Every finding on record at Golden Heights Healthcare

Based on interview, and record review, the facility failed to:Report, investigate, and provide a 5-Day Investigation Report to the State Survey Agency for an unwitnessed fall with injury that occurred on 01/03/2026 for one of the four sampled residents (Resident 2).Report within 24 hours the allegation that staff did not provide oral hygiene care to Resident 2 on 01/03/2026 at 5:30 PM and to investigate and submit the required 5 Day Investigation Report for the incident reported to the State Survey Agency on 01/12/2026.This failure had the potential to reduce accountability for resident safety, increase the risk that future suspicious injuries would be overlooked, delay corrective actions when allegations are confirmed, and diminish assurance of a safe living environment for residents.1. The facility failed to report, investigate, and provide a 5-Day Investigation Report to the State Survey Agency for an unwitnessed fall with injury that occurred on 01/03/2026 for one of the four sampled residents (Resident 2).During an interview on 07/24/2026 at 12:21 PM, the Director of Nursing (DON) confirmed that Resident 2's unwitnessed fall with injury on 01/03/2026 had not been reported to the State Survey Agency as an injury of unknown source, nor had the incident been investigated.During an interview on 07/27/2026 at 3:02 PM with the Nursing Home Administrator (NHA), the NHA confirms that Resident 2's unwithness fall with injury on 01/03/2026 should have been reported to the State Survey Agency, but the NHA was unsure whether it had actually been reported or investigated, noting the NHA began working at the facility on 01/07/2026. The DON had asserted in the previous interview that no reporting and investigation had occurred for Resident 2's unwitnessed fall with injury on 01/03/2026, while the NHA indicated uncertainty about whether the fall had been reported or investigated and was unable to provide documentation showing that any report had been made.During an observation on 07/22/2026 at 4:18 PM and an observation on 07/29/2026 at 10:21 AM in Resident 2's room, Resident 2 was sleeping and not interviewable. Resident 2 had a fall mat on Resident 2's left side next to Resident 2's bed. During an attempted interview on 07/23/2026 at 11:34 AM and an attempted interview on 07/29/2026 at 10:21 AM with Resident 2's Representative, Resident 2's Representative was not available for interview.During a review of admission Record for Resident 2, accessed on 07/22/2026 at 3:12 PM, the admission Record indicated Resident 2 was admitted to the facility on [DATE].During a review of the Minimum Data Set (MDS) - Version 3.0 Resident Assessment and Care Screening for Resident 2, dated 12/08/2025, the MDS indicated [NAME] has a Brief Interview for Mental Status (BIMS) Summary Score of 11. The Brief Interview for Mental Status (BIMS) is a short test used in nursing homes to check how clearly a resident is thinking and how well the resident remembers information. A score between 13 and 15 means the resident is thinking clearly with little to no memory problems. A score between 8 and 12 shows the resident has some memory or thinking difficulties, while a score between 0 and 7 indicates more serious problems with memory or thinking.During a review of Restorative Nursing Program Progress Note for Resident 2, dated 01/03/2026 at 12:36 PM, the Restorative Nursing Program Progress Note indicated that Resident 2 had been seen twice between 12/28/2025 and 01/03/2026 by the Restorative Nursing Assistant (RNA) for ambulation using a front wheeled walker and gait belt with two person assistance. Resident 2 reportedly tolerated 500 feet of ambulation with moderate assistance and was described as verbally responsive, cooperative, motivated, able to follow cues, and tolerating the activity well.During a review of Change of Condition Evaluation for Resident 2, dated 01/03/2026 at 11:21 PM, the Change of Condition Evaluation indicated Resident 2 had an unwitnessed fall on 01/03/2026 in the afternoon and no specific time was noted. The Change of Condition Evaluation also indicated the unwitnessed fall was reported to the primary care clinician on 01/03/2025 at 10:00 PM (2025 was likely a typo) and the primary clinician recommended STAT - XRAY Left Upper Arm Extremities, apply ice pack, cold compress. The name and title of the primary care clinician was not noted. The Change of Condition Evaluation also indicated that a skin assessment is relevant to the change of condition being reported, but no skin changes were described (i.e. abrasion, rash, skin tear, splinters, wound, discoloration, laceration, etc.). The Change of Condition Evaluation also included a pain status evaluation that indicated the resident had pain that was 4 on a scale of 0 to 10, the pain was described as breakthrough pain, and the location was noted as musculoskeletal pain, without indicating a specific location of pain. The Change of Condition Evaluation also indicated that Resident 2's Representative was called on 01/03/2026 at 11:00 PM and a message was left notifying of the fall. The note did not describe how Resident 2 was found after the fall, where they were located, or whether staff conducted any interview with Resident 2 following the incident. The note also did not indicate that facility leadership or the State Survey Agency had been notified.During a review of Orders Administration Note for Resident 2, dated 01/03/2026 at 6:52 PM, the Orders Administration Note indicated a licensed nurse gave Resident 2 pain medication for left arm pain that was rated 4 on a scale of 0 to 10. During the review of Resident 2's Interdisciplinary Team (IDT) Fall Review Note dated 01/05/2026 at 9:36 AM, the IDT Fall Review Note indicated that the fall occurred on 01/03/2026 at 6:30 PM in Resident 2's room--the time of the fall of 6:30 PM contradicts the documentation in the previous Change of Condition Note dated 01/03/2026 which noted the fall as occurring in the afternoon with no specific time provided. The IDT Fall Review Note identified the root causes as ambulating/transferring without assistance and gait imbalance. The IDT Fall Review Note further stated that, at the time of the incident, Resident 2 was found lying supine on the floor, alert, responsive, and able to communicate needs. The IDT Fall Review Note documented a conversation in which staff asked Resident 2 what had happened, and Resident 2 replied, I pull my blanket because I want to put it up more on my chest. IDT Fall Review Note documented Resident 2 demonstrated the ability to move all bilateral upper and lower extremities and no skin injuries were observed and that the nurse initiated a neurological assessment. The IDT Fall Review Note documented a conversation in which staff asked Resident 2 why they were getting up from bed, Resident 2 again responded with, I pull my blanket because I want to put it up more on my chest, pointing to their chest. The IDT Fall Review Note indicated that incident was not witnessed. The IDT Fall Review Note was inaccurate because ambulating/transferring without assistance did not align with the circumstances Resident 2 described regarding how the fall occurred. The IDT Fall Review Note documented that new interventions were required as a result of the fall, including: re-educating Resident 2 on using the call light for assistance; closely monitoring activities of daily living (ADLs); assisting with toileting after meals and before bedtime; referring Resident 2 to Physical Therapy for assessment; ensuring Resident 2 is comfortable in bed and blankets are not tucked; and using a foot cradle to ease linens for comfort. The Care Plan was updated, and this was noted as Resident 2's first fall episode.During a review of Forearm Radiology Results Report for Resident 2, dated 01/05/2026 at 12:32 PM, the Forearm Radiology Results Report included findings from a forearm X ray but did not specify whether the imaging was of the left or right forearm. The report noted distal radial and ulna fractures with mild displacement and mild soft tissue swelling, but did not clarify which forearm--right or left--these findings referred to.During a review of Nursing Progress Note for Resident 2, dated 01/05/2026 at 3:04 PM, the Nursing Progress Note indicated the facility had received the results of Resident 2's left forearm X-ray results which noted acute appearing distal radial and ulna fracture as noted. The Nursing Progress Note also indicated that the attending physician was notified at 2:49 PM.During the review of the Physician Progress Note for Resident 2, dated 01/05/2026 at 4:05 PM, the note indicated that the physician entered and signed orders for a splint to stabilize the left wrist and forearm, application of ice or cool compresses, non weight bearing restrictions for the left upper extremity, pain medication, and assessment of Resident 2 every shift for 72 hours to monitor for increased pain, swelling, skin discoloration, abnormal sensations, or weakness in the fingers or grip. During a review of Orders Administration Note for Resident 2, dated 01/05/2026 at 11:12 PM, the Orders Administration Note indicated that a splint was applied to Resident 2's left wrist forearm. The Orders Administration Note does not indicate which physician provided the order and the note was not signed by an MD.During a review of Order for Resident 2, dated 01/06/2026 at 9:32 AM, the Order indicated Resident 2 was scheduled for a visit at a Hospital Musculoskeletal Medicine Clinic on 01/13/2026 at 9:20 AM. During a review of Nursing Progress Note for Resident 2, dated 01/06/2026 at 9:40 AM, the Nursing Progress Note indicated a splint was placed on Resident 2's left wrist. It also indicated Resident 2 had an appointment scheduled on 01/13/2026 for the left wrist. During a review of the Custodial 60 Day Visit Physician Note for Resident 2, 01/06/2026 at 11:38 AM, the Custodial 60 Day Visit Physician Note indicated that this was identified as the only physician documentation addressing Resident 2's unwitnessed fall with injury on 01/03/2026-three days after the incident. The note described the encounter as a regular rounding visit, and the fall was mentioned only as an update rather than the purpose of the visit. The physician also documented that Resident 2 was unable to recall the fall or how they had ended up on the floor. This presents a contradiction: Resident 2's BIMS score of 11 (BIMS Summary Score of 11 dated 12/08/2025) indicates some memory or thinking difficulties but still has the capacity for meaningful recall, yet the Custodial 60 Day Visit Physician Note states that Resident 2 could not recall the fall only three days after it occurred. During a review of Nursing Progress Note for Resident 2, dated 01/06/2026 at 11:01 PM, the Nursing Progress Note indicated Resident 2 had a distal ulna and radial fracture with mild displacement and there was a physician order in place for splint application. The Nursing Progress Note also indicated that Resident 2 was initially non-compliant wearing the splint and told the nursing staff that nothing is wrong with me and also had questioned nursing staff for the need for treatment. The Nursing Progress Note also indicated that the affected hand had purplish discoloration. During a review of Skin or Wound Note for Resident 2, dated 01/09/2026 at 9:05 AM, the Skin or Wound Note indicated Resident 2's left hand had discoloration, was able to move it, and Resident 2 did not have pain. During a review of Care Conference Note for Resident 2, dated 01/09/2026 at 10:04 AM, the Care Conference Note indicated that a fall, accident, or injury had occurred during the review period; however, the date and time of the fall were not documented. The Care Conference Note identified the event as an unwitnessed fall resulting in a major injury-a fracture of the ulna-though it did not specify whether the right or left ulna was affected. The Care Conference Note also indicated that fall risk and related interventions were reviewed. No additional documentation was provided regarding the referenced fall.During the review of the Interdisciplinary Note for Resident 2, dated 01/09/2026 at 9:32 PM, the note-authored by the Nursing Home Administrator (NHA)-documented that Resident 2 reported asking their assigned CNA for nightly oral hygiene care on 01/03/2026. According to the note, the CNA refused to provide care and walked away, prompting Resident 2 to attempt to grab the CNA, resulting in a fall from the bed. The CNA's name was not recorded. The findings reveal four conflicting accounts of how the fall occurred: adjusting a blanket (IDT Fall Review Note, 01/05/2026); ambulating without assistance (IDT Fall Review Note, 01/05/2026); gait imbalance (IDT Fall Review Note, 01/05/2026); and attempting to grab a CNA (Interdisciplinary Note, 01/09/2026). Additionally, the Interdisciplinary Note creates an inconsistency regarding whether the fall was witnessed. All other fall documentation characterizes the incident as unwitnessed, yet this note describes a scenario in which a CNA was present, refused care, and interacted directly with Resident 2 immediately before the fall-implying the fall may not have been unwitnessed.During a review of Social Services Note for Resident 2, dated 01/10/2026 at 3:39 PM, the Social Services Note indicated the Social Services Assistant (SSA) documented a check in visit following Resident 2's 01/03/2026 fall and fracture. The Social Services Note indicated Resident 2 was calm, pleasant, and engaged, with no signs of distress or discomfort, responding, I'm doing okay, thank you. The Social Services Note also indicated that Resident 2 was unable to recall the fall, stating I don't remember, but reported wrist pain (side not specified). The SSA notified the nurse of the reported pain.During a review of Orders Administration Note for Resident 2, dated 01/15/2026 at 10:33 PM, the Orders Administration Note indicated that Resident 2 asked staff why Resident 2 had a splint on their left hand. Staff explained that the splint was necessary to stabilize the left wrist due to a recent fall resulting in a fracture. Resident 2 responded, I did not fall, I don't know why you guys treat me like this like I'm a crazy woman. The note further indicated that staff reoriented Resident 2, referenced ongoing confusion since admission, and documented that Resident 2's representative and attending physician were aware of the behavior. An order for a Montreal Cognitive Assessment (MoCA) was also noted to be in place.During review of the Nursing Progress Note for Resident 2, dated 02/18/2026 at 4:48 PM, the entry was identified as a late documentation of the unwitnessed fall that occurred on 01/03/2026--46 days prior. The Nursing Progress Note indicates that the resident was heard calling for help, prompting the nurse to respond and found Resident 2 lying on the floor in a supine position next to the bed. The Nursing Progress Note also indicated Resident 2 was alert, able to answer questions, able to move all extremities, denied pain, and showed no apparent injuries. The Nursing Progress Note also indicated vital signs were taken and no skin injuries were observed during the head to toe assessment. Resident 2 was then assisted back to bed; however, the documentation does not specify whether the transfer required one person or two person assistance. Resident 2's attending physician's office was contacted after the fall, though the note does not identify which provider was spoken to and only one order was initially received-neurological checks every 24 hours per protocol. The Nursing Progress Note further states that approximately one hour later--although the time Resident 2 was initially found on the floor was not documented, making the reference to one hour later unclear--the resident reported left arm pain and the attending physician's office was contacted again, and additional orders were issued, including a left arm X ray, splint application for immobilization, non weight bearing instructions, pain management, and use of cold compresses. The documentation again did not indicate which provider was contacted or which provider issued these orders. The Nursing Progress Note presents a contradiction: although it states that Resident 2 denied pain and showed no apparent injuries after the fall, later documentation identifies significant injuries-including a fracture (Forearm Radiology Results Report dated 01/05/2026), pain (Orders Administration Note dated 01/03/2026), soft tissue swelling (Forearm Radiology Results Report dated 01/05/2026), and discoloration (Skin or Wound Note dated 01/09/2026). 2. The facility failed to report within 24 hours the allegation that staff did not provide oral hygiene care to Resident 2 on 01/03/2026 at 6:30 PM and to investigate and submit the required 5 Day Investigation Report for the incident reported to the State Survey Agency on 01/12/2026.During a review of the State Survey Agency (SSA) Reporting Form for Resident 2, dated 01/09/2026, the SSA Reporting Form indicated it was completed on 01/09/2026 and marked as received by the SSA on 01/12/2026. The report stated that a Certified Nursing Assistant (CNA)--no name was provided--had neglected mouth care (oral hygiene care) on 01/03/2026 at 6:30 PM, the date of the incident. The form did not identify the individual who authored the report, nor did it list any persons with knowledge of the incident--a serious allegation of possible neglect includes no identification of the alleged staff member involved. The reporting was 6 days late and documentation does not acknowledge the late reporting or provide an explanation for the delay. During the review of the Interdisciplinary Note for Resident 2, dated 01/09/2026 at 9:32 PM, the note-authored by the Nursing Home Administrator (NHA)-documented that the NHA attended a conference with Resident 2's hospital care coordinator and learned that Resident 2 routinely receives nightly oral hygiene care. Resident 2 reported that on 01/03/2026, they requested this care from their assigned CNA, who refused and walked away. According to the note, Resident 2 attempted to grab the CNA as they left, resulting in a fall from the bed. The CNA's name was not recorded.During the review of the Interdisciplinary Note for Resident 2, dated 01/19/2026 at 8:32 AM, the entry-authored as a late note by the Nursing Home Administrator (NHA)-documented that the NHA conducted a follow up interview with Resident 2 regarding an incident on 01/15/2026; however, the nature of the incident was not described. The note further indicated that Resident 2 informed the NHA that they receive nightly oral hygiene care as part of their routine care.During a review of Nursing Progress Note for Resident 2, dated 01/20/2026 at 11:14 PM, the Nursing Progress Note indicated that Resident 2 refused oral hygiene care after dinner. The Nursing Progress Note also indicated that staff explained the risks associated with refusing oral hygiene care, and Resident 2 responded, Why you guys do this to me, I'm okay, I don't need to brush my teeth. The Nursing Progress Note further indicated that oral hygiene care was reoffered, and Resident 2 ultimately agreed to receive it.During a review of Nursing Progress Note for Resident 2, dated 01/21/2026 at 2:50 PM PM, the Nursing Progress Note indicated that Resident 2 was on behavior monitoring and had one episode of refusing oral hygiene care after breakfast. The Nursing Progress Note also indicated Resident 2 became upset and agitated, and staff returned after 15 minutes to re encourage oral hygiene care and Resident 2 ultimately agreed to receive the care.During a review of Nursing Progress Note for Resident 2, dated 01/22/2026 at 9:44 PM PM, the Nursing Progress Note indicated that Resident 2's behavior was being monitored and Resident 2 had refused oral hygiene care. This Nursing Progress Note was the last note documenting Resident 2's oral hygiene care available in the medical record. It is important to note that multiple consecutive refusals of oral hygiene care were documented after the incident reported to the State Survey Agency on 01/09/2026 (Survey Agency (SSA) Reporting Form dated 01/09/2026) and this Nursing Progress Note was the last to document oral hygiene care refusal.During a review of the facility's policy and procedure titled Abuse Reporting and Response, dated September 2017, it was noted that the policy requires the facility to immediately report any suspected or alleged abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injuries of unknown origin, in accordance with state and federal law. Staff must report all such concerns promptly to a supervisor and the Executive Director, and reports do not need to be specifically labeled as abuse or neglect to require action. The policy further states that the Executive Director or designee must report allegations to the state survey agency and other required authorities within 2 hours if the allegation involves abuse or results in serious bodily injury, and within 24 hours if the allegation does not involve abuse and does not result in serious bodily injury. Serious bodily injury is defined as extreme pain, risk of death, long term impairment, or injuries requiring significant medical intervention. Additionally, all investigation results must be submitted within 5 working days. The facility is required to report reasonable suspicion of a crime immediately, notify company management and legal representatives, report confirmed abuse findings to licensing boards or registries, and inform licensing authorities of any court actions indicating an employee is unfit for service.

Based on interview and record review, the facility failed to monitor two (Residents 1 and Resident 2 ) of 12 sample residents for signs and symptoms of emotional harm after alleged abuse.This failure had the potential for lack of and/or delayed provision of emotional support for Residents 1 and 2.Findings:Review of a facility's document titled REPORT OF SUSPECTED DEPENDENT ADUTL/ELDER ABUSE, dated 06/10/2025, indicated Resident 1 .delivered a letter to the Administrator .alleging abuse on the part of her CNA (Certified Nursing Assistant) .During a concurrent interview and record review on 07/23/2025 at 2:10 PM with the DON (Director of Nursing), DON stated her expectations were that nurses would monitor victims of alleged abuse every shift for 72 hours. The DON stated even if the allegations were not substantiated, staff were still expected to monitor these alleged victims for evidence of emotional harm such as: Mood changes (sad, tearful, depressed, anxious etc.), whether the resident feel safe/threatened. The DON searched Resident 1's medical records regarding the allegation on 06/10/2025 and was unable to find documented evidence that nursing staff were monitoring Resident 1 for signs and symptoms of emotional harm.Review of a facility's document titled REPORT OF SUSPECTED DEPENDENT ADUTL/ELDER ABUSE, dated 06/18/2025, indicated Nurse reported seeing [CNA] slapping [Resident 2] on the arm.During a concurrent interview and record review on 07/23/2025 at 2:10 PM with the DON, the DON was asked to search Resident 2's records for evidence nurses were monitoring Resident 2 for signs and symptoms of emotional harm for 72 hours after the alleged incident. The DON searched Resident 2's medical records regarding the allegation on 06/10/2025. The DON was unable to find documented evidence that nursing staff were monitoring Resident 2 for signs and symptoms of emotional harm.Review of the facility's policy titled Abuse and Neglect- Clinical Protocol, revised on March 2018, indicated .The staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood, and function.

Based on interview and record review, the facility failed to have correct and complete information on the POLST forms for one of three sampled residents (Resident 1). Acting on incomplete or erroneous information on a POLST form could contribute to a resident's death. In order for a POLST form to be valid in California it must be signed and dated by a physician, nurse practitioner, or physician's assistant, and the patient or the patient's legally recognized health care decision maker. [California Emergency Medical Services Authority, DNR, POLST and Medallion Information, https:// emsa.ca.gov/dnr_and_polst_forms/ accessed on [DATE]]. Resident 1's POLST form was not signed or dated with anyone's signature or any dates. When Resident 1 was admitted to the skilled nursing facility, her physician's orders indicated she was a full code. This meant all measures including CPR would be initiated should she stop breathing or her heart stopped beating. There were no later orders changing this full code status. Three days after admission to the skilled nursing facility, Resident 1 had difficulty breathing and was difficult to arouse. The staff administered oxygen and called 911. The RN who called 911 handed the EMS personnel who arrived at the skilled nursing facility the POLST form with Resident 1's name on it and without any signatures or dates. This RN (RN 1) told the EMS personnel Resident 1 was DNR. Resident 1 was breathing when she left the skilled nursing facility on a gurney with EMS personnel per RN 1. According to the skilled nursing facility administrator Resident 1 was not resuscitated in the ambulance and she died. Findings: The following abbreviations, definitions, and acronyms are used:911 = the phone number for the Emergency Response System in the US and Canadaantibiotics = medications used to treat bacterial or fungal infectionsBiPAP = bilevel positive airway pressure, a machine that pushes air into the lungs when breathing in and breathing out. The pressure is higher when breathing in. The patient is connected to the machine via a mask. There is no need for intubation (see below).CDPH = California Department of Public Health, the state agency that investigates reports from healthcare facilities and complaints from the public C-PAP = CPAP or continuous positive airway pressure, a machine connected to tubing and a mask that uses air pressure to keep the patient's airway open during sleep. CPR = cardiopulmonary resuscitation, an emergency procedure using chest compressions and rescue breaths to keep oxygenated blood flowing when a person stops breathing and their heart stops beating crash cart = a metal chest of drawers on wheels used to store equipment, and medications typically used to treat patients who stop breathing or whose heart stops beating.DNR = Do Not Resuscitate or do not do CPR (see above)DON = Director of NursingEMS = Emergency Medical Services (system of emergency treatment and transport which may include emergency medical technicians and paramedics who may also be firefighters).EMT = Emergency Medical Techniciangurney = a stretcher on wheelsintensive care = treatment, care, and constant monitoring of critically ill patients in a specialized unit of a hospitalintubate = a tube inserted down the throat (or nose) and into the trachea (windpipe) to keep the airway open.IV = intravenous, a needle inserted into a vein to provide medications or fluidsLN = licensed nurse refers to either a RN or LVN (see below)LVN = licensed vocational nurseMD = medical doctormg/dL = milligrams per deciliternasal cannula = nasal prongs, plastic tubing that goes inside the nostrils used to deliver supplemental oxygen non-invasive positive airway pressure = machines {C- PAP (see above) or BiPAP (see above)} that deliver oxygen under pressure via a mask. Unlike ventilators, they do not require a patient to be intubated (see above).pantoprazole = Protonix - a medication used to treat GERD or gastroesophageal reflux disease (ongoing heartburn).paramedic = an EMT (see above) with more training and skills in emergency treatmentPOLST = Physician Orders for Life-Sustaining Treatment is a portable medical order that travels with the patient that informs healthcare providers in ambulances, hospitals, nursing homes, etc. of the patient's wishes for treatment should a medical emergency occur. It typically indicates if they want CPR (see above), feeding tubes, and other forms of medical intervention. It is intended to be used for seriously ill and frail people [National POLST, https://polst.org accessed on [DATE]]RN = Registered Nurseskilled nursing facility = a healthcare facility that provides 24 hour nursing care. It may also provide physical, occupational, and speech therapy.sternal rub = a check for alertness by applying firm pressure with one's knuckles to the breastbone of a patient.vitals or vital signs = temperature, pulse, respiration, blood pressure, pain assessment A review of Resident 1's admission Record indicated she was admitted to the skilled nursing facility in March of 2025 and was discharged to a local hospital three days later. A review of Resident 1's Order Summary Report indicated FULL CODE (in boldface type), Full Treatment, No artificial means of nutrition, including feeding tubes. This order was dated [DATE]. A review of the [DATE] Progress Notes indicated LVN 1 gave Resident 1 pantoprazole at 6:30 a.m. This note indicated Resident 1 was awake and verbally responsive. A review of the [DATE] Progress Notes signed by LN 1 indicated LN 1 was making rounds around 7:25 a.m., and Resident 1 was lethargic, unable to arouse on stimulation, Vitals taken, BP (blood pressure) 94/54 (lower limits of normal 90/60); PR (pulse rate) 82 (normal range 60 to 100), RR (respiratory rate) 12 (normal range 12 to 18), (oxygen saturation) 91% (normal range 95% to 100%) (on) 4 (liters of oxygen via nasal cannula) temp(erature) 96.6 (normal range 97 to 99).Called 911 around 7:35 AM, EMTs arrived and transported resident via gurney at approximately 0755 AM. Resident is transferred to the hospital. Called (responsible party, name) @ 0800 AM. Notified MD. A review of the [DATE] Progress Notes signed by RN 1 indicated around 7:28 a.m., RN 1 was told by the charge nurse (LN 1) that Resident 1 was not responding and lethargic. RN 1's Progress Note indicated she went to Resident 1's room and found Resident 1 on her bed breathing labored, difficult to arouse, not responsive to verbal stimuli, vitals signs assessed (same as LN 1 note above) . Blood sugar: 73 mg/dl (normal fasting range 70 to 90) . warm to touch, lethargic. Called 911 @ 0738 AM, paramedics arrived around @ 0744 AM, verbal report given, paramedics assessed the patient, patient left the building around @ 0755. Called (responsible party) around @ 0758 AM regarding the transfer. A review of Resident 1's POLST form indicated it had no signatures or dates at the bottom of the form. A sticker with Resident 1's name, resident number, and health insurance name was on the top right corner of the POLST form. Check marks were placed next to Do Not Attempt Resuscitation/DNR (Allow Natural Death) and next to Selective Treatment - goal of treating medical conditions while avoiding burdensome measures. In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as needed. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care. In an interview with RN 1 on [DATE] at 2:55 p.m., she stated she was sitting at the front desk when another nurse called for help. RN 1 said she ran to Resident 1's room. RN 1 stated when she arrived in Resident 1's room multiple staff members were there taking her vitals, doing a sternal rub and they could not awaken Resident 1. RN 1 said she called for the crash cart and she called 911 herself. RN 1 said she started the paperwork. RN 1 stated she saw the POLST form with DNR and selective treatment checked. RN 1 stated she did not notice there were no signatures at the bottom of the POLST form. RN 1 said there was a sticker on the form. RN 1 stated she may have been asked by and told the 911 dispatcher Resident 1 was DNR when she called 911. RN 1 said she cannot recall if she said this as everything happened so fast. RN 1 stated when the EMS personnel arrived in the skilled nursing facility, she handed them the POLST form without dates or signatures but with check marks indicating Do Not Attempt Resuscitation/DNR (Allow Natural Death) and Selective Treatment. RN 1 said she told the EMS personnel who entered the skilled nursing facility to care for Resident 1 that Resident 1 was DNR. RN 1 said she saw Resident 1 on the gurney as she left the skilled nursing facility with EMS. RN 1 stated Resident 1 was breathing at that time. A review of the [DATE] follow up report from the skilled nursing facility Administrator indicated Resident 1 was not given CPR in the ambulance en route to the hospital and she was pronounced dead on arrival at the hospital. In an interview with the Administrator and DON on [DATE] at 4:35 p.m., the Administrator stated he obtained the information that Resident 1 was not given CPR in the ambulance and pronounced dead at the hospital from an RN Administrator at Resident 1's health insurance plan in calls over a two week period. A review of the facility's policy, Advance Directive indicated under Definitions, POLST: This document signed by an authorized health care professional, is a medical order that records residents' treatment wishes so that emergency personnel know what treatments to provide in the event of a medical emergency . Under Procedure, 4., this policy indicated, During the admission process, the POLST form (state specific) is offered, and assistance is provided in filling out these forms if the resident desires to have one.

Based on interview and record review, the facility failed to conduct a thorough investigation into an allegation of abuse for Resident 1, one of one sample resident. Review of the facility ' s investigation indicated only staff were interviewed regarding this allegation. Facility stated no residents were interviewed because all residents of interest were non-interviewable. The investigation was not thorough because the facility failed to: 1. Attempt to interview responsible parties of non-interviewable residents 2. Conduct assessments of non-interviewable residents for signs and symptoms of abuse (defensive bruising, bruising in private areas, change in social behavior etc.). The lack of a thorough investigation did not ensure all residents were protected from abuse. Findings: During an interview on 05/21/2025 at 11:40 AM, the Administrator was made aware of an allegation of abuse by Resident 1. The Administrator stated he would look into the allegation. On 06/02/2025 at 1:24 PM, the Administrator was asked to provide all documents, including raw data, related to his investigation regarding this allegation. Review of an untitled facility investigation document, dated 05/23/2025, indicated .A CNA (Certified Nursing Assistant) allegedly performed pericare (cleaning the genital/anal area) in a rough manner, causing pain but no injury. The resident stated she asked the CNA to not do that again but he did it again anyway. Resident doesn't remember name of the aide.the alleged victim, was a resident from 2/1/25-3/8/25. She was alert, responsive in conversation, and capable of expressing her needs clearly.Administrator interviewed the resident on 5/21/25. She stated that the CNA was male, .(Filipino), and had black hair.She stated that it was the same person that helped her on day shift all week, that it was on Thursday before she discharged , and that it was before lunch. From the assignment sheets it was determined that five different day shift aides worked with her that week .so it was not possible to narrow down a single aide that took care of her all week. The Administrator interviewed ten nurses and CNA's that worked with . (Resident 1) during that time, and none recall the event .(Resident 1) described, and none recall hearing any complaints about rough pericare. Summary of investigation: Based on interviews, available information, and lack of witnesses, the investigation is unable to substantiate abuse. During an interview on 06/02/2025 at 2:55 PM the Administrator was made aware he investigated the care provider side of the allegation. The Administrator was asked if he investigated the care recipients ' /residents ' side of the allegation? The Administrator then provided a new document from his investigation file indicating residents of interest such as roommates and other residents on Resident 1 ' s assignment were not interviewable. The Administrator was asked if he attempted to interview the family/responsible parties of these residents. The Administrator did not answer. During a communication on 06/03/2025 at 3:02 PM, the Administrator responded, One could interview families or additional staff; I don ' t believe any residents from the resident ' s time, interviewable or not were in the building anymore, so I chose (to interview) additional staff. During a communication on 06/04/2025 at 11:48 AM, the Administrator responded that assessing non-interviewable residents for 1. defensing bruising 2. bruising around the private areas 3. behavioral changes 4. sleep pattern changes 5. social interaction changes were reasonable tools to incorporate into an allegation of abuse investigation. During a telephone interview on 06/04/2025 11:51 AM, the Administrator was reminded even though Resident 1 was discharged , the alleged perpetrator may still be working at his facility. Therefore, not assessing the current group of residents within Resident 1 ' s assignment did not ensure the facility had investigated to rule out if other residents were affected. Review of a facility policy titled Abuse, Neglect, or Exploitation, updated on November 2016, .Initiate an investigation. Staff on duty at the time the alleged abuse occurred are interviewed prior to leaving their respective shift. This applies to staff as well as other residents in the area. Remind these individuals that they report facts rather than opinions or speculation. Written statements by staff are not advised unless directed otherwise by legal staff. Such statements may lack adequate information or objectivity. Instead, the investigator takes written notes about the facts reported during the interview. Review of the facility ' s abuse policy indicated there no language directing staff how to investigate if residents in the area were not interviewable.

Based on observation, interview, facility document review, and facility policy review, the facility failed to accurately record the discard date on the label for a potentially hazardous food (thawed chicken breast) stored in 1 of 3 refrigerators and failed to conduct temperature monitoring prior to placing a potentially hazardous cold food (chocolate mousse) on residents' meal trays that was identified prior to the tray line service with a temperature of 47.3 degrees Fahrenheit. This failure had the potential to affect 88 of 88 residents who received meals from the facility's kitchen. Findings included: An undated facility policy titled, Food Preparation and Service, indicated, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. The policy revealed the section titled, Policy Interpretation and Implementation included 2. 'Potentially Hazardous Food' (PHF) or 'Time/Temperature Control for Safety (TCS) Food' means food that requires time/temperature control for safety to limit the growth of pathogens (i.e. [id est, that is], bacterial or viral organisms capable of causing a disease or toxin formation). Examples of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt and cottage cheese. The policy revealed the section titled, Food Distribution and Service included 1. Proper hot and cold temperatures are maintained during food distribution and service. An undated facility policy titled, Food Receiving and Storage, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. The policy revealed the section titled Policy Interpretation and Implementation included 1. 'Critical Control Point [CCP]' means a specific point, procedure, or step in food preparation and serving process at which control can be exercised to reduce, eliminate, or prevent the possibility of a food safety hazard. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices. The policy revealed the section titled Refrigerated, Frozen Storage included 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ('use by' date). 2. PHF/TCS foods are stored at or below 41 F [degrees Fahrenheit], unless otherwise specified by law. Further review revealed 7. Refrigerated foods are labeled, dated and monitored so they are used by their 'use by' date, frozen or discarded. 1. During an observation on 03/24/2025 at 8:56 AM, the walk-in refrigerator revealed two plastic bus tubs were stored on the bottom shelf of the walk-in refrigerator. The plastic bus tubs contained multiple bags of thawed chicken breasts. Each of the two plastic bus tubs contained a printed label that recorded frozen chicken, opened 03/20/2025 at 1:55 PM, and discard Saturday, 04/19/2025 at 1:55 PM. During a concurrent interview, the Director of Food Service (DFS) stated that the facility used an automatic labeling system. The DFS stated that the printed labels were incorrect and should have a label that recorded the chicken thawing and not frozen chicken. The DFS stated the opened date of 03/20/2025 was correct, but the employee should have chosen the words chicken thawing from the menu on the label machine when he printed the label and not the words frozen chicken, so that the label had the correct use-by date. The DFS stated that the thawing chicken should have a use-by date of four days after opening and not 30 days as indicated on the label. She stated that when using the label system, staff should select the correct item they are putting in cold storage, and the label system automatically recorded the opened date and discard date for the item selected. She stated that the day of the week recorded on the label was the day of the week the food item should be discarded. During an interview on 03/25/2025 at 11:32 AM, [NAME] #5 stated that he removed the frozen chicken breasts from the freezer (on 03/20/2025), but that he chose the wrong item in the label machine. [NAME] #5 stated that he chose frozen chicken instead of chicken thawing, which printed a discard date 30 days out, which was the wrong discard date. During an interview on 03/25/2025 at 12:04 PM with the DFS, Dietary Supervisor (DS) #3, and DS #6, the DFS stated the supervisors should have gone behind the cooks during their rounds to ensure the labels were correct. DS #3 and DS #6 both stated that they missed seeing the incorrect label for a couple of days that was placed on the two plastic bus tubs that contained thawed chicken breasts. DS #3 and DS #6 both stated that this incorrect label should have been checked, and the error should have been caught during their kitchen rounds. During an interview on 03/25/2025 at 4:11 PM, the Director of Nursing (DON) stated it was her expectation that dietary staff followed policies for labeling and dating foods. The DON stated that due to the potential risk of salmonella, chicken should not be left in refrigeration for four days with the wrong label and discard date on the label. The DON stated that she expected the label on chicken to have an accurate date to discard and that she expected the supervisor there in the kitchen to monitor labels for accurate discard dates and catch these errors. During an interview on 03/26/2025 at 9:11 AM, the Administrator stated he expected the food provided to the residents to be provided according to the guidelines per the state. He stated that anything staff opened and put in the refrigerator should be labeled and dated, with daily monitoring, and if the date recorded was more than the threshold date, the food item should be removed from the refrigerator and tossed and should not be used. The Administrator stated that the dietary staff used a labeling sticker to record the open and discard dates. He stated that when dietary staff put chicken in the freezer, staff should use the frozen label for the freezer, and when the chicken was removed from the freezer to thaw, staff should change the label to a label for thawing chicken. The Administrator stated that he expected the DFS and supervisors to monitor and provide supervision. 2. A facility recipe titled, Chocolate Mousse, with a print date of 05/14/2024, revealed the ingredients for the recipe included chocolate mousse mix and 2% milk. The recipe revealed the section titled Directions included CCP: Chill and hold under refrigeration (41 F), until ready to serve. During an observation of temperature monitoring for the lunch meal tray line completed by Dietary Supervisor (DS) #3 on 03/25/2025 at 11:00 AM, the observation revealed a cart that contained four plastic bus tubs with multiple bowls of chocolate mousse covered with ice. DS #3 completed temperature monitoring of the chocolate mousse, which revealed a temperature of 47.3 F. DS #3 was observed instructing staff to put the bowls of chocolate mousse in the freezer, and the four plastic bus tubs of chocolate mousse were placed in the freezer by staff. During an interview on 03/25/2025 at 11:09 AM, Dietary Aide (DA) #4 stated he prepared the chocolate mousse around 8:00 AM to 8:30 AM on 03/24/2025 and put the chocolate mousse in the refrigerator. He stated that on 03/25/2025 around 9:00 AM to 9:30 AM, he put the chocolate mousse in bowls for the lunch meal service and placed the bowls of chocolate mousse in the refrigerator. An observation of the lunch meal service tray line on 03/25/2025 at 11:15 AM revealed a cart that contained two plastic bus tubs with multiple bowls of chocolate mousse covered with ice. DA #4 placed bowls of chocolate mousse on resident meal trays for the lunch meal service. During an observation on 03/25/2025 at 11:16 AM, the surveyor requested temperatures of the bowls of chocolate mousse that DA #4 had placed on resident meal trays for the lunch meal service. Temperature monitoring completed by the DFS of bowls of chocolate mousse placed on resident meal trays for the lunch meal service revealed temperatures of 49.1 F, 43 F, and 48 F. During a concurrent interview, the DFS stated that the temperature of the chocolate mousse was still too high and that the chocolate mousse needed to cool down. During an interview on 03/25/2025 at 11:24 AM, DA #4 stated he was trained to serve cold foods at 41 F or below. DA #4 stated that he should have waited for the chocolate mousse to cool down, but that he thought the chocolate mousse was in the freezer long enough to cool down. DA #4 stated that he did not ask a supervisor to obtain a temperature of the chocolate mousse before he placed the bowls of chocolate mousse on resident meal trays for service. During an interview on 03/25/2025 at 11:25 AM, DS #3 stated that the chocolate mousse should be served at a temperature of 41 F or below. DS #3 stated that when she completed temperature monitoring of the chocolate mousse before the lunch meal service, the temperature was too high, so she instructed staff to put more ice on the bowls of chocolate mousse and return the plastic bus tubs of chocolate mousse to the freezer. She stated that staff should have waited for her to recheck the temperature of the chocolate mousse before it was served. DS #3 stated that the temperature of the chocolate mousse placed on resident meals trays by DA #4 was still too hot to serve to residents. During an interview on 03/25/2025 at 12:08 PM, the DFS stated staff were trained to leave four plastic bus tubs of chocolate mousse on the tray line at one time but going forward she would instruct staff to have less chocolate mousse on the tray line at one time. She stated that staff were trained to keep cold foods at 40 F or below to be stricter than the regulations required. During an interview on 03/25/2025 at 4:11 PM, the Director of Nursing (DON) stated that it was her expectation that dietary staff followed policies for serving foods at the correct temperatures. The DON stated that staff should have checked the temperature of the chocolate mousse before it was served, since staff identified that the temperature of the chocolate mousse taken before the lunch meal service was too high. She stated that staff should ensure the chocolate mousse was served at the correct temperature. The DON stated that because milk was one of the ingredients in the chocolate mousse, there was a potential risk to the resident for a stomachache from a possible food borne illness. During an interview on 03/26/2025 at 9:11 AM, The Administrator stated he expected the food provided to the residents to be provided according to the guidelines per the state. He stated when the staff provided food to residents, staff should take the temperature of the food and make sure the temperature met the threshold. The Administrator stated that if staff found that food was not at the correct temperature, staff should fix it and correct the issue to get it right. He stated that staff should not serve food to residents that was not at the correct temperature. He stated he expected the staff to correct the problem and not serve potentially hazardous cold foods that were not cold enough. The Administrator stated that he expected the DFS and supervisors to monitor and provide supervision.

Based on observation, record review, and interview, the facility failed to ensure staff conducted finger-stick blood sugar (FSBS) checks in accordance with physician's orders for 1 (Resident #33) of 3 residents observed for blood sugar monitoring. Specifically, staff failed to perform Resident #33's FSBS before meals as specified by the physician. Findings included: An Admission Record indicated the facility admitted Resident #33 on 06/07/2024 and most recently admitted the resident on 08/21/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with diabetic chronic kidney disease. Resident #33's Care Plan Report included a focus area, initiated on 08/01/2024, that indicated the resident was at risk for hyperglycemia (high blood sugar levels) or hypoglycemia (low blood sugar levels). An intervention dated 08/01/2024 directed staff to complete FSBS checks as ordered and as needed. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 02/20/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #33's Order Summary Report contained an active order, dated 12/02/2024, to monitor the resident's blood sugar daily before meals and at bedtime. Resident #33's 03/2025 Medication Administration Record (MAR) revealed the resident's FSBS checks were scheduled for before meals and at bedtime at 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM each day. A concurrent observation and interview on 03/24/2025 at 12:41 PM revealed Resident #33 was in their room eating their lunch meal. Resident #33's lunch meal tray was approximately 75% complete when Licensed Practical Nurse (LPN) #2 entered the resident's room with medications and a glucometer. LPN #2 informed Resident #33 that he would provide medications and complete FSBS monitoring. LPN #2 administered the medications, completed a FSBS check, and informed the resident their FSBS result was 190 milligrams per deciliter (mg/dL). After LPN #2 administered the resident's medications and performed the FSBS check, LPN #2 exited the room and reviewed the resident's MAR with the surveyor. LPN #2 stated the resident's FSBS order specified to complete the FSBS checks before meals; however, LPN #2 stated, I just got back from taking my lunch, so I checked the blood sugar when I got back. I was very hungry, and I had to take a lunch break. LPN #2 stated he was trained to check blood sugars before meals, and that was what he should have done but thought he had an hour window to complete the FSBS check. During an interview on 03/25/2025 at 3:36 PM, the Director of Nursing (DON) stated that if a physician's order for FSBS checks specified before meals, the lunchtime FSBS should be conducted between 11:00 AM and 11:30 AM, before lunch. The DON further stated that if a nurse checked a resident's blood sugar during a meal, the results could provide inaccurate information, which defeated the purpose of the physician specifying to check the blood sugar before meals. The DON reviewed Resident #33's MAR and confirmed the resident's FSBS check order specified before meals and at bedtime. The DON stated that the nurse should have completed Resident #33's FSBS monitoring before the resident's lunch meal and before the nurse took his lunch break, because FSBS monitoring only took one to two minutes to complete. During an interview on 03/26/2025 at 9:44 AM, the Administrator stated he expected nurses to complete FSBS checks before meals, per Resident #33's physician's order, because FSBS results would be different before a meal than they would be after a meal or after the resident already started eating.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that medications were stored in a safe and secure manner for 2 (Resident #2 and Resident #27) of 2 residents observed with medications at their bedside. Findings included: A facility policy titled, Storage of Medications, revised 04/2007, revealed, The facility shall store all drugs and biologicals in a safe secure and orderly manner. The policy revealed the section titled Policy Interpretation and Implementation included 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. A facility policy titled, Self-Administration of Medications, revised 11/2022, revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy revealed the section titled Policy Interpretation and Implementation included 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re-assessed periodically based on changes in the resident's medical and/or decision-making status. Further review revealed, 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. A facility policy titled, Administering Medications, revised 12/2012, revealed, Medications shall be administered in a safe and timely manner, and as prescribed. The policy revealed the section titled Policy Interpretation and Implementation included 21. Topical medications used in treatments must be recorded on the resident's treatment record (TAR). Further review revealed, 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR [medication administration record] space provided for that drug and dose. The policy revealed, 24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 1. An Admission Record revealed the facility admitted Resident #2 on 05/14/2018. According to the Admission Record, the resident had a medical history that included diagnoses of senile degeneration of the brain and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/03/2025, revealed Resident #2 had a Brief Interview for Mental Status score (BIMS) of 10, which indicated the resident had moderate cognitive impairment. During an observation on 03/24/2025 at 9:12 AM, Resident #2 was dipping their finger into a blue jar of ointment and then putting their finger with the ointment just inside both nostrils. During a concurrent interview, Resident #2 stated they used Vicks VapoRub (a medicated ointment) so they would not get a cold. The blue jar of the medicated ointment had the resident's name on the jar. Resident #2 then placed the jar of medicated ointment into the drawer of their nightstand that was next to the bed. Resident #2 had slight redness under each nostril. During this observation, a staff member was in the room tending to Resident #2's roommate's bed. Resident #2's Orders Summary Report, with active orders as of 03/25/2025, contained an order dated 12/28/2024, informing staff that the resident was incapable of understanding rights, responsibilities, and informed consent. The Order Summary Report revealed no order for the medicated ointment. Resident #2's Care Plan Report revealed no focus area or interventions related to the self- administration of medication for the medicated ointment. During an observation on 03/25/2025 at 9:35 AM, Resident #2 was in their room in a wheelchair and the jar of medicated ointment was on top of the bedside table. During a concurrent interview Resident #2 stated the jar was Vicks VapoRub. Resident #2 stated they used it daily. Resident #2 would not state who gave them the jar of medicated ointment. During an observation on 03/25/2025 at 11:48 AM, Resident #2 was in their room lying down in bed doing a word search, and the jar of medicated ointment was on the resident's nightstand and visible from the hallway. During an observation on 03/25/2025 at 11:57 AM, Registered Nurse (RN) #7 observed the medicated ointment on Resident #2's bedside table while the resident was lying down in bed doing a word search. RN #7 confirmed that the jar was Vicks VapoRub. RN #7 reviewed the resident's physician orders and during a concurrent interview, confirmed there was an active order that informed staff that the resident could not understand rights, responsibilities, and informed consent. RN #7 stated she was not aware of a self-administration for medications assessment for Resident #2. RN #7 stated the certified nursing assistants (CNAs) should check the residents' side tables every shift and notify the nurse if there were medications. RN #7 stated she was not aware of the medicated ointment until that day at the time of the observation. During an interview on 03/25/2025 at 12:03 PM, RN #8 stated there should be a physician order for any topical lotions. RN #8 stated the resident was supposed to have a self-administration medication assessment if they could self-administer medications. RN #8 stated if they got the okay for a resident to self-administer medications, then the doctor would say to keep it at the bedside or not. RN #8 stated if it was okay for the resident to keep the medication at bedside then staff needed to ask the resident where they put the medication on their body, when they used it, and if they had any side effects. RN #8 said the nurses would document this under the Progress Notes and report it to the next nurse to watch for side effects. RN #8 stated that the CNAs on every shift were to check the bed side table and let the nurse know if they found anything, like medications or treatments. RN #8 confirmed there was no physician order for Resident #2 to self-administer the medicated ointment and no self-administration of medication assessment. During an interview on 03/25/2025 at 5:16 PM, the Director of Nursing (DON) stated her expectation would be that medications should not be at the resident's bedside. She stated they had assigned staff members that checked cabinets, drawers, and closets to ensure there were no medications at bedside. The DON stated this was done by two staff members every day on every shift. She stated the two staff members should have found the medicated ointment. During an interview on 03/26/2025 at 8:35 AM, the Staff Development Director (SDD) stated two CNAs were on modified duty. The SDD stated they had special duties that included checking the resident's room. She stated CNA #10 and CNA #11 were the CNAs on modified duty. She confirmed that on 03/24/2025, no staff that was on modified duty was assigned to Resident #2. The SDD stated the CNA assigned to Resident #2 on 03/24/2025 was CNA #9 who worked from 7:00 AM to 3:00 PM. She stated the CNA assigned to Resident #2 on 03/25/2025 from 7:00 AM to 3:00 PM was CNA #12 and further indicated that CNA #10 and CNA #11 were also working and primarily responsible for looking for medications in the residents' rooms. During an interview on 03/26/2025 at 10:01 AM, CNA #10 stated she worked with Resident #2 on 03/25/2025. She stated that for Resident #2 she was able to open their drawer and only saw personal belongings. She stated she did not see the medicated ointment. During a phone interview on 03/26/2025 at 11:06 AM, CNA #9 confirmed she worked on 03/24/2025 from 7:00 AM to 3:00 PM and worked with Resident #2. She stated Resident #2 had medicated ointment, and after she took the resident to the shower around 8:00 AM she saw it. She stated the resident was in their room and was putting something on their nose. CNA #9 stated she saw the medicated ointment on the resident's nightstand, and it had the resident's name on it. She stated the resident wrote their name on all their items. CNA #9 stated she told the SDD after lunch on Monday (03/24/2025) that Resident #2 had medicated ointment on their table. CNA #9 stated the SDD informed her to take it from the resident if she could. CNA #9 stated the resident refused and told her that it was their belongings. CNA #9 stated that at that point she did not feel comfortable taking it. CNA #9 stated she did not let the SDD know at end of her shift, but she let RN #7 know. During an interview on 03/26/2025 at 11:53 AM, CNA #12 confirmed she regularly worked with Resident #2 and that she worked 03/25/2025 from 7:00 AM to 3:00 PM. She stated she did not see medications at Resident #2's bedside. She stated that Resident #2 usually refused to allow staff to touch their drawers. During an interview on 03/26/2025 at 8:57 AM, MDS RN #13 confirmed Resident #2 did not have a self-administration for medication evaluation (assessment). During an interview on 03/26/2025 at 10:06 AM, the Administrator stated his expectation was that if a staff member saw something like medications at the resident's bedside, they were to remove it. The Administrator stated they would let the doctor know, and the doctor would determine if the resident could have the medication at bedside. The Administrator stated there would be an order if a resident could have the medication at bedside. 52224 2. An Admission Record indicated the facility admitted Resident #27 on 02/24/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of chronic pain. An admission Minimum Data Set (MDS), with an Assessment Reference Date of 03/02/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #27's Order Summary Report, with active orders as of 03/25/2025, contained an active order dated 02/24/2025, for docusate sodium 250 milligrams (mg), with instructions to give one capsule by mouth daily for bowel regularity. The Order Summary Report contained an order dated 02/24/2025 for senna 8.6 mg, with instructions to give two tablets by mouth two times daily for constipation. Further review revealed there were no physician orders to leave medication at the bedside for self-administration. Resident #27's March 2025 Medication Administration Record [MAR] included a transcription of an order for docusate sodium 250 mg, with instructions to give one capsule by mouth daily for bowel regularity and senna 8.6 mg, with instructions to give two tablets by mouth two times daily for constipation. The MAR revealed that Licensed Practical Nurse (LPN) #2 documented that on 03/24/2025 at 9:00 AM, they administer the resident's docusate sodium and Senna. During an interview and observation on 03/24/2025 at 12:26 PM, Resident #27 expressed concerns with constipation but stated that the stool softeners received from LPN #2 that morning (03/24/2025) were not taken when offered by LPN #2. Resident #27 stated that they had agreed to take the stool softeners later. A medicine cup that contained three pills (one red and two brown pills) was observed on Resident #27's over bed table. Resident #27 stated the pills in the medicine cup were the stool softeners that they told LPN #2 would be taken later, but then they decided not to take the medication. Resident #27 stated that when they agreed to take the medication later, LPN #2 left the medicine cup with the three pills for them to self-administer later. During an interview and observation on 03/24/2025 at 12:47 PM, LPN #2 entered the room of Resident #27. The surveyor asked LPN #2 if he left the medication in the medicine cup on Resident #27's over bed table for the resident. LPN #2 stated that he left docusate sodium and senna in the medicine cup that morning (03/24/2025) at about 9:30 AM because Resident #27 declined to take the medication when he offered it. He further stated that the resident agreed to self-administer the medication after breakfast, so he left the medication for the resident to self-administer because Resident #27 was alert and oriented, and he trusted the resident to do so. LPN #2 stated he was trained to keep the medication if the resident did not take the medication when offered and to offer the medication again when the resident was ready to take it. LPN #2 further stated that Resident #27 promised to take the medication after breakfast. He stated that he believed the resident, so he left the medication for the resident to take. The Director of Nursing (DON) was interviewed on 03/25/2025 at 2:58 PM. The DON stated that Resident #27 had told the nurse in the past which medication they wanted to take at the time of medication administration. The DON stated if a resident requested to take medication later, she expected the nurse to come back and offer it later. The DON stated that the nurse should not leave medication for the resident to take later, but that the medication that was declined should be taken back by the nurse, offered later in the same shift, and endorsed to the next nurse to administer if the medication was not taken by the resident during the shift. The DON stated that the nurse should be present for administration of medications if the resident did not have an assessment that allowed the resident to self-administer medications but should not be left at bedside unless there was a physician's order to do so. The DON reviewed Resident #27's medical record during the interview and confirmed there was no physician's order for the resident to keep medication at the bedside. The Administrator was interviewed on 03/26/2025 at 9:30 AM. The Administrator stated that the nurse should not give the resident medication if the resident refused but should go back again and offer the medication again. He further stated that if the resident still did not take the medication, the nurse should find a nurse who had a better rapport with the resident to see if the resident would take the medication from that nurse. He stated that if the resident still refused the medication, the nurse should record that the resident refused the medication. The Administrator stated the medication should not be left at the bedside for them to take themselves. The Administrator stated that should only occur for the resident who was assessed for self-administration. The Administrator stated that for Resident #27, the nurse should not have left the medication for the resident, who was not assessed for self-administration.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff did not document the administration of medications after the resident refused to take them for 1 (Resident #27) of 1 resident reviewed for refusal of medications. Findings included: A facility policy titled, Administering Medications, revised 12/2012, indicated, 18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. An Admission Record indicated the facility admitted Resident #27 on 02/24/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of dependence on renal dialysis. An admission Minimum Data Set (MDS), with an Assessment Reference Date of 03/02/2025, revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #27's Order Summary Report contained an active order, dated 02/24/2025, for docusate sodium (a stool softener) 250 milligrams (mg) by mouth daily for bowel regularity with instructions to hold for loose stools. The Order Summary Report also contained an active order, dated 02/24/2025, for Senna oral tablet (a laxative) 8.6 mg, 2 tablets by mouth two times daily for constipation with instructions to hold for loose stools. During a concurrent observation and interview on 03/24/2025 at 12:26 PM, a medication cup containing one red pill and two brown pills was observed on Resident #27's over-the-bed table. Resident #27 stated Licensed Practical Nurse (LPN) #2 brought them their stool softener (and laxative) after the resident returned from dialysis, but the resident did not want to take them at that time. The resident stated they sometimes did not take those medications, and the nurse would either leave the medications with them to take later or take the medications back out of the resident's room. Resident #27's 03/2025 Medication Administration Record (MAR) revealed the resident's docusate sodium and Senna were scheduled to be administered at 9:00 AM each day, and LPN #2 documented the medications were administered on 03/24/2025, as opposed to refused. During a concurrent observation and interview with LPN #2 on 03/24/2025 at 12:47 PM, LPN #2 observed the medication cup on Resident #27's over-the-bed table and confirmed he left the medications with the resident around 9:30 AM that morning and had not administered them at that time per the resident's request. LPN #2 stated he signed off on the resident's MAR to indicate he administered the medications because he trusted the resident would take them at a later time. During an interview on 03/25/2025 at 2:58 PM, the Director of Nursing (DON) stated that if Resident #27 requested to take medications at a later time, she expected the nurse to go back and offer the medications at a later time. The DON stated that the resident's MAR should reflect the resident refused the medications when the nurse offered to administer them. The DON stated that a MAR should not reflect the administration of medications if the medications were not administered. During an interview on 03/26/2025 at 9:30 AM, the Administrator stated that if a resident refused medication, the nurse should document the medication was refused. The Administrator stated that for Resident #27, since the resident did not take the medications, the nurse should not have documented the medications were administered.

Based on interview and record review, the facility failed to ensure one of 3 sampled residents (Resident 1) received care in accordance with professional standards of practice when there was no evidence of nursing notes and vital signs by night shift nurse on 6/14/24 for Resident 1. This failure had the potential to delay identifying symptoms of atrial fibrillation (Afib, an irregular and often rapid heart rate that commonly causes poor blood flow and can increase the risk of stroke) for Resident 1. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted on [DATE] with diagnoses including atrial fibrillation, hypertension (high blood pressure), benign prostatic hyperplasia (BPH, an enlarged prostate), and diabetes (high blood sugar). Resident 1 had a history of transient ischemic attack (TIA, known as a mini stroke which is a temporary disruption in the blood supply to part of the brain). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 6/13/24, indicated, his memory was intact. During an interview on 8/7/24 at 1:51 PM with Complainant via phone, Complainant stated, Resident 1 had been diagnosed with the new onset of Afib in XXXXX (the name of the hospital), so he was prescribed two new medications which are Amiodarone (a medicine to treat life-threatening heart rhythm problems) and Apixaban (known as Eliquis, a kind of blood thinner that is used to prevent and treat blood clots in blood vessels and the heart), then was sent to the facility on [DATE] for Rehabilitation (a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment). Complainant stated, Resident 1 was transferred from the facility to a hospital on 6/15/24 because the facility staff found him unconscious, and vomiting, then he passed away on 6/20/24. Review of Resident 1's death certificate, dated 7/5/24 indicated, his date of death was on 6/20/24 with the causes of death with (A) non-traumatic intracerebral hemorrhage (spontaneous bleeding into the brain tissue, a common cause of stroke) and (B) hypertension. Review of Resident 1's Medication Administration Record (MAR) from 6/1/24 to 6/30/24 indicated, Resident 1 took Amiodarone oral tablet 400 MG (milligram) 1 tablet by mouth two times a day and Apixaban oral tablet 5 MG 1 tablet by mouth two times a day for A-fib from 6/11/24 to 6/14/24 because he was discharged to the hospital on the morning of 6/15/24. Review of Resident 1's Weights and Vitals Summary dated from 6/14/24 to 6/15/24 indicated, . 06/14/2024 22:57 (10:57 PM) 115/79 mmHg (millimeters of mercury, a measurement of blood pressure) . Review of Resident 1's Nursing Note dated 6/15/24 at 7:50 AM indicated, . Noted resident verbally non-responsive (unconscious) but responsive to tactile stimuli (touch) . Mouth was clear. No respiratory distress noted however coffee-ground emesis (the act of vomiting) noted with elevated blood pressure, 210/108 (normal blood pressure for most adults is defined as less than 120/80). Promptly called 911 while immediate interventions are ongoing . no facial grimace (a facial expression usually of disgust, disapproval, or pain) noted. Afebrile . Paramedics arrived and assisted . Left facility at 8:15pm (typo of AM). Dr. (doctor) Agreeable with the transfer, noted. Called wife . Left a voice mail message on the second attempt . During an interview on 8/8/24 at 2:30 PM with Director of Nursing (DON), DON stated, Resident 1 did not fall on the floor on 6/15/24. DON stated, Resident 1 was found nonresponsive in his bed in the room. During a concurrent interview and record Review on 8/8/24 at 2:52 PM with DON, Resident 1's N Adv (Nursing Advantage) Skilled Evaluation, dated 6/14/24, and Nursing note, dated 6/15/24 were reviewed. N Adv Skilled Evaluation indicated, it was documented at 10:55 PM on 6/14/24 by Licensed Vocational Nurse (LVN) 1, and Nursing note was documented at 7:50 AM on 6/15/24 by Registered Nurse (RN) 1. DON stated, nurses should document resident assessments in the nursing note for each shift when asked about nursing documentation. During a concurrent interview and record review on 8/8/24 at 4:03 PM with DON, Resident 1's nursing note, and the facility's daily assignment sheets dated 6/14/24 and 6/15/24 were reviewed. DON stated, she could not find the night shift's charting on 6/14/24 when asked. DON stated, The missing one is Noc (Night shift), when asked about the nursing documentation. DAILY ASSIGNMENTS: GOLDEN HEIGHTS HEALTHCARE dated 6/14/24 indicated, LVN 1 was the PM shift, and RN 2 was the night shift. DAILY ASSIGNMENTS: GOLDEN HEIGHTS HEALTHCARE dated 6/15/24 indicated, RN 1 was the AM shift. DON stated, RN 2 who was the night shift nurse of 6/14/24 missed writing documents during her shift. DON stated, the facility has 3 shifts which are AM, PM, and Night shift, and every shift works for 8 hours. During an interview on 8/13/24 at 3:31 PM with DON via phone, DON stated, it was documented by the PM shift nurse on 6/14/24 when asked who documented Resident 1's blood pressure at 10:57 PM on 6/14/24. DON verified, RN 2 did not document Resident 1's vital signs and nursing note during her night shift. DON stated, the facility's policy and procedure on checking vital signs did not specify when to take vital signs, but with the facility's practice, nurses of the facility take vital signs at the beginning of the shift, prior to hypertensive/hypotensive medication administration, post incident evaluation, change of condition, and transferring a resident in/out. Review of the facility's policy and procedure (P&P) titled, Routine Resident Checks revised July 2013 indicated, . 1. To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each until at least once per each 8-hour shift. 2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc.

Based on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for five of six residents (Resident 1, 2, 3, 4, and 6). The resident responsible party and confidential interview reported a pattern of delayed response to call lights and waiting for a long period of time for staff assistance. Additionally, there was no policy and procedure in place for the use of call light. These failures resulted in delayed provision of care and services for Resident 1, 2, 3, 4, and 6; and had the potential to negatively impact the resident ' s physical, mental, and emotional well-being. Findings: Review of Resident 1 ' s admission record indicated, was admitted to facility on 8/25/20 with diagnosis including lung disease, heart disease, borderline personality disorder (a mental illness that severely impact a person ' s ability to manage their emotions), major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 3/2/24, indicated, no cognitive (thought process) impairment. During a telephone interview on 4/9/24 at 3:16 PM, Resident 1 ' s daughter stated, Call light issues are worst at night when mom has to wait for a long time, 35 minutes or more. No staff at front desk to answer calls. Resident 1 ' s daughter also stated that Resident 1 had UTI (urinary tract infection - an infection in any part of the urinary system) when she was left with wet diaper for a long time. During a confidential telephone interview on 4/10/24 at 9:54 AM, the Confidential Interview (CI) stated, he was aware of the daughter ' s issues and had witnessed delays in answering call lights during his visits at the facility. CI further stated, there is a monitor in front of the nurse ' s station showing the resident ' s room number and the number of minutes the light has been turned on. The CI confirmed and stated, observed during visits the call lights had been on for 35 minutes or so. During an observation on 4/10/24 at 3:09 PM, in resident ' s room, Resident 1 was sitting on the right side of the bed holding on to her call light, face was pinkish red in color. Resident 1 was observed on O2 (oxygen) on at 2 liters per minute (LPM) via nasal cannula (a thin, flexible tube that wraps around your head, typically hooking around your ears) and had a bedside commode by the window. During concurrent interview on 4/10/24 at 3:10 PM, Resident 1 stated in an irritable tone that she had been calling for her medications and needed help to go to the bathroom. Resident 1 stated, she pressed her call light several times, but the nurse turned it off and went out of the room without helping her. I feel confused. I need help with my head. During further interview, Resident 1 stated, she turns her call light on and off at night because she needed help to go to the bathroom. Resident 1 added, it takes a long time for them to come and change her diaper especially at night time. Resident 1 expressed feelings of frustration and anger for ignoring her call at night time and stated that she gets more anxious when staff does not attend to her immediately. During an interview on 4/10/24 at 3:16 PM, at the nurse ' s station, Licensed Vocational Nurse (LVN) 1 stated he was aware of Resident 1 ' s call light had been on for a while. Resident 1 wanted another dose of her medication, but it was not time yet. LVN 1 stated that CNA assigned had been paged to turn off the call light. Review of Resident 1 ' s care plan, reviewed on 4/4/24, indicated, Focus: The resident has behavior problems: yelling and asking for help for no apparent reason. Episodes of cursing towards staff and restlessness . The care plan interventions indicated, Attend to the resident ' s need timely. Educate on call bell use and keeping within reach . During an observation on 4/10/24 at 3:21 PM, at the nurse ' s station, five staff were on the computer. A television (TV) monitor was observed in front of the nurse ' s station that displayed the following: [Facility Name] - Nurse Call Activity for all Rooms 104 - Routine call (00:20:52) OVERTIME STAT 201 - Routine call (00:09:24) OVERTIME STAT 116 - Routine call (00:05:17) 215 - Routine call (00:01:29) 200 - Routine call (00:01:14) During an interview on 4/10/24 at 3:25 PM, LVN 2 stated, call lights does not sound when turned on, instead the room number will show on the monitor (referring to the TV monitor in front of nurse ' s station) if the resident ' s call light is turned on. During further interview LVN 1 acknowledged room [ROOM NUMBER] (Resident 1) and 201 ' s (Resident 4) call light had been on for a while and stated, OVERTIME STAT means resident need to be attended as soon as possible. LVN 1 added, the receptionist will page the CNA assigned to the room shown on the monitor, will page again after 5 minutes if room number still shows on the monitor. During an observation on 4/10/24 at 3:26 PM, at the nurse ' s station, a television (TV) monitor in front of the nurse ' s station displayed the following: [Facility Name] - Nurse Call Activity for all Rooms 201 - Routine call (00:14:48) OVERTIME STAT 116 - Routine call (00:10:41) OVERTIME STAT 215 - Routine call (00:06:53) OVERTIME 200 - Routine call (00:06:38) OVERTIME 211 - Routine call (00:01:09) During concurrent interview, LVN 2 confirmed and stated, the call light monitor indicated Resident 4 and Resident 2 ' s call light had been on for more than ten minutes (OVERTIME STAT) and that CNA need to check on the residents right away. LVN 2 also confirmed and stated Resident 6 and Resident 3 ' s call light had been on for more than 5 minutes (OVERTIME) and need to be attended as soon as possible. During concurrent observation and interview on 4/10/24 at 3:27 PM, in room [ROOM NUMBER], three male residents were inside the room and were asked who pressed the call light, Resident 2 responded and stated, he pressed the call light because he needed a brief change. Resident 2 further stated, he had been waiting for someone to come and change his disposable brief. During concurrent observation and interview on 4/10/24 at 3:29 PM, Certified Nursing Assistant (CNA) 1 came to Resident 2 ' s room, turned off the call light, and stated, I will get my supplies. During further interview, CNA 1 stated, she was taking other resident ' s vital signs when she saw Resident 2 ' s call light was turned on. CNA 1 stated she cannot respond right away when she ' s providing care to another resident. It depends if I ' m doing something. CNA 1 added, she would tell the resident calling to wait until she ' s done with the other resident. During an observation on 4/10/24 at 3:34 PM, in front of Resident 4 ' s room, a CNA went inside the room, spoke to the resident, and turned the call light off. During an interview on 4/10/24 at 4:45 PM, the Director of Nursing (DON) stated, call lights need to be answered promptly. Call lights has no sound that is why the receptionist monitors the call light. The DON explained that the room number of the resident calling and the number of minutes since the call light was on will appear on the monitor, the receptionist will then page the assigned CNA to the resident ' s room. For room numbers with more than 10 minutes of waiting will turn red, the receptionist will page again the assigned CNA. During a follow-up interview on 4/24/24 at 3:15 PM, Receptionist 1 stated, the receptionists were tasked to monitor the call light on a screen at the nurse ' s station from 8 AM to 8 PM, then the nurses will monitor from 8 PM to 8 AM. Receptionist 1 explained, the resident ' s room number and the number of minutes will show on the screen when a call light is turned on. Receptionist 1 further stated, it (referring to the room number and minutes shown on screen) will turn red if the call light was on for 10 minutes, CNA will be paged to go to the resident ' s room, if light is still on, will page again a couple of times every five minutes. During an interview on 4/24/24 at 3:21 PM, the DON stated, Normally they have a buddy system, if the assigned CNA is not available, will send someone else to the room to check on the resident. Furthermore, the DON stated there was no policy and procedure specific for use of call light, only for paging system. Review of facility ' s electronic mail (e-mail) document dated 4/25/24, indicated, the DON acknowledged and stated in the e-mail, I wasn ' t able to find another policy and procedure for answering call lights, as well as, for procedure to provide care as initiated via call light. During a telephone interview on 5/9/24 at 11:17 AM, the Administrator stated, staff need to respond to resident ' s call within five minutes, if with another resident, the pair they ' re working with or the charge nurse for that hallway will respond. The Administrator stated, the resident ' s room number and designated waiting time will change colors if call light was on for five to ten minutes or more. During further interview, the Administrator was not able to explain the meaning of each color changes and stated, I don ' t know what it means (referring to ' OVERTIME STAT ' shown on screen). Review of Resident Council for March 2024, dated 4/2/24, indicated, .Nursing concerns: .2. The call light sometimes takes a while to answer, especially at night . Review of facility ' s In Service Compliance Training Record titled ADLS/Communication with Family/Resident, dated 4/3/24, indicated, .Discussed topics included ADL, rounds every 2 hours, communication . 3. Make rounds every 2 hours. Before the end of the shift must make rounds. Report to charge nurse of any unusual observation . Review of facility ' s policy and procedure titled, Paging System, revised August 2006, indicated, .1. Our facility is equipped with a paging system for the purpose of paging personnel .to the resident rooms, to treatment areas . Call Lights - To announce call lights, press the ' Overhead Page ' button and say: ' Please answer call lights in rooms __ and __ (repeat x2). Thank you. ' Announce the call lights every 5 minutes. If it ' s already been 10 minutes or more, press the ' Overhead Page ' button and say: ' CNA to room __ (repeat x2). Thank you. ' ' CNA to rooms __ and __ (repeat x2). Thank you. ' Bathroom Call Lights - These are listed as priority call and shown in red. Be sure to announce these right away as they are typically more urgent . Review of facility ' s policy and procedure titled, Abuse and Neglect - Clinical Protocol, revised March 2018, indicated, .2. ' Neglect ' , as defined at 483.4, means ' the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. '

Based on interview and record review, the facility failed to provide protection to Resident 1 and other residents when Certified Nursing Assistant (CNA) 1 was not suspended immediately after an alleged abuse to Resident 1 was reported on 1/13/24. This failure placed Resident 1 at risk for further abuse and placed the other 15 residents assigned to CNA 1 for potential abuse. Findings: Resident 1 was admitted on [DATE] and was readmitted on [DATE], with diagnoses that include dysphagia (difficulty swallowing), dementia (impairment in the ability to remember, think, or make decisions that interferes with doing everyday activities), rheumatoid arthritis (chronic swelling and tenderness of joints and other parts of the body), and osteoarthritis (degenerative joint disease, in which the tissues in the joint break down over time). Review of Resident 1 ' s physician ' s Progress Notes, dated 12/12/23 at 5:49 PM indicated, NGT (nasogastric tube - a feeding tube that goes through the nose, down the throat, and into the stomach to deliver formula or medicine) via right nostril. Review of Resident 1 ' s minimum data set (MDS - a standardized assessment of a resident ' s functional capabilities and health needs), dated 12/13/23, indicated that Resident 1 was admitted with a feeding tube, had memory impairment and was dependent on facility staff with activities of daily living. Review of the facility ' s Event Investigation Summary ([NAME]), dated 1/24/24, indicated that Resident 1 was found by staff to have her right hand bound with a mitten, surgical gloves, plastic bag and loosely secured to the side rail of her bed to prevent the resident from pulling her Nasogastric Tube (NGT) out. The [NAME] indicated that the incident occurred during the NOC shift (nocturnal/night shift - starts from 11 PM to 7:30 AM) from 1/12/24 to 1/13/24 at approximately 4:30 AM. Further review of the [NAME] indicated, Staff Interviews . (name of CNA 1) was the CNA on duty assigned at Noc (NOC) shift on 1/13/24 (starts at 11 PM on 1/12/24 and ends at 7:30 AM on 1/13/24). The resident was restless from the start of the shift, didn ' t sleep the whole night. She repositioned the resident and went to take vital signs of other residents, then stayed with the resident due to trying to remove her NGT and had episode of behavior, too. At about 4:30 AM, The resident was still restless with her hands. To prevent the resident from pulling out her NGT, (name of CNA 1) took the white mitten and placed it on her (Resident 1) right hand, which she uses in trying to remove her NGT and restrained it so she (CNA 1) could leave to make her final rounds. She (CNA 1) did not tell anyone about what she did. She did not endorse it to anyone. During a concurrent interview and record review on 2/1/24 at 4:18 PM, Licensed Vocational Nurse (LVN) 1 stated that on 1/13/24, around 4 PM, she received a report from CNA 2 that she (CNA 2) found Resident 1 tied to her bed. LVN 1 stated that when she went to Resident 1 ' s room, she found Resident 1 ' s right hand with a mitten, right wrist tied to the bed ' s side rail with a plastic bag and a towel. LVN 1 stated that she immediately released Resident 1 from the restraint and immediately called the Director of Nursing (DON). LVN 1 stated, I know it ' s abuse. We (facility staff) should not do that; it could cause injury to the resident. LVN 1 reviewed Resident 1 ' s physician ' s orders for January 2024 and stated, I don ' t see any order (for restraint). During an interview on 2/1/24 at 4:35 PM, the Interim Director of Nursing stated, It was a restraint (referring to the use of a mitten and tying Resident 1 ' s hand to the bed). Restraint without a doctor ' s order is abuse. There was no order for restraint (for Resident 1). During an interview on 2/20/24 at 8 AM, LVN 2 stated, On 1/13/24, past 4 PM, I was told by (CNA 2 and LVN 1, names redacted) that they found Resident 1 tied to her bed with a towel and a plastic bag. LVN 2 also stated, Around 5 PM, the DON called me and asked what was happening. I told her of the situation . LVN 2 added, I spoke with her (CNA 1) in person, during change of shift. She worked NOC shift on 1/13/24. During a concurrent interview and record review on 2/23/24 at 11:48 AM, the Director of Staff Development (DSD) reviewed a copy of CNA 1 ' s Individual Employee Time Cards (IETC), with dates ranging from 1/1/24 to 1/15/24. The IETC indicated CNA 1 worked during the NOC shift starting from 10:54 PM on 1/13/24 to 6:57 AM on 1/14/24 and from 10:57 PM on 1/14/24 to 6:56 AM on 1/15/24. The DSD stated that the IETC is an official record of the staff ' s actual hours worked. The DSD verified that the incident was discovered on 1/13/24 at 4 PM and CNA 1 worked for two consecutive NOC shifts thereafter (CNA 1 continued to have access to the alleged victim, Resident 1, and to the other 15 residents assigned to her care for two (2) consecutive days during the 11 PM to 7:30 AM shifts on 1/13/24 and 1/14/24). The DSD stated, When there ' s an allegation of abuse, staff needs to be suspended pending investigation. She (CNA 1) should have not been allowed to work anymore. That ' s the policy. We put them on admin (administrative) leave (temporary removal of an employee from the workplace to address a particular situation) right away. During an interview on 2/23/24 at 1:33 PM, the Administrator stated that he was informed of the suspected abuse incident on 1/15/24 by the DSD. The Administrator added, When abuse is reported, for the safety of the residents, staff involved should be suspended (from work) immediately, away from the residents; away from the building, pending completion of investigation. Review of the facility policy and procedure, titled, Abuse Investigation and Reporting, revised on 7/2017, indicated Policy Interpretation and Implementation, Role of the Administrator . 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation .

Based on interview and record review, the facility failed to ensure nursing staff had the knowledge and competency to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of one of three sampled residents (Resident 1) when: 1. Two Certified Nursing Assistants (CNA) failed to recognize inappropriate use of restraint after observing Resident 1's hand was tied to her bed; and 2. Two nursing staff (Licensed Vocational Nurse [LVN] and CNA) were unaware that they could report instances or allegations of abuse to the state agency (which is CDPH - California Department of Public Health) and the local Ombudsman's Office. These resulted in failure to recognize a situation that could indicate abuse and placed the residents' safety at risk. Findings: 1. Resident 1 was admitted on [DATE] and was readmitted on [DATE], with diagnoses that include dysphagia (difficulty swallowing), dementia (impairment in the ability to remember, think, or make decisions that interferes with doing everyday activities), rheumatoid arthritis (chronic swelling and tenderness of joints and other parts of the body), and osteoarthritis (degenerative joint disease, in which the tissues in the joint break down over time). Review of the facility's Event Investigation Summary ([NAME]), dated 1/24/24, indicated that Resident 1 was found by staff to have her right hand bound with a mitten, surgical gloves, plastic bag and loosely secured to the side rail of her bed to prevent the resident from pulling her Nasogastric Tube (NGT - a feeding tube that goes through the nose, down the throat, and into the stomach to deliver formula or medicine) out. Further review of the [NAME] indicated, Staff Interviews . (name of CNA 4) worked on the night shift of 1/13/24. She was not assigned to (name of Resident 1) but assisted a nurse who was inserting a suppository. (CNA 4) saw the mitten on the right hand (but did not see the devises [sic] to restrain the resident's arm) . As a new CNA, orienting on the floor, (CNA 4) did not recognize the mitten as a restraint . (name of CNA 3) worked on am shift (AM shift - work hours from 7 AM to 3:30 PM) on 1/13/2. During her shift, she changed the resident's briefs twice. She saw the right hand tied but failed to report the restraint to nursing leadership due to her lack of knowledge that it was a restraint. Staff acknowledges oversite [sic] . During an interview on 2/1/24 at 11:31 AM, CNA 3 stated that on 1/13/24 during the AM shift, I saw resident's (Resident 1) right wrist tied with a towel and plastic bag and tied to the side rail on the bed. CNA 3 added, I did not report because I'm thinking she (Resident 1) used to take out the tube (NGT) and thought it was the reason her hand was tied to the bed. I did not know that the towel could be used as a restraint. During an interview on 2/1/24 at 4:35 PM, the Interim Director of Nursing stated, Most are saying they (CNAs) are new, but that is not reason to not report. They (CNAs) should be able to identify if something is used as restraint. It's expected for them to know if it's a restraint, it's part of their training. 2. During an interview on 2/1/24 at 11:31 AM, CNA 3 stated that she did know that she could report allegations of abuse to CDPH and the Ombudsman's Office. CNA 3 stated, I don't have the phone number. I don't know where it is. During an interview on 2/1/24 at 4:18 PM, Licensed Vocational Nurse (LVN) 1 stated that CNA 3 reported to her on 1/13/24, around 4 PM that Resident 1 was found tied to her bed. LVN 1 stated, Resident (Resident 1) was tied to the bed. I know it's abuse. LVN 1 confirmed that she did not report the incident to CDPH and the Ombudsman's Office, stating, I did not know that. During a concurrent interview and record review on 2/23/24 at 8:55 AM, the Director of Staff Development (DSD) provided a copy of an undated facility document, titled, General Orientation Checklist (GOC), indicating topics that include Adult Abuse Reporting and Elder Justice Act and Resident Rights, which include a video presentation on abuse by the DOJ. The DSD stated that identifying devices that can be used as restraints is included in orientation program for all nursing staff. The DSD stated, They (CNAs) should know (how to identify restraints), it's part of their training upon hire. The DSD also stated that all staff receive training on reporting of abuse during their orientation to the facility and during subsequent abuse in-service trainings. During an interview on 2/23/24 at 1:33 PM, the Administrator stated, If they (staff) see anything that could be abuse, they need to report to their supervisor immediately. Everybody is trained that they are mandated reporters, they can report to the state (CDPH) and the Ombudsman. Review of the facility policy, titled, Abuse Investigation and Reporting, revised on 7/2017, indicated Policy Statement: All reports of resident abuse .mistreatment . shall be promptly reported to local, state, and federal agencies (as defined by current regulations) . Policy Interpretation and Implementation .Reporting .2. An alleged violation of abuse, neglect, exploitation, or mistreatment . will be reported immediately, but not later than: a. Two (2) hours if alleged violation involves abuse .

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from the use of physical restraint (any device, equipment or material that cannot be easily removed by the resident and limits his/her freedom of movement or normal access to his/her body) for discipline purposes and staff convenience when CNA (Certified Nursing Assistant) 1 placed a mitten on Resident 1's right hand and tied her right hand to her bed. This failure had the potential to cause physical harm, pain or mental anguish to Resident 1. Findings: Resident 1 was admitted on [DATE] and was readmitted on [DATE], with diagnoses that include dysphagia (difficulty swallowing), dementia (impairment in the ability to remember, think, or make decisions that interferes with doing everyday activities), rheumatoid arthritis (chronic swelling and tenderness of joints and other parts of the body), and osteoarthritis (degenerative joint disease, in which the tissues in the joint break down over time). Review of Resident 1's physician's Progress Notes, dated 12/12/23 at 5:49 PM indicated, NGT (nasogastric tube - a feeding tube that goes through the nose, down the throat, and into the stomach to deliver formula or medicine) via right nostril. Review of Resident 1's minimum data set (MDS - a standardized assessment of a resident ' s functional capabilities and health needs), dated 12/13/23, indicated that Resident 1 was admitted with a feeding tube, had memory impairment, and was dependent on facility staff with activities of daily living. Review of the facility's Event Investigation Summary ([NAME]), dated 1/24/24, indicated that Resident 1 was found by staff to have her right hand bound with a mitten, surgical gloves, plastic bag and loosely secured to the side rail of her bed to prevent the resident from pulling her Nasogastric Tube (NGT) out. The [NAME] indicated that the incident occurred during the NOC shift (nocturnal/night shift - starts from 11 PM to 7:30 AM) from 1/12/24 to 1/13/24 at approximately 4:30 AM. Further review of the [NAME] indicated, Staff Interviews . (name of CNA 1) was the CNA on duty assigned at Noc (NOC) shift on 1/13/24 (starts at 11 PM on 1/12/24 and ends at 7:30 AM on 1/13/24). The resident was restless from the start of the shift, didn ' t sleep the whole night. She repositioned the resident and went to take vital signs of other residents, then stayed with the resident due to trying to remove her NGT and had episode of behavior, too. At about 4:30 AM, The resident was still restless with her hands. To prevent the resident from pulling out her NGT, (name of CNA 1) took the white mitten and placed it on her (Resident 1) right hand, which she uses in trying to remove her NGT and restrained it so she (CNA 1) could leave to make her final rounds. She (CNA 1) did not tell anyone about what she did. She did not endorse it to anyone. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3, on 2/1/24 at 9:45 AM, Resident 1 was in bed, covered with a blanket up to her chest. After requesting permission from Resident 1, LVN 3 lowered the blanket to show Resident 1's PEG tube (percutaneous endoscopic gastrostomy - the placement of a feeding tube through the skin and the stomach wall) that was loosely covered with a towel. LVN 3 stated, She (Resident 1) used to have NGT, now she's on g-tube (short for PEG tube). Review of Resident 1's history and physical, dated 1/29/24, indicated Resident 1 had recurrent problems with NGT feeding, now s/p (status post - after a procedure or surgery) PEG tube placement 1/25/24 for continued artificial nutrition. Review of Resident 1's Progress Notes, dated 1/13/24 at 4 PM, indicated CNA (referring to CNA 2, name redacted) found resident on [sic] restrained on right wrist tied on the side rail of bed; towel and plastic bag were used to restraint [sic] the right hand with mitten. During an interview on 2/1/24 at 11:31 AM, CNA 3 stated that on 1/13/24 during the AM shift (morning shift - work hours from 7 AM to 3:30 PM), I saw resident's (Resident 1) right wrist tied with a towel and plastic bag and tied to the side rail on the bed. During an interview on 2/1/24 at 2:10 PM, the Director of Staff Development (DSD) stated that during her phone interview with CNA 1 on 1/15/24, She (CNA 1) admitted it's her (CNA 1) fault, told me about her reason for tying the resident, wanted to prevent pulling of NGT and needed to do rounds of her residents before her shift ends. During an interview on 2/1/24 at 4:04 PM, CNA 2 stated that on 1/13/24, Around 4 PM, I saw she's (Resident 1) tied to the bed, right hand tied with plastic garbage bag, right hand in mitten (a soft padded device/s that covers the hand/s; used to restrict a person's use of their hands by placing either one or both hands within them), garbage bag wrapped around the right wrist, both ends of garbage bag tied to a towel, towel is tied to the rail (side rail). CNA 2 further stated, It's abuse when resident is tied to the bed, could cause bruising. She (CNA 1) should have asked for help or told the charge nurse. During a concurrent interview and record review on 2/1/24 at 4:18 PM, Licensed Vocational Nurse (LVN) 1 stated that on 1/13/24 around 4 PM, she received a report from CNA 2 that she (CNA 2) found Resident 1 tied to her bed. LVN 1 stated that when she went to Resident 1's room, she found Resident 1's right hand with a mitten, right wrist tied to the bed's side rail with a plastic bag and a towel. LVN 1 stated, I know it's abuse. We (facility staff) should not do that; it could cause injury to the resident. LVN 1 reviewed Resident 1's physician's orders for January 2024 and stated, I don't see any order (for restraint). During an interview on 2/1/24 at 4:35 PM, the Interim Director of Nursing (IDON) stated, It was a restraint (referring to the use of a mitten and tying Resident 1's hand to the bed). Restraint without a doctor's order is abuse. There was no order for restraint (for Resident 1). The IDON also stated that the application of restraint to Resident 1 could result to either she (Resident 1) will end up with bruising or skin tear, or compromised skin integrity. During an interview on 2/20/24 at 8 AM, LVN 2 stated, I spoke with her (CNA 1) on 1/13/24. She (CNA 1) admitted she tied the resident (Resident 1) to her bed to prevent her (Resident 1) from pulling out her NGT. LVN 2 stated, They (CNAs) are not supposed to make such decisions by themselves, they have to report to the charge nurse. They should know what to do, they know they're not supposed to do that. During an interview on 2/23/24 at 11:17 AM, the Social Service Director (SSD) stated, Patient (Resident 1) will be at risk of trauma, it might affect her mentally, emotionally, as a potential result of tying Resident 1 to her bed. Review of the facility policy and procedure (P&P), titled, Use of Restraints, revised on 4/2017, indicated Policy Statement . Restraints shall only be used to treat the resident(s) medical symptoms and never for discipline or staff convenience, or for the prevention of falls. Policy Interpretation and Implementation: 1. Physical Restraints are defined as any manual, method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . 3. Examples of devices that are/may be considered physical restraints include . hand mitts, soft ties . that the resident cannot remove . Review of the facility P&P, titled, Resident Rights, revised on 12/2016, indicated Policy Statement - Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse . d. be free from .physical or chemical restraints not required to treat the resident's symptoms . Review of the facility P&P, titled, Bed Safety, revised on 12/2007, indicated Policy Interpretation and Implementation .12. The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals .

Based on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) and the local Ombudsman within the required two-hour period for one of three sampled residents (Resident 1) when CNA (Certified Nursing Assistant) 1 placed a mitten on Resident 1's right hand and tied her right hand to her bed. This failure had the potential to cause delay in the abuse investigation and increased risk of harm to the residents by placing Resident 1 at risk for potential repeated abuse, and other residents at risk for potential abuse. Findings: Review of the facility's Event Investigation Summary ([NAME]), dated 1/24/24, indicated that Resident 1 was found by staff to have her right hand bound with a mitten, surgical gloves, plastic bag and loosely secured to the side rail of her bed to prevent the resident from pulling her Nasogastric Tube (NGT - a feeding tube that goes through the nose, down the throat, and into the stomach to deliver formula or medicine) out. The restraint was discovered by (name of staff redacted) at 4 PM on January 13, 2024 . Review of the facility's fax Transmission Verification Report to CDPH and the Ombudsman's Office, indicated that the facility reported the alleged incident to CDPH on 1/17/24 at 5:20 PM and the Ombudsman's Office on 1/17/24 at 5:23 PM, four (4) days after the facility discovered the alleged incident. Resident 1 was admitted on [DATE] and was readmitted on [DATE] with diagnoses that include dysphagia (difficulty swallowing), dementia (impairment in the ability to remember, think, or make decisions that interferes with doing everyday activities), rheumatoid arthritis (chronic swelling and tenderness of joints and other parts of the body), and osteoarthritis (degenerative joint disease, in which the tissues in the joint break down over time). During a concurrent interview and record review on 2/1/24 at 4:18 PM, Licensed Vocational Nurse (LVN) 1 stated that on 1/13/24, around 4 PM, she received a report from CNA 2 that she (CNA 2) found Resident 1 tied to her bed. LVN 1 stated that when she went to Resident 1's room, she found Resident 1's right hand with a mitten, right wrist tied to the bed's side rail with a plastic bag and a towel. LVN 1 stated that she immediately released Resident 1 from the restraint and immediately called the Director of Nursing (DON). LVN 1 stated, I know it's abuse. We (facility staff) should not do that; it could cause injury to the resident. LVN 1 reviewed Resident 1's physician's orders for January 2024 and stated, I don't see any order (for restraint). During an interview on 2/1/24 at 4:35 PM, the Interim Director of Nursing stated, It was a restraint (referring to the use of a mitten and tying Resident 1's hand to the bed). Restraint without a doctor's order is abuse. There was no order for restraint (for Resident 1). During an interview on 2/20/24 at 8 AM, LVN 2 stated, On 1/13/24, past 4 PM, I was told by (CNA 2 and LVN 1, names redacted) that they found Resident 1 tied to her bed with a towel and a plastic bag. LVN 2 also stated, Around 5 PM, the DON called me and asked what was happening. I told her of the situation and since she is now aware, I asked her to do the reporting (to CDPH and other appropriate authorities). During an interview on 2/24/23 at 1:33 PM, the Administrator confirmed that the DON or any of the staff did not report the alleged incident to CDPH and the Ombudsman's Office within the required two-hour timeframe. The Administrator stated that it was not until 1/17/24 that he was informed by the DON that the alleged incident has not been reported to CDPH and the Ombudsman's Office. Review of the facility policy and procedure, titled Abuse Investigation and Reporting, revised on 7/2017, indicated Policy Statement - All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation .Role of the investigator: .3. The investigator will notify the ombudsman that an abuse investigation is being conducted . 4. The investigator will consult daily with the Administrator concerning the progress/findings of the investigations . Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property, will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman .2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury .

Based on observation, interview, and record review, the facility failed to implement its infection control and prevention practices during a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak when: 1. The Licensed Nurse 1 (LN1) did not wash hands before wearing gloves and before entering the room of four residents, Resident 1 (R1), Resident 2 (R2), Resident 3 (R3) and Resident 4 (R4), who were on transmission-based precautions (TBP - used in addition to standard precautions for patients who are known or suspected infections with pathogens that can be transported by airborne, droplet, or contact routes). 2. The LN1 did not remove the surgical mask and put on an N95 respirator (a respiratory protective device designed to protect against particulate matter such as dust, fumes, mists, aerosols, and smoke particulates) and face shield (to protect eyes, nose, mouth and face from flying objects and liquids) before entering the room of four residents, R1, R2, R3, and R4, who were on TBP. 3. The door of the room of four residents, R1, R2, R3, and R4 was left wide open who were on TBP. This failure of the facility had the potential for the spread of infection that can jeopardize the health of residents, staff, and visitors. Findings: During an observation on 2/1/24 at 10:09AM in the hallway, LN1 did not wash hands and wear proper Personal Protective Equipment (PPE- protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission), merely donning (simply putting on) gloves, and a gown instead of N95 respirator and face shield before entering the room of four residents, R1, R2, R3, and R4 who were on TBP. During an observation on 2/1/24 at 11:26AM in the hallway, the door of the room of four residents, R1, R2, R3, and R4 was left wide open who were on TBP. The TBP sign was posted at the side of the doorframe. The TBP sign titled, Enhanced Respiratory and Contact Precautions indicated, . Keep Door Closed at All Times . During a concurrent observation and interview on 2/1/24 at 11:37PM with LN1 in the hallway, LN1 washed his hands, put on gloves and a gown, kept wearing a black surgical mask, didn't put on the required N95 respirator and face shield, held a rectangular container with medications in it, and was trying to get into the room of four residents, R1, R2, R3, and R4, who were on TBP. A PPE supply set-up was observed outside the room. The door was open and had a sign posted on the wall beside the door frame indicating, Enhanced Respiratory and Contact Precautions indicated, . All Staff Must Wear: Gown, Respirator: N95 or higher level respirator, Eye protection: Goggles or face shield, Gloves . LN1 stated, I didn't wear an N95 respirator and an eye shield when trying to get inside this room, I forgot, and I should have. It is important to wear proper PPE to protect the residents since they are immunocompromised and to protect me and other residents that I might expose . It is important to wash hands before entering and when leaving the residents on isolation room to prevent the spread of infection. During an interview with the Director of Nursing (DON) on 2/1/24 at 2:10PM, the DON stated, It is important to follow and wear proper PPE to prevent the spread of infection. PPE should depend on the kind of isolation the resident is in, if it's on enhance respiratory and contact precaution, staff must wear, gown, N95, face shield and gloves, should wash hands before entering and leaving the room. During a review of the facility's census, dated 2/1/24, it was indicated that R1, R2, and R3 were being monitored for signs and symptoms to rule out COVID-19 due to an exposure from their roommate R4, who was on isolation for COVID-19 from 1/26/2024-2/5/2024. During a review of facility's policy and procedure titled, Isolation- Categories of Transmission- Based Precautions, revised January 2012, indicated, .Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others . Droplet Precaution: Resident Placement,1. Place the resident in the private room if possible. 2. When private room is not available, residents with the same infection with the same microorganisms but with no other infection maybe cohorted. 3. When private room is not available and cohorting is not achievable, use a curtain and maintain at least 3 feet of space between the infected resident and other residents and visitors . During a review of facility's policy and procedure titled, Infection Control Guidelines for All Nursing Procedures, revised August 2012, indicated, .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection .Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or potentially infectious materials . During a review of facility's policy and procedure titled, Hand Washing/Hand Hygiene, revised August 2015, indicated, .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: Before and after entering isolation precaution settings . During a review of the National Institute for Occupational Safety & Health (NIOSH), Donning and Doffing PPE: Proper Wearing, Removal, and Disposal, revised October 3, 2022, indicated, .Donning means to put on and use PPE properly to achieve the intended protection and minimize the risk of exposure. Doffing means removing PPE in a way that avoids self-contamination . Follow strict donning and doffing procedures, for highly infectious agents: Always wash hands with soap and water before wearing and after removal of PPE .

Based on interview and record review, the facility failed to ensure behavioral monitoring for one of three residents reviewed. (Resident 1) This failure had resulted to Resident 1 had eloped from the facility on 7/03/23 sustained mid nose abrasion and then was sent to acute hospital for evaluation. Findings: During record review of Resident 1 ' s clinical record, Resident 1 was admitted on [DATE] with diagnoses of congestive heart failure (heart cannot supply enough blood for the body), dementia (memory loss), metabolic encephalopathy (brain dysfunction due to metabolism). Review of Resident 1 ' s care plan dated 6/12/23 addressing falls indicated Monitor every two hours Review of Resident 1's treatment administration record dated 6/2023, indicated there was no evidence of documentation Resident 1 was monitored every two hours. Interview with director of nursing (DON) on 9/01/23, at 2:45 pm, DON acknowledged that there was lack of documentation that Resident 1 was monitored every two hours. During interview with Registered Nurse 1 (RN) on 8/11/23 at 10:58am, stated Based on my assessment I knew that resident is a risk for elopement and needed supervision. I told Director of Nursing (DON) and I was redirected to Assistant Director of staff development (ADSD) the need for sitter, and I was told that no one was available. Review of the facility Policy and Procedure (P&P) dated March 2018 titled Falls, Clinical protocol indicates 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.

Based on interview and record review, the facility failed to provide food prepared in a form designed to meet resident's individual needs for one of three residents reviewed (Resident 2). This failure had the potential to result to Resident 1's choking accident. Findings: During review of Resident 2's clinical record, indicated, Resident 2 was admitted with diagnoses included dementia (memory loss), anxiety (feeling of fear) and dysphagia (difficulty of swallowing). During an interview with registered nurse 2 (RN 2) on 8/08/2023 at 2:37 PM, RN 2 stated that there were times facility staff were not serving the appropriate meal because it was not matched to the meal ticket. Sometimes the physician changes the diet order after hours however the dietary supervisor do not update on their system. During review of the speech therapist note dated 3/24/2023, indicated discharge recommendations, Diet- Mechanical Soft textures, Thin liquids To facilitate safety and efficiency, it is recommended the patient use the following strategies and/or maneuvers during oral intake: general swallow techniques /precautions upright posture during meals and upright posture for >30mins after meals. Review of the physician's order dated 3/27/2023, diet order indicated Regular diet, pureed texture, nectar thick consistency. There was a discord between physician's diet order and speech therapist diet recommendation.

Based on interview and record review, the facility failed to develop and implement an effective discharge care plan for one of three residents reviewed. (Resident 2) This failure resulted to Resident 2's home health care needs not being identified and met. Findings: During review of Resident 2 ' s clinical record, Resident 2 was admitted on [DATE] with diagnoses included displaced fracture (Broken bone), Transient ischemic attack (temporary disruption of blood flow to brain), Depressive disorder (feeling of sadness, hopelessness and loss of interest). Review of Resident 2 ' s Care plan dated 12/20/20 addressing discharge plan indicated Wishes to return home. Resident of Resident 2 ' s Care plan dated 12/21/20 addressing discharge plan indicated Discuss Progress towards goals with resident and family/representatives chosen, Prepare documents to be sent with resident and representatives on discharge, provide resident and representative education on medications, diet, treatments, prior to/at discharge, Will offer and provide assistance as needed for safe and better dc. There was no comprehensive person-centered interventions that included referral and coordination to home health care. During an interview with social services worker (SW) on 8/2/23 at 10:17 am, stated We should indicate specific interventions on care plan. It should be indicated on the care plan that a referral to home health will be done. Assist patient with DME ordering, indicate specific orders of MD. Review of Facility ' s Policy and procedure (P&P) titled, Transfer or Discharge, preparing a resident for dated December 2016 indicated 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Review of The facility ' s policy and procedure (P&P) titled, care plans, comprehensive person-centered dated December 2016, indicated, 8.The comprehensive, person-centered care plan will:b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on Interview and record review, the facility failed to ensure one of three residents reviewed (Resident 2) had received treatment and care in accordance with professional standards of practice, when Resident 2 had no comprehensive person-centered care plan to address risk of bleeding. This failure had resulted to Resident 1 was transferred to hospital on 11/22/21 and 11/23/21 due to left hand bleeding laceration. Findings: During review of Resident 2's clinical record, Resident 1 was admitted on [DATE] with diagnoses included dysphagia (difficulty in swallowing), cerebral infarction (disrupted blood flow to brain) and gastrostomy (GT, opening into the stomach) . Review of Resident 2's physician order dated 11/19/21 indicated Xarelto tablet 20 mg, give 1 tablet via Peg tube one time a day for atrial fib. Review of Resident 2's change in condition note dated 11/21/21, indicated Resident 2 was seen with skin flesh protrusion at L hand in between first and second fingers at around 15:00 . Skin condition was relayed to Dr. [NAME] by the tx nurse and received an order t clense with wound cleanser, put pressure and apply triple atb ointment then dry dressing and wrap with kerlix. MD also ordered to transfer to [NAME] ED if bleeding does not stop. Pressure dressing applied. At 21:40, dressing was saturated. Called Royal ambulance and spoke with Anasthasia from BLS transportation to [NAME] ED. 04:00 am is the ETA of the BLS. Review of Resident 2's care plan dated 11/22/2021to address laceration between first and second fingers with sutures indicated treatment as ordered, monitor s/s of infection. Notify MD/RP PRN, meds as ordered. There was no comprehensive person- centered intervention included. Review of Resident 2's change of condition evaluation dated 11/23/21, indicated third, fourth, fifth finger laceration Review of Resident 2's interdisciplinary note dated 11/23/21, indicated Upon further Investigation and review, laceration likely caused by resident wrapping the GT tubing tightly around his left hand and GT connector tip causing injury to self. Resident has significant edema to L hand since admission, leading to fragile skin and high risk for skin breakdown. Review of the care plan dated 11/19/21 to address risk of bleeding indicated Administer medications as ordered. Obtain labs as ordered by MD. Handle resident Gently during care . There was no comprehensive person-centered intervention included to address risk of bleeding. During interview with assistant director of nursing (ADON) on 8/1/23 at 1:11 p.m., stated this should have been called to 911, when the bleeding saturated the dressing. ADON stated because it is hemorrhaging, and we cannot control the bleeding and the patient continues to have blood loss in the facility. ADON stated care plan should have indicated exact interventions that was done and ordered for it to be individualized ADON stated we would indicate care plan interventions to prevent further injury like ask order to wrap the hand. Review of the facility ' s policy and procedure (P&P) titled, Transfer or Discharge, Emergency dated December 2016 indicated, a.The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;

Based on food preparation observations, dietary management staff interview and departmental document review, the facility failed to ensure correct portioning for greater than 90 residents when the dessert for the noon meal was not prepared using the proper scoop size. Consistently providing incorrect food portions may result in over or undernutrition further compromising medical status. Findings: During general food production observations on 07/17/23 at 09:17 AM, Dietary Staff 1 was portioning butterscotch pudding, the noon dessert, into individual bowls using a scoop with an ivory handle. In a follow up observation and interview, in the dish room, on 07/17/23 at 10:20 AM, with the Director of Food Services (DFS) it was noted there was a clean/sanitized ivory scoop drying on the wire rack. The DFS identified the scoop size as a #10, which equated to a serving size of 3 ounces. Review of facility document titled Daily Spreadsheet dated 07/17/23 guided staff to utilize a #8 scoop, which would have equated to 4 ounces of dessert. 38614

Based on interview and record review the facility failed to implement the pain management for one out of three sampled residents (Resident 1) when: 1. Pain assessment were not done before and/or after pain medication administration. This failure had the potential to administer incorrect doses and inaccurately assess the effectiveness of the pain medications which could negatively affect the resident's quality of life. 2. The physician was not notified for severe pain according to the plan of care. The deficient practice resulted to Resident 1 requiring transfer to the acute care hospital on [DATE] for uncontrolled pain on the right leg. Definitions: Pain Management is defined in the facility policy as the process alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Pain Scale (PS) is developed to help medical observers assess the level of pain. There are many different kinds of pain scales, but a common one is a numerical pain scale (NPS) from 0 to 10. Findings: 1. Record review of the Admission Record (AR) indicated Resident 1 was admitted on [DATE]. The Admission History and Physical Notes (H & P) dated 4/17/19 indicated a [DIAGNOSES REDACTED]. The Minimum Data set (MDS an assessment tool) dated 5/2/19, Section C0200, Brief Interview for Mental Status (BIMS) indicated Resident 1 was oriented to year, date, and month, was able to remember words correctly, and was able to recall after cueing. During an interview on 1/16/20 at 2:25 PM, the DON stated the staff needed pain scale, as part of the pain assessment, to determine the correct dose to give. During a review of the May, 2019 Physician's Orders indicated: [MEDICATION NAME] 5 mg (milligrams) give 1 (one) tab . for moderate pain. [MEDICATION NAME] 5 mg give 2 (two) tabs as . for severe pain. During a review of the May, 2019 Physician's Orders indicated, Monitor pain level . 5-8= moderate and 9-10= severe and call the M.D. (physician). During a review of the May, 2019 Medication Administration Record [REDACTED] On 5/28/19 at 4:45 AM, No documented preassessment of pain level. [MEDICATION NAME] 5 mg two tablets were given. Post assessment of pain showed c (with) help; On 5/28/19 at 10 AM, there was no documented preassessment of pain level. [MEDICATION NAME] 5 mg two tablets were given. Post assessment of pain showed c (with) help. During a review of the Physician's Order dated 6/4/19 at 12:00 noon indicated, DC (discontinue) [MEDICATION NAME]. [MEDICATION NAME] 5-325 mg 1 (one) tab . for moderate pain. [MEDICATION NAME] 5-325 mg 2 (two) tabs . for severe pain. During a review of the June, 2019 Physician's Orders indicated, Monitor pain level . 5-8= moderate and 9-10= severe and call the M.D. During a review of the June, 2019 MAR indicated [REDACTED] On 6/6/19 at 8:10 AM, the pain level preassessment was at 9/10 before the pain medication was given. [MEDICATION NAME] 5/325 mg two tablets were given. The post assessment of pain showed, c (with) relief. There was no pain scale documentation. On 6/13/19 at 10:45, the pain level preassessment was at 9/10 before the pain medication was given. [MEDICATION NAME] 5/325 mg two tablets were given. The post assessment of pain showed, c (with) relief. There was no pain scale documentation. On 6/17/19 at 2:30 AM, the pain level preassessment was at 10/10 before the pain medication was given. [MEDICATION NAME] 5/325 mg two tablets were given. The post assessment of pain showed, c (with) help. There was no pain scale documentation. On 6/26/19 at 5 AM, the pain level preassessment was at 8/10 before the pain medication was given. [MEDICATION NAME] 5/325 mg two tablets were given. The post assessment of pain showed, c (with) help. There was no pain scale documentation. During a review of the Physician's Order dated 7/3/19 at 8:00 PM indicated, [MEDICATION NAME] 10-325 mg tablet: give 1/2 tab . for moderate pain, give 1 (one) tab . for severe pain., signed and dated by the physician on 10/26/19. During a review of the Physician's Orders date 7/2/19 at 1:50 PM indicated: Start [MEDICATION NAME] 5 mg 1 (one) tab . breakthrough pain., signed by the provider (Nurse Practitioner) on 7/2/19. During a review of the July, 2019 Physician's Orders indicated: Monitor pain level . 5-8= moderate and 9-10= severe and call the M.D. During a review of the July, 2019 MAR indicated [REDACTED] On 7/8/19 at 8:00 AM, [MEDICATION NAME] 10-325 mg one tablet was given. There was no documented pain assessment before or after the pain medication was given. On 7/10 19 at 9:00 PM , the preassessment of pain level was documented at 8/10. [MEDICATION NAME] 10-325 mg one tablet was given. The post assessment of pain level was documented as c (with)help. On 7/11/19 at 1:00 AM, there was no documented preassessment of pain level before [MEDICATION NAME] 5mg tablet was given. The post assessment of pain level was documented as c help. On 7/12/19 at 4:35 AM, the preassessment of pain level was 8/10 before [MEDICATION NAME] 10-325 mg one tablet was given. The post assessment of pain level showed, c help. During concurrent review of the April, May, June, and July, 2019 MARs and interview on 1/8/20 at 3:20 PM, the Director of Nursing (DON) acknowledged the pain assessments were not documented on 7/8/19 and on 7/11/19 she said the word with help meant it was up to the nursing judgment. During an interview on 1/8/20 at 3:50 PM, the License Vocational Nurse (LVN) 1 explained the word with help could mean, pain was less or no pain. During an interview on 1/8/20 at 3:55 PM, LVN 2 explained with relief or with help could mean pain was not completely gone. During a review facility policy titled Pain Assessment and Management with the last effective date of June, 2016, it indicated: Purpose: The purposes . are to help staff identify pain . to develop interventions that are consistent with the resident's goal and needs . Procedure: 1. The pain management program is based on . facility commitment to resident's comfort. 6. Assess the resident's pain and consequences of pain . Assessing Pain: 1. 2. assess pain using a consistent approach and a standardized pain assessment instrument . Monitoring and Modifying Approaches: 1. Re- assess resident's pain . 3. Monitor the resident by performing a basic assessment . with standardized assessment tools (e.g. approved pain scale . During a review of the facility policy titled Clinical Pain Protocol with the last revised date of 3/18 indicated: Assessment and Recognition: 1. 3. The staff . will identify pain . : a. Staff will use a consistent approach and standardized pain assessment instrument appropriate to the resident's cognitive level. Monitoring: 1. The staff will reassess the individual's pain . 2. Review of the resident's nursing care plan indicated: On 4/16/19, the resident was identified with a problem of At risk for pain. The goal showed Episode of pain will be resolved by 7/19. The Approach Plan showed, Assess location . Administer pain medication as ordered; Assess effectiveness .Notify MD . [MEDICATION NAME] as ordered ; Tylenol as ordered. During a review of the May, 2019 Physician's Orders indicated: [MEDICATION NAME] 5 mg give 1 (one) tab . for moderate pain. [MEDICATION NAME] 5 mg give 2 (two) tabs as . for severe pain. During a review of the May, 2019 Physician's Orders indicated, Monitor pain level . 5-8= moderate and 9-10= severe and call the M.D. (physician). During a review of the May, 2019 Medication Administration Record [REDACTED] On 5/8/19 at 4:40 AM, two tablets of [MEDICATION NAME] 5 mg were given for severe pain at 10/10 pain scale; On 5/8/19 at 9:00 AM, two tablets of [MEDICATION NAME] 5 mg were given for severe pain at 10/10 pain scale; On 5/26/19 at 1:00 PM, two tablets of [MEDICATION NAME] 5 mg were given for severe pain at 9/10 pain scale. During a review of the Physician's Order dated 6/4/19 at 12 noon indicated, DC (discontinue) [MEDICATION NAME]. [MEDICATION NAME] 5-325 mg 1 (one) tab . for moderate pain. [MEDICATION NAME] 5-325 mg 2 (two) tabs . for severe pain. During a review of the June, 2019 Physician's Orders indicated, Monitor pain level . 5-8= moderate and 9-10= severe and call the M.D. During a review of the June, 2019 MAR indicated [REDACTED] On 6/17/19 at 2:30 AM, two tablets of [MEDICATION NAME] 5-325 mg were given for severe pain at 10/10 pain scale; 6/21/19 at 12AM, two tablets of [MEDICATION NAME] 5-325 mg were given for severe pain at 10/10 pain scale; On 6/21/19 at 2:09 PM, two tablets of [MEDICATION NAME] 5-325 mg were given for severe pain at 9/10 pain scale; On 6/28/19 at 3:30 AM, two tablets of [MEDICATION NAME] 5-325 mg were given for severe pain at 10/10 pain scale. During a review of the Physician's Order dated 7/3/19 at 8:00 PM indicated, [MEDICATION NAME] 10-325 mg tablet: give 1/2 tab . for moderate pain, give 1 (one) tab . for severe pain., signed and dated by the physician on 10/26/19. During a review of the July, 2019 Physician's Orders indicated: Monitor pain level . 5-8= moderate and 9-10= severe and call the M.D. During a review of the July, 2019 MAR indicated [REDACTED] On 7/1/19 at 2:00 PM, one tablet of [MEDICATION NAME] 10-325 mg was given for severe pain at 10/10 pain scale; On 7/5/19 at 12:30 AM, one tablet of [MEDICATION NAME] 10-325 mg was given for severe pain at 10/10 pain scale; On 7/6/19 at 3:30 PM, one tablet of [MEDICATION NAME] 10-325 mg was given for severe pain at 9/10 pain scale; On 7/7/19 at 9:30 PM, one tablet of [MEDICATION NAME] 10-325 mg was given for severe pain at 9/10 pain scale. During an interview on 1/14/20 at 9:32 AM, the DON could not provide any evidence the physician was notified when Resident 1 complained of severe pain at 10/10 pain scale on the dates mentioned above during the months of May, June, and July, 2019. During a review of the policy titled Clinical Protocol for Pain with the last revised date of 2/18 it indicated, Assessment and Recognition: 1 .Treatment/Management: 1 . 2. The physician will order appropriate . medication . Monitoring: 1 . 2. The staff will . report the resident's . PRN [MEDICATION NAME] . During a review of the facility policy titled Comprehensive Care Plans with the last revised date of 9/2010, indicated: An individualized comprehensive care plan . is developed for each resident. Policy Interpretation/Implementation: 1 .5. Care plan interventions are designed . consideration of the relationship between the resident's problem areas and their causes. 6. Identifying problem areas . developing interventions that are targeted and meaningful to the resident . During a review of the Situation Background Assessment Request (SBAR) document dated 7/12/19 at 7:40 PM, indicated uncontrolled pain 10/10 leg pain bilateral (both legs), resident is requesting to be transfer to hospital, and transfer to ED (Emergency Department) via 911 d/t (due to) uncontrolled pain. During a review of the Emergency Department Notes dated 7/12/19 indicated Resident 1 presented with progressively worsening right foot/ankle/distal lower leg pain for the last several days. The section on Radiology Studies indicated CT scan (a computerized tomography scan (CT or CAT scan) uses computers and rotating X-ray machines to create cross-sectional images of the body) was done on 7/12/19 and the result of the imaging study was, concerning for gas forming infection, and the [DIAGNOSES REDACTED]., caused by a break in the skin or mucous membrane that fails to heal) right lower leg., electronically signed and dated by the physician on 7/13/19 at 12:09 AM.