff went into her room and approached her left side of bed. Resident 1 was in a sitting position on her bed and Laundry Staff stood on the left side. Laundry Staff grabbed her left hand and pulled it toward his groin area. Resident 1 stated the way Laundry Staff grabbed her hand form a fist position. Resident 1 said Laundry Staff rubbed the back of her hand below his belt buckle over his pants approximately six times back and forth between his belt-buckle and his penis. Laundry Staff was looking back toward the bedroom door to see if anyone was approaching her bedroom. Laundry Staff released her left hand and put his finger to his mouth and said Shh, shh shh, I'll be back. 3. Resident 1 stated on 9/1/23 between 10 am to 11 am, Laundry Staff went into her room and approached her left side of bed. Resident 1 stated she was in a sitting position on her bed and the Laundry Staff stood on the left side. Laundry Staff grabbed her left hand and pulled it towards his groin area. Resident 1 stated the way Laundry Staff grabbed her hand form a fist position. Resident 1 said the Laundry Staff rubbed the back of her hand below his belt buckle over his pants two times. Resident 1's hand was rubbed back and forth between his belt-buckle and his penis. Resident said she was in shock the other two times that Laundry Staff assaulted her and now she was angry and pulled her hand away. Resident 1 recalled saying No don't ever do that again, Laundry Staff walked away and never returned. 4. Resident 1 stated she notified LVN 1 on 9/2/23. 5. Resident 1 stated on 9/5/23 at around 9 am the Laundry Staff walked in her room and said, Momma, momma, momma, please don't. I have a sick daughter in college. Please momma, please don't get me fired. I won't be able to get work. 6. The report indicated the Resident 1 was coherent and provided detailed statements and the allegation appeared credible. During an interview on 9/7/23 at 11:20 am, the DON stated she was informed by LVN 1 on 9/3/23 around 2:30 pm on Sunday of Resident 1's sexual abuse allegation. The DON stated Resident 1's allegation was not investigated because the allegations was not considered sexual abuse since Resident 1 has dementia (progressive or persistent loss of intellectual functioning). The DON stated she told LVN 1 on 9/3/23 that she will come back tomorrow (9/4/23) to assess the sexual allegation. The DON stated she talked to Resident 1 on 9/4/23 around 6:35 pm. The DON stated she did not report Resident 1's allegation of sexual abuse to the adult protective services, the state survey agency, ombudsman, and the local law enforcement, and did not investigate the allegation of sexual abuse because Resident 1 has dementia. The DON stated the facility's Abuse policy indicated the facility's abuse coordinator was the ADM who should report any allegation of abuse to the Department, adult protective services, ombudsman, and local law enforcement within two hours. The DON admitted it was her fault she did not inform the ADM and suspend the Laundry Staff when she was informed by LVN 1 about the sexual abuse allegation on 9/3/23. The DON denied being informed of the allegation of sexual abuse on 9/2/23 as reported by Resident 1 to the law enforcement and the surveyor. Resident 1 stated FAM 1 informed LVN 1 about the sexual abuse by the Laundry Staff on 9/2/23. During an interview on 9/7/23 at 11:50 am, ADM stated he was not informed of Resident 1's sexual abuse allegation on 9/2/2023. The ADM stated he was notified of the alleged sexual abuse during the morning meeting on 9/5/23 around 9 am. The ADM stated the DON and LVN 1 did not report Resident 1's allegation of sexual abuse to CDPH, adult protective services, ombudsman, and the local law enforcement. The ADM stated the facility's Abuse policy indicated the facility should report any allegation of abuse to CDPH, ombudsman, and local law enforcement within two hours of alleged sexual abuse. During an interview on 9/12/23 at 10:35 am LVN 1 stated Resident 1's Family (FAM 1) called him around noon time on 9/3/23 and told him Resident 1 was being sexually abused by the Laundry Staff on 8/30/23, 8/31/23 and 9/1/23. LVN 1 went to Resident 1's room to gather information from Resident 1. LVN 1 stated at the beginning, on 9/3/23 Resident 1 was in shock and hesitated to tell the whole story. LVN 1 stated Resident 1 reported feeling anxious and afraid to go to the nursing station to look for him. LVN 1 stated Resident 1 was able to give detailed information of the sexual abuse incident clearly and was not confused. LVN 1 stated he reported Resident 1's allegation of sexual abuse to DON around 2 pm on 9/3/23. LVN 1 denied that he received Resident 1's allegation of sexual abuse on 9/2/23 as reported by Resident 1 to the police officer and the surveyor. During an interview on 9/12/23 at 12:10 pm with Maintenance and Laundry supervisor (MLS), stated that he was informed by LVN 1 on 9/3/23 about the Resident 1's alleged sexual abuse by the Laundry Staff. Laundry Staff was off on 9/3/23 and 9/4/23. MLS stated Laundry Staff returned to work on 9/5/23. During an interview on 9/13/23 at 3:20 pm with DON, stated that she talked to the Laundry Staff on 9/5/23 to inform him not to go to Resident 1's room. The DON stated she did not suspend the Laundry Staff on 9/3/23 when LVN 1 reported to her the alleged sexual abuse of Resident 1 by the Laundry Staff. A review of Resident 1's progress note titled Psych evaluation following an alleged sexual abuse, dated 9/8/23, indicated Resident 1 was sexually violated by a facility staff on 8/30/23, 8/31/23 and 9/1/23. The evaluation indicated, on 8/30/23 the Laundry Staff came into to her room and stoked her face with his hand; on 8/31/23 Resident 1 stated the Laundry Staff came to her room and stoked her arms; Resident 1 stated she felt uncomfortable and unhappy by the action of the Laundry Staff; and on 9/1/23 Resident 1 stated the Laundry Staff came to her room and held her left hand to rub his groin. Resident 1 reported she felt violated and disgusted by the action of the Laundry Staff. A review of the facility's policy and procedure, titled Abuse Prevention and Prohibition Program revised on 10/24/22, indicated the residents had the right to be free from abuse and the facility had zero-tolerance for abuse, neglect, and mistreatment of each resident. The policy indicated the facility will: 1. Protect residents from abuse by anyone, including from the facility staff. Protect the resident from any harm that could result from investigation; and the facility staff member accused of committing abuse against a resident is suspended until the investigation is complete, and the findings had been reviewed by the Administrator. 2. Promptly and thoroughly investigate reports of resident abuse. If the ADM receives a report of abuse and mistreatment, the ADM or designee will appoint a member of the facility's management team to investigate the allegation by making an investigation report, interview witnesses, resident (as medically appropriate) and review all relevant documents. 3. Report resident's allegation of abuse no later than two hours after forming the allegation to the ombudsman, law enforcement: adult protective services and state survey agency. The ADM will submit initial and follow up written reports of the result of all the abuse investigation consequences actions to the appropriate agencies. 4. Prevent resident from abuse by ensuring the supervisors immediately intervene, correct, and report identified situation where about is at risk for occurring.

Based on interviews and record reviews, the facility failed to notify the attending physician (Physician 1) and responsible party (Family 1 and 2) promptly when a resident, who tested positive for COVID-19 (coronavirus disease 2019; a disease caused by a very contagious virus and often causes respiratory symptoms) on 8/16/23, had a change in condition (COC) and developed unresolved cough, difficulty breathing, congestion, [an abnormal or excessive accumulation of body fluid]), and shallow breathing (rapid, deep breathing) on 8/17/23 and 8/18/23 for one of four sampled residents (Resident 1), in accordance with the resident ' s plan of care for COPD (chronic obstructive pulmonary disease) and the facility policy on COC Notification. In addition, the facility failed to notify the physician when the resident had faint (weak) heartbeat and facility staff had to place Resident 1 on nonrebreather oxygen mask (a device that gives high concentration of oxygen, usually in an emergency) due to low saturation levels [normal blood oxygen levels are between 95% to 100%]) (actual oxygen saturation level not documented in resident ' s records), on 8/18/23. These deficient practices resulted to a delay in respiratory care, treatment, and services of Resident 1 ' s respiratory condition. Resident 1 passed away on 8/18/23 between the hours of 9:15 PM to 9:30 PM, while in the facility (two days after testing positive for COVID-19). On 8/23/2023 at 3:06 PM, during the facility ' s Focused Infection Control Survey (a focused survey conducted by the California Department of Public Health to Skilled Nursing Facilities associated with the transmission of COVID-19 among staff and residents in facilities), 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 regarding the facility ' s failure to notify Physician 1 regarding significant changes in Resident 1 ' s respiratory conditions (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat) in accordance with the facility ' s policy on Change of Condition Notification and the plan of care for COPD. On 8/25/2023 at 3:06 PM, the IJ was removed after the surveyors verified and confirmed the facility implemented the facility ' s IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the Regional Clinical Director (RCD). The acceptable IJ Removal Plan included the following: 1. On 8/23/2023, the Director of Staff Development (DSD), Minimum Data Set (MDS; an assessment screening tool) Nurse and another licensed staff/designee re-assessed all 56 residents identified to have COVID 19 positive results from rapid testing for any changes in condition and assessments to be completed on 8/24/2023. All 56 residents care plans for COVID 19 were updated and revised on 8/24/2023 for risks of COVID related symptoms by the licensed nurses and communicated to the staff. 2. On 8/23/2023, the facility ' s Medical Director was notified by the Regional Clinical Director (RCD) regarding the 56 residents with positive COVID 19 results. 3. On 8/23/2023, an in-service was provided by the RCD to all licensed nurses present during the 3 PM to 11 PM shift regarding contacting the attending physician as soon as possible for any residents ' change in the condition and decreased oxygen saturation levels. 4.On 8/24/2023, the RCD provided one on one in-service to LVN 2 regarding facility policy for resident change in condition and notification of physician. 5.On 8/24/2023, the RCD provided in-service and education to licensed staff to review the POLST when there is a change of condition for residents to ensure licensed staff follow any directives for life sustaining treatments. 6. On 8/24/2023, the RCD created a mini orientation checklist for registry licensed staff regarding the facility ' s policy/processes at the facility to be provided by the DSD during Monday to Fridays and lead licensed staff for Saturdays and Sundays. 7. The RCD to provide one on one training to the Director of Nurses (DON) upon return to work at the facility as DON is currently on sick leave. Trainings to include resident ' s change of conditions, providing supervision and follow up assessments, prompt communication to physician for new orders, and possible transfer to hospital based on facility policy. Cross Reference to F695. Findings: A review of Resident 1 ' s Face Sheet (admission record) indicated the facility admitted the resident on 5/8/2023 with diagnoses that included vascular dementia (brain damage caused by multiple strokes [occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts]), hyperlipidemia (high level of fat particles in the blood), and hypertension (high blood pressure). A review of Resident 1 ' s POLST signed and dated by Physician 1 on 6/25/2023, indicated the following medical interventions if the resident is found with a pulse and/or is breathing to perform selective treatment (goal of treating medical conditions while avoiding burdensome measures) and additional orders that indicated a handwritten note, Hospital. A review of Resident 1 ' s History and Physical assessment dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. The History and Physical Assessment indicated Resident 1 had COPD. A review of Resident 1 ' s care plan for COPD dated 7/30/2023, indicated Resident 1 is at risk for shortness of breath/respiratory distress (a life-threatening lung injury that allows fluid to leak into the lungs) related to COPD. The care plan interventions indicated the staff would monitor the resident for shortness of breath, irregular (abnormal) respiration, wheezing (a high-pitched whistling sound made while breathing, often associated with difficulty breathing), crackles (brief popping when a person breathes, often associated with presence of fluid in the lungs), rhonchi (occur when there are secretions or obstruction in the larger airways of the lungs), excessive secretion, and inform the physician promptly. The care plan interventions indicated to administer oxygen inhalation as ordered, monitor oxygen saturation as needed/ordered, breathing treatment as ordered and monitor the effect of treatment. The care plan indicated to inform the physician if treatment is ineffective. A review of Resident 1 ' s care plan for COVID-19 Positive antigen rapid test dated 8/16/2023, did not indicate physician notification in the nursing interventions for any changes in resident condition related to COVID-19. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment and screen tool) dated 8/11/2023 indicated Resident 1 had moderately impaired cognitive (thought process) skills for daily decision making. The MDS indicated Resident 1 required total dependence (full staff performance every time during entire seven-day period) with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 1 ' s written Physician order dated 8/16/2023 timed at 10 AM, indicated Transmission Based Precaution (TBP; extra measures centered on a specific mode of transmission for patient with known or suspected infection) contact isolation precautions (use of appropriate protective equipment prior to patient contact) for COVID 19 virus for 14 days . A review of Resident 1 ' s Situation, Background, Assessment, Recommendation (SBAR; a communication document for licensed nurses for residents with change of conditions) Communication Form dated 8/16/23, indicated Resident 1 had a change in condition with signs and symptoms observed COVID + (positive) and coughing that started on 8/16/2023. The SBAR indicated Resident 1 ' s most recent blood pressure was 140/59 millimeters of mercury (mmHg; unit of measurement to measure blood pressure) ., and oxygen saturation level at 95 % on room air (when a resident is not receiving any supplemental oxygen, then the resident is breathing on room air). The SBAR indicated Family 1 and 2, including Physician 1 was notified on 8/16/23 timed at 10 AM. The SBAR did not indicate what specific information was provided to Physician 1 and Family 1 or 2. The SBAR did not indicate any other new physician orders but to monitor vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a person ' s essential body functions). A review of Resident 1 ' s Licensed Personnel Weekly Progress Notes indicated the following information for dates 8/17/2023 to 8/18/2023: 1. On 8/17/2023 timed at 3 PM to 11 PM shift (no specific time written), authored by LVN 2, indicated On monitoring for COVID + (positive), has coughing noted, no signs and symptoms (s/s) of fever, nausea/vomiting (n/v), diarrhea (loose, watery stools three or more times a day), chills, fatigue noted at this time. All needs are met . Vital signs blood pressure (B/P) 117/80, pulse is 70, respiration is 17, temperature is 97.8 . 2. On 8/18/23 timed at 11 PM to 7 AM (no specific time written) authored by LVN 2, indicated Monitoring for COVID + (positive), has coughing noted, no s/s of any fever, n/v, diarrhea, chills noted at the moment. All needs met. B/P 127/80, pulse 67, respiration 17, temperature is 97.8 . 3. On 8/18/2023 timed at 7 AM to 3 PM (no specific time written) authored by LVN 1, indicated Resident 1 on monitoring for COVID 19 positive and no cardiac arrest (occurs when the heart suddenly and unexpectedly stops pumping)/distress noted, no signs/symptoms of pain, or discomfort noted, vital signs within normal limits (WNL) . nonproductive cough noted. 4. On 8/18/2023 timed at 3 PM to 11 PM (no specific time written) authored by LVN 1, indicated Resident 1 passed away at 9:15 PM, family in to visit and say last goodbyes. MD (Physician 1) notified; mortuary (a funeral home) . Resident 1 ' s body warm to touch, heartbeat faint (weak) upon family arrival. No pulse or respiratory noted. Resident 1 was placed on nonrebreather upon low oxygen saturation level (sic). During a telephone interview with Resident 1 ' s family members (Family 1 and 2) on 8/22/2023 at 4 PM, Family 1 stated she called the facility every day to check on Resident 1. Family 1 stated the facility staff did not tell her Resident 1 was not feeling well. Family 1 stated she called the facility in the morning on 8/18/2023 and staff told her Resident 1 was okay but was sleeping. Family 1 stated she called the same day, later in the afternoon, and no one answered. Family 1 stated at around 9:15 PM on 8/18/2023, she received a call from the facility, instructing her to come now, because Resident 1 is dying. Family 1 stated she arrived at the facility at 9:30 PM. Family 1 stated when Family 1 and 2 arrived at Resident 1 ' s room, Resident 1 was receiving oxygen attached to clear balloon. Family 1 stated she did not know what the clear balloon was used for. Family 2 stated there was an oxygen tank in Resident 1 ' s room, but it was not attached to Resident 1 when Family 1 and 2 arrived in Resident 1 ' s room on 8/18/23. Family 1 stated an unknown nurse was also in Resident 1 ' s room. Family 1 stated the unknown nurse in the room did not mention to transfer Resident 1 to the acute hospital. Family 1 stated Resident 1 passed away shortly 15 to 30 minutes after they arrived at the facility. Family 2 stated Resident 1 has had a cough since 8/15/2023. On 8/22/2023 at 5:54 PM, during a concurrent interview and record review of Resident 1 ' s Licensed Nurses Weekly Progress Notes (from 8/16/2023 to 8/18/2023) with the Registered Nurse Supervisor (RNS), the RNS stated Resident 1 passed away on 8/18/2023 at 9:15 PM due to infection (a condition in which bacteria or viruses that cause disease have entered the body) and COVID 19. The RNS stated there was no documented evidence in Resident 1 ' s progress notes and clinical record that Physician 1 was notified of changes in the resident ' s medical condition (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat) before Resident 1 passed away on 8/18/23. During a concurrent interview and record review of Resident 1 ' s SBAR Communication Forms for the month of August 2023 with the RNS on 8/22/2023 at 5:57 PM, RNS stated the only change of condition with physician notification documented in the resident ' s records were from 8/16/2023, when Resident 1 became positive with COVID 19. During an interview with LVN 1 on 8/22/2023 at 6:51 PM, LVN 1 stated she did not notify Physician 1 of Resident 1 ' s change of condition (low saturation levels, congestion, use of nonrebreather oxygen mask, faint heartbeat), because she expected the DON, who was also in Resident 1 ' s room on 8/18/2023, to notify Physician 1. LVN 1 stated the DON spoke with Resident 1 ' s family and transferring the resident to the acute hospital was not offered to Family 1 and 2. LVN 1 stated she thought the DON would document in Resident 1 ' s SBAR form, which is why LVN 1 did not document Resident 1 ' s change of condition. LVN 1 stated she forgot to document all the vital signs she took from Resident 1 on 8/18/2023 during the 7 AM to 3 PM shift and 3 PM to 11 PM shift. During the same interview, on 8/22/23 at 6:51 PM, LVN 1 further stated she bumped up (increased) Resident 1 ' s oxygen therapy and used a nonrebreather mask instead of a nasal cannula (a medical device that consists of a small, flexible tube with two prongs that sit inside a patient ' s nostrils). LVN 1 stated she increased Resident 1 ' s oxygen therapy up to 8 liters per minute via nonrebreather mask. LVN 1 stated when she noticed that Resident 1 was still unresponsive to 8 LPM of oxygen therapy, LVN 1 stated she called and notified Resident 1 ' s family. LVN 1 stated she did not remember what Resident 1 ' s oxygen saturation level during the time she called Resident 1 ' s family. LVN 1 stated she did not document any of Resident 1 ' s vital signs in the resident ' s records. LVN 1 stated when Resident 1 ' s family arrived, Resident 1 was wearing a nonrebreather mask, and presented with shallow breathing (rapid, deep breathing). LVN 1 stated during the endorsement report from LVN 2 (11 PM to 7 AM night shift licensed nurse) on 8/18/2023, LVN 2 reported that during the night shift, LVN 2 stated that Resident 1 was suctioned (removing mucus and fluids from the nose, mouth or back of the throat with a bulb syringe [a device that is used to inject fluid into, or withdraw fluid from the body]) or a catheter [thin flexible tube]) in the mouth. LVN 1 stated she also suctioned Resident 1 orally on 8/18/2023 but could not recall the time. LVN 1 stated Resident 1 sounded congested (abnormal or excessive accumulation of a body fluid) in his chest. LVN 1 stated she did not listen to Resident 1 ' s lung sounds. LVN 1 stated she looked at Resident 1 and saw Resident 1 ' s oxygen saturation level was low. LVN 1 stated she did not document Resident 1 ' s oxygen saturation level and vital signs on 8/18/2023. LVN 1 stated she could not recall Resident 1 ' s oxygen saturation level and vital signs during that time (8/18/2023). During the same interview, on 8/22/23 at 6:51 PM, LVN 1 stated she worked a double shift from 7 AM to 3 PM and 3 PM to 11 PM shifts on 8/18/23 and was assigned to care for Resident 1. LVN 1 stated the certified nursing assistant (CNA 1) informed her that Resident 1 was not feeling well after dinner on 8/18/2023. LVN 1 stated prior to dinner, Resident 1 did not have any issues. LVN 1 stated after CNA 1 notified her of Resident 1 ' s status (not feeling well after dinner), LVN 1 went to Resident 1 ' s room and took the resident ' s vital signs. LVN 1 stated she did not document and could not recall the results of Resident 1 ' s vital signs on 8/18/2023, after dinner. LVN 1 stated Resident 1 looked like he was transitioning (beginning of the final stage of dying). LVN 1 stated that on 8/18/2023, Resident 1 was transitioning and had a change of condition but could not recall the exact time, after dinner of Resident 1 ' s change of condition. LVN 1 was asked to explain what she meant by Resident 1 was transitioning and stated her definition of transitioning was if I am looking at him (Resident 1), skin was pale, it looks like something was changing that I could not take care of him, it was something he could not recover from. During a telephone interview with the DON on 8/22/2023 at 7:59 PM, the DON stated she was at the Nursing Station when LVN 1 informed her that Resident 1 ' respiratory condition was declining (to deteriorate gradually) due to low saturation levels and difficulty breathing. The DON stated she did not check the entirety of Resident 1 ' s documented POLST which indicated Resident 1 may be transferred to an acute hospital as a form of selective treatment. The DON stated she went to Resident 1 ' s room on 8/18/2023 and checked Resident 1 ' s pulse and oxygen saturation level. The DON stated she could not remember the time she went inside Resident 1 ' s room and what Resident 1 ' s oxygen saturation level was on 8/18/23. The DON stated the oxygen saturation of Resident 1 was 88 % or something. The DON stated she did not write Resident 1 ' s oxygen saturation level down anywhere in the resident ' s medical records. During the same telephone interview, on 8/22/2023 at 7:59 PM, the DON stated, I was thinking LVN 1 was going to notify Physician 1 of resident ' s change of condition (unresolved cough, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat). The DON stated she told LVN 1 that if Resident 1 started declining, to notify the family and Physician 1. The DON stated she knew Resident 1 was a DNR but did not check Resident 1 ' s entire POLST document. The DON stated she did not see the additional selective treatments indicated in Resident 1 ' s POLST that Resident 1 could be transferred to an acute hospital. The DON stated she could not find documented evidence in Resident 1 ' s POLST not to transfer Resident 1 to the acute hospital. The DON stated Resident 1 ' s family did not request Resident 1 not to be transferred to an acute hospital and the DON did not ask Resident 1 ' s family if they wanted Resident 1 to be transferred to the acute hospital. The DON stated she did not document anything with regards to the change of condition in Resident 1 ' s medical records, on 8/18/23. During a telephone interview with Physician 1 on 8/23/2023 at 10 AM, Physician 1 stated he was not notified of Resident 1 ' s death, on 8/18/23. Physician 1 stated he went to the facility a few days after Resident 1 ' s death. Physician 1 stated he was not notified of Resident 1 ' s change of condition (difficulty breathing, low saturation levels not improving with oxygen administration) on 8/17/2023 or 8/18/2023. Physician 1 stated he did not know Resident 1 ' s oxygen level was not improving with oxygen administration. Physician 1 stated that Resident 1 had end stage dementia (the stage in which dementia loss of memory, language, problem-solving and other thinking abilities symptoms become severe to the point where a person requires help with everyday activities) but if he was notified of the Resident 1 ' s change in condition (difficulty breathing, low saturation levels not improving with oxygen administration) on 8/18/23, he would have contacted Resident 1 ' s family members (Family 1 and/or 2) and discussed if family members (Family 1 or 2) would have wanted the resident to be transferred to the acute hospital. Physician 1 stated he would have ordered the facility ' s licensed nurses for Resident 1 to be transferred to the acute hospital. During the review of Resident 1 ' s Licensed Personnel Weekly Progress Notes from 8/17/2023 through 8/18/2023 did not indicate documented evidence that Physician 1 was notified and consulted of a decline or abnormal changes (unresolved cough, congestion, low saturation levels, difficulty breathing requiring the use of nonrebreather mask, faint heartbeat) in Resident 1 ' s respiratory status. During a telephone interview with LVN 2 on 8/23/2023 at 11:06 AM, LVN 2 stated she was assigned to Resident 1 on 8/17/2023 during the 3 PM to 11 PM and the next shift on 11 PM to 7 AM. LVN 2 stated that on 8/17/2023, during the 3 PM to 11 PM shift, the DON and the infection prevention nurse (IPN) were present in Resident 1 ' s room when Resident 1 had a change of condition (difficulty breathing, congestion, low saturation level). LVN 2 stated when she came back from her lunch break during the 3 PM to 11 PM shift (unable to recall exact time), on 8/17/2023, she was told by the DON and IPN that Resident 1 was not blinking. LVN 2 stated the DON and IPN told her Resident 1 was breathing, but not breathing well (difficulty breathing) so when they suctioned the resident, LVN 2 that the IPN and DON informed her that Resident 1 Came back to the normal oxygen saturation level. LVN 2 stated the DON, the IPN, and another unknown LVN she could not remember, were all in Resident 1 ' s room and got Resident 1 back to baseline (provides a critical reference point for assessing changes and impact, as it establishes a basis for comparing the situation before and after an intervention, because Resident 1 was unresponsive). LVN 2 stated she did not know what Resident 1 ' s baseline or oxygen saturation levels before and after the resident was suctioned by IPN and the DON. LVN 2 stated that on 8/17/2023, she did not assess or listen to Resident 1 ' s lung sounds because she was on her lunch break. LVN 2 stated there was no documentation of Resident 1 ' s change of condition (difficulty breathing, congestion, low saturation level) on 8/17/2023 during the 3 PM to 11 PM shift, while she was on lunch break. LVN 2 stated she did not call and notify Physician 1 of Resident 1 ' s change of condition on 8/17/2023. LVN 2 stated she was unsure if Physician 1 was notified by any other licensed nurses, regarding Resident 1 ' s change of condition on 8/17/2023. During an interview with the IPN on 8/23/2023 at 2:12 PM, the IPN stated that on 8/17/2023 during the 3 PM to 11 PM shift, she heard a commotion by Resident 1 ' s room. IPN stated she went to Resident 1 ' s room and saw Resident 1 was coughing and having trouble breathing. The IPN stated the DON was also inside Resident 1 ' s room. The IPN stated Resident 1 was not on any oxygen therapy at that time (8/17/23). The IPN stated she saw that there was a suctioning machine set up (a type of medical device that is primarily used for removing or aspirating obstructions - like secretions (discharges), saliva) at Resident 1 ' s bedside. The IPN stated because she saw the suctioning machine set up and saliva fluids in Resident 1 ' s mouth, she told the DON Let ' s suction. The IPN stated she and the DON suctioned Resident 1 (on 8/17/2023). The IPN stated she suctioned Resident 1 ' s saliva and used a yankauer (a firm, plastic suction tip used to suction thick oral secretions). The IPN stated she did not know and did not verify if Resident 1 had physician orders for suctioning. The IPN stated she did not notify Physician 1 of providing suctioning treatment to Resident 1 due to the resident having difficulty breathing. The IPN stated a change of condition should have been completed and documented in Resident 1 ' s medical records. The IPN stated But like I said, the DON was there and another licensed nurse, I assumed they were taking care of everything, I only went in there because I heard a noise and to see if they needed help. A review of the facility ' s policy and procedure titled Change of Condition Notification, dated 6/1/2017 indicated the licensed nurse will notify the resident ' s Attending Physician when there is a significant change in the resident ' s physical, mental or psychological status, deterioration in health, mental or psychosocial status, life-threatening conditions or clinical complications. The policy indicated the licensed nurse will assess the resident ' s change of condition and document the observations and symptoms. The policy indicated the Attending Physician will be notified timely with a resident ' s change in condition. The policy indicated notification to the Attending Physician will include a summary of the condition change and an assessment of the resident ' s vital signs and system review focusing on the condition and/or signs and symptoms for which the notification is required. The policy indicated the licensed nurse will review the resident ' s advanced directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and ensure that the Attending Physician is aware of the resident ' s wishes. The policy indicated in emergency situations if the resident deteriorates, the symptoms serious, and the most rapid intervention available would place the resident in great jeopardy, call 911 for transport to the hospital. The policy indicated the licensed nurse will document the time the family/responsible person was contacted.

Based on interview and record review, the facility failed to provide the necessary respiratory care and implement interventions in accordance with the resident ' s needs, care plan, facility policy and professional standards of practice, consistently across all shifts (7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM) for one of four sampled residents (Resident 1) by: 1. Not monitoring and informing the attending physician (Physician 1) in accordance with the resident ' s care plan for COPD (chronic obstructive pulmonary disease; a group of lung diseases that block airflow and make it difficult to breathe) when Resident 1 experienced shortness of breath (SOB), irregular respiration, excessive secretion, wheezing (a high-pitched whistling sound made while breathing, often associated with difficulty breathing), crackles (brief popping when a person breathes, often associated with presence of fluid in the lungs), and/or rhonchi (occur when there are secretions or obstruction in the larger airways of the lungs). 2. Not monitoring and informing Physician 1, in accordance with the resident ' s care plan for COPD when Resident 1 was having congestion, difficulty breathing and had low oxygen saturations (amount of oxygen circulating in the blood [normal blood oxygen levels are between 95% to 100%]) on 8/17/2023 and 8/18/2023. 3. Ensuring the facility ' s licensed nurses for all shifts (Licensed Vocational Nurses [LVN] 1 and 2), Infection Preventionist Nurse (IPN), and the director of nurses (DON) monitor and document Resident 1 ' s respiratory changes in conditions, respiratory status and treatments rendered in accordance with professional standards of practice, Resident 1 ' s care plan for COPD, and facility policy on Change of Condition Notification. 4. Not monitoring and documenting Resident 1 ' s signs and symptoms of COVID 19, vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions), including oxygen saturation on 8/17/2023 and 8/18/2023 every four hours consistently, in accordance with the physician ' s order. 5. Not following the facility ' s policy on Oxygen Administration to obtain a physician ' s order for oxygen therapy that includes oxygen flow rate, method of administration, usage of therapy, titration (selection of oxygen delivery system based on level of oxygen support required) instructions when LVN 1 and 2, the IPN, and the DON applied oxygen and a nonrebreather mask (a special medical device that helps provide oxygen in emergencies) to Resident 1 and increase the oxygen flow rate up to 8 liters per minute (LPM; unit of measurement for oxygen therapy) on 8/17/23 and 8/18/23. Resident 1, who was diagnosed with COPD and tested positive for COVID-19 (coronavirus disease 2019; a disease caused by a virus that can be very contagious and often causes respiratory symptoms that may attack more than lungs and respiratory system)on 8/16/2023. These failures resulted in the delay in diagnosis, care, and services of Resident 1 ' s respiratory condition. Resident 1 passed away on 8/18/2023 between the hours of 9:15 PM to 9:30 PM, two days after testing positive for COVID 19, due to difficulty breathing and low saturation levels (actual oxygen saturation level not documented in resident ' s records). On 8/23/2023 at 3:09 PM, during the facility ' s Focused Infection Control Survey (a focused survey conducted by the California Department of Public Health to Skilled Nursing Facilities associated with the transmission of COVID-19 among staff and residents in facilities), 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 regarding the facility ' s failure to provide necessary respiratory care and implement interventions in accordance with the resident ' s needs, care plan, facility policy and professional standards of practice, consistently across all shifts. On 8/25/2023 at 3:06 PM, the IJ was removed after the surveyors verified and confirmed the facility implemented the facility ' s IJ Removal Plan (a detailed plan to address the IJ findings) while onsite by observation, interview, and record review. The IJ was removed in the presence of the Regional Clinical Director (RCD). The acceptable IJ Removal Plan included the following: 1. On 8/23/2023, the RCD contacted the facility Medical Director to discuss appropriate Oxygen orders, parameters (factors or limits that affect the way something can be done), and standard of practice acceptable for a resident with diagnosis of COPD and other respiratory condition. 2. On 8/23/2023, an in-service was provided by the RCD to all licensed nurses to monitor resident ' s vital signs and oxygen saturation per physician ' s order, resident care plan intervention implementation and documentation of specific interventions provided to a resident with diagnosis of COPD, and to review policy and procedure regarding oxygen administration specifically on obtaining a physician order prior to oxygen administration. 3. On 8/24/2023, the RCD developed a respiratory monitoring checklist for licensed nurses each shift to monitor the respiratory changes/status of each resident with a diagnosis of COPD. An in-service regarding the monitoring checklist was given to the 3 PM to 11 PM staff and ongoing. 4.On 8/24/2023, the RCD and Minimum Data Set (MDS; an assessment and monitoring tool) Nurse reviewed residents clinical records, out of 56 COVID 19 positive residents, 11 residents had COPD diagnosis. Four of 11 residents had routine oxygen orders. 5. On 8/24/2023, the MDS Nurse/Director of Staff Development (DSD) and other licensed staff-initiated re-assessments and re-evaluation of residents with COPD with oxygen therapy orders for symptoms of SOB and low oxygen saturation levels. 6. On 8/24/2023, the MDS Nurse/DSD validated the active diagnosis of COVID 19 positive residents with their primary care physician for active monitoring and updated the plan of care. 7. On 8/24/2023, the Medical Records Personnel updated the face sheet for the active diagnoses of all residents identified with COVID 19 in the facility. Cross Reference to F580. Findings: A review of Resident 1 ' s Face Sheet (admission record) indicated the facility admitted the resident on 5/8/2023 with diagnoses that included vascular dementia (brain damage caused by multiple strokes), hyperlipidemia (high level of fat particles in the blood), and hypertension (high blood pressure) A review of Resident 1 ' s History and Physical assessment dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. The History and Physical Assessment indicated Resident 1 had COPD. A review of Resident 1 ' s care plan for COPD dated 7/30/2023, indicated Resident 1 is at risk for shortness of breath/respiratory distress (a life-threatening lung injury that allows fluid to leak into the lungs) related to COPD. The care plan interventions indicated the staff would monitor the resident for shortness of breath, irregular respiration, wheezing, crackles, rhonchi, and excessive secretion, and inform the physician promptly. The care plan interventions indicated to administer oxygen inhalation as ordered ., monitor oxygen saturation as needed/ordered, breathing treatment as ordered and monitor the effect of treatment. The care plan indicated to inform the physician if treatment is ineffective. A review of Resident 1 ' s MDS dated [DATE] indicated Resident 1 had moderately impaired cognitive (thought process) skills for daily decision making. The MDS indicated Resident 1 required total dependence (full staff performance every time during entire seven-day period) with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of the facility ' s undated Resident Line List (a template/list for data collection and active monitoring of both residents and staff during a suspected/active outbreak) indicated Resident 1 received a positive COVID 19 test result on 8/16/2023. A review of Resident 1 ' s written Physician ' s order dated 8/16/2023 timed at 10 AM, indicated Transmission Based Precaution (TBP; extra measures centered on a specific mode of transmission for patient with known or suspected infection) contact isolation precautions (use of appropriate protective equipment prior to patient contact) for COVID 19 virus for 14 days . Monitor vital signs every 4 hours for 14 days (blood pressure, temperature, pulse, respiratory rate, oxygen saturation level, and pain) and monitor for COVID 19 virus symptoms every 4 hours (0= none, 1= headache, 2= cough, 3= shortness of breath, 4= increase in temperature, 5= nausea and vomiting, 6= diarrhea, 7= chills, 8= sore throat, 9= fatigue or weakness, 10= new loss of taste or smell). A review of Resident 1 ' s Situation, Background, Assessment, Recommendation (SBAR) Communication Form indicated Resident 1 had a change in condition with signs and symptoms observed COVID + (positive) and coughing that started on 8/16/2023. The SBAR indicated Resident 1 ' s most recent blood pressure was 140/59 millimeters of mercury (mmHg; unit of measurement to measure blood pressure) ., and oxygen saturation level at 95 % on room air. The SBAR indicated Family 1 and 2, including Physician 1 was notified on 8/16/23 timed at 10 AM. The SBAR did not indicate any other new physician orders but to monitor vital signs. A review of Resident 1 ' s Licensed Personnel Weekly Progress Notes indicated the following information: 1. On 8/17/2023 timed at 3 PM to 11 PM shift (no specific time written) authored by LVN 2, indicated On monitoring for COVID +, has coughing noted, no signs and symptoms (s/s) of fever, nausea/vomiting (n/v), diarrhea, chills, fatigue noted at this time. All needs are met . Vital signs B/P (blood pressure) 117/80, pulse is 70, respiration is 17, temperature is 97.8 . 2. On 8/18/23 timed at 11 PM to 7 AM (no specific time written) authored by LVN 2, indicated Monitoring for COVID +, has coughing noted, no s/s of any fever, n/v, diarrhea, chills noted at the moment. All needs met. B/P 127/80, pulse 67, respiration 17, temperature is 97.8 . 3. On 8/18/2023 timed at 7 AM to 3 PM (no specific time written) authored by LVN 1, indicated Resident 1 on monitoring for COVID 19 positive and no cardiac arrest distress noted, no signs/symptoms, pain, or discomfort noted, vital signs within normal limits (WNL) . nonproductive cough noted. 4. On 8/18/2023 timed at 3 PM to 11 PM (no specific time written) authored by LVN 1, indicated Resident 1 passed away at 9:15 PM, family in to visit and say last goodbyes. MD (Physician 1) notified; mortuary (a funeral home) . Resident 1 ' s body warm to touch, heartbeat faint (weak) upon family arrival. No pulse or respiratory noted. Resident 1 was placed on nonrebreather mask upon low oxygen saturation level (sic). During the review of Resident 1 ' s Licensed Personnel Weekly Progress Notes for 8/17/2023 and 8/18/2023 did not indicate documented evidence that Physician 1 was notified and consulted of changes in Resident 1 ' s respiratory condition. During a telephone interview with Resident 1 ' s family members (Family 1 and 2) on 8/22/2023 at 4 PM, Family 1 stated she called the facility every day to check on Resident 1 . Family 2 stated Resident 1 has had a cough since 8/15/2023. Family 1 stated she called the facility in the morning of 8/18/2023 and facility staff told her Resident 1 was okay but was sleeping. Family 1 stated she called the same day, later in the afternoon, and no one answered from the facility. Family 1 stated at around 9:15 PM on 8/18/2023, she received a call from the facility, instructing her to come now, because [Resident 1] is dying. Family 1 stated she arrived at the facility at 9:30 PM. Family 1 stated when Family 1 and 2 arrived at Resident 1 ' s room, Resident 1 was receiving oxygen was attached to clear balloon. Family 1 stated she did not know what the clear balloon was used for. Family 2 stated there was an oxygen tank in Resident 1 ' s room, but it was not attached to Resident 1 when Family 1 and 2 arrived in Resident 1 ' s room on 8/18/23. Family 1 stated an unknown nurse was also in Resident 1 ' s room. Family 1 stated the facility should have sent Resident 1 to the acute hospital. Family 1 stated Resident 1 passed away shortly 15 to 30 minutes after their arrival. On 8/22/2023 at 5:54 PM, during a concurrent interview and record review of Resident 1 ' s Licensed Nurses Weekly Progress Notes (from 8/16/23 to 8/18/23) with the Registered Nurse Supervisor (RNS), the RNS stated Resident 1 passed away on 8/18/2023 at 9:15 PM due to infection (a condition in which bacteria or viruses that cause disease have entered the body) and COVID 19. RNS stated she could not find documented evidence in Resident 1 ' s progress notes that Physician 1 was notified for any changes in condition before Resident 1 passed away on 8/18/2023. On 8/22/2023 at 6 PM, during a concurrent interview and record review of Resident 1 ' s Monitoring for Signs and Symptoms of COVID 19 and Vital Signs every Four Hours form with the RNS, the RNS stated that Resident 1 ' s signs and symptoms of COVID 19 dated 8/17/2023 timed at 4 PM and 8 PM were blank. The RNS further stated that on 8/18/2023 at 12 AM, 4 AM, 8 AM, 12 PM, 4 PM, and 8 PM, Resident 1 ' s COVID 19 Monitoring for signs and symptoms form were also blank. The RNS further stated that Resident 1 ' s vital signs, including oxygen saturation levels on 8/18/2023 timed at 8 AM, 12 PM, 4 PM, and 8 PM were left blank. The RNS stated she could not find documented evidence that Resident 1 ' s signs and symptoms of COVID 19 and vital signs were consistently monitored every four hours on 8/17/2023 and 8/18/2023, according to the physician ' s orders. During an interview with LVN 1 on 8/22/2023 at 6:51 PM, LVN 1 stated she worked a double shift on 7 AM to 3 PM and 3 PM to 11 PM shifts on 8/18/23 and was assigned to care for Resident 1. LVN 1 stated the certified nursing assistant (CNA 1) informed her that Resident 1 was not feeling well after dinner on 8/18/2023. LVN 1 stated prior to dinner, Resident 1 did not have any issues. LVN 1 stated after CNA 1 notified her of Resident 1 ' s status (not feeling well after dinner), LVN 1 went to Resident 1 ' s room and took the resident ' s vital signs. LVN 1 stated she did not document and could not recall the results of Resident 1 ' s vital signs on 8/18/2023, after dinner. LVN 1 stated Resident 1 looked like he was transitioning (beginning of the final stage of dying). LVN 1 stated that on 8/18/2023, Resident 1 was transitioning but could not recall the exact time, after dinner. LVN 1 was asked to explain what she meant by Resident 1 was transitioning and stated her definition of transitioning was if I am looking at him (Resident 1), skin was pale, it looks like something was changing that I could not take care of him, it was something he could not recover from. During the same interview, on 8/22/23 at 6:51 PM, LVN 1 stated she did not notify Physician 1 because she expected the DON to notify the physician of Resident 1 ' s change of condition (difficulty breathing, low saturation levels not improving with oxygen administration, faint heartbeat). LVN 1 stated she thought the DON would document the resident ' s symptoms and change in condition (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat) in Resident 1 ' s SBAR form. LVN 1 stated she did not document Resident 1 ' s changes in condition (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask) and interventions provided on 8/18/2023. LVN 1 stated she forgot to document all the vital signs she took from Resident 1 on 8/18/2023 during the 7 AM to 3 PM shift and 3 PM to 11 PM shift. During the same interview, on 8/22/23 at 6:51 PM, LVN 1 further stated she bumped up (increased) Resident 1 ' s oxygen therapy and used a nonrebreather mask instead of a nasal cannula (a medical device that consists of a small, flexible tube with two prongs that sit inside a patient ' s nostrils). LVN 1 stated she increased Resident 1 ' s oxygen therapy up to 8 liters per minute via nonrebreather mask. LVN 1 stated when she noticed that Resident 1 was still unresponsive to 8 LPM of oxygen therapy, LVN 1 stated she called and notified Resident 1 ' s family. LVN 1 stated she did not remember what Resident 1 ' s oxygen saturation level during the time she called Resident 1 ' s family. LVN 1 stated she did not document any of Resident 1 ' s vital signs in the resident ' s records. LVN 1 stated when Resident 1 ' s family arrived, Resident 1 was wearing a nonrebreather mask, and presented with shallow breathing (rapid, deep breathing). LVN 1 stated during the endorsement report from LVN 2 (11 PM to 7 AM night shift licensed nurse) on 8/18/2023, LVN 2 reported that during the night shift, LVN 2 stated that Resident 1 was suctioned (removing mucus and fluids from the nose, mouth or back of the throat with a bulb syringe [a device that is used to inject fluid into, or withdraw fluid from the body]) or a catheter [thin flexible tube]) in the mouth. LVN 1 stated she also suctioned Resident 1 orally on 8/18/2023 but could not recall the time. LVN 1 stated Resident 1 sounded congested (abnormal or excessive accumulation of a body fluid) in his chest. LVN 1 stated she did not listen to Resident 1 ' s lung sounds. LVN 1 stated she looked at Resident 1 and saw Resident 1 ' s oxygen saturation level was low. LVN 1 stated she did not document Resident 1 ' s oxygen saturation level and vital signs on 8/18/2023. LVN 1 stated she could not recall Resident 1 ' s oxygen saturation level and vital signs during that time (8/18/2023). During an interview with CNA 1 on 8/22/2023 at 7:13 PM, CNA 1 stated when he arrived at the facility for the 3 PM to 11 PM shift at around 3 PM, on 8/18/2023, Resident 1 was wearing an oxygen nonrebreather mask. CNA 1 stated LVN 1 suctioned Resident 1 ' s mouth right before dinner. CNA 1 stated after Resident 1 was suctioned he tried to feed Resident 1, and Resident 1 ate a little and then would not eat anymore. CNA 1 stated prior to dinner, Resident 1 was breathing fast while wearing the nonrebreather mask. CNA 1 stated he went back to Resident 1 ' s room around 8 PM and CNA 1 noticed Resident 1 was not breathing anymore. CNA 1 stated I did not see him breathing and CNA 1 stated he felt Resident 1 ' s pulse was faint (weak), so he called and notified LVN 1. During a telephone interview with the DON on 8/22/2023 at 7:59 PM, the DON stated she was at the Nursing Station when LVN 1 informed her that Resident 1 was declining (to deteriorate gradually). The DON stated she went to Resident 1 ' s room and checked Resident 1 ' s pulse and oxygen saturation level. The DON stated she forgot what Resident 1 ' s oxygen saturation level was on 8/18/2023. The DON stated the oxygen saturation of Resident 1 was 88 % (normal blood oxygen levels are between 95% to 100%) or something. The DON stated she could not remember the time she went inside Resident 1 ' s room and what Resident 1 ' s oxygen saturation level was on 8/18/2023. The DON stated when she walked into Resident 1 ' s room and Resident 1 was wearing a nonrebreather mask, the resident ' s oxygen was at 4 LPM before it was increased to 8 LPM. The DON stated she told LVN 1 to make sure Resident 1 ' s oxygen therapy was increased to 8 LPM. The DON stated she did not write Resident 1 ' s oxygen saturation level down anywhere in the resident ' s medical records. The DON stated she did not document anything with regards to the change of condition (unresolved, congestion, low saturation levels requiring oxygen, use of non-rebreather oxygen mask, faint heartbeat) in Resident 1 ' s medical records, on 8/18/23. The DON stated she did not listen to Resident 1 ' s lung sounds as indicated in Resident 1 ' s care plan for COPD. During a telephone interview with Physician 1 on 8/23/2023 at 10 AM, Physician 1 stated he was not notified of Resident 1 ' s death, on 8/18/23. Physician 1 stated he was not notified by the facility staff of Resident 1 ' s change of condition (unresolved cough, congestion, difficulty breathing, congestion, low oxygen saturation) on 8/17/2023 or 8/18/2023. Physician 1 stated he did not know Resident 1 ' s oxygen level was not improving with oxygen administration. Physician 1 stated if he was notified of the resident ' s change in condition (difficulty breathing, low saturation levels not improving with oxygen administration) on 8/18/23 . Physician 1 would have ordered Resident 1 to be transferred to the acute hospital. On 8/23/2023 at 10:04 AM, during a concurrent interview and record review of Resident 1 ' s COPD care plan with the DON, the DON stated she did not review and implement all of Resident 1 ' s care plan for COPD. The DON stated she did not know she needed to assess and listen to Resident 1 ' s lungs sound. The DON stated she should have assessed Resident 1 ' s lungs. The DON stated she wanted to check on Resident 1 ' s oxygen saturation levels at first and stated that was her fault. During a telephone interview with LVN 2 on 8/23/2023 at 11:06 AM, LVN 2 stated she was assigned to Resident 1 on 8/17/2023 during the 3 PM to 11 PM and the next shift on 11 PM to 7 AM. LVN 2 stated that on 8/17/2023, during the 3 PM to 11 PM shift, the DON and the infection prevention nurse (IPN) were present in Resident 1 ' s room, when Resident 1 had a change of condition. LVN 2 stated when she came back from her lunch break on 8/17/2023, she was told by the DON and IPN that Resident 1 was not blinking. LVN 2 stated the DON and IPN told her Resident 1 was breathing, but not breathing well so when they suctioned him . LVN 2 stated she did not assess or listen to Resident 1 ' s lung sounds because she was on her lunch break. LVN 2 stated she did not know what Resident 1 ' s oxygen saturation levels before and after the resident was suctioned. LVN 2 stated there was no documentation of Resident 1 ' s change of condition on 8/17/2023 during the 3 PM to 11 PM shift, while she was on lunch break. LVN 2 stated she did not call Physician 1 on 8/17/2023. LVN 2 stated she was unsure if Physician 1 was notified by any other licensed nurses, regarding Resident 1 ' s change of condition on 8/17/2023. During an interview with the IPN on 8/23/2023 at 2:12 PM, the IPN stated that on 8/17/2023 during the 3 PM to 11 PM shift, she heard a commotion by Resident 1 ' s room. IPN stated she went to Resident 1 ' s room and saw Resident 1 was coughing and having trouble breathing. The IPN stated the DON was also inside Resident 1 ' s room. The IPN stated Resident 1 was not on any oxygen therapy at that time (8/17/23). The IPN stated she saw that there was a suctioning machine set up (a type of medical device that is primarily used for removing or aspirating obstructions - like secretions [discharges], saliva) at Resident 1 ' s bedside. The IPN stated because she saw the suctioning machine set up and saliva fluids in Resident 1 ' s mouth, she told the DON Let ' s suction. The IPN stated she and the DON suctioned Resident 1 (on 8/17/2023). The IPN stated she suctioned Resident 1 ' s saliva and used a yankauer (a firm, plastic suction tip used to suction thick oral secretions). The IPN stated she did not know and did not verify if Resident 1 had physician orders for suctioning. The IPN stated she did not notify Physician 1 of providing suctioning treatment to Resident 1 due to the resident having difficulty breathing. The IPN stated Resident 1 ' s change of condition should have been documented in Resident 1 ' s medical records to reflect the resident ' s symptoms and treatments provided. The IPN stated But like I said, the DON was there and another licensed nurse, I assumed they were taking care of everything, I only went in there because I heard a noise and to see if they needed help. A review of the facility ' s policy and procedure titled Change of Condition Notification, dated 6/1/2017 indicated the licensed nurse will assess the resident ' s change of condition and document the observations and symptoms. The policy indicated the Attending Physician will be notified timely with a resident ' s change in condition . The policy indicated the licensed nurse will review the resident ' s advanced directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and ensure that the Attending Physician is aware of the resident ' s wishes. The policy indicated in emergency situations if the resident deteriorates, the symptoms serious, and the most rapid intervention available by a physician would place the resident in great jeopardy (danger), call 911 for transport to the hospital. A review of the facility ' s policy and procedure titled Oxygen Administration, dated 6/1/2017 indicated a physician ' s order is required to initiate oxygen therapy, except in an emergency situation, the order shall include oxygen flow rate, method of administration, usage of therapy, titration instructions, and indications for use. The policy indicated that a physician is to be contacted as soon as possible after initiation of oxygen therapy in emergency situations, for verification and documentation of the order for oxygen therapy consultation, and further orders. The policy indicated oxygen saturations will be measured and documented at a minimum of daily for resident ' s receiving oxygen therapy.

Based on observation, interview, and record review, the facility failed to prevent the development and promote healing of pressure ulcer (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction) for two of three residents (Residents 8 and 9) observed for pressure ulcers in a total of 19 sampled residents. For Resident 8, the facility failed to: 1. Revise the plan of care to address pressure relief to Resident 8's contracted right arm to prevent skin breakdown while he is lying in bed. 2. Follow the physician's orders [REDACTED]. 3. Implement the facility's policy and procedure to monitor the skin condition and assess pressure ulcer on a weekly basis. 4. Provide treatment to Resident 8's contracted right elbow Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle; slough (dead tissue usually light colored, soft, moist and stringy) or eschar (thick, leathery, frequently brown or black, dead or devitalized tissue) may be present on some parts of the wound bed, often includes undermining and tunneling). 5. Notify the physician of the Registered Dietician's (RD) recommendation for supplements to aid in wound healing. These failures resulted in Resident 8 developing an avoidable Stage 4 pressure ulcer to his right elbow and caused a delay in the healing of his pressure ulcer. For Resident 9, the facility failed to: 1. Assess and document the size, characteristics, and progression of the pressure ulcer weekly per facility policy. 2. Turn, reposition, and offload resident every two hours or as needed to prevent worsening of the pressure ulcer. 3. Follow up with the physician regarding recommendations from the registered dietician for supplements to aid in wound healing. 4. Apply proper settings to the resident's pressure reducing device Low Air Loss Mattress (a mattress which provides both alternating pressure and low air loss pressure which aids in the management of pressure ulcers). These failures resulted in the delayed healing of Resident 9's Stage 4 pressure ulcer to the sacrococcyx (the region of the sacrum (the triangular bone at the base of the spine) and coccyx (tailbone)). Findings: a. A review of Resident 8's Admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED].) without behavioral disturbances. According to the Braden Scale for Predicting Pressure Sore Risk (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure ulcer) dated January 16, 2015, the resident scored 10 and on May 17, 2017, the resident scored 12 (total score of 12 or less represents high risk). A review of the Nurses' Admission Record dated April 20, 2016, indicated Resident 8 was admitted with a Stage II pressure ulcer (partial thickness loss of dermis (inner layer of the two main layers of cells that make up the skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough and may also present as an intact or open/ruptured blister) on the coccyx (tailbone) area with perirectal (tissues surrounding the rectum) redness. According to the Weekly Pressure Ulcer Documentation dated May 5, 2016, the stage II pressure ulcer on the resident's coccyx resolved. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated May 17, 2017, indicated Resident 8 was severely impaired in his cognitive skills for daily decision making, rarely/never understood others and rarely/never made self understood, and required total assistance from the staff for all activities of daily living (ADL's). The MDS indicated the resident had functional limitation in range of motion on both sides of the upper extremities and one side of the lower extremity and was always incontinent of bowel and bladder. According to the MDS, the resident was at risk of developing pressure ulcers, but did not have any pressure ulcers. A review of the Nursing Care Plan dated May 20, 2015, indicated Resident 8 had the potential for impairment of skin integrity related to bowel and bladder incontinence, decreased mobility, skin fragility, and impaired cognition. The care plan goal indicated Resident 8 will be free from tissue injury and skin breakdown daily and review every three months. The nursing interventions included to turn and reposition every two hours, keep clean and dry at all times, provide/assist with good skin care, provide pressure relieving device, and notify physician if resident has swelling, redness, skin tears, bruises, and discoloration. There was no nursing interventions on preventing pressure to resident's contracted right arm to prevent skin breakdown while Resident 8 is lying in bed. A review of the Resident Care Plan dated May 20, 2015, indicated Resident 8 was at risk for further decline in ADL's and development of contractures. The care plan goal indicated the resident will maintain joint mobility status, minimizing decline daily for 90 days and review every three months. The listed nursing interventions included to provide rehabilitation treatment as ordered or restorative nursing assistant program as ordered. A review of the Weekly Pressure Ulcer Documentation dated August 9, 2017, indicated Resident 8 had an unstageable pressure ulcer (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) to his contracted right elbow measured 1.0 centimeters (cm) in length (L) by 1.8 cm in width (W). There was no documented evidence that Resident 8's change of skin condition to his right elbow was reported to any staff until August 9, 2017, when the resident's right elbow was assessed having an unstageable pressure ulcer. A review of a physician's orders [REDACTED]. According to a short term care plan dated August 9, 2017, Resident 8 had impaired skin integrity due to a right elbow unstageable pressure ulcer. The care plan goal indicated the resident's skin will be cleared and intact by 21 days. The listed nursing interventions included to administer treatment as ordered, notify the physician of signs and symptoms of infection and failure to heal and respond to the treatment plan, turn and reposition at least every two hours and position off site as much as possible, keep the resident clean and dry, and provide pressure relieving devices as needed. The care plan however, did not address how to position off site and relieve pressure on the right elbow. A review of the wound consultant's progress note dated August 16, 2017, indicated Resident 8's right elbow was assessed with [REDACTED]. cm. The assessment indicated the wound had a light amount of serous (pale yellow and transparent) drainage with no odor, wound bed with 100% slough, and maceration (softened by surrounding liquid) on the periwound (tissue surrounding wound). Under plan and additional orders, the wound consultant indicated to cleanse and irrigate wound with NSS, pack wound with [MEDICATION NAME], and cover with foam dressing every day and as needed (PRN), implement pressure relieving measures and offloading as tolerated and registered dietician (RD) consultation to implement nutrition plan. A review of the Resident Care Plan for Pressure Sore Potential dated August 17, 2017, indicated Resident 8 was at risk for further skin breakdown related to decreased mobility, incontinence of bowel and bladder, cognitive impairment, thin and fragile skin, and contracture of extremities. The care plan goal indicated Resident 8 will be free of skin breakdown and maintain comfortable positioning, adequate skin care and hygiene daily through the next review. The listed nursing interventions included to monitor for signs and symptoms of skin breakdown, keep skin clean and dry as possible, encourage and assist to turn every two hours, use pressure relieving device in bed and in wheelchair, refer to RD as needed (PRN) to evaluate diet, protein, fluids and supplement needs, and report changes to the physician and obtain treatment as ordered. The care plan however, did not include revised interventions to address offloading of the resident's right elbow Stage IV pressure ulcer as ordered by the wound consultant. According to a physician's orders [REDACTED]. A review of a Dietary Progress Note by the RD dated September 15, 2017, indicated Resident 8 with pressure ulcer on right elbow which measured 1.5 cm by 1.0 cm by 0.4 cm. RD indicated to continue tube feeding of [MEDICATION NAME] 1.2 cal at 55 milliliters per hour (ml/hr) over 20 hours to provide 1100 ml/1320 calories and water flushes of 300 ml every shift and add multivitamin with minerals (used to treat vitamin or mineral deficiencies caused by illness or poor nutrition) and vitamin C (helps with growth, development and repair of all body tissues) to aid in wound healing. During an initial tour observation of the facility with Licensed Vocational Nurse (LVN) 9 on September 21, 2017, at 6:25 p.m., Resident 8 was observed lying in bed on his back with eyes closed, receiving [MEDICATION NAME] 1.2 cal at 55 ml/hr via gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach). Resident 8's right arm was contracted and his right elbow was observed wrapped with a dressing, directly resting on a pillow. LVN 9 stated that Resident 8 has a pressure ulcer on the right elbow. During observations on September 22, 2017, at 2:45 p.m. and 3:30 p.m., Resident 8 was observed lying in bed on his back with eyes closed. Resident 8's right arm was contracted with a dressing on the right elbow. The right elbow was observed resting directly on a pillow. At 4:40 p.m. and 5:10 p.m., on the same day, Resident 8's right elbow was observed resting directly on a rolled towel. During an interview on September 22, 2017, at 5:12 p.m., Certified Nursing Assistant (CNA) 2 stated that Resident 8 has a wound on the right elbow, but she had not seen it because it was always covered with a dressing. CNA 2 stated that she turns the resident every two hours and elevates his contracted right arm with a pillow to relieve pressure. CNA 2 was unaware that she needed to offload the resident's right elbow. During an interview on September 22, 2017, at 5:30 p.m., the Director of Nursing (DON) was asked about Resident 8's skin. The DON was unaware that the resident had any skin problems. When told that the resident was observed with a dressing on the right elbow, the DON stated that the resident probably just has a Stage 1 or Stage 2. During an observation on September 22, 2017, at 5:30 p.m., the DON and the surveyor went inside Resident 8's room and observed Resident 8 lying in bed with the right arm contracted and right elbow covered with a dressing, resting directly on a pillow. The DON stated that Resident 8's right elbow should be suspended on the air and not touching the pillow. During a subsequent observation on September 22, 2017, at 5:35 p.m., the DON removed the dressing from Resident 8's right elbow. Resident 8 was observed with a wound on the right elbow which approximately measured 0.3 cm by 0.5 cm with an area of 3 cm by 3 cm. The wound was dry and brown in color with a small amount of yellow slough. According to the DON, the wound is healing. During an interview on September 22, 2017, at 5:51 p.m., the DON reviewed the resident's clinical record and stated that Resident 8's right elbow Stage 4 pressure ulcer developed in the facility and there were no documented interventions or revisions on Resident 8's plan of care to address pressure relief and prevent skin breakdown to Resident 8's contracted right arm. The DON also reviewed the Weekly Pressure Ulcer Documentation for the resident's right elbow Stage 4 pressure ulcer and stated that the last assessment and measurement of the wound was done on September 6, 2017. The DON stated that pressure ulcers should be assessed and measured every week to monitor progression of the wound. The DON also reviewed the nurses notes and was unable to find documented evidence of skin monitoring from August 1, 2017 to September 23, 2017. According to the DON, there were no nurses notes because Resident 8 did not have any change in condition. During the same interview on September 22, 2017, at 5:51 p.m., the Treatment Record for September 2017 was reviewed with the DON. The Treatment Record indicated Resident 8 received treatment to his right elbow pressure ulcer as ordered by the physician from September 1, 2017 to September 20, 2017. The Treatment Record further indicated the treatment order ended on September 20, 2017, and the resident did not receive treatment for [REDACTED]. The DON stated that the physician should have been called to obtain further treatment orders when the treatment order was completed on September 20, 2017. Upon further interview, the DON was asked about the RD's recommendation to add multivitamin with minerals and vitamin C to aid in wound healing. The DON stated that the RD's recommendation was faxed to the resident's physician on September 15, 2017, but the physician prefers to write his own orders when he visits the facility. The DON was unable to find documented evidence that the facility made a follow up to the resident's physician regarding the RD's recommendations. The facility's undated policy and procedure titled Policy: Pressure Sores indicated all available measures will be taken to prevent skin breakdown and pressure sores. If these conditions occur, treatment will be initiated immediately and preventive measures taken to prevent further deterioration of the skin. In cases where the resident's condition promotes a high risk of skin breakdown, preventive measures will be employed routinely. The policy indicated activities to be completed: assess resident care on a continuous basis to ensure that good skin care is being carried out, identify residents at risk for skin breakdown, evaluate resident with skin problem/s, complete weekly skin checks to ensure that skin problems are identified and treated on a timely basis, notify the physician when skin problems are identified and obtain treatment orders, document findings in the licensed nurse notes, identify problems on resident care plan and update as needed, initiate Skin/Decubitus Progress Report Form, pressure sore monitoring will be done daily, discuss with the dietary department any appropriate nutritional interventions, assess progression/regression of pressure sore and notify the physician and modify current preventive measures and request treatment change if necessary, use appropriate pressure reducing devices for residents identified with skin problems or has potential for skin problems, and turn/reposition residents in a manner that reduces the potential for skin breakdown. b. An admission face sheet indicated Resident 9 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A Nurses' Admission and Assessment Record dated August 22, 2017, indicated Resident 9 was admitted with multiple pressure ulcers including: 1. A deep tissue injury (DTI) to the sacrum (the triangular bone at the base of the spine). A deep tissue injury is a pressure injury to the subcutaneous tissue (fatty layer of skin) the skin is intact and the pressure injury presents itself as a bruise. 2. A Stage 3 pressure ulcer (pressure sore that extends into the fatty tissue beneath the skin, forming a small crater) to the left lateral malleolus (the malleolus is a bony projection to one side of the ankle). 3. Pressure ulcers to the left and right earlobes. The stage and number of pressure ulcers to the earlobes were not indicated on the Nurses' Admission and Assessment Record. physician's orders [REDACTED]. dressing every day for 30 days. The treatment for [REDACTED]. On September 23, 2017 at 3 p.m., during an observation of Resident 9's wounds the left lateral malleolus was observed without a dressing. Licensed Vocational Nurse (LVN 2) stated It must have fell off. LVN 2 was asked if she had done the treatment to the left malleolus, LVN 2 stated Yes In the morning. Review of the TAR (treatment administration record) for the month of September 2017, indicated treatment ended on September 21, 2017, there was no documentation indicating treatment to the left malleoulus was adminstered on September 22, 2017. A physician's orders [REDACTED]. This type of dressing absorbs water forming a gel which can aid in the wound healing process. A review of a Wound Care Surgeon report, dated August 30, 2017, indicated Resident 9 had a Stage 4 pressure ulcer to the Sacrum 5.0 centimeter (cm) x 3.5 cm x 0.2 cm (length x width x depth). A stage four pressure ulcer refers to full thickness tissue loss with exposed bone, tendon, or muscle. An untitled nursing care plan dated August 30, 2017, indicated Resident 9 had impaired skin integrity related to a Stage 4 pressure ulcer. The nursing interventions included turning and repositioning at least every two hours, position off the site as much as possible, and pressure relieving devices as needed. A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated September 1, 2017, indicated Resident 9 was sometimes understood and sometimes able to understand others. The MDS indicated Resident 9 was totally dependent on staff for transfers to and from bed, chair, wheelchair, and standing position, as well as for activities of daily living (ADL's) including dressing, eating, toileting, and personal hygiene. According to the MDS the resident had one pressure Stage 3 pressure ulcer (full thickness skin tissue loss, subcutaneous fat may be exposed) and one Stage 4 pressure ulcer. Review of a recommendation from the registered dietician (RD) dated September 4, 2017, indicated to administer Ready Care (supplement) 2.0 60 milliliters (ml) twice a day, ice cream every lunch and dinner, multivitamins with minerals one tab every day, vitamin C 500 milligram (mg) tab every day and Zinc 220 milligrams every day for 30 days. On September 22, 2017 at 4:20 p.m. the director of nursing (DON) stated the recommendations were faxed to the physician on September 4, 2017. According to the DON as of September 22, 2017, the physician had not responded to the RD recommendation. There was no documented evidence staff followed up with the physician regarding the RD recommendations. The DON acknowledged staff did not follow up with the physician. A review of Resident 9's Weekly Pressure Ulcer Documentation dated September 11, 2017, indicated the Stage 4 pressure ulcer measured 2.0 cm x 2.1 cm x 0.3 cm with 60% necrosis and 40% slough to the sacrococcyx. The Weekly Pressure Ulcer Documentation for the week of September 18, 2017, was not completed by the treatment nurse according to facility policy. During initial tour on September 21, 2017 at 5:40 p.m., Resident 9 was observed lying in bed, on his back with the head of the bed (HOB) flat. Resident 9's gown was pulled up exposing his diaper and the urinary catheter tubing (a flexible plastic tube used to drain urine from the bladder when a person cannot urinate) was observed underneath Resident 9's lower buttocks and left and right upper thigh. Licensed Vocational Nurse 1 (LVN 1) was notified about Resident 9's positioning in the bed and of the tubing to the urinary catheter lying underneath his buttocks and legs. At 7:59 p.m. Resident 9 was observed lying in the same position on his back in bed with the urinary catheter tubing lying underneath his upper left and right thigh. A review of a Wound Care Surgeon's report (from the hospice physician), dated September 22, 2017, indicated Resident 9 had a sacral pressure injury. The assessment described an irregularly shaped, and shallow pressure injury with a significant amount of slough (dead or necrotic tissue) and some peripheral granulation (tissue formed on the surface of a wound during the healing process). According to the Wound Care Surgeon's report, debridement (removal of dead tissue) of the wound was done. Post debridement, the wound was described as 1.6 cm x 1.7 cm x 0.2 cm. Aggressive offloading, turning every two hours, and no prolonged sitting was recommended. Dietary recommendation indicated to administer L-[MEDICATION NAME] Supplement (amino acid composed mostly of protein). The Wound Care Surgeon's Report indicated pus (a whitish-yellow, yellow, or brown-yellow protein-rich fluid that accumulates at the site of an infection) was observed draining from the tissue, and antibiotics were recommended for the prevention of a fungal infection. During an interview on September 22, 2017 at 3:00 p.m., LVN 2 stated Resident 9's treatment was as follows, cleanse Stage 4 wound with normal saline (NS) and cover with Duoderm dressing. LVN 2 stated interventions to prevent worsening of the pressure ulcer included repositioning from side to side every two hours. During an interview on September 22, 2017 at 3:20 p.m., Certified Nursing Assistant 1 (CNA 1) stated he was assigned to Resident 9. Duties included assisting residents with activities of daily living (ADL's) as well as transfers and repositioning. According to CNA 1, residents who are bed bound or have wounds related to pressure should be turned every two hours. When asked if the facility had a specific turning schedule CNA 1 stated he was not sure. CNA 1 returned at 3:40 p.m., and stated the facility did have a turning schedule and presented a chart indicating the time of day and the position residents should be placed which included facing the door, window, and on his/her back. When asked if there was any specific positioning that was contraindicated for Resident 9 CNA 1 stated, he was not sure ,I think he has a sore. On September 22, 2017 at 4:20 p.m., during an observation and in the presence of the director of nursing (DON) Resident 9 was observed lying on his back. Upon turning the resident, the dressing to the sacrococcyx was observed partially off exposing the periwound and the pressure ulcer. The DON stated Resident 9 moved around in bed making it difficult to position him. According to the DON pillows could be used to aid in proper positioning in order to avoid lying the resident on his back. The setting to the low air loss (LAL) mattress was observed at 350 lbs. The mattress was observed with a fitted sheet, a draw sheet, and a bedpad (chux). During an interview at 4:20 p.m., the DON stated the LAL mattress, ordered by the physician on August 22, 2017, was set up by the company that delivered it and the settings had not been changed since. The DON was asked if she knew what setting the setting should be. The DON stated she did not know. Review of the user manual for the low air loss mattress indicated the pump and mattress are intended to help reduce the incidence of pressure ulcers while optimizing patient comfort. According to the user manual the pressure should be adjusted according to the patient's weight. Review of the medical record indicated Resident 9's weight was 113 pounds (lbs). On September 23, 2017, at 6:30 a.m., and 8:45 a.m., Resident 9 was also observed lying on his back on. Review of a Weekly Pressure Ulcer Documentation dated September 23, 2017, indicated Resident 9's Stage 4 pressure ulcer to the Sacrococcyx was 3 cm x 3 cm, pink/whitish in color, with 80 % slough, and no drainage or odor. The peri-wound (area around the wound) was described as pinkish red in color. The facility's undated policy and procedure titled Prevention and Care of Pressure Sores, indicated bedridden residents and all residents who are not mobile should be turned and repositioned every two hours as his or her condition will allow. The facility's undated policy and procedure titled Pressure Sores, indicated to complete and document weekly skin checks to ensure that skin problems are identified and treatment orders are obtained, and to identify and update residents' care plan as needed.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was admitted to the facility with no pressure sore (a localized injury to the skin and / or underlying tissue, usually over a bony prominence, as a result of pressure), and was identified at risk for developing pressure sore, was provided necessary treatment and services (reporting redness, bruising, skin tears, or discoloration to physician) for prevention and to promote healing of pressure sores by failing to: 1. Provide and assist with good skin and perineal care, 2. Report to physician if resident had swelling, redness, skin tears, bruises, and discoloration, 3. Monitor skin for red areas or skin breakdown and notify physician. These deficient practices resulted in Resident 1 developing a perianal excoriation (a break in skin surface below the pelvic diaphragm and between the legs) and scrotal skin tear (an anatomical male reproductive structure that consists of a suspended sack of skin), a suspected deep tissue injury (SDTI - 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) to the resident's sacrum (buttock area) measuring 7 centimeters (cm) x 10 cm. Findings: A review of the clinical record indicated Resident 1 was admitted to the facility, on 12/7/15, with [DIAGNOSES REDACTED]. to perform everyday activities) and [MEDICAL CONDITION] (a condition where nerve damage affects several areas such as feet and hands). A review of Resident 1's pressure sore risk assessment, dated 12/7/15, indicated the resident scored 20, representing the resident was at low risk for developing a pressure sore (a total score of 12 or less represent high risk). A review of Resident 1's nursing care plan, dated 12/7/15, for potential impairment of skin integrity related to bowel and bladder incontinence (inability to control urine and bowel movements), [MEDICAL CONDITION] (swelling), decreased mobility, skin fragility, impaired cognition and use of diuretics (water pill) indicated goals for the resident to be free from tissue injury and skin breakdown daily. The care plan interventions included turning and repositioning every two hours, keep clean and dry at all times, provide and assist with good skin and perineal care, report to physician if resident had swelling, redness, skin tears, bruises, and discoloration, assist with bed mobility or transfer as needed, and schedule toileting whenever possible. A review of Resident 1's nursing care plan, dated 12/8/15, for risk of skin breakdown related to resident needing extensive assistance with bed mobility indicated goals for the resident to have no skin breakdown. The care plan interventions included turning and repositioning Resident 1 with pillow support every two hours, apply pressure reducing mattress, provide diet as ordered, provide good skin care with each elimination or after each episode of incontinence, monitor skin for red areas or skin breakdown and notify physician. A review of the nurses' admission record, dated 12/7/15, indicated Resident 1 was admitted with fungal rash on the left and right foot, a red bump on the resident's left abdominal area, a bump on the resident's left forearm, and [MEDICAL CONDITION] to the resident's left and right lower extremities (legs). There was no documented evidence the resident was admitted or assessed with [REDACTED]. A review of Resident 1's initial history and physical completed and signed by the physician, on 12/8/15, indicated the resident had no [MEDICAL CONDITION] and the resident did not have the capacity to understand and make decisions. A review of Resident 1's minimum data set (MDS - an assessment and care planning tool), dated 12/18/15, indicated the resident had the ability to express ideas and needs and usually made self understood. Resident 1 was assessed needing extensive assistance with bed mobility requiring two persons physical assist to move to and from lying position, turning side to side and positioning body while in bed. The MDS indicated the resident required extensive assistance with toilet use, personal hygiene and bathing, with two persons physical assist. The MDS assessment tool indicated under skin conditions, Resident 1 was at risk for developing pressure ulcers, and the skin and ulcer treatments applied during assessment included a turning and repositioning program. A review of Resident 1's weekly non-pressure ulcer form, dated from 12/7 - 12/30/15 indicated documentation of the resident's left and right foot fungal rash. There was no documented evidence the resident was assessed with [REDACTED]. A review of Resident 1's Interdisciplinary Progress Notes, dated 12/30/15, at 6 a.m., indicated the resident was difficult to arouse and licensed vocational nurse 2 (LVN 2) checked the vital signs and noted the resident's blood pressure was low at 78/50 mm/hg (normal blood pressure 120/80 mm/hg), pulse rate 112 (normal rate 60-80), respiratory rate 28 (normal rate 16-20), body temperature 78.7 degrees Fahrenheit (normal 98.6 F) and oxygen saturation 90-93% room air (oxygen saturation is the amount of oxygen bound in the blood). The progress note indicated Resident 1 received oxygen inhalation at 2 liters per minute via nasal cannula a device used to deliver supplemental oxygen or increased airflow to a patient) and the resident's oxygen saturation was measured at 95%. At 6:30 a.m., 9-1-1 paramedics was notified, the physician and responsible party were notified of the resident's condition. A review of a Body Check Assessment, dated 12/30/15, indicated the resident was assessed with [REDACTED]. No other skin condition was assessed at that time. A review of Resident 1's physician's orders [REDACTED]. A review of an initial physician pressure ulcer progress note from the general acute care hospital, dated 12/30/15, indicated Resident 1 was assessed with [REDACTED]. The progress note indicated the resident was assessed, on 12/31/15, with a suspected deep tissue injury (SDTI - 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) to the resident's sacrum (buttock area) measuring 7 centimeters (cm) x 10 cm. On 7/21/16, at 2:45 p.m., an interview was conducted with LVN 1 who stated she cared for Resident 1 the night prior to transferring the resident to the general acute care hospital. LVN 1 stated she was not aware of Resident 1 having any treatment orders for open wounds, or that the resident was assessed with [REDACTED]. During a telephone interview, on 8/12/16, at 9:15 a.m., LVN 2 who cared for Resident 1 the morning the resident was transferred to the general acute care hospital, stated the resident did not have any pressure sores prior to being transferred to the acute hospital. On 8/12/16, at 11 a.m., an interview was conducted with the director of nursing (DON) who stated a weekly summary documentation and all body check was conducted and completed for all residents. Licensed nurses on each shift were assigned residents to check on skin breakdown and a recapitulation was completed on a weekly basis. The DON stated a daily charting communication sheet was completed and daily verbal and written endorsement was conducted for each resident. The DON stated Resident 1 was not assessed with [REDACTED]. A review of Resident 1's clinical record indicated no documented evidence of pressure sore or skin breakdown. A review of the facility's policy and procedures titled, Change of Condition Policy, indicated ensuring proper assessment and follow through for any resident with a condition change. The physician would be called promptly with a change of condition such as open or red areas, bruises, lacerations, or skin tears.