Every finding on record at Golden Rose Care Center

Based on observation, interview, and record review, the facility failed to ensure the call light (a communication system that the residents use to ask nurses or staff for help) was within resident's arm's reach for one (1) of four (2) sampled residents (Resident 2) who was assessed to be dependent (helper does all the effort) with lower body dressing and need partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene in accordance with the facility's policy. This deficient practice resulted in Resident 2 not being able to call the facility staff for assistance in changing his soiled diaper and had the potential for the resident not to be able to call the facility staff for help especially during an emergency. Findings: During a review of Resident 2's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included bone density disorder (the bones are losing their strength and minerals, making them thin, fragile, and easily breaks) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition caused by brain injury that results in a varying degree of weakness, stiffness, and a lack of control in one side of the body). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 6/30/2026, the MDS indicated Resident 2 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 2 was dependent with lower body dressing and putting on/taking off footwear and required substantial/maximal assistance (helper does more than half the effort) with toileting, shower, upper body dressing. The MDS further indicated Resident 2 required partial/moderate assistance with oral and personal hygiene and required supervision (helper provides cues) with eating. During a review of Resident 2's Care Plan, revised on 1/27/2026, the Care Plan indicated the resident was at risk for fall due to gait (the manner or pattern of how someone walks, runs, or moves on foot) and balance problems and generalized weakness and included an intervention to ensure the resident has a working and reachable call light. The Care Plan also indicated anticipating and ensuring Resident 2's needs are met. During another review of Resident 2's Care Plan, revised on 1/27/2026, the Care Plan indicated the resident was at risk for fall related to unsteady gait and an intervention to provide assistance with transferring and locomotion (a person's ability to move from 1 place to another independently) as needed. During a review of Resident 2's Fall Risk Assessment (a nursing tool that uses a scoring system to evaluate resident's risk of fall), dated 6/23/2026, the Fall Risk Assessment indicated Resident 2 was high risk for fall due to muscle and strength weakness, gait and balance disorders and history of falls. During a concurrent observation inside the resident's room and interview on 8/14/2026 at 9:16 AM, Resident 2 was heard yelling for help and no visible light from outside the resident's room to alert the staff. Resident 2 stated his diaper was wet 15 minutes ago and was calling to have his diaper changed. Surveyor did not observe a call light within the resident's reach. Resident 2 also stated he did not know where his call light was. During an observation in Resident 2's room on 8/14/2026 at 9:18 AM, the Registered Nurse (RN) entered Resident 2's room to look for the resident's call light after being approached by the surveyor from the hallway. RN looked for Resident 2's call light and found it on the head part of the bed towards the back and out of the resident's reach. During an interview on 8/14/2026 at 12:51 PM, the Licensed Vocational Nurse (LVN) stated Resident 2 should have his call lights somewhere close to him where it was accessible and within the resident's reach for emergency purposes and if the resident needed help and assistance with anything. During an interview on 8/14/2026 at 1:21 PM, the RN stated Resident 2's call light was not placed within the resident's reach and should be within the resident's reach to prevent falls if the resident would try to get up to ask for assistance and because the resident is unsteady on his feet. RN also stated Resident 2 needs to have his call lights within his reach to be able to request help from the staff. During a review of the facility's Policy and Procedure (P&P) titled, Communication - Call System, revised 10/24/2022, the P&P indicated its purpose was to provide a mechanism for residents to promptly communicate with nursing staff. The P&P also indicated that the call cords (call light) will be placed within the resident's reach in the resident's room.

Based on interviews, and record reviews, the facility failed to provide treatment and care in accordance with the professional standards of practice (the established rules, guidelines, and expectations that define the level of competence, ethical conduct, and quality required from individuals working within a specific field) for one (1) of two (2) sampled residents (Resident 1) who were having diarrhea (loose, watery, or liquid bowel movements 3 or more times in a single day) episodes by:The facility did not notify the physician of Resident 1's Change of Condition (COC, any significant or sudden change in a resident's physical, mental, behavioral, or functional health compared to their normal baseline) of diarrhea noted 7/23/2026. The facility did not notify the physician to obtain an order or review treatment plan related to the use of Resident 1's GlycoLax (a laxative- a drug used to treat occasional constipation by retaining water in the stool to soften it and ease bowel movement) powder 17 grams (unit of weight used to measure how much active medicine is in a dose) when Resident 1 was noted to have diarrhea on 7/23/2026. Developed a baseline and/or comprehensive care plan to address Resident 1's loose bowel movement more than three times noted on 7/23/2026. These deficient practices may result in Resident 1's continued episodes of diarrhea which could potentially lead to severe dehydration (a life threatening medical emergency where the body has lost so much water and salt that it can no longer keep your blood pressure stable, pump blood properly, or keep your organs working) and dangerous electrolyte imbalance (when the body has too much or too little of certain minerals that are vital for the body's functions) affecting the health and well-being of the resident. Findings:During a review of Resident 1s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (an abnormal, uncontrolled growth of cells that can invade surrounding tissue and spread to other parts of the body), muscle wasting and atrophy (a decrease in muscle mass, often due to an extended period of immobility) and protein calorie malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 7/26/2026, the MDS indicated Resident 1 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing, and putting/taking off footwear and required partial/moderate assistance (helper does less than half the effort) with personal hygiene, and upper body dressing. The MDS further indicated Resident 1 required supervision (helper provides cues) with eating and oral hygiene. During a review of Resident 1's Physicians order dated 7/20/2026 at 8:37 PM, the Physicians order indicated GlycoLax powder 17 grams by mouth once a day for bowel management. The Physicians order also indicated to hold for loose stools. During a review of Resident 1's Bowel and Bladder elimination tasks for the month of July, the Bowel and Bladder elimination records indicated the resident was incontinent (loss of bowel control resulting in accidental leaks of stool) and the reisdent had 3 large loose (diarrhea (bowel movement) on 7/23/2026 at 12:41 AM, 1:35 PM, and 11:55 PM, During a review of Resident 1's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of July 2026, the Medication administration record indicated GlycoLax powder 17 gm was administered on 7/23/2026 and 7/24/2026 at 9 AM. During an interview on 8/14/2026 at 9:28 AM, Resident 3 was lying in bed and stated Resident 1 had diarrhea and the staff were changing Resident 1 all the time. During an interview on 8/14/2026 at 11:42 AM, Certified Nursing Assistant 1 (CNA 1) stated she was assigned to Resident 1 for four (4) days and the resident had at least 2 - three (3) large loose bowel movements (BMs) on her shift sometimes early in the morning and before breakfast which would often leak out of the resident's diaper and to her legs even when the resident was in bed. During an interview on 8/14/2026 at 12:51 PM, the Licensed Vocational Nurse (LVN) stated the licensed staff should have notified the physician and Infection Prevention Nurse (IPN) for Resident 1's episodes of diarrhea noted on 7/23/2026 and follow the facility's policy. LVN also stated the licensed staff should not have given Resident 1's GlycoLax powder if the resident has loose stools to prevent diarrhea which could lead to problems like dehydration. During an interview on 8/14/2026 at 1:21 PM, Registered Nurse (RN) stated the CNAs should notify the charge nurses when any of the residents had diarrhea. RN also stated a COC should be done when the resident had 3 episodes of loose BM and the physician should have been notified to see if the resident would need to be treated and isolated and or any changes with the medication order. RN also stated the licensed staff should have held the laxatives when Resident 1 had loose BMs to prevent it from getting worse. RN also stated Resident 1 could get dehydrated from losing so much water from the loose BMs. During a concurrent interview and record review of Resident 1's pre-admission records received by the facility on 7/20/2026 from General Acute Care Hospital (GACH) with the IPN on 8/14/2026 at 3:20 PM, IPN stated the report from the GACH indicated Resident 1 was treated for the clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea). IPN also stated the staff did not report to her that Resident 1 had diarrhea and should have been notified so she could check if the diarrhea was related to C. diff. IPN further stated if a resident had 3 episodes of loose BM the physician should be notified and put the laxatives on hold for loose BMs as indicated in the physician's orders. During a concurrent interview and review of Resident 1's Electronic Medical Record (EMR, an electronic version of the resident's medical history that is maintained by the provider over time) dated from 7/23/2026 to 7/28/2026, with the DON on 8/14/2026 at 3:46 PM, the EMR did not indicate a Care Plan was initiated on the resident's diarrhea episodes. During an interview on 8/14/2026 at 4:17 PM, CNA 2 stated he worked 3 to 11 shift (unable to recall date) and had been assigned to Resident 1. CNA 2 also stated Resident 1 was incontinent with loose BM for at least 3 times on his shift and had notified the charge nurse. During an interview on 8/14/2026 at 4:36 PM, the Director of Nursing (DON) stated the licensed staff should have done a COC on Resident 1 regarding the episodes of diarrhea and notified the physician to ensure the resident received proper treatment and medications. The DON also stated the physician notification is important to ensure the physician could review, hold, or discontinue Resident 1's current medications that might cause the resident's diarrhea. The DON added Resident 1 should have a Care Plan initiated related to the resident's diarrhea noted on 7/23/2026 to ensure the staff would be able to provide proper care and intervention to the resident. During a review of the facility's Policy and Procedure (P&P) titled, Change of Condition Notification, revised 6/1/2017, the P&P indicated the facility ensures that the resident's physicians are informed of changes in the resident's condition in a timely manner. During a review of the facility's P&P titled, Medication - Administration, revised 6/1/2017, the P&P indicated that the facility provides practice standards for safe administration of medications for residents in the facility. The P&P also indicated the licensed nurse must know the precautions and special considerations about any medication they are administering. During a review of the facility's P&P titled, Care Planning, revised 6/12/2025, the P&P indicated that the facility ensures that a comprehensive person-centered care plan is developed based on the resident's assessed needs. The P&P also indicated the facility's Inter Disciplinary Team (IDT, comprised of team members from different disciplines working together, with a common purpose, to set goals, make decisions, and share resources and responsibilities) will develop a baseline care plan and/or comprehensive care plan for each resident in accordance with Omnibus Budget Reconciliation Act (OBRA, a nursing home reform act that was enacted by Congress to protect people from abuse in nursing homes) and MDS guidelines.

Based on interview, and record review, the facility failed to provide wound treatment from 7/21/2026 to 7/22/2026 for one (1) of two (2) sampled residents (Resident 1) who was identified with unstageable pressure injury/ulcer (a wound with an undetermined level of tissue injury because the entire base of the wound is covered by dead tissue separating from living tissue and/or dead tissue that falls off from healthy skin) to the Sacro-coccyx (pertains to both large triangular shaped bone in the lower spine that forms part of the pelvis and the tailbone) area in accordance with the facility's policy. This deficient practice had the potential to result in life threatening infection and delayed healing of Resident 1's pressure injury/ulcer affecting the health and well-being of the resident.Findings:During a review of Resident 1s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (an abnormal, uncontrolled growth of cells that can invade surrounding tissue and spread to other parts of the body), muscle wasting and atrophy (a decrease in muscle mass, often due to an extended period of immobility) and protein calorie malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 7/26/2026, the MDS indicated Resident 1 had moderate impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower, lower body dressing, and putting/taking off footwear and required partial/moderate assistance (helper does less than half the effort) with personal hygiene, and upper body dressing. The MDS further indicated Resident 1 required supervision (helper provides cues) with eating and oral hygiene. During a review of Resident 1's Nursing admission Skin assessment dated [DATE], the Nursing admission Skin Assessment indicated the resident has pressure injury/ulcer on the residents sacral (a large, flat, triangular shaped bone nested between the hip bones and positioned below the last lumbar vertebra) area which did not indicate the stage. During a review of Resident 1's Skin Observation Checks dated 7/21/2026 at 8:52 AM, the Skin Observation Checks indicated the resident has an unstageable pressure injury/ulcer on the resident's Sacro-coccyx. During a review of Resident 1's Physicians order dated 7/22/2026 at 10:53 AM, the Physicians order indicated an order to cleanse the pressure injury/ulcer with normal saline (NS-a saltwater solution), pat dry, apply Santyl ointment (used to remove damaged tissue from chronic skin ulcers), cover with calcium alginate (a light, nonwoven fabrics derived from algae or seaweed) dressing then secured with foam dressing times 30 days. During a review of Resident 1's Skin Weekly assessment dated [DATE] at 15:26 PM, the Skin Weekly Assessment indicated the resident had an unstageable pressure injury/ulcer to the Sacro-coccyx area with a current treatment plan to cleanse the pressure injury/ulcer with normal saline, pat dry, apply Santyl ointment, cover with calcium alginate dressing then secured with foam dressing times 30 days. During a concurrent interview and review of Resident 1's Nursing admission Skin assessment dated [DATE] and the Skin Observation Checks dated 7/21/2026 with the Treatment Nurse (TN) on 8/14/2026 at 3:55 PM, the TN stated Resident 1 had an unstageable pressure injury/ulcer on the Sacro-coccyx when admitted at the facility on 7/20/2026. The TN also stated the wound care doctor, or the admitting doctor should have been notified as soon as the pressure injury/ulcer was identified so proper wound treatment could be started. During a review of Resident 1's undated Care Plan, the Care Plan indicated the resident has an unstageable pressure ulcer located on the Sacro-coccyx and included an intervention to administer treatments as ordered. During a concurrent interview and record review of Resident 1' TAR for the month of July 2026 with the Director of Nursing (DON) on 8/14/2026 at 4:36 PM, the Treatment Administration Record (TAR) indicated the wound treatment for Resident 1's pressure injury/ ulcer on Sacro- coccyx was not started until 7/23/2026. The DON stated the staff should have called the physician right away after they had identified an unstageable pressure injury/ulcer on Resident 1 on 7/20/2026 to obtain a wound treatment order and to ensure the residents pressure injury/ulcer was being treated early and properly. During a review of the facility's P&P titled, Medication - Administration, revised 6/1/2017, the P&P indicated, medications will be administered by a licensed staff per order of an attending physician or licensed independent practitioner. During a review of the facility's P&P titled, Physician Order, revised 5/1/2019, the P&P indicated that whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order. During a review of the facility's Policy and Procedure (P&P) titled, Pressure Ulcer Prevention, dated 1/1/2026, the P&P indicated the facility would identify residents at risk for skin breakdown, implement measures to prevent and/or manage pressure ulcer and minimize complications.

Based on observation, interview, and record review, the facility failed to provide adequate supervision, conduct a wandering and elopement risk assessment, and to develop and implement an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) for one (1) of three (3) sampled residents (Residents 1) at risk for elopement (a form of unsupervised wandering that leads to the resident leaving the facility) as indicated on the facility's policy and procedure (P&P). These deficient practices resulted in Resident 1 eloping from the facility on 7/17/2026 at 8 PM to 7/18/2026 at 8 AM (12 hours) which posed a significant risk to Resident 1's safety. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia ( a medical term for a mental health condition where a person loses touch with reality and experience intense fear, suspicion, and false beliefs that others are trying to harm or spy on them), general anxiety disorder (mental health condition marked by persistent excessive worry, fear, or nervousness that interferes with daily life), and alcohol abuse disorder ([NAME], a medical condition characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences) and history of auto vs. pedestrian accident (a crash where a motor vehicle hits a person who is walking, running, or using a wheelchair) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/7/2026, the MDS indicated Resident 1 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort, Resident does none of the effort to complete the activity) with lower body dressing and putting on/ taking off footwear. The MDS also indicated Resident 1 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed. There were no mood or behavioral symptoms. During a review of Resident 1's Care Plans, dated 6/2/2026 to 7/17/2026, the care plans did not reflect and addressed Resident 1's wandering behavior and elopement risk. During a review of Resident 1's Nurse's Progress Notes (NPN), dated 7/18/2026 at 1:15 AM, the NPN indicated during change of shift rounds of the evening (3 PM to 11 PM) and Night (NOC, 11 PM to 7 AM]) shift, Registered Nurse Supervisor (RNS) observed that Resident 1 was not in his room. RNS informed the outgoing evening shift Charge nurse and RN Supervisor that Resident 1 was not seen in or around the facility. The staff conducted a room-by-room search, and nursing staff also drove around the neighboring streets in an effort to locate Resident 1. During a review of Resident 1's NPN, dated 7/18/2026 at 8 AM, the NPN indicated Resident 1 was safely back at the facility after staff found resident around the area of the facility. Resident 1 was assessed with normal vital signs and was transferred to emergency room (ER) for further evaluation. During a review of Resident 1's NPN, dated 7/18/2026 at 6 PM. The NPN indicated Resident 1 was back at the facility from the ER and was asked why he left the faciity on 7/17/2026 and Resident 1 stated, I wanted to get ice cream somewhere and I thought I can just leave and come back. During a review of Resident 1's Wandering & Elopement Risk Assessment, dated 7/18/2026 (after Resident 1 was back from the elopement). Resident 1 Scored 2, which meant the resident was moderately at risk for wandering and elopement. During an interview on 7/30/2026 at 12:13 PM with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated on 7/18/2026, when he was driving to work before 7AM. LVN 2 saw Resident 1 walking on the sidewalk near the facility. LVN 2 recognized Resident 1 immediately because of his distinct mustache. LVN 2 pulled over and asked Resident 1 if he was okay. LVN 2 then called the facility and was informed that Resident 1 had been missing since the previous night (7/17/2026). LVN 2 offered and gave Resident 1 a ride back to the facility. Resident 1 stated he walked around the city. LVN 2 stated Resident 1 reportedly likes to walk around the facility. LVN 2 stated the staff should conduct hourly rounds and monitor doors and hallways. LVN 2 stated if a resident leaves the facility, they may place themselves in immediate danger. During an interview on 7/30/2026 at 1:20 PM with Certified Nursing Assistant 1 (CNA 1), CNA1 stated that the last time she saw Resident 1 was at 4:45 PM on 7/17/2026, before dinner. CNA 1 stated she thought Resident 1 was in the front lobby talking with the receptionist. CNA1 stated she made room rounds around 7 PM and noted that Resident 1 was not in his room. CNA 1 assumed Resident 1 was walking around the facility and talking with others. CNA 1 stated Resident 1 did not eat dinner in his room, so she thought he was in the dining room. CNA1 stated she did not make rounds until the end of her shift (at 11 PM). CNA 1 stated that if a resident leaves the facility without notifying staff, there is a possibility they could become lost and could get injured. During an interview on 7/30/2026 at 1:31 PM with LVN 1, LVN 1 stated that the last time she saw Resident 1 was between 6 PM and 8 PM on 7/17/2026, walking at the west nursing station. LVN 1 was unsure where Resident 1 went afterward. LVN 1 stated no staff observed Resident 1 from 8 PM to 11 PM on 7/17/2026. LVN 1 further stated that if a resident leaves the facility without notifying staff, there is a possibility that the resident could get hurt or experience other harmful situations. During an interview on 7/30/2026 at 1:41 PM with LVN 1, LVN 1 stated that sometime last month (June 2026), Resident 1 had randomly mentioned wanting to go out on an outing around Pasadena and expressed that he wanted to be free. LVN 1 explained the process to Resident 1 that he would need to have an out on pass order from the doctor and believed the resident was fine, as he did not bring it up again. During a concurrent review of Resident 1's medical records and interview on 7/30/2026 at 2:35 PM with the Director of Nursing (DON), the DON stated Resident 1 did not and should have a Wandering and Elopement Risk Assessment upon admission and should be reassessed during a significant change of condition. During a concurrent record review of Resident 1's medical records and interview with MDS Nurse (MDSN) on 7/30/2026 at 2:52 PM, MDSN stated Resident 1 significantly improved with functional abilities including walking after Resident 1 received physical therapy (PT, a medical treatment used to restore functional movements, such as standing, walking, and moving different body parts) services. MDSN stated the facility should have reassessed Resident 1 for Wandering and Elopement risk when resident had a significant improvement in function. MDSN stated Resident 1 should always have 1 person assisting him during ambulation or should be supervised because Resident 1 is at risk for wandering/ elopement and fall. During an interview on 7/30/2026 at 3:38 PM with the DON, the DON stated Resident 1 was missing from 8 PM to 11 PM on 7/17/2026, and that going three hours without checking on the resident was not acceptable. The DON stated staff should have checked on Resident 1 every two hours or as needed. The DON further stated that if a resident leaves the facility, there are significant safety concerns, including possible injury and other potential risks. During an interview on 7/30/2026 at 3:40 PM with the DON, the DON stated according to Resident 1, he left on 7/17/2026 at night by exiting the double doors on the left side of the facility, facing the parking lot. The DON stated the double doors were left unlocked from the inside but were locked from the outside, wherein no visitors can come inside the facility unless a facility staff will allow them to come in. The DON stated these doors should have been locked because Residents can get out of these doors without anyone noticing if no one is supervising them. During a concurrent review of Resident 1's medical record and interview on 7/30/2026 at 4:06 PM with the DON, the DON stated that if Resident 1 had asked staff about going on an outing, staff should have asked additional questions and reported it to the RNS and the Social Services Director (SSD). Staff should also have explained the risks and safety considerations. The DON added that the facility could have arranged the outing Resident 1 wanted by obtaining an out-on-pass and including him in a planned outing activity. The DON stated this could have prevented Resident 1 from eloping. The DON stated Resident 1 did not have a care plan for wandering and elopement. The DON stated the facility should have had interventions such as the use of wander guard (a bracelet that can be integrated with a resident's security system to alert staff when residents have wandered) to prevent Resident 1 from leaving the facility unsupervised on 7/17/2026. During a concurrent interview and record review on 7/30/2026 at 4:43 PM with the DON, the facility's P&P titled, Elopement & Wandering, revised on 4/24/2026 was reviewed. The P&P indicated the resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the Interdisciplinary Team (IDT, a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a resident) upon admission, readmission, quarterly, and upon change in condition according to the Resident Assessment Instrument (RAI, the complete system used to evaluate a resident's functional capacity, strengths, and clinical needs) guidelines. The DON stated the staff did not follow the policy because Resident 1 was not assessed for wandering or elopement upon admission or was reevaluated for risk once the resident had significant functional improvement, including ability to ambulate after receiving PT services. The DON also stated the facility did not follow its policy because Resident 1 did not and should have a care plan for elopement, which could have prevented Resident 1 from leaving the facility without staff awareness on 7/17/2026. During an interview on 7/30/2026 at 4:48 PM with the DON, the DON stated they do not and should have a P&P for supervising residents to prevent elopement. During a review of the facility's P&P titled, Elopement & Wandering, revised on 4/24/2026, the P&P indicated the resident's risk for elopement and preventative interventions will be documented in the resident's medical record and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition according to the RAI guidelines.

Based on observation, interview, and record review, the facility failed to promote healing, and prevent development and worsening of pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for two (2) of 2 sampled residents (Resident 19 and 71), reviewed for pressure ulcer and skin condition in accordance with the facility's policy and procedure by: Failing to ensure Resident 19's low air loss mattress (LAL - a specialized medical bed surface featuring inflatable air chambers with tiny, perforated holes with airflows to wick away moisture and regulate skin temperature for preventing and healing the skin and the underlying tissue damage) air pressure setting was set up according to the resident's body weight.Failing to ensure Resident 71's LAL mattress air pressure setting was set according to the resident's weight and the weekly skin assessments were completed for Resident 71's pressure ulcer after 6/17/2026. This deficient practice had the potential to cause discomfort, friction, and worsening to Resident 19 and Resident 71's pressure ulcers.Findings: 1. During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 19's diagnoses included type 2 diabetes mellitus with foot ulcer (a patient with chronically high sugar level in the blood stream who has developed an open sore or wound on their foot), encounter for attention to gastrostomy (a medical procedure that creates a small, artificial opening through the abdomen directly into the stomach, it allows for the insertion of a feeding tube [G-tube] to safely deliver liquid nutrition, fluids, and medications, and dysphagia oral pharyngeal phase [difficulty initiating a swallow, where food or liquid cannot move properly from the mouth to the top of the esophagus]). During a review of Resident 19's Minimum Data Set (MDS, resident assessment tool), dated 5/29/2026, the MDS indicated Resident 19 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 19 was dependent (helper does all of the effort) with oral hygiene, toileting hygiene, shower/bath self, upper and lower body dressing, putting on/ taking off footwear, roll left and right, and sitting to lying. During a review of Resident 19's weight from the vital sign section of the point click care system (an electronic health record [HER] and healthcare software platform designed specifically for the senior care, long-term care, and post-acute care industries. It acts as a central system for nursing homes and assisted living facilities to manage patient records, medications, and billing) dated 6/62026, it indicated Resident 19 weighed 113 pounds. During a review of Resident 19's Care Plan on low air loss mattress for wound management, initiated on 2/19/2026, the Care Plan indicated Resident 19's low air loss mattress is set according to resident weight, comfort and manufacture setting, monitoring the air pressure setting and functionality of the mattress. During an observation on 7/7/2026 at 12:56 PM in Resident 19's room, observed Resident 19's low air loss mattress machine's setting was at the range of between 280 pounds to 320 pounds. During an interview on 7/9/2026 at 2:16 PM with Wound Care Nurse 1 (WCN 1), WCN 1 stated Resident 19 LAL's air mattress setting was supposed to be set according to Resident 19's body weight, which was 113 pounds. WCN 1 also stated it is very important to set the LAL's air pressure according to resident's body weight and monitor the air pressure setting to make sure the LAL maximizes the mattress's pressure redistribution, protects vulnerable skin, and prevents existing wounds from worsening or causing discomfort. During a concurrent interview and record review on 7/9/2026 at 3:22 PM with Maintenance Manager (MM), LAL mattress model menu (undated) was reviewed. The LAL mattress menu indicated LAL mattress setting should be in accordance with the resident's weight. MM stated Resident 19's LAL mattress model menu instruction for the setting of the machine is to set the LAL's mattress according resident's weight for optimal comfort and support. During an interview on 7/9/2026 at 4:56 PM with the Director of Nursing (DON), the DON stated it is important to set the LAL's air pressure according to resident's body weight and monitor the air pressure setting per the LAL mattress menu's instruction to maximize the LAL mattress's pressure redistribution, protects vulnerable skin, and prevents existing wounds from worsening or causing discomfort to Resident 19. During a review of the facility's Policy and Procedure (P&P) titled, Support Surface Guidelines, revised 5/1/2026, the P&P indicated the purpose is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The P&P indicated the Facility will implement measures to reduce tissue pressure that include frequent repositioning, protective devices and the use of support surfaces such as Pressure Reducing Support Surface (Pressure Redistribution Support Surface) and an example of which is low-air-loss mattresses. 2. During a review of Resident 71's admission Record, the admission Record indicated Resident 71 was admitted to the facility on [DATE] with diagnoses that included muscle wasting (weakening, shrinking, and loss of muscle) and atrophy (the partial or complete wasting away, degeneration, or decrease in size of a body part, tissue, or organ), pressure ulcer of sacral (bone at the end of the spine) region, pressure ulcer of other site, pressure ulcer of left heel and pressure-induced deep tissue (the internal structural layers beneath the skin and superficial fat) (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear)damage of right hip. During a review of Resident 71's Skin Observation Checks, dated 6/14/2026, the Skin Observation Check indicated Resident with the following pressure injuries: Left heel; unstageable (a pressure ulcer/injury whose true depth and severity cannot be measured because dead tissue blocks the view) Sacrum; unstageable Right hip trochanter (hip); suspected deep tissue injury Right upper back; stage 2 (partial-thickness loss of skin, presenting as a shallow open sore or wound) Vertebrae (upper mid [right]) (one of the bones that make up the spinal column); stage 2 During a review of Resident 19's Care Plan LAL Mattress for Wound Management, initiated 6/16/2026, the Care Plan indicated Resident 71's LAL mattress is set according to resident weight, comfort and manufacture setting and monitor the air pressure setting and functionality of the mattress. During a review of Resident 71's admission MDS, dated [DATE], the MDS indicated Resident 71 had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 71 required substantial/maximal assistance (helper does more than half the effort) with shower/bathing self and toileting hygiene, partial/moderate assistance (helper does less than half the effort) with oral and personal hygiene, and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating. The MDS also indicated Resident 71 had one or more unhealed pressure ulcers. During an observation on 7/7/2026 at 10:12 AM at Resident 71's bedside, Resident 71's LAL mattress machine's setting was at the range of between 80 pounds to zero pounds. During an interview on 7/9/2026 at 3:22 PM with the MM, The MM stated according to Resident 71's LAL mattress model menu instructions, the LAL's mattress should be set according to resident's weight for optimal comfort and support. During a concurrent interview and record review on 7/10/2026 at 12:13 PM with Licensed Vocational Nurse 2 (LVN 2), Resident 71's electronic medical record, dated 6/13/2026 through 7/10/2026 was reviewed. Resident 71's electronic medical record indicated Resident 71's last weight on 6/23/2026 is 113 pounds. LVN 2 stated Resident 71 LAL's mattress setting should have been set in accordance with the resident's body weight of 113 pounds on 7/7/2026. During a concurrent interview and record review on 7/10/2026 at 2:39 PM with the Director of Nursing (DON), the facility's P&P titled, Support Surface Guidelines, revised 5/1/2026, was reviewed. The P&P indicated the purpose was to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The P&P indicated the Facility will implement measures to reduce tissue pressure that include frequent repositioning, protective devices and the use of support surfaces such as Pressure Reducing Support Surface (Pressure Redistribution Support Surface) and an example of which is low-air-loss mattresses. The P&P failed to indicate LAL mattresses will be set according to weight but should because that is the facility's protocol and the manufacturer's recommendations. The DON stated it was important to ensure the LAL mattress was set correctly to make sure it was functioning properly to treat and prevent the pressure ulcers of the residents. During a concurrent interview and record review on 7/10/2026 at 11:52 AM with LVN 2, Resident 71's electronic medical record, dated 6/13/2026 through 7/10/2026, was reviewed. Resident 71's electronic medical record did not indicate a completed weekly skin assessment for Resident 71's pressure ulcers for the weeks of 6/21/2026 through 6/27/2026, 6/28/2026 through 7/4/2026 and 7/5/2026 through 7/10/2026. LVN 2 stated there were no weekly skin assessments completed after 6/17/2026 and the facility wound care nurse was responsible for completing and documenting the assessments. During an interview on 7/10/2026 at 12:13 PM with Wound Care Nurse 2 (WCN 2), WCN 2 stated skin assessments are completed weekly for residents, and it should be documented in the resident's electronic medical records when done. During an interview on 7/10/2026 at 12:50 PM with the Medical Records Director (MRD), the MRD stated Resident 71 only had a weekly skin assessment completed on 6/17/2026, from admission until today [7/10/2026]. During an interview on 7/10/2026 at 2:33 PM with the Director of Nursing (DON), the DON stated Resident 71 should have completed weekly skin assessments for the resident's pressure ulcers documented in his chart and there was no documented evidence to ensure it was done. The DON stated it was important to ensure weekly skin assessments are done to assess and make sure the pressure ulcers are improving or if they are declining, if the treatments are effective or if new orders are needed for treatment so that proper care and treatment can be provided. During a review of the facility's P&P titled, Pressure Ulcer Prevention, dated 1/1/2026, the P&P indicated the Licensed Nurses will conduct a skin assessment for a resident upon admission, readmission, weekly and as needed and the results of the weekly skin assessment will be documented in the medical record. During a review of the facility's P&P titled, Wound Management, dated 5/1/2026, the P&P indicated wound (including pressure ulcer) documentation will occur at a minimum of weekly until the wound is healed and the documentation will include wound measurements, appearance of wound base, drainage amount and characteristics, appearance of wound edges, and presence of pain. The P&P further indicated Licensed Nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis.

Based on observation, interview and record review, the facility failed to ensure dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) services and care were provided as indicated on the physician's order and facility policy for two (2) of 2 sampled residents (Residents 9 and 70 ) reviewed for dialysis by failing to ensure:1. Resident received dialysis treatment on 5/7/2026, 6/9/2026, at 6/13/2026.2.a. Resident 70 received dialysis treatment on 6/13/2026 and 6/20/2026.2.b. Resident 70, who was on fluid restrictions, was not provided with a water pitcher at bedside.These deficient practices have the potential for Residents 9 and 70 to experience life threatening complications such as dangerous waste and fluid buildup, resulting to difficulty breathing, heart problems, hospitalization, and death. Findings: 1.During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction caused by a chemical imbalance, organ failure, or lack of nutrients in the body), dependence on renal (kidneys) dialysis, and end stage renal disease (permanent kidney failure when the kidneys can no longer filter waste and extra fluid from the blood to keep a person alive). During a review of Resident 9's Minimum Data Set (MDS- a resident assessment tool), dated 6/14/2026, the MDS indicated Resident 9 was assessed having severely (never/rarely made decisions) impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 9 required partial/moderate assistance (helper does less than half the effort) with oral hygiene and upper body dressing. The MDS indicated Resident 9 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, shower/bathe self, and personal hygiene. The MDS also indicated Resident 9 was dependent (helper does all of the effort) with rolling left and right, sit to lying, sit to stand, and toilet transfer. The MDS further indicated Resident 9 was on dialysis. During a review of Resident 9's Order Summary Report, dated 7/10/2026, the Order Summary Report indicated a physician order, with a start date of 6/8/2026, for dialysis Tuesday, Thursday, Saturday with chair time of 6 AM. Resident will be picked up between 5:15 AM and 5:30 AM. During a review of Resident 9's Progress Note, dated 5/7/2026, at 6:49 AM, the Progress Note indicated that Resident 9 was unable to go to dialysis appointment due to no escort. It also indicated communication with Dialysis Center 1 (DC 1) if Resident 9's dialysis could be rescheduled at later time but no available chair time. During a review of Resident 9's Progress Note, dated 6/9/2026, at 5:04 AM, the Progress Note indicated that Resident 9 was unable to go to dialysis due to no escort. It also indicated communication with DC 1 for an inquiry on availability on 6/9/2026 but there was no available chair time for the resident. The Progress Notes further indicated the dialysis appointment was scheduled for the next day, 6/10/2026 at 5 AM and on Thursday on Resident 9's regular chair time. During a review of Resident 9's Progress Note, dated 6/13/2026, at 5:31 AM, the Progress Note indicated that Resident 9 was unable to go to dialysis due to no escort. It also indicated communication with DC 1 for an inquiry on availability for 6/13/2026 but there was no available chair time for the Resident until Monday and was requested to call back later in the day to reschedule chair time. During a concurrent interview and record review on 7/8/2026, at 4:24 PM, with Case Manager (CM), Resident 9's Progress Notes were reviewed. CM stated that on 5/7/2026, 6/9/2026, and 6/13/2026, Resident 9 needed to be accompanied by an escort to his dialysis appointments because he was only getting courtesy rides by his insurance. CM stated Resident 9's escort was either a Certified Nursing Assistant (CNA) or an Activity Staff. CM stated an escort was required to go with Resident 9 because the courtesy ride was an Uber (company that provides on demand transportation services through a mobile app, allowing people to request rides from nearby drivers) and not an ambulance. CM stated Resident 9 did not go to dialysis on 5/7/2026, 6/9/2026, and 6/13/2026 because he did not have an escort. During a follow up interview on 7/9/2026, at 8:41 AM, with DSD and ADSD, ADSD stated that Resident 9 did not go to dialysis on 5/7/2026 because of a miscommunication and CNA 4 was not assigned and informed on 5/6/2026 that he was going to escort Resident 9 to his dialysis appointment on 5/7/2026. During the same interview on 7/9/2026, at 9:15 AM, with DSD and ADSD, ADSD stated that Resident 9 did not go to dialysis on 6/9/2026 because he was readmitted back to the facility on 6/8/2026. ADSD stated CM did not clearly communicate Resident 9's dialysis pick up time with DSD and ADSD. ADSD stated she and DSD misunderstood Resident 9's pick up time and chair time and thought Resident 9's chair time was actually his pick up time. ADSD stated that CNA 5 was informed on 6/8/2026 that he was assigned to escort Resident 9 to dialysis at 6 AM on 6/9/2026. ADSD stated there was no escort available when Resident 9's Uber came to pick him up at 6 AM because CNA 5 did not arrive at the facility until 7 AM. During the same interview on 7/9/2026, at 9:15 AM, with DSD, DSD stated there were a lot of miscommunications regarding Resident 9's escort for dialysis and needed to review the text messages. After reviewing her text messages, DSD stated that on 6/8/2026, they were not informed of Resident 9's readmission until he physically arrived at the facility at 7:49 PM. DSD stated they were not notified that Resident 9 needed an escort to his dialysis appointment until 8:28 PM and by that time there did not have any staff available to accompany Resident 9 to his dialysis appointment on 6/9/2026. DSD stated Resident 9 missed his dialysis appointment on 6/9/2026 because facility was not able to arrange an escort for him on 6/8/2026. During an interview on 7/9/2026, at 9:48 AM, with DSD and ADSD, both DSD and ADSD stated Resident 9 did not go to dialysis on 6/13/2026 because CNA 5 was not informed that he was assigned to escort Resident 9 to his dialysis appointment that day. DSD stated it was important to assign an escort to residents ahead of time, so dialysis appointments are not missed. DSD stated escort assignments should be communicated and confirmed with CNAs and AS to prevent miscommunications. DSD stated it was important for dialysis residents to keep their dialysis appointments because dialysis cleans the kidneys and if not done as scheduled can cause residents to have fluid overload and end up in the hospital. During an interview on 7/10/2026, at 10:28 AM with CNA 4, CNA 4 stated he was not informed by DSD or ADSD that he was assigned to escort Resident 9 to dialysis on 5/7/2026. CNA 4 stated 5/7/2026 was his regular day off from the facility. During an interview on 7/10/2026, at 10:31 AM, with CNA 5, CNA 5 stated he was not informed by DSD or ADSD that he was assigned to escort Resident 9 to dialysis on 6/9/2026 and 6/13/2026. During an interview on 7/10/2026, at 11:02 AM, with the Director of Business Development (DBD), the DBD stated that the residents' dialysis chair time, pick up time, and need for escorts are immediately endorsed to nursing once it is confirmed by the CM. The DBD stated it was important to coordinate this information immediately to nursing to prevent the residents from missing their dialysis appointments. During an interview on 7/10/2026, at 1:22 PM with the Director of Nursing (DON), the DON stated it was unacceptable for residents to miss one to two days of dialysis. The DON stated residents who miss their dialysis appointments can go into fluid overload, sepsis (the body's extreme, life-threatening response to an infection), and can get very sick. The DON stated escorts for dialysis should be informed and scheduled ahead of time to prevent missed dialysis appointments. The DON stated the policy for dialysis was not followed. 2.a During a review of Resident 70's admission Record, the admission Record indicated Resident 70 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD- irreversible kidney failure), and dependence on renal (kidney) dialysis. During a review of Resident 70's MDS, dated [DATE], the MDS indicated Resident 70 had intact cognitive skills for daily decision making. The MDS indicated Resident 70 required partial/moderate assistance with oral hygiene, supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating and substantial/maximal assistance with toileting hygiene and shower/bathing self. The MDS further indicated Resident 70 was on dialysis. During a review of Resident 70's Order Listing Report, dated 7/10/2026, the Order Listing Report indicated for hemodialysis on Tuesday/ Thursday/ Saturday, with chair time of 4:45 AM to 9 AM, active 6/9/2026 and on hold as of 7/6/2026 and a temporary order for hemodialysis on Tuesday/ Thursday/ Saturday, chair time 11:30 AM, active as of 7/6/2026. During a review of Resident 70's Progress Notes, the Progress Notes indicated Resident 70 was unable to go to his scheduled dialysis on Saturday, 6/13/2026 due to no escort and on Saturday, 6/20/2026 due to no escort and transportation. During an interview on 7/7/2026 at 9:20 AM with Resident 70, Resident 70 stated he has dialysis on Tuesdays, Thursdays, and Saturdays, and has had to miss dialysis a couple of times because of no transportation or escort staff available. During an interview on 7/10/2026 at 11:19 AM with the Director of Staff Development (DSD), the DSD stated there was a miscommunication between the facility staff on 6/13/2026 and 6/20/2026. The DSD stated there were no staff available to accompany Resident 70 to his dialysis appointment. The DSD stated the facility should make sure all of Resident 70's dialysis appointments are being met because missed appointments are not good for Resident 70's health. During an interview on 7/10/2026 at 2:47 PM with the Director of Nursing (DON), the DON stated Resident 70 had missed dialysis treatments due to transportation and/or staffing issues. The DON stated Resident 70 should not have missed the dialysis treatments. The DON added that the facility is responsible in ensuring dialysis is given as ordered. The DON also stated it was important for Resident 70 to receive dialysis as ordered because he already has ESRD and missing dialysis could cause fluid overload, sepsis (a life-threatening blood infection), and the resident could get very sick. During an interview on 7/10/2026 at 3:41 PM with the Case Manager (CM), the CM stated facility staff including herself and nursing were responsible for arranging transportation for Resident 70's dialysis appointments. During a review of the facility Policy & Procedure (P&P) titled, Dialysis Care, revised 5/1/2026, the P&P indicated the facility will be responsible for the overall care delivered to the resident and will arrange for dialysis care for residents as ordered by the physician. The facility also indicated the facility will arrange transportation to and from the dialysis provider. 2.b. During a review of Resident 70's Order Listing Report, dated 7/10/2026, the Order Listing Report indicated for fluid restrictions 1200 cubic centimeter (cc- a metric unit of measurement for volume) per day; dietary 600 cc, nursing 600cc every shift, active as of 6/9/2026. During a concurrent observation in Resident 70's room and interview on 7/7/2026 at 9:20 AM with Resident 70, a water pitcher was observed on Resident 70's bedside table. Resident 70 stated that the water pitcher was for him to drink from and that facility staff refilled it with ice and water whenever he asked. Resident 70 also stated he was not prescribed any fluid restrictions. During an observation in Resident 70's room on 7/9/2026 at 9:12 AM, a water pitcher was observed on Resident 70's bedside table. During a concurrent observation in Resident 70's room and interview with Licensed Vocational Nurse 1 (LVN 1) on 7/9/2026 at 11:12 AM, a water pitcher was observed on Resident 70's bedside table. LVN 1 stated Resident 70 has a physician's order for fluid restrictions and should not have a water pitcher at his bedside, according to facility policy. LVN 1 further stated that Resident 70 should not have a water pitcher at his bedside because staff would not be able to measure his fluid intake or ensure he followed his 1200 cc per day fluid restriction. LVN 1 stated Resident 70 would be at risk for fluid overload, where the body has too much fluid that the kidneys cannot get rid of, which could negatively affect his health. During an interview on 7/10/2026 at 2:51 PM with the DON, the DON stated Resident 70 should not have a water pitcher at bedside per facility protocol. The DON also stated Resident 70 received dialysis because his kidneys did not function properly and having a water pitcher at bedside puts him at risk for fluid overload. During a review of the facility's P&P titled, Fluid Restrictions, revised 5/1/2026, the P&P indicated the licensed nurse will educate the resident and/or responsible party regarding fluid restriction, initiate intake measurement per the physician order and remove the water pitcher and notify care givers of fluid restriction.

Based on observation, interview, and record review, the facility failed to ensure its medication error (the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) rate was less than five (5) percent (%). Two (2) medication errors out of 25 opportunities (observed administered medications) for error which yielded a facility medication error rate of 8 % for one (1) of 8 (eight) sampled residents (Resident 56) observed for medication administration (med pass). These deficient practices had the potential to result in harm to Resident 56 by not administering medications as prescribed by the physician in order to meet Resident 56's medication needs.Findings: During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), gastroparesis (a condition where the stomach empties food too slowly, despite there being no physical blockage), and gastrostomy (G-Tube- a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) malfunction. During a review of Resident 56's Minimum Data Set (MDS- a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 56 was assessed having severely impaired (never/rarely made decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 56 is dependent (helper does all of the effort, resident does none) with oral/toileting/personal hygiene, upper/lower body dressing, and shower/bathe self. The MDS indicated Resident 56 had a G-Tube. During a review of Resident 56's Order Summary Report, dated 7/10/2026, the Order Summary report indicated the following physician orders:Bethanechol (medication used to treat urinary retention) 25 milligrams (mg- unit of measurement for weight), to give 1 tablet via G-tube three times a day for bladder emptying, with a start date of 12/5/2025.Multivitamin (a supplement), give 1 tablet via G-tube one time a day for supplement, with a start date of 3/23/2026.Flush enteral tubing (g-tube- a soft, flexible plastic tube used to deliver liquid nutrition, fluids, or medications directly into the stomach) with at least 5 to 15 milliliters (ml- unit of measurement for liquid) of water in between each medication, with a start date of 7/5/2026. During a review of Resident 56's Care Plan, revised on 2/26/2026, the Care Plan indicated Resident 56 had a gastrostomy tube secondary to dysphagia (difficulty or discomfort in swallowing). Resident 56's Care Plan intervention indicated to use 10 ml of water to mix with crushed meds. During an observation of the medication preparation, on 7/9/2026, at 4:42 PM, LVN 4 crushed the following medications and placed them in medication cups:Bethanechol 25 mg 1 tabletMultivitamin 1 tabletLVN 4 transferred Resident 56's bethanechol and multivitamin medications from the medicine cups in a large clear plastic cup (5 ounces (oz- unit of measurement for weight and liquid volume) or approximately 148 ml). LVN 4 added approximately 50 ml of water in each clear plastic cup and swirled each cup to mix the medication with the water. LVN 4 grabbed another clear plastic cup and poured approximately 120 ml (3/4 full) of water into the clear plastic cup. LVN 4 entered Resident 56's room to administer the medications. During a concurrent observation and interview, on 7/9/2026, at 4:48 PM, with LVN 4 of medication administration, LVN 4 administered Resident 56's Bethanechol and multivitamins via G- Tube. LVN 4 drew up the remaining contents of water (approximately 50 ml) from the clear plastic cup and flushed Resident 56's G-tube. LVN 4 reconnected Resident 56's G-tube feeding and exited the room. LVN 4 stated she did not measure the amount of water she added to Resident 56's bethanechol and multivitamin medication. LVN 4 stated, LVN 4 did not flush Resident 56's G-tube with 5 to 15 ml of water in between each medication and did not flush Resident 56's G-tube with 20-30 ml of water after administering Resident 56's medications. During an interview on 7/9/2026, at 5:14 PM, with LVN 4, LVN 4 stated she flushed Resident 56's G-tube with the remaining water in the clear plastic cup after administering Resident 56's medications. LVN 4 further stated she did not know that she had to flush Resident 56's G-tube with 10 ml of water in between medications. During an interview on 7/10/2026, at 10:40 AM, with LVN 1, LVN 1 stated licensed nurses should use the medication cup when adding water to dilute the medication because it had measurements, which help ensure the correct amount of water is added to the medications per the physician's order. LVN 1 stated the clear plastic cup should not be used when mixing the medications with water because it could hold around 150 ml of water and the medication can end up getting mixed with too much water. LVN 1 stated crushed medications should be mixed with approximately 10 ml of water before administering the medication in the G-tube. LVN 1 stated licensed nurses should follow the residents' physicians order and care plan on flushing the G-tube during medication administration. During an interview on 7/10/2026, at 1:04 PM, with the Director of Nursing (DON), the DON stated crushed medications should be mixed with approximately 10 ml of water before administering the medication through the G-tube and not more than 10 ml. The DON stated licensed nurses should flush the G-tube with 20 to 30 ml of water before and after medication administration and not more than 30 ml of water. The DON stated licensed nurses should measure the amount of water that is flushed and mixed with the medications. The DON stated giving the Resident too much water through the G-tube can cause stomach discomfort. The DON stated licensed nurses should follow the physicians order and the care plan for the safety of the resident. During a review of the facility's policy and procedure (P&P), titled, Medication-Administration, revised 6/1/2017, the P&P indicated:Medication will be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner.The resident's MAR (Medication Administration Record) will be reviewed for allergies and/or special considerations for administration including accepted professional standards and principles. During a review of the facility's P&P, titled, Feeding Tube-Administration of Medication, revised 6/1/2017, the P&P indicated:Medications are administered appropriately and safely when the resident has a feeding tube in place and medication are delivered through the feeding tube.Dilute medication according to resident's administration orders making sure that medications are dissolved completely prior to administration.Check for tube placement by gently inserting 15 cc of air into the tube via the piston syringe (a type of syringe used to safely administer medications directly into a feeding tube) and auscultating (listening) the resident's abdomen about 3 inches (unit of measurement) below the sternum with the stethoscope.Medication must be given separately, flush with 5 cc of warm water in between each medication.Flush with 30 cc of water after the final medication is administered.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored as indicated on the facility's policy and procedure (P&P) by failing to ensure: 1. One (1) of four (4) medication carts (MC- med cart) were not left unattended and locked on 7/8/2026 and during medication administration on 7/9/2026.This deficient practice had the potential for unauthorized access to medications by staff and visitors which could lead to medication overdose (taking a toxic or poisonous amount of a drug or medicine), unauthorized use, adverse reactions (any unexpected or dangerous reactions to a drug), or harmful drug interactions (a reaction between two or more drugs or between a drug, and a food, beverage, or supplement). 2. To defrost (become free of accumulated ice) two of three medication refrigerators (Medication Refrigerators 1 and 2).This deficient practice had the potential to affect the temperature quality of Medication Refrigerators 1 and 2, which might affect the efficacy (the power or capacity of a drug, treatment, or action to produce a desired or intended result) of the refrigerated medications for the residents. 1. During a concurrent observation and interview on 7/8/2026, at 1:27 PM, MC 1 was left unattended and unlocked. Medications of residents were observed inside the first and second drawers of MC 1. Licensed Vocational Nurse 2 (LVN 2) stated he did not lock MC 1 before stepping away from it. During an observation in the resident rooms' hallway on 7/9/2026, at 4:51 PM, LVN 4 did not lock MC 1 before entering a resident's room. During an observation in the resident room hallway on 7/9/2026 at 4:51 PM, LVN 4 was observed failing to lock MC 1 before entering a resident's room. During an observation in the resident room hallway on 7/9/2026 at 5:01 PM, LVN 4 was observed failing to lock MC 1 before entering a resident's room. During an interview on 7/9/2026, at 5:18 PM, with LVN 4, LVN 4 stated she forgot to lock MC 1 before she entered the residents' rooms. LVN 4 stated it was important to lock the MC to prevent residents and staff from accessing the medications inside the MC. During an interview on 7/10/2026 at 12:15 PM with LVN 2, LVN 2 stated that licensed nurses administering medications should ensure the MC was locked before walking away to prevent unauthorized residents, staff, and visitors from accessing the medications inside. LVN 2 stated unauthorized staff or visitors could steal and distribute medications. LVN 2 further stated residents could accidentally take the medications and experience a drug interaction, adverse reaction, or overdose, which could result in hospitalization or death. During an interview on 7/10/2026, at 1:11 PM, with the Director of Nursing (DON), the DON stated MCs in the facility should not be left unlocked and unattended. The DON stated if left unlocked and unattended, residents can have access and take the medications which could lead to hospitalization. The DON stated the policy for medication storage was not followed. During a record review of the facility's policy and procedure (P&P), titled, Medication Storage in the Facility, dated, 1/2022, the P&P indicated: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. During a concurrent observation of Medication Refrigerator 1 and interview with Registered Nurse Supervisor 1 (RNS 1) on 7/10/2026 at 11:06 AM, RNS 1 verified that Medication Refrigerator 1 was filled with built up ice. RNS 1 stated that this was not acceptable because it may affect the temperature of the entire fridge and affect the efficacy of the residents' refrigerated medications. During a concurrent observation of Medication Refrigerator 2 and interview with Licensed Vocational Nurse 1 (LVN 1) on 7/10/2026 at 11:11 AM, LVN 1 stated that almost half of the freezer compartment in Medication Refrigerator 2 was filled with built up ice. LVN 1 stated the refrigerator should have been defrosted because it can impact the temperature quality of refrigerator. During a concurrent observation of Refrigerator 2 and interview with RNS 2 on 7/10/2026 at 11:19 AM, RNS 1 verified that almost half of the freezer compartment in Medication Refrigerator 2 was filled with built up ice. RNS 2 was unable to state and provide documented evidence when the last time Medication Refrigerators 1 and 2 were defrosted. During a review of Facility's P&P titled, Medication Storage in the Facility, revised in January 2018, the P&P indicated medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures.

Based on observation, interview, and record review, the facility failed to follow the dietary menu (a planned food program designed to meet the nutritional needs of residents) and ensure to use the correct measuring scooper (a food serving utensil used to measure even portions) on 7/9/2026 for the lunch meal servings of beans and brown rice provided to 32 of 78 residents. This failure resulted in inconsistent portion sizes and had the potential to cause the 32 affected residents to receive inadequate nutritional intake, placing them at risk for not meeting daily dietary requirements, which could lead to weight loss. Findings: During a review of the facility's Summer Menus, dated 7/9/2026, the Summer Menu indicated for staff to follow the following recipes:1. Ranch style beans- use #12 scooper (a food serving utensil that measures one third [1/3] of a cup portion) for the controlled carbohydrate diet (CCHO - a diet of set or equal amounts of carbohydrates at meals to help stabilize blood glucose levels) and regular diet (no dietary restrictions) lunch serving portion.2. [NAME] rice- use #12 scooper for the renal diet (a specialized diet for residents with kidney disease that limits sodium [salt], potassium, phosphorus, and protein) and low fat/cholesterol diet lunch serving portion. During an observation on 7/9/2026 from 11:38 AM to 12:48 PM with the Dietary Supervisor (DS), in the facility kitchen, [NAME] 1 was observed:1. Using the #8 measuring scooper (a food serving utensil that measures one half of a cup portion) to scoop the ranch style beans and serve on residents' plates.2. Using an unmeasured (not having a known size or amount) scooper to scoop brown rice and serve on residents' plates. During a concurrent interview and record review on 7/9/2026 at 12:48 PM with the DS and [NAME] 1, the Summer Menus, dated 7/9/2026 were reviewed. The DS and [NAME] 1 confirmed the menu indicated to use a #12 scooper for the ranch style bean serving portion and a #12 scooper for the brown rice serving portion. [NAME] 1 stated she used the wrong sized scoopers for the ranch style beans and the brown rice and should have followed the scooper sizes indicated on the menu. The DS stated staff are to follow the recipe and provide residents with the exact portion sizes indicated to ensure residents get the right nutrition to maintain and improve their health. During a review of the facility's Diet Type Report, printed 7/10/2026, the Diet Type Report indicated the following:16 residents with a prescribed CCHO diet and solid texture (the physical consistency and structure of foods and liquids).12 residents with a prescribed regular diet and solid texture.3 residents with a prescribed renal diet and solid texture. 1 resident with a prescribed low fat/cholesterol diet and solid texture. During a review of the facility's Policy & Procedure (P&P) titled, Therapeutic Diets, revised 6/1/2027, the P&P indicated the facility will provide therapeutic diets to residents that meets nutritional guidelines, the correct equipment is available for the preparation and serving of therapeutic diets and that food portions served are equal to the written portion sizes. During a review of the facility's P&P titled, Dietary Department - General, the P&P indicated the dietary department is responsible for establishing a program that meets the nutritional needs of the residents. The P&P also indicated the primary objectives of the dietary department include preparation and provision of nutritionally adequate, attractive, well-balanced meals that are consistent with physician's orders and accommodates residents' allergies, intolerances and preferences.

Based on observation, interview, and record review, the dietary staff failed to ensure food was served at an appetizing and proper temperature on 7/9/2026 during lunch as indicated on the facility Policy & Procedure (P&P). This deficient practice had the potential to result in rapid growth of bacteria that can cause foodborne illness (any illness resulting from eating contaminated/spoiled foods) and had the potential to result in insufficient meal intake and weight loss for 56 residents. Findings: During a concurrent observation and interview on 7/9/2026 at 1:09 PM with the Dietary Supervisor (DS), the Dietary Supervisor (DS) was observed taking the temperatures on the test meal tray (an ordered meal used to evaluate food temperatures, palatability [tastiness], and tray accuracy) that included a pork loin, ranch style beans and southern style green beans. The temperature readings for the pork, beans and green beans were 116 degrees Fahrenheit (F- a method of measuring temperature). The DS stated the food temperatures should be more than 140 degrees F. The DS stated the food items were too cold. During an interview on 7/10/2026 at 3:31 PM with the Dietary Supervisor (DS), the DS stated dietary staff should make sure the served food is at a temperature above 140 degrees F to ensure it is safe for residents to eat. During a review of the facility's P&P titled, Food Temperatures, reviewed 1/1/2026, the P&P indicated foods prepared and served in the facility will be served at proper temperatures to ensure food safety. The P&P also listed the required serving temperature to be greater than 140 degrees F for meat, entrees, and vegetables.

Based on observation, interview, and record review, the facility failed to ensure proper food handling and food storage practices in accordance with the facility's policy and procedure (P&P) by failing to ensure: 1. Food was stored appropriately in the refrigerator and dry storage. 2. Dietary staff maintained sanitary measures during the preparation and serving of food during tray line. These deficient practices have the potential to result in pathogen (germ) exposure to residents, which could place 56 residents consuming food by mouth at risk for developing foodborne illness (caused by food contaminated with bacteria) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.Findings:1. During a concurrent observation and interview on 2/10/2025 at 7:58 AM in the facility kitchen with the Dietary Supervisor (DS), the following food items were observed in the dry storage and refrigerator: a. One (1) bag of cocoa powder stored in a partially closed bag inside of a cardboard box.b. Refrigerated container of pumpkin labeled with an expiration date of 7/5/2026.The DS stated all foods should be stored according to the policy. During a review of the facility's P&P titled, Food Storage, dated 1/1/2026, the P&P indicated food items will be stored, thawed and prepared in accordance with good sanitary practice. The P&P also indicated for opened products to be placed in storage containers with tight fitting lids in dry storage. 2. During an observation on 7/9/2026 from 11:38 AM to 12:48 PM, in the facility kitchen, DS failed to change disposable gloves or perform hand hygiene after intermittently leaving the cooking area and using his gloved hand to open the refrigerator door and touch his personal clothing before returning to prepare cornbread and handle cooking and serving utensils. During an interview on 7/9/2026 at 1 PM with the DS, the DS stated that he should have changed his gloves and performed hand hygiene after touching his clothing and the refrigerator door handle. The DS stated that food should be prepared and served in a sanitary manner to prevent residents from getting sick and to reduce the risk of foodborne illness. During a review of the facility's P&P titled, Dietary Department - General, the P&P indicated the dietary department will maintain standards for sanitation and safety. The P&P also indicated [dietary] staff should maintain wearing intact disposable gloves in good condition that are changed appropriately to reduce the spread of infection.

Based on observation, interview, and record review, the facility failed to follow proper food storage practices in accordance with its policy and procedure (P&P) by failing to ensure one of one resident refrigerator temperature was 41 degrees Fahrenheit (F- a method of measuring temperature) or less. This deficient practice had the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) to the residents.Findings: During a concurrent observation and interview on 7/7/2026 at 9:06 AM with the DS in the facility Activity/Dining Room, the resident refrigerator was observed to have a temperature of 51 degrees F. The DS stated the refrigerator temperature should be maintained at 41 degrees F or below to keep food safe for residents to eat. The DS stated the food items in the residents' refrigerator were brought in by the residents' family and/ visitors. During a review of the facility's P&P titled, Refrigerator/Freezer Temperature Records, dated 1/1/2026, the P&P indicated refrigerator temperature must be 41 degrees F or below.

Based on observation, interview, and record review, the facility staff failed to provide the necessary infection control measures and services for seven (7) of 7 sampled residents (Residents 56, 32, 88, 73, 82, 2 and 95) reviewed for infection control and oxygen use in accordance with the facility's policy and procedure (P&P) by failing to ensure:Licensed Vocational Nurse 4 (LVN) performed hand hygiene (the process of cleaning the hands to remove germs, dirt, and microorganisms by washing with soap and water or using an alcohol-based hand sanitizer [hand sanitizer]) after removing her soiled gloves during medication administration for Residents 56, 32, 88, and 73.Resident 82, 2, and 95's indwelling catheter (a tube inserted into the bladder to help drain urine) drainage bags (a bag used to collect urine from an indwelling catheter) and/or tubing were not touching the floor.Resident 56's respiratory equipment was stored in a clean and sanitary manner to prevent contamination. These deficient practices had the potential to put Residents 56, 32, 88, 73, 82, 2 and 95 at higher risk for healthcare associated infections and potential spread of infections in the facility.Findings: a. During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), gastroparesis (a condition where the stomach empties food too slowly, despite there being no physical blockage), and gastrostomy (G-Tube- a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) malfunction. During a review of Resident 56's Minimum Data Set (MDS- a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 56 was assessed having severely impaired (never/rarely made decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 56 is dependent (helper does all of the effort, resident does none) with oral/toileting/personal hygiene, upper/lower body dressing, and shower/bathe self. The MDS indicated Resident 56 had a G-Tube. During a review of Resident 56's Care Plan, revised on 11/17/2025, the Care Plan indicated Resident 56 was on enhanced barrier precautions related to G-tube and secondary to history of candida auris positive on 11/5/2025. Resident 56's Care Plan interventions included hand hygiene, practice good infection control (example: proper hand hygiene), and cleaning hands including before entering and when leaving the room. During a review of Resident 56's Order Summary Report, dated 7/10/2026, the Order Summary report indicated a physician order, with a start date of 3/28/2026, for enhanced barrier precautions (EBP- an infection control measure used in long-term care facilities to prevent the spread of multidrug-resistant organisms [MDRO] ) secondary to indwelling (an invasive device left inside the body) medical device (G-tube) and history of MDRO Candida Auris (a multidrug- resistant yeast infection). b. During a review of Resident 88's admission Record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses that included Parkinsonism (a ground of neurological disorders that cause motor symptoms like tremors, slowed movement, and muscle stiffness), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 88's MDS, dated [DATE], the MDS indicated Resident 88 was assessed having severely impaired cognitive skills for daily decision making. The MDS indicated Resident 88 required supervision or touching assistance with eating and rolling left and right. The MDS indicated Resident 88 required partial/moderate assistance (helper does less than half the effort) with sit to lying, and lying to sitting on side of the bed. The MDS indicated Resident 88 required substantial/maximal assistance (helper does more than half the effort) with toileting/personal hygiene, upper/lower body dressing, shower/bathe self, and tub/shower transfer. c. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), cerebral infarction (when the blood supply to part of the brain is blocked or reduced), and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 was assessed having moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 32 required partial/moderate assistance with eating. The MDS indicated Resident 32 was dependent (helper does all of the effort) with toileting hygiene, shower/bathe self, upper/lower body dressing, sit to lying, and chair/bed-to-chair transfer. d. During a review of Resident 73's admission Record, the admission Record indicated Resident 73 was admitted to the facility on [DATE] with diagnoses that included unspecified injury of head, urinary tract infection (UTI- an infection in any part of the urinary system), and paranoid schizophrenia. During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73 had intact memory and cognitive skills for daily decision making. The MDS indicated Resident 73 required supervision or touching assistance with eating. The MDS indicated Resident 73 required substantial/maximal assistance with toileting/personal hygiene, shower/bathe self, upper body dressing, and sit to lying. The MDS further indicated Resident 73 was dependent with lower body dressing and putting on/taking off footwear. During an observation on 7/9/2026, at 4:31 PM, LVN 4 put on a gown and gloves and entered Resident 56's room. LVN 4 checked Resident 56's blood pressure with a blood pressure monitor, removed her gown and gloves and exited Resident 56's room without performing hand hygiene. During an observation on 7/9/2026, at 4:42 PM, LVN 4 put on new gloves, prepared Resident 56's bethanechol (a medication used to treat urinary retention) and multivitamin medications. LVN 4 removed her gloves and did not perform hand hygiene. During an observation on 7/9/2026, at 4:46 PM, LVN 4 replaced her gloves and put on a gown and re-entered Resident 56's room. LVN 4 checked Resident 56's G-tube for placement and administered Resident 56's medications through the resident's G-tube. LVN 4 removed her gown and gloves, exited Resident 56's room and charted the administered medications in the computer. LVN 4 did not perform hand hygiene after removing her gloves and before charting Resident 56's medications in the computer. During an observation on 7/9/2026, at 4:51 PM, LVN 4 took out the blood glucose monitor (BGM- a device used to measure the residents' current blood sugar level) from the medication cart drawer, put on gloves, and checked Resident 88's blood sugar. After LVN 4 checked Resident 88's blood sugar, LVN 4 removed her gloves, exited Resident 88's room. LVN 4 did not perform hand hygiene after removing her gloves and before exiting Resident 88's room. During an observation on 7/9/202, at 4:57 PM, LVN 4 put on gloves and prepared Resident 88's gabapentin (a medication used to treat seizure, nerve related pain) medication. LVN 4 removed and replaced her gloves, entered Resident 88's room and administered Resident 88's medication. LVN 4 removed her gloves, exited Resident 88's room and charted the administered medication in the computer. LVN 4 did not perform hand hygiene after removing her gloves and before charting Resident 88's medication on the computer. During an observation on 7/9/2026, at 5:01 PM, LVN 4 put on gloves and crushed Resident 32's risperidone (medication used to treat schizophrenia), mixed the crushed risperidone with apple sauce. LVN 4 poured Resident 32's Prostat (a protein supplement) into another medicine cup then LVN 4 removed her gloves, did not perform hand hygiene and donned (put on) new gloves. LVN 4 entered Resident 32's room and administered Resident 32's medications. During an observation on 7/9/2026, at 5:05 PM, LVN 4 removed her gloves, exited Resident 32's room without performing hand hygiene and charted the administered medications in the computer. During an observation on 7/9/2026, at 5:08 PM, LVN 4 put on gloves and prepared resident 73's Seroquel (medication used to treat schizophrenia) and fenofibrate (medication used to lower cholesterol [fat-like substance that can build up in the blood vessels]) medications. LVN 4 then removed her gloves, did not perform hand hygiene and donned new gloves. LVN 4 entered Resident 73's room and administered the resident's medications, removed her (LVN 4) gloves and exited Resident 73's room and charted the administered medications in the computer. LVN 4 did not perform hand hygiene after removing her gloves and before charting Resident 73's medications in the computer. During an interview on 7/9/2026, at 5:18 PM, LVN 4 stated she did not perform hand hygiene before she put on her gloves and after she removed her soiled/ used gloves. LVN 4 did not give a reason why hand hygiene was not performed. LVN 4 stated facility staff were supposed to perform hand hygiene before putting on and after removing gloves for infection control. During an interview on 7/10/2026, at 12:15, with LVN 2, LVN 2 stated facility staff should perform hand hygiene after removing gloves and when leaving the residents' room. LVN 2 stated not using the alcohol- based hand sanitizer or washing the hands after removing the gloves or leaving the residents' room can cause contamination and spread infection in the facility. During an interview on 7/10/2026 at 2:18 PM with Infection Prevention Nurse (IPN), the IPN stated facility staff should always use hand sanitizer and wash their hands after removing their gloves. IPN stated staff must at least use hand sanitizer if hand washing was not possible at the time. IPN stated facility staff's hands can sweat while wearing gloves, which can promote bacterial growth and contaminate equipment and infect the residents and in the facility. IPN stated infections can cause residents to get sick and lead to hospitalization. During a review of the facility's P&P, titled, Hand Hygiene, revised 2/20/2025, the P&P indicated: The facility will ensure that all individuals use appropriate hand hygiene while at the facility. Facility staff follows the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors. Alcohol-based hand hygiene products can and should be used to decontaminate hands: Immediately upon exiting a resident occupied area (example: before exiting into a communal area such as a corridor) regardless of glove use. After removing personal protective equipment (PPE- a barrier precaution which includes use of gloves, gown, mask, face shield, shoe covers, head covers, respirators, etc. when you anticipate contact with blood or body fluids or other communicable toxins or agents) Hand hygiene is always the final step after removing and disposing of personal protective equipment. 2. a. During a review of Resident 82's admission Record, the admission Record indicated Resident 82 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included immunodeficiency, urinary tract infection, and abnormalities of gait and mobility. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82 was assessed having moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 82 required substantial/maximal assistance with oral/toileting hygiene, personal hygiene, shower/bathe self, sit to stand, and toilet transfer. The MDS indicated Resident 82 had an indwelling catheter. During a review of Resident 82's Order Summary Report, dated 7/10/2026, the Order Summary Report indicated a physician order, with a start date of 6/30/2026, for indwelling catheter 16 French (FR - the standard sizing scale) with 10 cubic centimeter (cc- unit of measurement for volume) bulb connect to straight drainage every shift related to obstructive and reflux uropathy (blockage in the body that makes it difficult or impossible to urinate). During a concurrent observation and interview, on 7/7/2026, at 11:48 AM, in Resident 82's room, Resident 82 was asleep in bed with Certified Nursing Assistant 6 (CNA 6) sitting on a chair next to the resident's bed. Resident 82's indwelling catheter drainage bag was touching the floor. CNA 6 stated Resident 82's drainage bag should not touch the floor and should be placed in a basin to prevent it from touching the floor. During an interview on 7/10/2026, at 12:51 PM, with the Director of Nursing (DON), the DON stated it was important for the residents' indwelling catheter drainage bag to not touch the floor to prevent urinary tract infections. The DON stated drainage bags should be placed in a basin if the bed needed to be at a low level to prevent the bag from touching the floor. The DON stated the policy for indwelling catheter care was not followed. During a review of the facility's P&P, titled, Catheter- Care of, revised 5/1/2026, the P&P indicated: The facility will prevent catheter-associated urinary tract infections while ensuring that residents are not given indwelling catheters unless medically necessary. Collection bags should always be kept below the level of the bladder, including during transport, avoiding contact with the floor. Take care to ensure the collection bag does not touch the floor at any time. 2 b. During a record review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) affecting the right dominant side, dysphagia (difficulty swallowing), carcinoma of the penis (an external organ in the male reproductive and urinary system) and urine retention (the inability to completely empty your bladder). During a review of Resident 2's admission MDS, dated [DATE], the MDS indicated Resident 2 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 2 required dependent assistance with eating, dressing, shoer/bathing self, oral, personal and toileting hygiene. The MDS also indicated Resident 2 had an indwelling catheter. During a review of Resident 2's Order Summary Report, dated 7/9/2026, the Order Summary Report indicated an indwelling catheter 16 FR with 10cc bulb may connect to drainage bag every shift carcinoma in SITU (CIS- diagnosis identifies abnormal, pre-cancerous cells that remain exactly where they first formed and have not invaded surrounding tissues), ordered 6/11/2026. During an observation on 7/7/2026 at 10:12 AM at Resident 2's bedside, Resident 2's indwelling catheter drainage bag was observed touching the floor. 2 c. During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm (cancer) of prostate (a male reproductive gland), obstructive and reflex uropathy. During a review of Resident 95's Physician's Order, dated 7/6/2026, the Physician's Order indicated indwelling foley catheter 16FR with 10cc bulb connect to straight drainage every shift for diagnoses obstructive uropathy. During a review of Resident 95's admission MDS, dated [DATE], the MDS indicated Resident 95 had severely impaired cognitive skills for daily decision making. The MDS also indicated Resident 95 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completed activity) with eating, oral and personal hygiene and substantial/maximal assistance with toileting hygiene. The MDS also indicated Resident 95 had an indwelling catheter. During an observation on 7/7/2026 at 10:34 AM at Resident 95's bedside, Resident 95's indwelling catheter drainage bag was observed touching the floor. During an interview on 7/9/2026 at 9:44 AM with Infection Preventionist Nurse (IPN), the IPN stated indwelling catheter care included ensuring the catheter drainage bag and tubing are not touching the floor. IPN stated collection bags should be placed in a basin to create a barrier between the bag and floor and if a collection bag or catheter is found touching the floor, it needs to be changed. IPN also stated the indwelling catheter tubing and collection bag that has touched the floor can cause the resident to get infections including UTI. During a concurrent interview and record review on 7/10/2026 at 2:22 PM with the DON, the facility's P&P titled, Catheter- Care of, revised 5/1/2026, the P&P indicated the [indwelling catheter] collection bag does not touch the floor at any time. The DON stated the facility policy does not say the indwelling catheter should not touch the floor but should because that is the facility standard of practice. The DON stated the indwelling catheter and collection bag are to not touch the floor to ensure it is free of contamination that can lead to the risk of infections for the residents. 3. During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), type 2 DM and shortness of breath. During a review of Resident 56's Order Summary Report, dated 12/5/2025, the Order Summary Report indicated oxygen at 2 liters per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed due to increased secretions every 24 hours. During a review of Resident 56's annual MDS, dated [DATE], the MDS indicated Resident 56 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident 56 required dependent assistance with oral, personal and toileting hygiene, dressing, and shower/bathing self. During a concurrent observation and interview on 7/7/2026 at 9:53 AM with Restorative Nurse Assistant 1 (RNA 1) at Resident 56's bedside, a plastic bag containing an oxygen mask (a medical or emergency device worn over the nose and mouth to transfer oxygen from a storage source directly to the lungs) with tubing (a small plastic tube, used for providing supplemental oxygen) (connected to a device on the nightstand) was observed on the floor under the resident's bed. RNA 1 stated the bag and respiratory equipment (oxygen mask and tubing) was under the bed, touching the floor and must have fallen [from the nightstand]. RNA 1 was then observed picking the plastic bag and equipment from the floor, removing the oxygen mask and tubing out of the plastic bag and then placing the oxygen mask into a second plastic bag already stored in a nightstand drawer. RNA 1 stated he did not need to discard the oxygen mask and tubing, just the plastic bag. During an interview on 7/9/2026 at 10:03 AM with IPN, IPN stated Resident 56's respiratory equipment and plastic bag are to be stored in the bedside drawer and not on the floor. IPN stated all respiratory equipment, and bag should have been discarded because it became contaminated once it was on the floor. IPN further stated it was important to maintain infection control and clean respiratory equipment to prevent respiratory infections including pneumonia (an infection/inflammation in the lungs). During an interview on 7/10/2026 at 2:11 PM with the DON, the DON stated RNA 1 should have informed a licensed nurse or respiratory therapist that the respiratory equipment and plastic bag was on the floor so it could have been discarded and new equipment provided instead of placing it in Resident 56's drawer. The DON stated if the contaminated equipment was used, Resident 56 had a potential for respiratory infections. During a review of the facility's P&P titled, Oxygen Administration, dated 1/1/2026, the P&P indicated for infection control all oxygen tubing, masks and cannulas (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) will be changed weekly and when visibly soiled and oxygen items will be stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 1/1/2026, the P&P indicated the facility will establish and maintain and infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in accordance with federal and state requirements.

Based on observation, interview, and record review, the facility failed to provide privacy for one (1) of 1 sampled resident (Resident 1) reviewed for dignity by failing to keep the curtains drawn on 7/8/2026 while the resident was receiving care as indicated on the facility's policy. This deficient practice resulted in Resident 1 being visible to the other residents and visitors in the room, which had the potential for loss of dignity and self-esteem. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), encounter to attention to tracheostomy (a surgically created opening through the front of the neck into the windpipe), and second degree burn (affects the outer and middle layers of skin, causing blisters, severe pain, redness, and swelling) of face. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 6/7/2026, the MDS indicated Resident 1 had severely impaired (never/rarely made decisions) cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 1 was dependent (helper does all of the effort) in toileting hygiene, shower/ bathe self, upper and lower body dressing, putting on/ taking off footwear and personal hygiene. During an observation on 7/8/2026 at 2:44 PM in Room A, Resident 1 was observed in Bed B receiving emergency medical services from paramedics (a highly trained healthcare professional who specializes in emergency medical care) and assigned facility staff due to a report of chest pain. The bedside curtain between Bed B and Bed A was not drawn, and the resident in Bed A and her visitor were observed watching Resident 1. The visitor of the resident in Bed C was also observed peeking through the bedside curtain that was drawn between Bed B and Bed C. The Infection Prevention Nurse (IPN) was observed near the foot area of Bed A. Paramedics were observed conducting assessments, including taking vital signs and performing an electrocardiogram (EKG, which is a test that measures the heart's electrical activity using electrodes placed on the chest, arms, and legs, which records these natural impulses as wavy lines on paper or a screen) During an interview on 7/8/2026 at 5 PM with IPN, IPN stated that she should have asked the visitor of Room A's bed to step outside the room while Resident 1 in bed B was receiving emergency care from the paramedics. During an interview on 7/10/2026 at 7:56 AM with the Director of Nursing (DON), the DON stated all residents should be treated with respect and dignity. The DON stated providing privacy while rendering care to residents should be practiced. The DON stated that on 7/8/2026, facility had to call 911 (universal emergency telephone number) for Resident 1 for complaints of chest pain. The DON stated Resident 1's Licensed Vocational Nurse, Registered Nurse, and Respiratory therapist should be in the room to assist the paramedics in rendering emergency service to Resident 1. The DON stated the IPN who was in the room should have made sure that Resident 1 was not being observed by other residents and visitors in the room. During a review of the Facility's policy and procedure (P&P) titled, Privacy and Dignity, revised 5/1/2026, the P&P indicated the facility respects resident's private space and property. The P&P indicated staff focuses on residents as when providing care and services. The P&P also indicated residents are afforded a right to privacy and confidentiality as part of the admission agreement and the resident is informed of these rights during the admission process.

Based on observation, interview and record review, the facility failed to ensure the call light (a handheld medical device that allows residents to easily contact staff for assistance) was within resident's reach for one (1) of two (2) sampled residents (Resident 2), reviewed for accommodation of needs, as indicated on the care plan and facility policy.This failure had the potential for Resident 2 to have unmet needs unmet and inadequate assistance, which could negatively affect the resident's care and overall wellbeing. Findings:During a record review of Resident 2's admission Record, the admission Record indicated Resident was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) affecting the right dominant side, dysphagia (difficulty swallowing), carcinoma of the penis (an external organ in the male reproductive and urinary system), and urine retention (the inability to completely empty the bladder). During a review of Resident 2's admission Minimum Data Set (MDS- a resident assessment tool), dated 6/15/2026, the MDS indicated Resident 2 had moderately impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS indicated Resident 2 was dependent (helper does all the effort) with eating, dressing, shoer/bathing self, oral, personal and toileting hygiene. During a review of Resident 2's Care Plan for At Risk for Falls related to Confusion, Gait/Balance Problems., dated 6/12/2026, the Care Plan indicated the staff interventions were to ensure Resident 2's call light is within reach and working, and that Resident 2 required a prompt response to all requests for assistance. During a concurrent observation in Resident 2's room and interview on 7/7/2026 at 10:12 AM with Resident 2, Resident 2's call light was observed out of Resident 2's reach. Resident 2 stated he needed help turning in bed. Resident 2 was then observed trying to reach his call light twice and stated he was unable to reach the call light to call for assistance. During a concurrent observation in Resident 2's room and interview on 7/7/2026 at 10:18 AM with Certified Nurse Assistant 2 (CNA 2), Resident 2's call light was observed out of reach. CNA 2 stated Resident 2's call light was out of his reach and should not be. During a concurrent interview and observation in Resident 2's room on 7/9/2026 at 9:44 AM with the Infection Preventionist Nurse (IPN), Resident 2 stated he needed assistance with water. The IPN instructed Resident 2 to press his call light for assistance. Resident 2 then stated he cannot reach his call light. Resident 2's call light was observed out of reach, positioned on the bed frame. The IPN stated Resident 2's call light was out of reach and should not be. The IPN also stated the call lights needed to remain within reach of the residents for safety, to prevent falls, and to ensure staff can promptly respond to residents' needs. During an interview on 7/10/2026 at 2:29 PM with the Director of Nursing (DON), the DON stated it was important to ensure call lights were in the reach of residents to prevent accidents, injuries, and so that residents can notify staff when they need assistance. The DON further added if call lights are not within resident's reach, staff will not be able to meet their needs. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights- Accommodation of Needs, dated 1/1/2025, the P&P indicated the facility ensures to provide an environment and services that meet the residents' individual needs. During a review of the facility P&P titled, Communication- Call System, dated 5/1/2026, the P&P indicated the facility is to provide residents with a mechanism to promptly communicate with nursing staff. The P&P also indicated call cords will be placed within the resident's reach in the resident's room.

Based on observation, interviews, and record review, the facility failed to ensure the Notice of Medicare Non-Coverage (a form issued by the facility to indicate Medicare-covered services are ending) for one of three sampled residents (Resident 87) reviewed for Beneficiary Notification was signed by the responsible party.This failure had the potential to result in Resident 87 not being able to exercise the right to file an appeal.Findings:During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 87's diagnoses included encephalopathy (disease of the brain from damage or malfunction), cognitive communication deficit (difficulty with communication process and organized thoughts effectively), and dementia (group of symptoms affecting loss of memory, language, problem-solving and other thinking abilities). The record indicated Resident 87's has two individuals listed as the resident's responsible parties. During a review of Resident 87's History and Physical (H&P) form, dated 8/4/25, the H&P indicated Resident 87 does not have the capacity to understand and make decisions. During a review of Resident 87's Minimum Data Set (MDS- a resident assessment tool), dated 5/1/2026, the MDS indicated Resident 65 was severely impaired with cognitive skills (the ability to think and reason) for daily decision making and required extensive assistance (helper does more than half the effort) with staff for activities of daily living. During a review of Resident 87's Notice of Medicare Non-Coverage, dated 5/7/2026, the notice indicated Resident 87 received and understood the notice by signing it with her signature. During an observation on 7/10/2026 at 9:50 AM in Resident 87's room, Resident 87 was awake in bed, but did not respond to questions. During an interview on 7/10/2026 at 9:52 AM with Certified Nurse Assistant 1 (CNA1), CNA 1 stated Resident 87 has dementia and is unable to comprehend or respond to attempts at communication. During an interview on 7/10/2026 at 10:12 AM with Business Office Staff (BOS) 1, BOS 1 stated Resident 87 does not have the mental capacity to make an informed decision and sign a legal document. BOS 1 also stated the facility should contact Resident 87's responsible party for signature, and if no one is available then the document should be marked as unable to complete. During an interview on 7/10/2026 at 3 PM with the Administrator (ADM), the ADM stated Resident 87 does not have the mental capacity to make decisions, and the signature is invalid. ADM stated the facility should have contacted Resident 87's responsible party or family member to complete the document. During a review of the facility's undated policy and procedures (P&P) titled, Form Instruction for the Notice of Medicare Non-Coverage, the P&P indicated the facility need to contact resident's representative when the resident is not competent to sign the form.

Based on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the Resident and/or the individual's surrogate or representative) for two (2) of 25 sampled residents (Resident 88 and 32) when Resident 88 and 32's electronic medical records were left exposed by leaving the computer on and unattended during medication administration on 7/9/2026. This deficient practice violated Resident 88 and 32's right to privacy and confidentiality.Findings:1. During a review of Resident 88's admission Record, the admission Record indicated Resident 88 was admitted to the facility on [DATE] with diagnoses that included Parkinsonism (a ground of neurological disorders that cause motor symptoms like tremors, slowed movement, and muscle stiffness), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 88's Minimum Data Set (MDS- a resident assessment tool), dated 6/11/2026, the MDS indicated Resident 88 was assessed having severely (never/rarely made decisions) impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS indicated Resident 88 required supervision or touching assistance with eating and rolling left and right. The MDS indicated Resident 88 required partial/moderate assistance (helper does less than half the effort) with sit to lying, and lying to sitting on side of the bed. The MDS also indicated Resident 88 required substantial/maximal assistance (helper does more than half the effort) with toileting/personal hygiene, upper/lower body dressing, shower/bathe self, and tub/shower transfer. During an observation on 7/9/2026, at 4:51 PM, of Licensed Vocational Nurse 4 (LVN 4) outside of Resident 88's room, LVN 4 removed the blood glucose monitor (BGM- a device used to measure the residents current blood sugar level) and Resident 88's gabapentin (a medication used to treat seizure, nerve related pain) medication from the medication cart (med cart) drawer and placed them on top of the med cart. LVN 4 verified the Resident 88's medication orders on the computer placed on top of the med cart. LVN 4 did not turn off the computer and left the computer unattended with Resident 88's medical records showing on the screen, then LVN 4 and entered Resident 88's room to check the resident's blood sugar and administered Resident 88's gabapentin medication. 2. During a review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), cerebral infarction (when the blood supply to part of the brain is blocked or reduced), and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 was assessed having moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 32 required partial/moderate assistance with eating. The MDS indicated Resident 32 was dependent (helper does all of the effort) with toileting hygiene, shower/bathe self, upper/lower body dressing, sit to lying, and chair/bed-to-chair transfer. During an observation of LVN 4 outside of Resident 32's room, on 7/9/2026, at 5:01 PM, LVN 4 removed Resident 32's Prostat (a protein supplement) and risperidone (a medication used to treat schizophrenia) medications and placed them in individual cups on top of the med cart. LVN 4 verified Resident 32's medication orders on the computer on top of the med cart and entered Resident 32's room. LVN 4 did not turn off the computer and left the computer unattended outside the resident's room when LVN 4 administered Resident 32's medications. During an interview on 7/9/2026, at 5:18 PM, with LVN 4, LVN 4 stated she forgot to close (pull down the screen) the computer or sign off from the computer on top of med cart before she entered Resident 88 and 32's rooms to administer the residents' medications. LVN 4 stated it was important to close the computer to prevent other people from accessing Resident 88 and 32 information. LVN 4 stated not closing the computer or not signing out and leaving the residents' information unprotected was a Health Insurance Portability and Accountability Act (HIPAA- a federal law designed to protect sensitive resident health information from unauthorized disclosure and theft) violation. During an interview on 7/10/2026, at 12:15 PM, with LVN 2, LVN 2 stated licensed nurses administering medications should close the computer or sign out from the computer before walking away from the med cart. LVN 2 stated it was important for licensed nurses to ensure resident information was protected and not left exposed to unauthorized people. During an interview on 7/10/2026, at 1:11 PM, with the Director of Nursing (DON), the DON stated staff did not follow the policy to protect Resident 88 and 32's health information on 7/9/2026. The DON stated LVN 4 did not protect Resident 88 and Resident 32's health information when LVN 4 left the computer on with the residents' health information showing and unattended before walking into the residents' rooms. During a review of the facility's policy and procedure (P&P), titled, Disclosure of Public Health Information (PHI), revised 6/1/2017, the P&P indicated:Facility Staff will keep medical records secure and confidential.Care should be taken to keep a medical record shielded and inaccessible to other residents or to the general public.

Based on observation, interview and record review, the facility failed to ensure the environment for one (1) of two (2) residents (Resident 56), in the environment task, was clean and free of dirt in accordance with the facility's policy and procedure (P&P) titled, Resident Rooms and Environment. This failure had the potential to negatively affect Resident 56's quality of life.Findings:During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), gastroparesis (a chronic digestive disorder where the stomach takes too long to move food into the small intestine), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 56's Order Summary Report, dated 12/5/2025, the Order Summary Report indicated enteral feed (a medical method of delivering liquid nutrition and medications directly into the stomach or small intestine) order every shift related to gastrostomy, Glucerna 1.5 (a nutritional supplement), calories (Cal) give 40 cubic centimeters (cc- a metric unit of measurement for volume)/hours x 20 hours, on at 2:00 PM off at 10:00 PM or until dose complete. During a review of Resident 56's annual Minimum Data Set (MDS- a resident assessment tool), dated 6/9/2026, the MDS indicated Resident 56 had severely impaired cognitive skills (ability to understand and make decisions) for daily decision making. The MDS also indicated Resident 56 required dependent (helper does all the effort) assistance with oral, personal and toileting hygiene, dressing, and shower/bathing self. During an observation on 7/7/2026 at 9:53 AM at Resident 56's bedside, dried tan and brown spots were observed on Resident 56's gastrostomy tube pump (G- Tube pump an electronic or battery-powered medical device designed to deliver liquid nutrition, hydration, or medications directly into a resident's stomach), the floor, floor mat (a cushioned floor pad designed to help prevent injury should a person fall) and nightstand table. During a concurrent observation and interview on 7/9/2026 at 9:58 AM with Infection Preventionist Nurse (IPN) at Resident 56's bedside, the previously observed dried tan and brown spots were observed on Resident 56's G-Tube pump, floor, floor mat and nightstand table. IPN stated Resident 56's environment was visibly dirty and there was dried enteral feeding [Glucerna] that dripped and spilled on the G-Tube pump, floor, floor mat and ran down Resident 56's nightstand. IPN stated Resident 56's environment is to be clean and sanitary, and this should have been cleaned up. During an interview on 7/10/2026 at 2:27 PM with the Director of Nursing (DON), the DON stated the residents' environments should always be clean and free from dirt to ensure quality of care and homelike environment. During a review of the P&P titled, Resident Rooms and Environment, dated 1/1/2026, the P&P indicated the facility will provide residents with a safe, clean, comfortable and homelike environment. The P&P also indicated facility staff aim to create a personalized, homelike atmosphere, paying close attention to the cleanliness and order.

Based on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 25) reviewed for restraints (any device, medication, or physical method used to restrict a patient's freedom of movement or access to their body) was free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body) in accordance with the facility's policy and procedure (P&P), titled Restraints. This deficient practice had the potential to result in limiting Resident 25's mobility and may cause injury. This also had the potential for Resident 25 not to be treated with respect and dignity with the use of restraints.Findings:During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry) and dependence on ventilator (a medical device to help support or replace breathing) status. During a review of Resident 25's Quarterly Minimum Data Set (MDS - a resident assessment tool), dated 6/1/2026, the MDS indicated Resident 25 had severely impaired (never/rarely made decisions) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 25 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 25 was dependent (helper does all of the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. During a review of Resident 25's Order Summary Report, dated 7/9/2026, indicated an order of may have left hand mitten (a large, soft, padded glove used in healthcare to cover a patient's hands) due to attempting to pull out life sustaining tubes (medical devices that keep a person alive by delivering oxygen, liquid food, or hydration when the body cannot do so on its own), ordered on 3/26/2026, order transcribed by Registered Nurse Supervisor 2 (RNS 2). During an observation on 7/8/2026 at 9:19 AM, in Resident 25's room, Resident 25 was observed with left hand mitten. During a concurrent observation and interview on 7/9/2026 at 1:05 PM, Resident 25 was observed with no left-hand mitten, and no nursing staff at bedside. MDS Registered Nurse (MDSRN) stated Resident 25 did not and should have a hand mitten on the resident's left hand. During an interview on 7/9/2026 at 1:07 PM, with RNS 2, with the presence of MDSRN, RNS 2 stated Resident 25's left hand mitten is not placed because they only apply it on as needed basis. During a concurrent record review and interview on 7/9/2026 at 1:23 PM with MDSRN, Resident 25's medical records dated from 3/26/2026 to 7/9/2026. MDSRN stated Resident 25's left hand mitten order was transcribed by RNS 2, and the order can be understood as as needed because it was ordered may have left hand mitten. RNS 2 stated the staff will only apply the left hand mitted as needed, MDSRN added probably when Resident 25 seems agitated. MDSRN stated Resident 25 did not have a restraint assessment prior to use of hand mitten and Resident 25 should have a restraint assessment. MDSRN was not able to provide documentation of the restraint assessment for Resident 25 from 3/26/2026 to 7/9/2026. MDSNRN stated he had seen Resident 25 with a left-hand mitten restraint from 3/26/2026 to 7/9/2026. MDSRN stated there is no documented evidence that Resident 25 is being observed or checked every 30 minutes while the resident is on restraint and it should have been done per the facility's policy and procedure for use of restraints. MDSRN added there should be an order to observe Resident 25 every 30 minutes, and it should reflect on Resident 25's Treatment Administration Record (TAR). During an interview with the Director of Nursing (DON) on 7/9/2026 at 7:38 AM, the DON stated, she had seen Resident 25 with left hand mitten from 3/26/2026 to 7/9/2026. The DON stated that prior to use of hand mitten, RNS 2 should complete a restraint assessment for the use of hand mitten because it can be a form of physical restraint. The DON stated, hand mitten is a device that limits hand movement, and that means it is considered as a restraint. The DON stated restraints like Resident 25's left hand mitten should not be used as as needed. During a review of facility's Policy and Procedure (P&P), titled Restraints, revised in 5/1/2026, the P&P indicated facility will ensure that restraints will not be imposed for purposes of discipline or convenience. The P&P indicated the facility will not use restraints on a prn (as needed) or as necessary basis. The P&P indicated an assessment will be completed by a Registered Nurse prior to the application of any device that restricts movement or access to one's body. The assessment will be repeated quarterly thereafter. The P&P also indicated that a resident placed in a restraint will be observed at least every 30 minutes by nursing staff.

Based on interview and record review, the facility failed to ensure accurate assessment and documentation of the Minimum Data Set (MDS, a resident assessment tool) for three (3) of 25 sampled residents (Resident 13, 25 and 86) in accordance with the facility's policy and procedure (P&P) by failing to ensure the MDS reflected:Resident 13's weight of 103 pounds (lbs) on 3/5/2026 and 101 lbs on 6/5/2026.Resident 25 reflected the resident's active diagnosis of psychiatric/mood disorder (a mental health condition where your persistent emotional state, your mood, is severely disrupted).Resident 86's basal cell carcinoma (BCC- the most common type of skin cancer) skin lesions.This deficient practice had the potential for the facility to not develop and implement an individualized care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives, interventions and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs), which could negatively affect Residents 13, 25, and 86's care and overall well-being. Findings: 1. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 13's diagnoses included metabolic encephalopathy (a brain dysfunction caused by an underlying chemical process problem), protein calorie malnutrition (body lacks both enough energy calories and protein), dementia (a group of symptoms affecting loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 13's medical record, dated 3/5/26, the record indicated Resident 13's documented weight was103 lbs. During a review of Resident 13's significant change MDS, dated [DATE], the MDS indicated Resident 13's documented weight was 117 lbs. The MDS indicated Resident 13 had moderate impaired (rarely makes decisions) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making, and need assistance from another person to complete any activities. During a review of Resident 13's medical record, dated 6/5/26, the record indicated Resident's 13's documented weight as 101.0 pounds. During a review of Resident 13's quarterly MDS, dated [DATE], the MDS indicated Resident 13's documented weight as 117 pounds. (MDS quarterly assessment) During an interview on 7/9/2026 at 9:17 AM, with MDS Registered Nurse (MDSRN, a registered nurse who specializes in evaluating and documenting the health, daily function, and care needs of residents), MDSRN stated his responsibility is to gather and ensure the accuracy of the MDS assessment. MDSRN stated Resident's 13 MDS documented weight on 3/6/2026 and 6/4/2026 did not reflect the resident's correct weight at the time of assessment. MDSRN stated inaccurate documentation can result in missed identification of significant changes in health status and can affect the accuracy of care plans and interventions. The MDSRN stated consequently Resident 13 may not receive timely nutritional support or medical attention, potentially increasing the risk of complications. 2. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), anxiety (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry) and dependence on ventilator (a medical device to help support or replace breathing) status. During a review of Resident 25's Psychiatric Notes (official medical records written by a mental health professional after a patient visit), the Psychiatric Notes, dated 5/2/2026, indicated Resident 25 has a past psychiatric history of dementia and anxiety. It also indicated a diagnosis of depression (a serious mood disorder that causes persistent sadness and a lack of interest in life). During a review of Resident 25's Quarterly MDS, dated [DATE], the MDS indicated Resident 25 had severely impaired (never/rarely made decisions) cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making. The MDS indicated Resident 25 had episodes of feeling or appearing down, depressed or hopeless, trouble falling or staying asleep or sleeping too much, feeling tired or having little energy, and trouble concentrating on things, such as reading newspaper or watching television. The MDS indicated Resident 25 required substantial/maximal assistance (helper does more than half the effort) with oral hygiene, upper body dressing and personal hygiene. The MDS indicated Resident 25 was dependent (helper does all of the effort) with toileting hygiene, shower, lower body dressing and putting on/taking off footwear. In addition, the MDS indicated Resident 25 has a diagnosis of dementia. During a concurrent record review and interview on 7/9/2026 at 1:25 PM with MDS Registered Nurse (MDSRN), Resident 25's medical records dated from 5/2/2026 to 6/1/2026 were reviewed. MDSRN stated Resident 25's psychiatrist note dated 5/2/2026, indicated a diagnoses dementia, anxiety and depression. MDSRN stated the diagnoses of anxiety and depression were not and should have been reflected in the MDS on 6/1/2026. MDSRN stated that accurate MDS is important for the facility to develop a resident centered care plan. During an interview on 7/10/2026 at 7:44 AM with the Director of Nursing (DON), the DON stated it was important for the MDS to be accurate to ensure the development and implementation of an individualized resident care plan. 3. During a review of Resident 86's admission Record, the admission Record indicated Resident 86 was admitted to the facility on [DATE] with diagnoses that included BCC of skin of unspecified parts of face, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dysphagia (difficulty swallowing). During a review of Resident 86's Skin Weekly Assessment 1.1, dated 6/17/2026, the Skin Weekly Assessment indicated upon admission, Resident 86 had facial BCC lesions with granulation (a new connective tissue; beefy red) and necrotic (dead, non-functioning; brown, black, leather, scab-like) tissue present. During a review of Resident 86's admission MDS, dated [DATE], the MDS indicated Resident 86 had intact cognitive skills for daily decision making. The MDS also indicated Resident 86 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, partial/moderate assistance (helper does less than half the effort) with toileting hygiene, dressing, shower/bathing self, and supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with oral and personal hygiene. During a concurrent interview and record review on 7/10/2026 at 12:25 PM with the MDSRN, Resident 86's admission MDS, dated [DATE], the MDS indicated that no ulcers, wounds and skin problems were present. The MDSRN stated Resident 86 had facial cancer lesions at the time this assessment was completed and open lesions should have been reflected on the MDS. The MDSRN stated Resident 86's MDS was not accurate and per facility policy should be. The MDSRN stated the MDS needs to be accurate to ensure residents receive proper care and care planning. The MDSRN stated an inaccurate MDS can result in an inaccurate or incomplete care plan. During a review of the facility's policy and procedure (P&P) titled Resident Assessment Instrument (RAI- a standardized clinical system used in long-term care settings to evaluate a resident's health status, functional capabilities, and care needs) Process, dated 1/1/2026, the P&P indicated the RAI is used in conducting comprehensive assessments as part of an ongoing process through which the facility identifies each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessment once problems have been identified. The P&P also indicated all information recorded within the MDS Assessment must reflect the resident's status at the time of the ARD.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse (non-consensual sexual contact of any type with a resident) for one of two sampled residents (Resident 1) who has a diagnoses of aphasia (a disorder that makes it difficult to speak), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition that causes weakness or an inability to move on one side of the body) was free from sexual abuse (non-consensual sexual contact of any time with a resident) by Certified Nurse Assistant 1 (CNA 1). This deficient practice resulted in Resident 1 subjected to sexual abuse by CNA 1 on 7/20/2024. Based on psychiatric evaluation conducted on 7/24/2024, the resident was assessed being anxious, irritable, making intermittent (not happening regularly or continuously) eye contact, withdrawn (not wanting to communicate with other people), and affect (a response to some event) was tearful and cried unconsolably (in a state of extreme sadness or disappointment where no one can make you feel better). Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility admitted the resident on 9/30/2021 with diagnoses including aphasia, hemiplegia and hemiparesis following cerebral affecting right dominant side, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/3/2024, indicated Resident 1 had severe impairment of cognitive (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) skills for daily decision making. The MDS indicated Resident 1 required supervision with eating and required maximal assistance (helper does more than half the effort) from staff with oral hygiene, toileting, showering, dressing and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for rolling from lying on back to left and right side, transfers, and wheeling herself at least 150 feet. During a review of Resident 1's Care Plan (CP), dated 4/2/2024, the CP indicated Resident 1 has a communication problem related to aphasia. The staff interventions included were to anticipate and meet resident's needs and to monitor/document resident's ability to express and comprehend language. During a review of Resident 1's CP, dated 4/1/2024, the CP indicated Resident 1 has an Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) performance deficit (loss/lacking) related to hemiplegia. The staff interventions included were to check the resident at least every two hours and as needed for soiling (to make something dirty) and wetness, encourage resident to complete tasks, and provide reinforcement for activities attempted and/or partially achieved. During an interview on 11/22/2024 at 1 PM, Resident 1 stated that there was an incident when a male staff abused her. Resident 1 stated she cannot remember the exact date and time, but she remembered that it was after dinner. Resident 1 stated that while she was in bed, a male CNA (no name, unable to remember) repositioned her in bed and Resident 1 felt pain on her hip. Resident 1 stated she does not want to talk about it further. During a review of a facility form titled, Change in Condition (COC) Evaluation, dated 7/20/2024, timed 7:38 PM, indicated at 6:50 PM on 7/20/2024, Resident 1 reported to Licensed Nurse that a male CNA touched her private area (part of the body that is usually covered by clothing) when CNA was assisting her with incontinent (involuntary loss of bladder or bowel control) diaper change. During a review of the Staffing Assignment on dated 7/20/2024, indicated CNA 1 worked in the facility during the 3 PM to 11 PM shift and was assigned to care for Resident 1. During a review of the facility's Final Investigation and verification report summary, dated 7/25/2024, the report indicated at approximately 6:50 PM, Saturday 7/20/2024, the Director of Nurses (DON) was notified about Resident 1's allegation of sexual abuse from CNA1. The report indicated Resident 1 was noted to be visibly upset and claimed assigned male CNA (CNA 1) touched her private area while CNA 1 was assisting her during incontinent brief change. Resident 1 motioned to brief and repeated [NAME], Sangre, Sangre (Spanish for: look, blood, blood). Scant serosanguineous (a combination of blood and clear fluid) fluid noted on Resident 1's incontinent brief (diaper) as assessed by LVN 1 and Registered Nurse 1 (RN 1). Resident noted with facial grimacing and continued to motion towards perineal area, but ultimately unable to describe any pain. Upon genitourinary (the urinary and genital organs) assessment, Resident 1 was noted with light pinkish fluid from vaginal area. There were no new skin injuries or discoloration noted to perineal area. During an interview on 7/24/2024 at 10:17 AM, the Director of Nursing (DON) stated Director of Staff Development (DSD) contacted the Registry agency where CNA1 was employed and reported the abuse allegation. The DON stated the Registry agency was made aware that the facility will no longer utilize the services of CNA1. During an interview on 11/22/2024 at 3 PM, DSD stated CNA 1 had not been back to the facility to work since 7/20/2024. The DSD stated CNA 1 was detained in jail on 7/20/2024. The DSD added facility made sure CNA 1 was not on the list of registry CNAs that were being sent to the facility. During a review of the General Acute Care Hospital (GACH) Emergency Department History and Physical (H&P), dated 7/21/2024, timed 12:27 AM, the H&P indicated Resident 1 was brought in from nursing facility who reported Resident 1 had accused a male nursing staff of sexually assaulting (an act of sexual abuse in which one intentionally sexually touches another person without that person's consent) her earlier that day. The H&P also indicated Resident 1 stated that CNA 1 digitally penetrated (to move into or through something) his penis into the resident's vagina. During a review of the GACH Sexual Assault Response Team (SART), dated 7/21/2024, timed at 2:45 AM, the report indicated findings included bruising bilaterally on the inner labia minora (a pair of small, hairless folds of skin that form the inner lips of the vulva [female genital]). During a review of the GACH SART amended report, dated 7/23/2024, the report indicated Upon review of the genital photos, the patient had vaginal bleeding which makes it difficult to fully visualize the genitalia. Therefore, examiner is not able to confirm the bruising documented on the 923 report (Forensic Medical Report [a report to clearly convey what has or has not happened to a victim based on evidence]: Acute Adult Sexual Assault Examination) as a genital finding. The examiner was not able to also confirm the source of vaginal bleeding. Patient (Resident 1) disclosed to examiner that she does not have menstrual cycles, however due to patient's history of stroke [damage to the brain from interruption of its blood supply] and verbal impairment as patient was struggling to articulate, examiner is unsure if the bleeding is from a menstrual cycle, or a medical condition and/or from injury. It also indicated GACH performed a pregnancy test, and results were negative. During a review of the Nurse's Progress Notes, dated 7/21/2024, the notes indicated Resident 1 returned from GACH via stretcher accompanied by 2 Emergency Medical Technician (EMT, provide emergency medical care). During a review of Resident 1's Psychiatric evaluation (a clinical assessment of a person's mental health that can help diagnose and treat mental health conditions) report, dated 7/24/2024, the report indicated Resident 1 was anxious and irritable, making intermittent (not happening regularly or continuously) eye contact. Resident 1's mood was withdrawn (not wanting to communicate with other people), and affect (a response to some event) was tearful. The report indicated that according to staff, Resident 1 had mood instability (when there is no control over moods resulting in difficulty managing behaviors), cried unconsolably (in a state of extreme sadness or disappointment where no one can make you feel better), and had difficulty being redirected. The report also indicated Resident 1 accused CNA1 of sexually assaulting her. During a review of the local law enforcement reports released on 11/27/2024, the reports indicated the following: 1. The Police Department (PD) Patrol Report, dated 7/21/2024, indicated Police Officer 1 (PO1) requested local Fire Department to respond to the location with an ambulance to transport Resident 1 to General Acute Care Hospital (GACH). 2. The PD Patrol Investigation Report, dated 7/21/2024, indicated on Saturday, 7/20/2024, at approximately 6 PM, while Resident 1 was lying down on her bed, a male nurse exited the bathroom door and walked over to Resident 1's bedside. The nurse raised Resident 1's bed upwards and lifted both of her legs up. The nurse then pulled down his pants and penetrated her with his penis, which caused pain. Resident 1 could not state how many times she was penetrated or how long he penetrated her for. As Resident 1 was explaining what occurred to the Police Officers, Resident 1 kept gesturing with her left hand inward and outward and pointing towards her vagina. Resident 1 also stated, There is proof inside, and again pointed towards her vagina. Resident 1 described the suspect as a male, white, young, wearing a black hat. 3. The PD Patrol Supplemental report, dated 7/21/2024, indicated CNA 1, CNA 2, and Licensed Vocational Nurse 1 (LVN 1) were interviewed by PO 2. The PD Patrol Supplemental report indicated the following: a. CNA 1 stated he picked up a registry (agency that offers healthcare related contracts for nurses) shift at the facility, which started at 3:20 PM on 7/20/2024. b. CNA 1 stated Resident 1 asked him to have her diaper changed after dinner. CNA 1 stated, at approximately 6:15 PM, Resident 1 was sitting in her wheelchair beside the bed. CNA 1 assisted Resident 1 to her bed and had her lie down on her back. CNA 1 stated he prepared warm wash cloths to conduct the diaper change. CNA 1 stated he had gloves covering his hands and proceeded to wrap the washcloth around his pointer and middle finger and wipe Resident 1's vagina in a downward action toward her anus. CNA 1 stated he noticed some pus on the washcloth as well as a small amount of blood. CNA 1 stated he showed Resident 1 that she was bleeding, and Resident 1 said Si, Si (Spanish for: yes, yes). c. LVN 1 stated on 7/20/2024, approximately 6:30 PM, she entered Resident 1's room and provided her medication. Approximately 30 minutes after, Resident 1 arrived in the nursing station and began telling the nurses that she had been sexually assaulted. d. CNA 2 stated that on 7/20/2024, she was at the nursing station with LVN 1 when Resident 1 rolled toward them in her wheelchair. CNA 2 stated although Resident 1 spoke Spanish, she had a hard time understanding what Resident 1 was saying. CNA 2 stated she began looking at Resident 1's gestures and believed she was telling them that a man had had intercourse (sexual activity involving insertion and thrusting of the male penis inside the female vagina) with her. 4. The Forensic Medical Report, dated 7/21/2024, indicated Resident 1 was examined for Adult Sexual Assault examination (a full body examination, including internal examinations of the mouth, vagina, and/or anus). The forensic medical report indicated Resident 1 stated, The suspect (CNA1) held her legs up and entered her five (5) or six (6) times. The report indicated Resident 1 had vaginal bleeding and was crying when describing the attack. It also indicated genital examination was done and specimens (dried and moist secretions, stains, and foreign materials) were collected. 5. The Detective investigation Report, dated 11/19/2024, indicated semen was detected in Resident 1's vagina and perianal area (the area of the body surrounding the anus [butthole]), and that suspect CNA 1 was the contributor. Detective 1 conducted an interview with CNA 1 and the Detective investigation report indicated the following: a. CNA 1 was asked about what happened on 7/20/2024, CNA 1 answered, He went in resident's (Resident 1) room after dinner to change the residents. CNA 1 said Resident 1 kept tapping her hand on her vagina (over her diaper and gown) and he believed she wanted me to, like, do stuff with her. CNA1 stated he declined and proceeded to change Resident 1 like normal. b. CNA 1 stated Resident 1 went to the nurse's station and told them (CNA2 LVN 1) in Spanish that he (CNA1) stuck his penis inside her and made her bleed. c. CNA 1 was asked about the tapping motion he described Resident 1 did, CNA 1 answered Resident 1 wanted him to touch her vagina because of how she was touching it. d. CNA 1 was asked what made him believe Resident 1 was telling him she wanted him to touch her sexually rather than change her diaper, CNA 1 responded, I don't know what she wanted me to do and I don't know what she was trying to say, like I said, it's a different language, you know what I mean, I don't know what she was trying to say. e. CNA 1 stated he heard Resident 1 claimed CNA 1's big fat penis made her bleed. I asked him if it did, and he responded, I don't know, did it? f. CNA 1 was asked why his semen would be in Resident 1's vagina, and he denied putting any semen in her vagina. g. DNA report (a document detailing the results of a DNA analysis, which compares an individual's DNA profile to another sample) was showed to CNA 1, and CNA1 changed his story to having consensual (with consent) sex with Resident 1. h. CNA 1 stated Resident 1 put her fingers in her vagina and then grabbed his hand and put it in her vagina because she was horny (feeling or arousing sexual excitement). CNA 1 said he denied having sex with her because, It's embarrassing to say you had sex with a 60 something year old woman. He added he is messed up and he did not use good judgment. He repeatedly said he did not rape Resident 1 and that she wanted it. During a concurrent observation and interview on 11/26/2024 at 4:21 PM, with Resident 1 in the conference room, in the presence of Social Service Director (SSD), Resident 1 was observed to have difficulty communicating and agreed to have the SSD help and translate her statement in English. Resident 1 stated there was a time when she told a male CNA (no name, unable to remember) to change her diaper after dinner time. Resident 1 stated that she was in bed when the male CNA came to her room. Resident 1 stated she saw the CNA's penis in her vagina, and she felt it was inserted twice. Resident 1 stated CNA 1 grabbed and held her leg up and repositioned her that was why she could not reach the call light. Resident 1 stated all she remembered was the male CNA was bald, tall, and was wearing a head gear, black top, and pants. During a phone interview on 11/27/2024 at 2:54 PM, LVN 1 stated, on 7/20/2024, Resident 1 was upset and reported to her while at nursing station 1 that CNA 1 took off his pants in front of her and proceed to touching her inappropriately. Resident 1 stated CNA1 had a sexual intercourse with her. During an interview on 11/27/2024 at 4:20 PM, LVN 2 stated, on 7/20/2024, Resident 1 wheeled herself to nursing station 2. Resident 1 was crying and was trying to say something, [NAME], [NAME]. Resident 1 was trying to remove her diaper to show the blood on the diaper. LVN 2 stated Resident 1 wanted to show evidence of blood stain as result of CNA1 sexually assaulting Resident 1. LVN 2 stated seeing a stain on the wheelchair pad where Resident 1 was sitting on. LVN 2 stated she assisted Resident 1 back to her room while RN 1 also came to the room and informed LVN 2 that Resident 1 had also reported to LVN 1 the allegation that she was touched inappropriately by CNA 1. LVN 2 stated she observed a pinkish stain on the towel after wiping Resident 1's vaginal area. LVN 2 stated any kind of abuse was not acceptable. LVN 2 stated residents needed their care and should be free from abuse of any kind. During an interview on 11/27/2024 at 5 PM, the Interim DON stated staff to resident relationship, including sexual intercourse was not acceptable in the facility. The Interim DON stated, We're here to care for the residents and not to assault (the act of causing or attempting to cause physical harm or unwanted physical contact to another person) or rape (a type of sexual assault involving sexual intercourse, or other forms of sexual penetration, carried out against a person without their consent) them. The Interim DON stated based on resident 1's cognition, sexual intercourse between her and another individual would not be consensual (made by mutual consent without an act of writing). During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated 8/1/2023, the P&P indicated, Each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property. The following were the facility's corrective actions: 1. The facility immediately initiated their abuse protocol which included immediately removing Resident 1 and other residents from the care of CNA 1 on 7/20/2024, after Resident 1 reported the allegation of sexual abuse to the Licensed Nurses. 2. Resident 1 was assessed by the licensed staff and provided psychosocial support on 7/20/2024. 3. Resident 1's physician and responsible party were notified of the allegation of sexual abuse on 7/20/2024. 4. Local law enforcement was notified of the sexual abuse incident and was immediately dispatched to the facility on [DATE]. Local law enforcement conducted an interview with the resident and requested Local Fire Department for an ambulance to transport Resident 1 to GACH on 7/20/2024 for further evaluation. 5. Local Law enforcement placed CNA 1 into properly adjusted double locked handcuff and placed him in the back of patrol vehicle and was transported to GACH on 7/20/2024 for SART exam. CNA 1 was transported to local police jail where he was booked for rape. 6. The facility contacted the Registry agency where CNA1 was employed and reported the abuse allegation on 7/20/2024. 7. The facility did not utilize CNA 1 since after the reported allegation of sexual abuse. 8. The facility initiated and completed an investigation on the sexual abuse allegation. 9. Psychiatry evaluation for Resident was completed on 7/24/2024.

Based on interview and record review, the facility failed to provide continuity of respiratory care and treatment to three (3) of 38 sampled residents (Residents 1, 2 and 3). 1. Resident 1, who was diagnosed with chronic respiratory failure (a long term condition that makes it difficult to breathe because the lungs cannot exchange air properly), chronic obstructive pulmonary disease (COPD; a common lung disease that makes it hard to breathe) and asthma (a chronic lung disease that causes the airways in the lungs to narrow and swell making it difficult to breathe), and on continuous oxygen (colorless, tasteless and odorless gas) therapy (treatment that provides oxygen to people who have breathing problems or lung disease) was transferred from the Long-Term Acute Care Hospital (LTACH, a facility whose specialty is treating patients who require a longer period of closely monitored healthcare) to the facility. Upon admission to the facility, facility staff failed to: A. Obtain an order for Resident 1's continuous oxygen therapy by (via) nasal cannula (NC; a medical device that provides supplemental oxygen to patients through their nose) at five (5) liters per minute (LPM; a unit of measurement for flow rate) in accordance with the LTACH's transfer packet (document/s that summarizes a resident's hospital care and provides instructions for their post- hospital care for continuity of care). B. Obtain an order to administer Resident 1's bilevel positive airway pressure (BIPAP; a medical device that helps people breathe by delivering pressurized air into the airways) at night and as needed (PRN) in accordance with the LTACH's transfer packet. C. Administer Resident 1's respiratory treatments of albuterol sulfate (medication for breathing) 1.25 milligram (mg, unit of measurement) inhalation via nebulizer (a device for producing a fine spray of liquid, used for inhaling a medicinal drug) every 6 hours and budesonide (medication for breathing) 0.5 mg inhalation via nebulizer twice a day from [DATE] at 11:17 PM until Resident 1 was found unresponsive on [DATE] before 3:20 PM (approximately 16 hours from admission) in accordance with the LTACH's transfer packet. As a result of these deficient practices, Resident 1 was found unresponsive by facility staff on [DATE] (time not specified). Facility staff started Cardiopulmonary resuscitation (CPR; an emergency procedure that is used to restart a person's breathing and heartbeat when they've stopped) and called 911 (phone number used to contact emergency services). Paramedics (person trained to give emergency medical care to people who are injured or ill) arrived at the facility at 3:30 PM, continued CPR and pronounced Resident 1 dead at 4:28 PM. 2. Facility failed to ensure Resident 2 had an MD order before administering oxygen via NC at 5 LPM since admission to the facility. 3. Facility failed to ensure Resident 3's oxygen via NC was on the correct ordered setting of three (3) LPM. These deficient practices placed Resident 2 and Resident 3 at risk for experiencing shortness of breath (SOB; also known as dyspnea, is an uncomfortable feeling of being unable to breathe normally or deeply enough) or respiratory distress (a condition that occurs when the body needs more oxygen, resulting in difficulty breathing and low oxygen levels in the blood). On [DATE] at 6:52 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy (IJ; a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation regarding the facility's failure to provide continuity of respiratory care and treatment for Resident 1. The survey team notified the facility's Administrator (ADM) and the Director of Nursing (DON) of the IJ situation due to: failing to obtain an order for Resident 1's continuous oxygen therapy via NC at 5 LPM; failing to obtain an order to administer Resident 1's BIPAP at night and PRN; and failing to administer Resident 1's respiratory treatments of albuterol sulfate 1.25 mg inhalation via nebulizer every 6 hours and budesonide 0.5 mg inhalation via nebulizer twice a day from [DATE] at 11:17 PM until Resident 1 was found unresponsive on [DATE] before 3:20 PM in accordance with the LTACH's transfer packet. On [DATE] at 2:06 PM the IJ was removed in the presence of ADM, Clinical Director (CD), Administrator in Training (AIT) and Activities Director (AD) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices) and the surveyor verified and confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The acceptable IJ Removal Plan dated [DATE], included the following: a. On [DATE], Resident 1 was found unresponsive. CPR was initiated, and paramedics were called. Paramedics arrived at 3:30 PM, and Resident 1 was pronounced dead at 4:28 PM. b. On [DATE], the DON initiated an investigation into the failure to administer proper respiratory care, interviewed all staff involved and reviewed Resident 1's medical record and the hospital (LTACH's) transfer packet to identify gaps in care. c. On [DATE], the DON provided a one-on-one in-service (training) for the Licensed Vocational Nurse (LVN) who worked on [DATE] during the 3 PM to 11 PM shift regarding immediate physician notification, obtaining orders for oxygen for residents requiring oxygen therapy and obtaining orders for BIPAP therapy and respiratory treatment. d. On [DATE], the DON provided a one-on-one in-service to the LVN who worked during the night shift (11 PM to 7 AM) on [DATE], which focused on timely physician notification, oxygen therapy management, and respiratory treatment protocols. The nurse was re-educated on the facility's policies regarding obtaining and following respiratory care orders for residents requiring oxygen and BIPAP therapy. e. On [DATE], the DON provided a one-on-one in-service to the LVN who worked during the day shift (7 AM to 3 PM) on [DATE], which covered the importance of ensuring proper respiratory care, including timely administration of oxygen therapy and respiratory treatments. The nurse was re-educated on protocols for managing respiratory illnesses and promptly reporting changes in a resident's condition to the physician. f. On [DATE] and [DATE], Resource Nurse Consultant provided in-services to licensed nurses on immediate physician notification, obtaining orders for oxygen for residents requiring oxygen therapy and obtaining orders for BIPAP therapy and respiratory treatment. g. On [DATE], the DON and Medical Records Director/Designee reviewed the respiratory care orders for all residents requiring oxygen therapy and respiratory treatments to ensure that all orders were accurate and being followed. h. On [DATE], the DON and Medical Records Director/Designee audited all residents on continuous oxygen therapy or receiving respiratory treatments to ensure that proper orders were in place and that treatments were being administered as prescribed. i. On [DATE], the DON and Medical Records Director/Designee audited care plans for all residents on continuous oxygen therapy or receiving respiratory treatments to ensure that proper orders were in place and that treatments were being administered as prescribed. j. On [DATE], all licensed nurses were required to review the care plans of residents with respiratory diagnoses to confirm the correct therapy settings and timely treatments were provided to the resident. k. On [DATE], total of two (2) residents on continuous oxygen therapy, 38 residents receiving respiratory treatments, zero (0) residents on BIPAP were audited to ensure proper care for oxygen and respiratory therapy were in place and followed. l. On [DATE], the DON and Medical Records Director/Designee audited 38 residents with a respiratory diagnosis. Specifically, they (DON and Medical Records Director/ Designee) checked the care plans of 38 residents to ensure that the correct therapy settings were in place and that all respiratory treatments were being administered timely. m. On [DATE], the DON and Medical Records Director/Designee reviewed oxygen flow rates for 2 residents on continuous oxygen, BIPAP settings and 38 nebulizer treatments. n. On [DATE], the DON and Medical Records Director/Designee reviewed 38 residents receiving respiratory treatments including albuterol sulfate, budesonide, and other prescribed inhalation treatments. o. Starting [DATE], all newly admitted residents requiring oxygen therapy or respiratory treatments will have their physician orders reviewed and verified by a Charge Nurse within 2 hours of admission to ensure accuracy and timely implementation. p. Effective [DATE], the DON implemented a protocol requiring nurses to immediately notify the primary physician for any new admission from the hospital or any resident requiring oxygen therapy. Failure to notify physician within 1 hour will result in escalation to the DON and Medical Director. For late hours and weekends, the Charge Nurse on duty will be responsible for verifying physician orders and ensuring that oxygen therapy and respiratory care treatments are administered within one hour from verification of physician's orders. Once the physician orders are verified, routine medications and treatments will be the responsibility of the Charge Nurse on duty. For weekend admissions, the Charge Nurse will be responsible for following the same verification process and will notify the DON within one hour if any discrepancies or issues arise that require attention. All the new licensed staff will be oriented on the current processes including verification of physician orders, administering medications without delay, and utilizing STATSAFE (secure medication system ensuring that critical medications, including respiratory treatments, are readily available for immediate use). In case of emergencies or off-hours, medications will be made available through STATSAFE to ensure that critical medications like albuterol sulfate, budesonide, ipratropium bromide (medication for breathing) and prednisone (medication to help with swelling), are readily accessible and can be administered without delay. The updated list of medications included in STATSAFE was reviewed and finalized in consultation with the pharmacy on [DATE]. The contents of STATSAFE will include, but are not limited to albuterol sulfate, budesonide, ipratropium bromide, prednisone (oral) and Epinephrine (emergency medication used to treat life threatening conditions). The implementation of the updated STATSAFE list and contents took place on [DATE]. q. Effective [DATE], the Resource Nurse Consultant provided in-services to the DON and all Licensed Nurses and all licensed nurses in serviced on [DATE]. The focus was regarding respiratory care management, ensuring that the nursing team is updated on best practices for oxygen therapy, documentation, physician communication, the updated list of critical medications available in STATSAFE, how to access and administer these medications during off-hours, and proper documentation procedures for emergency and critical medication use. r. Effective [DATE], the Resource Nurse Consultant provided in-services to the DON and all licensed nurses which focused on respiratory care management, ensuring that the nursing team is updated on best practices for oxygen therapy, documentation, and physician communication. s. Effective [DATE], the facility educated all licensed nurses on the updated process for handling new admissions, off-hours protocols, and STATSAFE access during weekends and after office hours. This training was conducted by the Resource Nurse Consultant and the DON. The training covered the updated process for verifying and implementing physician orders during late hours and weekends, how to access STATSAFE and administer medications promptly and documentation protocols for respiratory treatments and critical medication administration. t. On [DATE], the Pharmacy Consultant conducted Medication Regimen Review (MRR; a systematic evaluation of a patient's mediation to ensure they are safe, effective, and appropriate) for all residents receiving respiratory treatments. The MRR reviewed all residents with the respiratory diagnosis and residents receiving oxygen therapy and reviewed if their medications were reconciled (process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider) and all orders were being followed as prescribed. No residents were affected by this deficient practice. u. Effective [DATE], the DON will provide monthly in-services for all licensed nurses and certified nurse assistants (CNAs), focusing on respiratory care management, proper documentation, and timely physician notification for residents with respiratory conditions. The monthly in-service will be ongoing and will continue for the next 6 months to ensure continued compliance. The initial in-service was completed on [DATE]. v. On [DATE], the DON provided an in-service to all licensed nurses, emphasizing that they must document the time of administration of all respiratory treatments, including oxygen therapy, nebulizer treatments (e.g., albuterol sulfate, budesonide), and BIPAP therapy, and notify the Charge Nurse immediately if there are any delays in treatment of oxygen therapy, nebulizer treatments and BIPAP therapy. w. Effective [DATE], any resident requiring continuous oxygen therapy will have their oxygen settings and respiratory treatments verified during daily rounds utilizing room rounds audit form by the Charge Nurse. Effective [DATE], any resident requiring continuous oxygen therapy will have their oxygen settings and respiratory treatments verified during daily rounds by the Charge Nurse. These rounds will be documented in the huddle form (tool that helps a team prepare for a day of patient care by reviewing charts and identifying tasks and concerns) will be completed to track compliance with oxygen therapy protocols. Any discrepancies will be corrected immediately. x. On [DATE], the DON/Designee started to monitor compliance with respiratory care protocols and ensure that all corrective actions are effectively implemented for all current residents requiring oxygen therapy or respiratory treatments. y. On[DATE], the DON/Designee started to oversee the administration of respiratory-related medications and ensure that physician orders are being followed daily. A respiratory care monitoring tool will be utilized to track the accuracy of oxygen therapy, respiratory treatments, and BIPAP usage. z. On [DATE], the charge nurses started to review and oversee all new admissions, ensuring that respiratory therapy orders are in place and that admission assessments are completed on the same day as admission. If a resident is admitted without a transfer medication list, a charge nurse will contact the discharging hospital to obtain, review, and reconcile the resident's hospital discharge medication list with the resident's primary care provider. The facility is emphasizing the importance of consistently following the existing policy, and staff will be re-educated as necessary to ensure compliance with the current policy. On[DATE], the facility ensured that all staff are reminded of this existing policy and will re-educate staff as needed to ensure continued compliance. aa. Starting [DATE], licensed nurse will also contact the primary care provider to clarify all orders for newly admitted residents and ensure that oxygen and respiratory treatments are initiated correctly. bb. Starting [DATE], the Charge Nurse will discuss non-compliance and necessary corrections during the facility's daily (Monday to Friday) clinical meeting to Interdisciplinary Team (IDT; a group of people from different disciplines who work together to achieve a common goal) team members. This will include any findings or non-compliance identified over the weekend, ensuring that weekend issues are addressed in the following Monday's clinical meeting. cc. Starting [DATE], the results of respiratory care audits and compliance with oxygen and treatment orders will be discussed monthly for three months or until 100% compliance is maintained during quality assurance (a systematic process to ensure that a product or service meets specified requirements) meetings and reviewed by the Quality Assurance Committee. This review will also include any findings or non-compliance identified during the weekends to ensure a comprehensive evaluation of all care provided throughout the week. dd. Starting [DATE], the Resource Nurse Consultant will provide in-services to the DON and all licensed nurses to enhance staff knowledge of respiratory care management, including oxygen therapy, physician notification, medication administration policy, admission assessment, and respiratory treatments. ee. Starting [DATE], the Pharmacy Consultant will complete Medication Regimen Review (MRR) for all residents requiring respiratory treatments, ensuring that the correct medications are ordered and administered appropriately. Any MRR discrepancies will be addressed promptly by the DON. The DON will provide in-services to licensed nurses if there are any MRR discrepancies or any non- compliance. ff. Starting [DATE], the DON/Designee will conduct ongoing monthly in-services for three months with the facility's primary care providers to reinforce the correct procedures for respiratory care, timely physician notification, and oxygen therapy management. gg. Starting [DATE], the DON or designee will conduct daily audits (a review) of all residents on oxygen therapy or respiratory treatments to ensure orders are being followed, and that physician notification is documented for new admissions. Findings will be reviewed during daily stand-up meetings. hh. On [DATE], the Pharmacy Consultant will review all residents' medication regimens and respiratory orders monthly to ensure that all treatments are being administered according to physician orders and any gaps in care are addressed immediately. ii. Beginning [DATE], the DON will hold daily clinical meeting from Monday to Friday to review audit results, discuss any ongoing concerns with respiratory care, and provide additional support or training as needed. jj. Effective [DATE], the facility's Quality Assurance Committee will review, monitor, and audit findings weekly for the first two weeks, and then monthly for three months, to ensure sustained compliance with respiratory care protocols. Cross Reference with F755. Findings: 1. During a review of Resident 1's LTACH transfer packet dated [DATE], the LTACH transfer packet indicated the following under Discharge (DC) Plan: Oxygen at 5 LPM via NC or oxymizer (a nasal cannula that delivers oxygen during inhalation and exhalation and is designed to increase oxygenation) BIPAP: ,d+[DATE] (BIPAP inspiratory pressure [breathing in air into the lungs] and expiratory [breathing out air from the lungs] pressure setting) FIO2 (fraction [percentage of air the person inhales into the lungs] of inspired oxygen; BIPAP setting) 45% at night and as needed. During a review of Resident 1's Reconciled and Needing Reconciliation Report from LTACH dated [DATE] at 4:29 PM, the Reconciled and Needing Reconciliation Report indicated Resident 1's medications included: Albuterol sulfate, 1.25 mg, inhalation, medical nebulizer (med neb), solution, every 6 hours (q6h) with Resident 1's last dose being given on [DATE] at 12:38 PM. Budesonide, 0.5 mg, inhalation, med neb, suspension (susp; a liquid with small pieces of drug), twice a day (bid) with Resident 1's last dose being on [DATE] at 7:52 AM. During a review of Resident 1's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure, COPD, asthma, sleep apnea (a common sleep disorder that causes breathing to repeatedly stop or become very shallow during sleep) and shortness of breath (SOB). During a review of Resident 1's Progress Notes, dated [DATE], indicated Resident 1 was admitted to the facility on [DATE] at 11:17 PM. The Progress Notes indicated Resident 1 was receiving oxygen via NC at 2 LPM and the oxygen saturation was at 93% (oxygen saturation is a measurement of the amount of oxygen in a person's blood, which is a key indicator of how well the lungs are working, and a healthy level is between 95 percent [%] and 100%). During further review of Resident 1's Progress Notes and Order Summary upon the resident's admission, it did not indicate documented evidence an order was placed to administer oxygen to the resident. During a review of Resident 1's Baseline Care Plan Summary dated [DATE], the Baseline Care Plan Summary indicated under therapy and nursing services that Resident 1 needed oxygen. During further review of the Baseline Care Plan Summary, it did not indicate documented evidence Resident 1 was received oxygen therapy. During a review of Resident 1's Physician's Order, dated [DATE], transcribed at 1:04 AM (approximately 1 hour and 45 minutes from admission) by Registered Nurse 2 (RN 2), it indicated an order to give albuterol sulfate 1.25 mg by nebulizer every six (6) hours. During a review of Resident 1's Physician's Order, dated [DATE], transcribed at 1:27 AM (approximately 2 hours and 10 minutes from admission on [DATE]) by RN 2, it indicated an order to give budesonide 0.5 mg orally two times a day (BID). During a review of Resident 1's Pharmacy Fax Form (PFF) dated, [DATE], the PFF indicated the facility faxed the following orders to the pharmacy and were concurrently received by the pharmacy on [DATE] at 4:34 AM (Approximately 3 hours after RN 2 transcribed the physician's orders [[DATE] at 1:04 AM]): a. Albuterol 1.25 mg every 6 hours for wheezing (a high-pitched whistling sound that occurs when the airways in the lungs are narrowed or blocked) and SOB. b. Budesonide 0.5 mg BID for wheezing and SOB During a review of the Pharmacy Packing Slip Proof of Delivery (POD), dated [DATE], the POD indicated Resident 1's medications including albuterol and budesonide were delivered at the facility and received by RN 1 on [DATE] at 10:15 AM. The POD indicated RN 1 signed receipt of the medications from the POD. During a review of Resident 1's Progress Notes dated [DATE] at 3:20 PM entered by LVN 3, the Progress Notes indicated LVN 3 was notified by a staff member (unidentified) that Resident 1 was found unresponsive (specific time not indicted), CPR was initiated immediately with backboard (a deice that is flat and with firm surface used during CPR to ensure effectivity of CPR) to the resident's back and 911 was called. The Progress Notes also indicated paramedics arrived at 3:30 PM (on [DATE]) and attempted to revive the resident. During a review of Resident 1's Progress Notes dated [DATE] at 5:20 PM entered by the DON, the Progress Notes indicated the primary physician (MD) was made aware of the resident's condition (did not indicate specific condition) and paramedics pronounced Resident 1's time of death at 4:28 PM (on [DATE]). During a review of Resident 1's Paramedic Record dated [DATE], the Paramedic Record indicated when the paramedics arrived on scene (at the facility), Resident 1 was lying supine (lying on the back with face up) in bed and found pulseless and apneic (when one stops breathing). The report also indicated, paramedics immediately began CPR with advanced life support (ALS; a set of life-saving skills and protocols that extend beyond basic life support) interventions and continued treatment for 40 minutes. Resident 1 had no improvement throughout treatment and CPR was discontinued. The report indicated Resident 1's time of death was at 4:28 PM per MD 2. During a concurrent interview and record review on [DATE] at 10:40 AM with Registered Nurse (RN) 2, Resident 1's Order Summary Report and Medication Administration Record (MAR) dated [DATE] was reviewed. Resident 1's Orders Summary Report and MAR did not indicate an order to administer oxygen therapy. RN 2 stated the Order Summary Report and MAR for Resident 1 did not have documented evidence that the oxygen therapy was ordered to administer oxygen of 5 LPM was administered to the resident. RN 2 also stated, upon a resident's admission to the facility, the facility's policy and procedure is for licensed staff to notify the resident's MD to obtain medication and treatment orders and review discharge orders from the acute hospital to ensure continuity of care. RN 2 also stated the resident's admitting nurse needs to review the transfer orders from where the resident was admitted from and ensure the MD orders were carried out (complete the MD order) and notify the MD if the resident needed oxygen therapy, so they can obtain the order for the oxygen therapy and administer it to the resident. RN 2 further stated if a resident that needs oxygen does not receive it, they could have a medical emergency and be sent to the hospital or die. During a concurrent review and interview with Licensed Vocational Nurse 3 (LVN 3) on [DATE] at 11:19 AM, Resident 1's Medication Administration Record (MAR), for the month of ,d+[DATE] was reviewed. LVN 3 stated, the MAR indicated 9 in the MAR box (area which is initialed by the licensed nurse to indicate the medication was administered), which meant to check the documentation in the progress notes for the following medications: a. Budesonide 0.5 mg on [DATE] at 9 AM b. Albuterol sulfate 1.25 mg on [DATE] at 12 PM During the same concurrent review and interview with LVN 3 on [DATE] at 11:19 AM, Resident 1's Progress Notes dated [DATE] timed at 9:41 AM was reviewed. The progress notes indicated, awaiting pharmacy to deliver budesonide. LVN 3 verified budesonide was not administered to Resident 1. LVN 3 stated Resident 1's progress notes dated [DATE] timed at 12:58 PM indicated, awaiting pharmacy to deliver albuterol sulfate. LVN 3 also verified albuterol sulfate was not administered to Resident 1. During an interview on [DATE] at 4:01 PM with LVN 1, LVN 1 stated he was the nurse in charge during Resident 1's admission to the facility on the night of [DATE]. LVN 1 also stated when Resident 1 was admitted to the facility, he called the resident's family member and texted the MD stating the resident had arrived and admitted to the facility. LVN 1 further stated he endorsed the resident's admission to LVN 2 (night shift nurse on [DATE]). During an interview on [DATE] at 1:28 PM with LVN 2, LVN 2 stated on the night of [DATE], she worked the 11 PM - 7 AM shift and that Resident 1 was admitted by LVN 1 during the 3 PM - 11 PM shift. LVN 2 stated she did not call or text the MD on her shift to verify the resident's admission orders and that LVN 1 should have been the one to contact the MD regarding Resident 1's admission. LVN 2 also stated, once a resident is admitted to the facility, the admitting licensed nurse notify the MD to verify and obtain the resident's medications and orders to see what to continue, change or discontinue and that ideally it is best to get MD verification and orders right away within an hour or two hours. LVN 2 also stated Resident 1 did not have an order for the BIPAP and that the resident's BIPAP was not administered during the 11 PM to 7 AM shift (on [DATE]) since they were still waiting for the admission orders and BIPAP settings to be clarified with the MD. LVN 2 further stated the order for BIPAP should have been clarified with the MD because the resident could have sleep apnea and SOB while asleep. LVN 2 stated if a resident who was being admitted from LTACH had an order for continuous oxygen, LVN 2 would contact the MD to obtain oxygen therapy orders. LVN 2 further stated the resident could have SOB or go into respiratory distress if the oxygen therapy order was not verified and obtained from the MD and was not carried out. During an interview on [DATE] at 2:44 PM with the DON, the DON stated before a resident is admitted to the facility, they get report from the LTACH to know what equipment the resident need such as oxygen or BIPAP and to ensure the facility or the resident has one. The DON stated once the resident comes in and is assessed, the licensed nurses in charge of admitting the resident should review the resident's medication list from the transferring facility and contact the MD to obtain orders and treatment to ensure continuity of care. The DON also stated if a resident comes in with oxygen and BIPAP, staff are required to ask the MD for clarification and obtain an order for the oxygen and the BIPAP and should be administered the same night the resident was admitted preventing complications such as resident experiencing SOB and/ or respiratory distress which can lead into resident's death. During an interview on [DATE] at 2:52 PM with the DON, the DON stated the BIPAP order should have been ordered or clarify transfer orders as soon as possible. The DON stated it is very important to verify the order because it affects the resident's breathing and to ensure the resident will not experience any respiratory distress especially at night. During an interview on [DATE] at 5:36 PM with LVN 1, LVN 1 stated when Resident 1 was admitted on [DATE], LVN 1 just entered the nurse notes, texted (a written message, often containing short forms of words, sent from one cell phone or pager to another) the MD to notify them that the resident had arrived at the facility and took a photo of Resident 1's medication reconciliation form and sent it to the MD on [DATE] at approximately 12:00 AM or 1:00 AM. LVN 1 stated, LVN 1 did not verify any orders from Resident 1's LTACH's transfer packet to the MD. LVN 1 stated he did not see the resident's order for oxygen therapy or BIPAP and was unable to recall if it was included in the text he sent to the MD. In addition, LVN 1 stated every resident's discharge order or transfer packet list from LTACH should have been sent to the MD to verify with the MD so licensed nurse know what orders to continue for the resident's safety and to address the resident's needs. LVN 1 also stated he had asked LVN 2 if they could please continue completing the admission orders including medication orders, BIPAP and oxygen therapy. During an interview on [DATE] at 11:06 AM with Medical Director (MD 1), MD 1 stated, as soon as a resident who is a new admission arrives to the facility, staff need to verify orders with the MD/ attending physician within the first hour of the resident's admission. MD 1 stated every discharge order needs a corresponding MD's order so that it can be carried out and the MD should also be informed if the resident comes with a BIPAP and/or oxygen. MD 1 also stated, if it is something that the resident is on, it needs to be communicated to the MD so that the MD can confirm the order and the MD in turn needs to reply within 30 minutes to an hour that they have received the order. MD 1 further stated he had informed staff if they are not able to reach the resident's MD, they need to notify MD1 if the MD did not respond right away. During a review of the facility's P&P titled Admission Assessment revised [DATE], the P&P indicated the Licensed Nurse will complete a drug regimen review upon admission or as close to the actual time of admission as possible to identify any potential or actual clinically significant medication issues. The P&P also indicated; the Licensed Nurse will contact the physician to communicate any identified medication issues. 2. During a review of Resident 2's Admission Record, it indicated the resident was init[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided to one of 36 sampled residents (Resident 1) who had a diagnoses of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), asthma (a chronic inflammatory disease of the lungs), sleep apnea (a sleep disorder that causes breathing to repeatedly stop or become very shallow during sleep), and shortness of breath (SOB) by failing to: 1. Administer albuterol sulfate (medication used to prevent and treat wheezing [a high-pitched whistling sound made while breathing often associated with difficulty breathing] and difficulty of breathing caused by lung diseases, such as COPD) 1.25 milligrams (mg, unit of measurement) inhalation via nebulizer (a device for producing a fine spray of liquid, used for inhaling a medicinal drug) every six (6) hours for wheezing and SOB as indicated on the physician's order. 2. Administer budesonide (medication used to prevent difficulty breathing, chest tightness, wheezing, and coughing caused by asthma and reduce COPD exacerbations) 0.5 mg inhalation via nebulizer twice a day for wheezing and SOB as indicated on the physician's order. 3. Have a system in place to receive medications that have been delivered by the pharmacy to ensure timely administration to the residents. 4. Ensure Licensed Vocational Nurse 3 (LVN 3) followed up with Pharmacy on the delivery of medication and checked the STATSAFE (emergency medication kit to secure medication system ensuring that critical medications, including respiratory treatments, were readily available for immediate use) for availability and timely administration of Resident 1's respiratory medications (albuterol sulfate and budesonide). As a result of these deficient practices, LVN 3 did not administer albuterol sulfate on [DATE] at 6 AM and 12 PM and budesonide on [DATE] at 9 AM to Resident 1. Resident 1 was found unresponsive by the facility staff (not identified) on [DATE] at 3:20 PM (approximately 16 hours after admission). Facility staff started Cardiopulmonary resuscitation (CPR, an emergency procedure that is used to restart a person's breathing and heartbeat when they've stopped) and called 911 (phone number used to contact emergency services). Paramedics (person trained to give emergency medical care to people who are injured or ill) arrived at the facility at 3:30 PM, continued CPR, and pronounced Resident 1 dead at 4:28 PM. On [DATE] at 6:55 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation regarding the facility's failure to ensure pharmaceutical services for Resident 1. The survey team notified the facility's Administrator (ADM) and the Director of Nursing (DON) of the IJ situation due to: failing to administer Resident 1's respiratory medications (albuterol sulfate and budesonide) for SOB and wheezing as indicated on the physician's order on [DATE]; failing to have a system in place to receive medications that have been delivered by the pharmacy to ensure timely administration to the residents; and failing to follow up with Pharmacy on the delivery of medication and check the STATSAFE for availability and timely administration of Resident 1's respiratory medications (albuterol sulfate and budesonide). On [DATE] at 2:06 PM the IJ was removed in the presence of ADM, Clinical Director (CD), Administrator in Training (AIT) and Activities Director (AD) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices) and the surveyor verified and confirmed onsite the facility's implementation of the IJ Removal Plan and the IJ situation was no longer present. The acceptable IJ Removal Plan, dated [DATE], included the following: 1. On [DATE], the Director of Nursing (DON) initiated an immediate investigation into why Resident 1's respiratory medications were not administered on time. Staff involved were interviewed, and the Medication Administration Record (MAR) was reviewed for errors. 2. On [DATE], the DON provided a one-on-one in-service to the Licensed Vocational Nurse (LVN) who worked on [DATE] during the three (3) PM to 11 PM shift (LVN 1), focusing on timely medication administration, especially for critical medications such as respiratory treatments. The nurse was re-educated on the facility's medication administration policies. 3. On [DATE], the DON provided a one-on-one in-service to the LVN who worked on [DATE] during the seven (7) AM to 3 PM shift (LVN 3) and the LVN who worked on [DATE] during the 11 PM-7 AM shift (LVN 2). Both nurses were similarly re-educated on timely medication administration, with a particular focus on critical medications such as respiratory treatments and were reminded of the facility's medication administration policies to ensure timely and accurate care. 4. On [DATE], the DON conducted an audit of residents receiving critical medications: including respiratory treatments for 36 residents and 11 residents receiving oxygen therapy to ensure proper orders are in place and being followed. No other residents were affected by this deficient practice. 5. On [DATE], the DON in serviced licensed nurses on timely medication administration and checking medication availability to ensure all medications are administered as ordered. All licensed nurses are anticipated to complete in-service by Tuesday, [DATE]. 6. The availability of medications will be checked through STATSAFE upon receipt of any physician's medication order for medications that are not yet processed by the pharmacy, such as for residents who are admitted to the facility after hours or during weekends. This ensures that critical medications are immediately accessible when the pharmacy is unable to fulfill the order on time. 7. As part of a routine process, the Charge Nurse on each shift will be responsible for checking the availability of critical medications in STATSAFE. This will be done?once per shift to ensure that all required medications are always stocked and accessible. 8. The Charge Nurse on duty will be responsible for verifying the availability of medications in STATSAFE during these routine checks and ensuring that any missing or low-stock items are reported to the pharmacy for restocking. The pharmacy will be notified within 1 hour if a medication is found to be depleted. 9. Staff communication regarding medication processes and updates will be handled through the Point Click Care (PCC, an electronic MAR system used by facility to document and review resident records) Dashboard and shift endorsements, ensuring that all nurses are aware of medication availability and any pertinent updates. The charge nurse receiving the medication will add the time of medication received in the pharmacy delivery binder and will also endorse it on PCC Dashboard. Staff communication regarding medication processes and updates will be handled through the PCC Dashboard and shift endorsements, ensuring that all nurses are aware of medication availability and any pertinent updates. 10. Once medications are delivered by the pharmacy, the?Charge Nurse?or?Medication Nurse?will confirm receipt of the medication by signing as an acknowledgement. The medication will be stored appropriately (e.g., refrigerated or secured in the medication cart) according to its requirements. The Charge Nurse will document the receipt of the medication on the pharmacy receipt. The charge nurse will update the?PCC Dashboard?to reflect that the medication has been delivered and is available for administration. 11. The availability of the medication will be communicated to the next shift through shift endorsements, where the incoming staff will be informed of the availability of the medication. All nurses will be required to review the updates on the?PCC Dashboard, at the start of their shift. The charge nurse responsible for medication administration will administer the medication according to the physician's order and document the time and dosage in the?Medication Administration Record (MAR). For late admissions or when the pharmacy is unable to process medications (example: after hours or weekends), the Charge Nurse will check?STATSAFE?for the availability of the prescribed medications. If the medications are available in STATSAFE, the Charge Nurse will retrieve and administer the medication per the physician's order. If the medications are?not available in STATSAFE, the Charge Nurse will contact the?on-call pharmacist to obtain the necessary medications as quickly as possible. If obtaining the medication immediately is not possible, the Charge Nurse will notify the?physician?to determine an alternative treatment plan until the medication is available. The process and any adjustments made will be communicated via?shift endorsements, ensuring that all staff are aware of the status of the resident's medication. Updates will also be reflected in the?PCC Dashboard?and?MAR?so that the next shifts can continue to monitor and administer medications as ordered once they are available. Once the pharmacy processes the late admission's medications, Charge Nurse will ensure that the medication is received and follows the same process as above (delivery confirmation, documentation, storage, and communication to staff). 12. On [DATE],?the DON and Medical Records Director/Designee conducted a facility-wide audit to identify other residents receiving critical medications, particularly for 25 residents requiring respiratory treatments and 11 residents requiring oxygen therapy in which two (2) residents are on continuous oxygen therapy. The MAR and physician orders were reviewed for each resident, for any missed or delayed doses. No other residents were affected by this deficient practice. 13. On [DATE], 36 residents with respiratory diagnoses were reassessed to ensure that their medication regimens were accurate and that medications were being administered according to the physician's orders. The DON/Designee updated care plans where necessary to prevent future issues. 14. Effective [DATE], the nursing staff will immediately clarify new orders with physicians, input the physicians' orders and fax all the orders to pharmacy within 2 hours to ensure timely processing and availability of medications. The respiratory medications will be available to be administrator immediately using STATSAFE supply. The pharmacy will deliver medications within four (4) hours. After hours and weekend medications will be delivered within 2 hours for STAT medications and 4 hours for regular medications. The critical/respiratory medications will be available in STATSAFE supply for immediate use. 15. On [DATE], the DON in serviced all Licensed Nurses on the importance of clarifying physician's orders, administering medications promptly, with a focus on residents with critical care needs such as respiratory failure, COPD, and asthma. The in-service also emphasized the escalation process for any missed or delayed doses, check availability of medications and ensuring that the DON or Registered Nurse (RN) Supervisor is immediately informed. Completion of all in-services to licensed nurses will be done by [DATE]. 16. When medication is received from the pharmacy, Charge Nurse will confirm receipt of the medication and cross-check it with the physician's orders for accuracy. The PCC Dashboard will be updated to reflect that the medication has been received and is ready for administration. Shift endorsements will be used to communicate the availability of the medication to all incoming nursing staff. 17. All staff will be required to review the PCC Dashboard at the start of each shift to ensure they are aware of the availability of medications. The importance of promptly checking and administering medications after pharmacy delivery will be emphasized during shift endorsements and daily clinical meetings. If a dose is missed or delayed, the nurse must immediately escalate the issue to the DON/ RN Supervisor and Medical Director. An investigation will be initiated to identify the cause of the delay, and corrective actions will be taken to prevent recurrence. 18. The DON/Designee or Medical Records Director/Designee will conduct?weekly audits?of MAR to ensure that medications are being administered on time. Results of these audits will be discussed during?monthly quality assurance meetings?to identify trends and further reinforce best practices. 19. Beginning [DATE], all respiratory medications will be reviewed in the MAR by DON on Monday to Friday and charge nurse on weekends, requiring documentation within 30 minutes of administration to ensure timely care by charge nurses. Nurses will be responsible for logging the exact time of medication administration to maintain compliance. 20. On [DATE], the DON initiated monthly in-services for licensed nurses focusing on medication administration for tracking and ensuring timely administration of high-priority medications, medication delivery process, adding it in delivery binder and adding on PCC Dashboard System and shift endorsements on PCC Dashboard. In-service included managing potential delays, including communication with the pharmacy, ensuring immediate availability of medications through STATSAFE, and escalating any issues to the DON or Charge Nurse. 21. All updates regarding the new protocols and medication processes will be communicated to staff via the PCC Communication Dashboard and daily shift endorsements. This will ensure that every licensed nurse in every shift is aware of the updated procedures and any immediate needs related to medication administration regarding the availability of medications from the pharmacy or STATSAFE, and any immediate needs related to medication administration. 22. When medications are delivered from the pharmacy, the Charge Nurse will ensure the medication is handed over directly to the assigned nurse responsible for administering it. The charge nurse will document the time of delivery on the receipt and add it PCC dashboard to shift endorsement to ensure administration occurs promptly. If a critical medication, such as a respiratory treatment, is not delivered on time, the Charge Nurse will contact the pharmacy immediately, and the situation will be escalated to the DON if the delay exceeds 30 minutes. 23. When medications are delivered from the pharmacy, the Charge Nurse will verify the receipt of the medication and ensure it matches the physician's order. The medication will be handed directly to the assigned nurse responsible for administering it. The Medical Records and DON will be doing daily random room rounds utilizing audit tool on weekly basis to ensure compliance. 24. The assigned nurse will immediately document the time of delivery on the pharmacy receipt and will be filed in the binder and add information to PCC Dashboard to ensure medications are delivered. The charge nurse will ensure the medication is administered according to the physician's order. If a critical medication, such as a respiratory treatment, is not delivered on time, the Charge Nurse will contact the pharmacy immediately to expedite delivery. If the delay exceeds 30 minutes, the Charge Nurse will escalate the issue to the DON for immediate action. 25. The Charge Nurse will monitor the process to ensure that medications are delivered and administered promptly by checking the PCC Dashboard at the start and end of each shift to verify if all medication orders have been fulfilled. 26. The DON or designated MR will conduct weekly audits of MAR to ensure the handover and timely administration process is being followed consistently. 27. The DON/Designee will conduct weekly audit using an audit log for medication delivery times and medication administration times. 28. Any recurring issues with delayed medication deliveries will be addressed directly with the pharmacy. The pharmacy's performance will be evaluated during monthly?Quality Assurance and Performance Improvement (QAPI)?meetings to ensure ongoing compliance and timely delivery of medications. 29. Starting [DATE], the?DON?will oversee the administration of respiratory medications, ensuring that any physician or pharmacy recommendations are implemented immediately. All respiratory medications, including those for residents with?chronic respiratory failure, COPD, and asthma, will be prioritized for timely administration. 30. Starting [DATE], the?DON/Designee/Medical Records Director (MRD)?will conduct daily audits utilizing audit log MAR?(Monday to Friday) to ensure compliance with physician orders for all respiratory treatments, including?albuterol sulfate?and?budesonide. Any discrepancies will be discussed during?daily clinical meetings, and the audit results will be reviewed in?monthly quality assurance meetings?by the?QAA Committee. On weekends, the?Charge Nurse on duty?will be responsible for ensuring the timely administration of all respiratory medications. The?Charge Nurse?will review the?MAR?for scheduled respiratory treatments and verify that all high-priority medications are administered within the required timeframes. This verification will be conducted before the end of each Charge Nurse's shift?to ensure that any issues are addressed promptly and passed on to the incoming shift if necessary. 31. Any delays or issues with medication administration over the weekend will be escalated to the RN Supervisor and documented in the PCC Communication Dashboard for immediate resolution. The weekend Charge Nurse will also ensure that any missed or delayed medications are reported to the DON/Designee and Medical Director/ PCP for follow-up on the next business day. The MD will be notified immediately if the missed or delayed medication involves a critical treatment, such as respiratory therapies, to ensure timely adjustments to the treatment plan if necessary. 32. Starting [DATE], the Quality Assurance Committee will monitor this process weekly for the first two weeks, then once a month for the next three months, to ensure compliance and the effectiveness of implemented changes. The DON/Designee will oversee this monitoring process, ensuring timely administration of all critical respiratory medications. Cross Reference with F695 Findings: During a review of Resident 1's Reconciled and Needing Reconciliation Report from Long-Term Acute Care Hospital (LTACH, a facility whose specialty is treating patients who require a longer period of closely monitored healthcare) LTACH, dated [DATE] at 4:29 PM, it indicated Resident 1's medications included: a. Albuterol Sulfate, 1.25 mg, inhalation, medical nebulizer (med neb), solution, every 6 hours with Resident 1's last dose being given on [DATE] at 12:38 PM. b. Budesonide, 0.5 mg, inhalation, med neb, suspension (susp, a liquid with small pieces of drug), twice a day with Resident 1's last dose being on [DATE] at 7:52 AM. During a review of Resident 1's Admission Record, it indicated the resident was admitted to the facility on [DATE] with diagnoses that included COPD, asthma, sleep apnea, and SOB. During a review of Resident 1's Physician's Order, dated [DATE], transcribed at 1:04 AM (approximately 1 hour and 45 minutes from admission) by Registered Nurse 2 (RN 2), it indicated an order to administer albuterol sulfate 1.25 mg by nebulizer every 6 hours for wheezing and SOB as indicated on the physician's order. During a review of Resident 1's Physician's Order, dated [DATE], transcribed at 1:27 AM (approximately 2 hours and 10 minutes from admission) by RN 2, it indicated an order to administer budesonide 0.5 mg orally two times a day (BID) for wheezing and SOB. During a review of Resident 1's Pharmacy Fax Form (PFF), dated [DATE], it indicated the facility faxed the following orders to the pharmacy and were concurrently received by the pharmacy on [DATE] at 4:34 AM (approximately three hours after RN 2 transcribed the physician's orders on [DATE] at 1:04 AM and 1:27 AM respectively): a. Albuterol Sulfate 1.25 mg every 6 hours for wheezing and SOB b. Budesonide 0.5 mg BID for wheezing and SOB During a review of the Pharmacy Packing Slip Proof of Delivery (POD), dated [DATE], it indicated Resident 1's medications including albuterol and budesonide were delivered to the facility on [DATE] at 10:15 AM. The POD indicated RN 1 signed receipt of the medications for Resident 1 on [DATE] at 10:15 AM. During a review of Resident 1's Progress Notes, dated [DATE] at 3:20 PM entered by LVN 3, it indicated LVN 3 was notified by a staff member (unidentified) that Resident 1 was found unresponsive. CPR was initiated immediately with backboard to the resident's back and 911 was called. The Progress Notes also indicated paramedics arrived on [DATE] at 3:30 PM and attempted to revive the resident. During a review of Resident 1's Progress Notes, dated [DATE] at 5:20 PM entered by the DON, it indicated the Medical Doctor (MD) was made aware of the resident's condition (did not indicate specific condition) and paramedics pronounced Resident 1's time of death at 4:28 PM. During a review of Resident 1's Paramedic Record, dated [DATE], it indicated when paramedics arrived on scene, Resident 1 was lying supine in bed and found pulseless and apneic (when one stops breathing). Paramedic immediately began CPR with advanced life support (ALS, a set of life-saving skills and protocols that extend beyond basic life support) interventions and continued treatment for 40 minutes. Resident 1 had no improvement throughout treatment and CPR was discontinued. The record indicated Resident 1 was pronounced dead at 4:28 PM by the paramedics. During a concurrent review of Resident 1's MAR, for the month of [DATE] and interview with LVN 3 on [DATE] at 11:19 AM, LVN 3 stated, he entered 9 in the MAR box (area which is initialed by the licensed nurse to indicate the medication was administered), which meant to check the documentation in the progress notes for the following medications: a. Albuterol sulfate 1.25 mg on [DATE] at 12 PM b. Budesonide 0.5 mg on [DATE] at 9 AM During the same concurrent review of Resident 1's Progress Notes, dated [DATE] timed at 9:41 AM and interview with LVN 3 on [DATE] at 11:19 AM, LVN 3 stated the progress notes indicated, awaiting pharmacy to deliver budesonide. LVN 3 verified budesonide was not administered to Resident 1 as ordered. LVN 3 stated Resident 1's Progress Notes, dated [DATE] timed at 12:58 PM indicated, awaiting pharmacy to deliver albuterol sulfate. LVN 3 also verified albuterol sulfate was not administered to Resident 1 as ordered. LVN 3 stated he did not check the STATSAFE for the availability of Resident 1's respiratory medications and he also did not call the pharmacy to follow up on the delivery of medications. LVN 3 stated that he did not call the doctor to notify him of the medications that were not administered to Resident 1. During an interview on [DATE] at 12:47 PM with RN 1, RN 1 stated she signed the Pharmacy Packing Slip POD and confirmed Resident 1's medications which included albuterol sulfate and budesonide were delivered on [DATE] at 10:15 AM. During an interview on [DATE] at 3:07 PM with RN 3, RN 3 stated if the medication was not available at administration time, the nurse should have called the pharmacy to follow up on the delivery of the medication and obtain the medication if available from the STATSAFE so it can be administered to the resident timely. During an observation and interview on [DATE] at 2:29 PM, RN 2 was observed logging into the STATSAFE and confirmed availability of albuterol sulfate. RN 2 stated if a resident was scheduled to receive albuterol sulfate and if the pharmacy has not delivered it, the LVN could have logged into the STATSAFE to obtain the medication and administer the medication as ordered. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated [DATE], it indicated: 1. Medication will be administered by a licensed nurse per the order of an attending physician. 2. Purpose is to provide practice standards for safe administration of medications for residents. 3. Medications may be administered one hour before or after the scheduled medication administration time. 4. If a medication is held the licensed nurse will document the reason a medication was held in the MAR. During a review of the P&P titled, Provider Pharmacy Requirements, dated ,d+[DATE], it indicated the provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to 2. Medication orders will be delivered by the primary pharmacy as soon as possible the next routine delivery or are available from the emergency medication kit.

Based on observation, interview, and record review the facility failed to practice infection control measures to prevent scabies (a contagious, intensely itchy skin condition marked by itching and small raised red spots caused by a tiny, burrowing [to make a hole or tunnel] mite) for two (2) of 2 residents (Residents 1 and 2) by failing to: 1. Detect symptoms of scabies (severe itching, pimple-like itchy rash) and provide treatment for Resident 1. 2. Respond to a scabies outbreak (2 or more confirmed cases or one (1) confirmed case and at least 2 suspected cases occurring among residents, healthcare workers (HCW), visitors, or volunteers during a 2 week period) by notifying California Department of Public Health (CDPH) and local health department on 1/27/2024 when four (4) Certified Nurses Assistants (CNAs 1, 2, 3, and 4) were identified as clinical suspected scabies cases on 1/24/2024 and one Resident (Resident 1) confirmed positive for scabies on 1/27/2024. 3. Control the spread of scabies when CNAs 1, 2, 3, 4, and 5, who were identified as clinically suspected scabies cases, continued to provide direct resident care and were not offered prophylactic (a medication or a treatment designed and used to prevent a disease from occurring) treatment. 4. Ensure symptomatic HCW were evaluated for scabies by employee/occupational health (an area of work in public health to promote and maintain highest degree of physical, mental and social well-being of workers in all occupations) or their private healthcare provider, in accordance with the facility's policy. 5. Offer prophylactic treatment to CNA 4 and 5 who were clinically suspected with scabies. 6. Develop a process to track and assess staff clinically suspected with scabies. 7. Prevent the spread of scabies infection when CNA 6 who had symptoms of scabies continued to work after CNA 6 was given an inservice on scabies on 2/7/2024. These deficient practices placed the residents, facility staff, and visitors at risk for contracting scabies and resulted to two residents (Residents 1 and 2) testing positive for scabies. On 2/6/2024 at 8:35 PM, the State Agency (SA) declared an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident and the situation created a need for an immediate corrective action). The Administrator (ADM), the Director of Nursing (DON), and the Infection Prevention Nurse (IPN) were notified at this time of the immediate actions that needed to be taken and the seriousness of the residents' threatened health and safety due to the facility's failure to ensure infection control practices were implemented during scabies outbreak. The facility failed to recognize and report scabies outbreak, control the spread of scabies when 4 CNAs (CNA 1, 2, 3, and 4) who were exhibiting symptoms of scabies, develop and implement a policy for symptomatic HCWs to be evaluated for scabies, administer prophylactic treatment to CNAs 4 and 5 who were clinically suspected of scabies, and develop a process to track and assess staff clinically suspected with scabies. On 2/8/2024 at 4:15 PM, the ADM provided an acceptable IJ removal plan of action. The IJ removal plan included the following: 1. Resident 1 was treated for scabies with Permethrin External Cream (a medication used in the management and treatment of scabies) five (5) percent (%) on 1/24/2024, 1/29/2024 and 2/5/2024 and was also treated with Ivermectin (a medication that treats some parasitic [an organism that lives on or in a host and gets its food from or at the expense of its host] diseases) oral tablet 3 milligrams (mg, unit of measure), on 1/31/2024 until 2/19/2024. 2. Resident 2 was treated with Permethrin on 2/3/2024. 3. On 2/5/2024, the DON, IP Nurse, and Treatment Nurses re-assessed all 77 residents for any suspected rashes or sign and symptoms of scabies. No other residents were identified as having any signs of scabies. 4. Weekly skin sweep started on 2/5/2025 and shall be done by treatment nurses for one month and then monthly thereafter to assess any new skin rashes, with signs and symptoms of scabies, per protocol. Any changes shall be reported to healthcare practitioner. A thorough assessment for scabies shall be done upon admission and physical examination focusing on characteristics of scabies and shall be reported immediately to the health practitioner for proper treatment. 5. On 2/6/2024, CNAs 4 and 5 have been removed from the schedule and both have received scabies prophylactic treatment on 2/6/2024. Both CNAs 4 and 5 will not return to work until treatment has been completed. 6. On 2/6/2024, Facility ADM, DON, and IPN reviewed the Californian Long-Term Care Facilities publication March 2008 titled, Prevention and Role of Scabies, and understands that prompt notification or reporting of outbreaks to the local health officer and to CDPH, Licensing and Certification District Office. 2 or more confirmed cases or 1 confirmed case and at least 2 suspected cases occurring among residents, HCWs, visitors, or volunteers during a 2-week period should be considered an outbreak for reporting purposes. 7. On 2/6/2024, the ADM provided an in-service to IPN on ensuring that any staff and resident with suspected rashes consistent with scabies shall be treated prophylactically per guidelines to prevent any outbreaks. Staff will directly be sent out to urgent care/employee health or their own private healthcare provider. If employees decline to see employer's occupational health, a signature of declination shall be documented. Symptomatic HCW shall not be permitted to provide direct care until they are cleared by a healthcare provider or until treatment has been completed. 8. On 2/7/2024, the ADM initiated revisions to the facility's Scabies policy and procedure to include: a. Immediate removal from work of symptomatic HCW, who are clinically suspected of scabies until they received prophylactic treatment or have been evaluated to rule out scabies by facility occupational health or their own private healthcare provider. b. Facility reporting policy to include reporting within 24 hours to CDPH, Licensing and Certification District Office of 2 or more confirmed cases or 1 confirmed case and at least 2 suspected cases occurring among residents, healthcare works, visitors, or volunteers during a 2-week period should be considered an outbreak for reporting purposes. c. If an employee refuses treatment, the employee will be immediately removed from the schedule and will not be able to return to work until they are cleared by a healthcare provider. d. If a resident refuses treatment, the facility will follow it's Change of Condition and Infection Control policy and procedures to include notification of physician and place resident on contact isolation until medically cleared. 9. The Regional Clinical Director (RCD) provided in-service training on 2/7/2024 at 9:30 AM to the ADM, DON, and IPN on reporting guidelines of scabies outbreak to include notification and communication to licensed nurses. Licensed nurses will be notified immediately via facility communication process such as shift to shift report, in-service, facility leadership communication to licensed nurses via in-service or utilizing encrypted (a form of data security whereby electronic medical records [EMR] are disguised so that unauthorized users may not read or make sense of them) communication device. 10. The RCD provided an in-service training on 2/7/2024 at 9:30 AM to the ADM, DON, and IPN on the updated policy to ensure that symptomatic HCWs were offered to be evaluated by employee/occupational health or their private healthcare provider. 11. The RCD provided an in-service training on 2/7/2024 at 9:30 AM to the ADM, DON, and IPN on the updated policy to ensure that symptomatic HCW were offered to be evaluated by employee/occupational health or their private healthcare provider. If employees decline to see employer's occupational health, a signature of declination shall be documented. Symptomatic HCW shall not be permitted to provide direct care until they care cleared by a healthcare provider or until treatment has been completed. 12. The DON and IPN provided an in-service on 2/7/2024 to staff on the updated policy and procedure regarding reporting any signs and symptoms of scabies identified with both residents and HCWs to IPN or licensed nurse. Employees have the option to be evaluated by employee/occupational health or their private healthcare provider. If employees decline to see employer's occupational health, a signature of declination shall be documented. Symptomatic HCWs shall not be permitted to provide direct care until they are cleared by a healthcare provider or until treatment has been completed. Completion date to have all staff in-serviced by 2/23/2024. 13. The DON and IPN provided an in-service to licensed nurses starting 2/7/2024 regarding scabies notification. a. If an employee reports signs and symptoms of scabies identified with both resident and/or the HCWs, the licensed nurse will follow the policy and procedure to include providing the option to seek medical treatment or provide prophylactic medication treatment. It also included a notification to local government agencies in the absence of the administrative staff if 2 or more confirmed cases or 1 confirmed case and at least 2 suspected cases occurring among the residents, HCWs, visitors, or volunteers during a 2-week period should be considered an outbreak for reporting purposes. 14. On 2/8/2024, the facility has implemented a Scabies Screening form for all staff to complete prior to entering the facility. All staff who report signs and/or symptoms will be assessed and provided treatment options as indicated in the policy and documented on the screening form. On 2/8/2024 at 4:15 PM, while onsite, after the Removal Plan was verified as implemented through observation, interviews, and record review, the ADM was notified the IJ was lifted. Findings: 1. A record review of Resident 1's Admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included were cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), dysphagia (difficulty swallowing), and heart failure (a lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). A review of Resident 1's History and Physical (H&P, the initial clinical evaluation and examination of the resident), dated 2/5/2024, indicated Resident 1 was alert and oriented times 2 to three (3) (measures the extent of a person's awareness to person, place, time, and situation). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/2/2024, indicated Resident 1 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment and did not have the capacity to understand and make decisions. The MDS indicated Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for shower/bathing and putting on/taking off footwear. Resident 1 required partial/moderate assistance (helper does less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for eating, oral hygiene, toileting hygiene, upper body dressing and personal hygiene (the ability to main personal hygiene, including combing hair, shaving, washing/drying face and hands). A review of the Resident 1's Dermatology (branch of medicine dealing with the skin) Notes, dated 1/19/2024, indicated Resident 1 had intertrigo (a common inflammatory skin condition that is caused by skin-to skin friction [rubbing] that is intensified by heat and moisture) with morphology (the form and structure) of erythematous (superficial reddening of the skin, usually in patches, as a result of injury or irritation) macerated (the process of skin softening and breaking down due to prolonged contact with moisture that is usually not present on the skin) patches on the pelvis (the lower part of the abdomen located between the hip bones) on 6.9 % on the body surface area (BSA, the total surface area of the human body), atopic dermatitis (often referred to as eczema [a group of conditions in which the skin becomes inflamed, forms blisters, and becomes crusty, thick and scaly], a chronic [long-lasting] disease that causes inflammation, redness, and irritation of the skin) with morphology of pink erythematous scaly plaques (a small, abnormal patch of tissue on a body part) on the head, neck, chest, abdomen, back, pelvis, upper extremities, and lower extremities on 100% of the BSA, and pruritis (severe itching) of the skin with morphology of traumatic skin damage involving the epidermis (the outermost layer of the skin) due to excoriations (skin becomes painful, and often red, and so starts to come off) on the head, neck, chest, abdomen, back, pelvis, upper extremities, and lower extremities. The plan included scabies precaution for pruritis of skin. The doctor indicated the plan was to start Permethrin 5% cream topical (applied directly to a part of the body) with directions to apply from neck down tonight and repeat in one week. Ivermectin 3 milligrams (mg-unit of measurement) tablet with directions to take 4 tablets today and report in 1 week. A review of Resident 1's Clinical Record did not show documented evidence of communicating the dermatology consult with the physician to ensure earlier treatment of scabies for Resident 1. A review of Resident 1's Nurses Notes, dated 1/21/2024, indicated Resident 1 was bleeding from the left forearm due to a self-inflicted scratching. A review of Resident 1's Physician Order Summary Report, dated 1/23/2024, indicated an order for skin scraping (obtain a sample of skin to check for parasites or fungus under the microscope). There was no skin scraping performed from 1/23/2024 to 1/26/2024. A review of Resident 1's Nurses Notes, dated 1/25/2024, indicated Resident 1 was on monitoring for generalized itchy raised bumps. A review of Resident 1's Skin Weekly Assessment, dated 1/26/2024, indicated Resident 1 was noted with general body atopic dermatitis, severe erythematous scaly plaques noted. A review of Resident 1's Laboratory Report, dated 1/28/2024, indicated a collection date on 1/27/2024 (4 days after skin scraping order) and an abnormal summary for the scabies exam, reported on 1/28/2024. A review of Resident 1's Care Plan, dated 1/29/2024, indicated isolation (special precautionary measures, practices, and procedures used in the care of residents with contagious or communicable diseases) for testing positive for scabies. Staff interventions included were to educate staff on how to handle residents on isolation, use contact precautions (used for infections, diseases, or germs that are spread by touching the patient or items in the room), and practice good infection control (i.e., proper hand hygiene). Resident 1's care plan also indicated the resident has general body scabies. Staff interventions included were to administer treatment as ordered and to give anti-pruritic medication (anti-itch drugs that inhibit the itching) as ordered by the doctor. A review of Resident 1's Skin Weekly Assessment, dated 2/2/2024, indicated Resident 1 was noted with general body scabies with linear track burrows noted. A review of Resident 1's Physician Order Summary Report, dated 2/5/2024, indicated to give Ivermectin oral tablet 3 mg 4 tablets by mouth every Monday for pruritus (severe itching) of skin for seven (7) days. A review of Resident 1's Order Summary Report, dated 2/5/2024, indicated to apply Permethrin External Cream 5% to the resident's neck to toe topically (applied directly to a part of the body) 1 time a day every Monday for pruritus of skin for 14 days. A review of Resident 1's Medication Administration Record (MAR) for the month of January 2024, indicated Resident 1 received Ivermectin oral tablet 3 mg 4 tablets by mouth one time a day every Thursday for 14 days on dates 1/25/2024 and 1/31/2024 for pruritis skin. A review of Resident 1's Treatment Administration Record (TAR) for the month of January 2024, indicated Resident 1 received Permethrin External Cream 5% with directions to apply 1 time to neck to toe topically for raised itchy bumps. TAR indicated to leave for eight (8) to 12 hours and wash after 1/24/2024 and 1/29/2024. 2. A review of Resident 2's Admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included unspecified psychosis (a mental disorder characterized by a disconnection from reality), dorsalgia (describes uncharacteristic, mostly chronic pain in the chest, shoulder, neck and arm regions due to changes to or false posture of the spine), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 2's H&P, dated 1/14/2024, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was independent with cognitive skills for daily decision making and had the capacity to understand and make decisions. The MDS indicated Resident 2 required partial/moderate assistance for toileting hygiene, shower/bathing, lower body dressing, and personal hygiene. A review of Resident 2's Skin Weekly Assessment, dated 1/29/2024, indicated Resident 2 was noted with general body atopic dermatitis, pink erythematous scaly plaques. A review of Resident 2's Physician Order Summary Report, dated 1/29/2024, indicated for a STAT (a common medical abbreviation for urgent or rush) skin scraping. A review of the Resident 2's Dermatology Notes, dated 1/30/2024, indicated Resident 2 had scabies on the medial chest sternal (relating to or near the sternum [the main bone at the center of the chest]) with the plan for a biopsy (a procedure to remove cells, tissue or fluid for examination). A review of Resident 2's Nurses Notes, dated 2/1/2024, indicated Resident 2 was on a 72-hour monitor for multiple raised bumps and status post (S/P, a term used in medicine to refer to a treatment, diagnosis or just an event, that a resident has experienced previously) bedside skin biopsy. A review of Resident 2's Care Plan, 2/2/2024, indicated Resident 2 had multiple red raised bumps. The staff interventions included were to monitor for itchiness and any warmth to affected area, and for skin scraping. Resident 2's care plan also indicated Resident 2 has general body scabies with staff interventions to administer treatment as ordered, place on contact isolation, and to monitor rashes for increased spread or signs of infection. A review of Resident 2's Change of Condition, dated 2/2/2024, indicated Resident 2 was diagnosed with scabies. A review of Resident 2's Physician's Order, dated 2/2/2024, indicated Ivermectin oral tablet 3 mg 4 tablets by mouth to start 2/3/2024, every Saturday for 14 days for scabies. A review of Resident 2's Physician's Order, dated 2/2/2024, indicated Permethrin External Cream 5% apply to neck to toe topically at bedtime every Friday for 14 days, leave for 8 to 12 hours then shower. A review of Resident 2's MAR for the month of February 2024 indicated Resident 2 received Ivermectin oral tablet 3 mg 4 tablets by mouth on 2/3/2024 in the morning. A review of Resident 2's TAR for the month of February 2024, indicated Resident 2 received Permethrin External Cream 5% to neck to toe topically on 2/2/2024. During an interview on 2/6/2024 at 11:13 AM, IPN stated the 4 CNAs (CNA 1, 2, 3, and 4) notified the IPN of their scabies symptoms on 1/29/2024. The IPN stated she observed all 4 CNAs with symptoms with scratches that looked alarming. The IPN stated staff continued to work and were allowed to work after the CNAs informed the IPN of their symptoms. The IPN stated the 4 CNAs were given the Permethrin cream and were treated on 1/30/2024 or 1/31/2024 (given after the 4 CNAs continued to work and provide direct resident care). The IPN stated CNA 5 was assigned to Resident 2 and complained she was itchy on 2/3/2024. The IPN stated CNA 5 continue to work with residents after reporting symptoms of scabies. The IPN stated CNA5 received treatment on 2/4/2024 (1 day after she reported symptoms of scabies). During a concurrent interview and record review of Resident 1's electronic medical records (EMR) on 2/6/2024 at 11:13 AM with the IPN, the IPN stated Resident 1 had a skin scraping done on 1/23/2024 and was confirmed positive for scabies on 1/27/2024. The IPN stated Resident 1 received both Ivermectin and Permethrin starting on 1/24/2024. The IPN stated Resident 2 was identified as a second scabies case on 2/2/2024. The IPN stated the facility had notified CDPH on 2/3/2024 of the scabies outbreak (7 days after Resident 1 was confirmed to have scabies). During a concurrent observation and interview on 2/6/2024 at 12:31 PM with CNA 4, CNA 4 was observed with pimple like rash on both arms. CNA 4 stated on 1/29/2024, both her arms were very itchy and saw pimple like rash on her arms. CNA 4 stated she informed Registered Nurse 1 (RN 1) about her scabies symptoms. CNA 4 stated RN 1 acknowledged but did not provide any instructions for her to leave work and stop providing direct resident care. CNA 4 stated RN 1 did not offer treatment for her symptoms. During an interview on 2/6/2024 at 1 PM, RN 1 stated she was not aware of any staff complaining about having itchy skin rashes. RN 1 stated, when and if a staff were to inform the DON and IPN of scabies symptoms, the staff would be sent home to prevent the spread of scabies. During a concurrent observation and interview on 2/6/2024 at 1:19 PM Resident 2 was observed lying in bed. Resident 2's upper chest had multiple red raised bumps. Resident 2 stated she had been itching and was diagnosed with scabies. During an interview on 2/6/2024 at 1:29 PM, IPN stated CNAs 1 and 2 came to notify her of scabies symptoms, sometime prior to 1/29/2024, but could not recall the exact date. The IPN stated the 4 CNAs (CNA 1, 2, 3, and 4) came in to complain to her about itching and pimple like rash to their skin. The IPN stated the 4 CNAs continued to provide direct resident care after they reported symptoms of scabies. The IPN stated the 4 CNAs were not given the Permethrin cream until 1/31/2024 and 2/1/2024 (7 to 8 days after complaint of itching or pimple like rash) During a concurrent record review of the facility's scabies policy and interview on 2/6/2024 at 1:35 PM, the IPN stated Licensed Vocational Nurse 1 (LVN 1) had notified her of CNA 5's complaint of itching on 2/3/2024 at 7:30 AM. The IPN stated CNA 5 continued to work her shift. The IPN stated, We had a scabies outbreak and we're aware of the situation on 2/3/2024. CNA 5 should had been advised not to continue working. The IPN stated CNA 5 could infect other staff and residents and cause the spread of scabies. During a concurrent observation and interview on 2/6/2024 at 2:05 PM, CNA 1 stated she was itching, and bumps started to flare on her arms, stomach, chest, areolas (the pigmented area on the breast around the nipple), thighs, butt, left side of back shoulder, both legs, and ears on 1/24/2024. There was a pimple like rash observed on CNA 1's arms and chest. CNA 1 stated the IPN said Resident 1 had a rash and it was not contagious on 1/24/2024. CNA 1 stated she was never informed that Resident 1 was positive for scabies. CNA 1 stated she had continued to work and received the prophylactic treatment for scabies on 1/29/2024 (5 days after onset of pimple like rash) and treated herself that night. CNA 1 stated during the time she had the symptoms and had not received treatment, she worked with residents who did not require staff to use Personal Protective Equipment (PPE, protective clothing, helmets, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness). CNA1 stated she worked with Resident 2 before the resident was diagnosed with scabies. CNA 1 stated she had not been informed to stay home. During an interview on 2/6/2024 at 2:55 PM, the IPN stated she did not have any documentation when the Permethrin cream was given to the CNAs. The IPN stated the pharmacy delivered the Permethrin cream on 1/31/2024. The IPN stated she personally handed the Permethrin cream to CNA 1 and CNA 2 on 1/31/2024. The IPN stated she did not recall giving the Permethrin cream to CNA3 and CNA 4. The IPN stated she did not and should have notified the 4 CNAs (CNA 1, 2, 3, and 4) right away when Resident 1 was confirmed positive for scabies since they had direct contact with Resident 1. The IPN also stated the symptomatic CNAs should not have been allowed to continue to work. The IPN stated the CNAs needed to undergo scabies treatment first prior to resuming with work to prevent the spread of scabies and a large outbreak. During a concurrent observation and interview on 2/6/2024 at 3:46 PM with CNA 3, CNA 3 stated she started itching about a month ago. CNA 3 informed the IPN about the itching and bumps on her arms 2 to 3 weeks ago (but does not remember exact date). CNA 3 stated she has multiple pimple like rashes located on her arm, breasts, and abdomen. CNA 3 stated she was not informed to stop working. CNA 3 stated she received treatment for her symptoms of itching about a week ago (but does not remember exact date. This is approximately 7 to 8 days after onset of itching). CNA 3 stated, Right now, I am still itchy and have new bumps on my breast and abdomen. CNA 3 stated she took care of residents who did not require use of PPE. During an interview on 2/6/2024 at 4:36 PM, CNA 2 stated she told the IPN on 1/24/2024 about having itchy symptoms. CNA 2 stated she had continued to work her regular schedule on 1/24/2024 and 1/25/2024. CNA 2 stated she received the treatment from 1 of the treatment nurses on 1/27/2024 (3 days after onset of CNA 3's itchy symptoms). During a concurrent interview and record review of the staff schedule on 2/6/2024 at 4:45 PM with the IPN, schedule indicated the following: a. CNA 1 worked on the following dates while she had symptoms of scabies prior to prophylactic treatment: 1/25/2024 from 3-11 PM 1/26/2024 from 3-11 PM 1/28/2024 from 7-3 PM 1/31/2024 from 3-11 PM b. CNA 2 worked on the following dates while she had symptoms of scabies prior to prophylactic treatment: 1/24/2024 from 3-11 PM 1/25/2024 from 3-11 PM 1/29/2024 from 3-11 PM 1/30/2024 from 3-11 PM c. CNA 3 worked on the following dates while she had symptoms of scabies prior to prophylactic treatment: 1/24/2024 from 3-11 PM 1/25/2024 from 3-11 PM 1/26/2024 from 3-11 PM 1/27/2024 from 3-11 PM 1/30/2023 from 3-11 PM 1/31/2024 from 3-11 PM d. CNA 4 worked on the following dates while she had symptoms of scabies prior to prophylactic treatment: 1/25/2024 from 7-3 PM 1/29/2024 from 7-3 PM and 3-11 PM 1/30/2024 from 7-3 PM and 3-11 PM 1/31/2024 from 7-3 PM e. CNA 5 worked on the following dates while she had symptoms of scabies prior to prophylactic treatment: 1/25/2024 from 7-3 PM 2/3/2024 from 7-3 PM 2/5/2024 from 7-3 PM During an interview on 2/6/2024 at 5:21 PM, CNA 5 stated on 2/3/2024 she started itching on her arms and all over her body. CNA 5 stated she had a pimple like rash on her right arm. CNA 5 stated she provided direct care to Resident 2 prior to Resident 2's diagnosis of scabies on 2/2/2024. CNA 5 stated she reported her symptoms to the supervisor on 2/3/2024 and no one told her anything about going home or getting treatment. During an interview on 2/6/2024 at 5:51 PM, the IPN stated Resident 1 tested positive on 1/27/2024 through skin scraping. The IPN stated the 4 CNAs had symptoms along with Resident 1. The IPN stated the scabies outbreak was not reported at this time and stated she could not answer as to when it was supposed to be reported. The IPN stated the ADM reported the outbreak on 2/3/2024 (7 days after the scabies outbreak). During a concurrent interview and record review of the Prevention and Control of Scabies in California Long-Term Care Facilities on 2/6/2024 at 6:29 PM with the ADM, the ADM stated when she was notified of the first positive scabies case, her interpretation was that it was not reportable unless there were 2 positive results. The ADM stated the facility should have reported the scabies outbreak on 1/27/2024 to local public health and to CDPH since an outbreak for scabies was also defined as 1 confirmed scabies and at least 2 clinically suspected cases identified in residents, HCWs, volunteers and/or visitors during a 2-week period of time. The ADM stated she was aware CNAs had symptoms of scabies and they continued to work before getting treatment. The ADM stated the facility should have offered the Permethrin cream, to the CNAs, and removed the CNAs from the work schedule until they received the treatment. During an interview on 2/6/2024 at 6;38 PM, the IPN stated the CNAs should have been referred to employee health or given the option to see their own primary doctor. The IPN stated the symptomatic CNAs were not and should have been referred to Employee Health for consultation. During a follow up interview on 2/6/2026 at 7:11 PM, the IPN stated CNA 5 had not received the Permethrin cream. During an interview on 2/7/2024 at 11:28 am, LVN 1 stated Resident 2 had developed small, itchy, raised red bumps to her body sometime January 2024. LVN 1 stated Resident 2's skin biopsy came back positive for scabies on 2/2/2024. During an interview on 2/7/2024 at 3:21 PM, the DON stated the facility had 2 confirmed cases on 2/2/2024. The DON stated the facility reported the scabies outbreak the following day on 2/3/2024. The DON stated the facility did not report to CDPH when there was 1 positive scabies case with at least 2 suspected cases. The DON stated they waited until they had 2 positive cases of scabies and reported to CDPH the following day. The DON stated the affected CNAs could expose other residents they were taking care of and transfer the scabies. The DON stated symptomatic staff should not work and be taken off from the schedule to receive treatment or be seen by a doctor. The DON stated the P&P for scabies was very general and it did not and should include what HCWs should do when they were symptomatic. The DON stated the staff may have scabies since they are symptomatic. The DON stated the resident being care by these staff could contract the scabies which could be dangerous for the residents. During an interview on 2/8/2024 at 10:45 AM, CNA 6 stated she received an in-service for scabies yesterday, 2/7/2024. CNA 6 stated staff needed to notify the IPN, ADM or charge nurse if experienced any signs and symptoms of scabies. CNA 6 stated if they showed any signs and symptoms of scabies, they had the option of getting the treatment or seeing the doctor. CNA 6 stated she had informed RN 1 regarding 4 dots on her left arm about a week ago (does not remember exact date) and was not offered treatment. CNA 6 stated she was currently providing direct resident care for the residents who did not require contact isolation. CNA 6 stated it was important not to work when having symptoms of scabies to prevent residents from a huge outbreak amongst residents. There were bumps and slight redness observed on CNA 6's arm. During an interview on 2/8/2024 at 11:02 AM, the IPN stated she did not remember CNA 6 informing her about her itching or her bum [TRUNCATED]

Cross reference: F726 Based on observation, interview, and record review the facility failed to honor one of two sampled residents (Resident 1) decision for refusal of treatment in accordance with the facility policy and procedure. This deficient practice violated Resident 1's and/or the representative's right to refuse cardio-pulmonary resuscitation (CPR, an emergency lifesaving procedure performed with chest compressions combined with artificial ventilation when the heart stops beating) and have resulted in Resident 1 experiencing chest pain on [DATE] and sustained right and left side rib fractures (when one of the bones in the rib cage breaks or cracks). Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's choice for medical interventions if found with a pulse and/or was breathing was for Comfort- Focused Treatment (primary goal of maximizing comfort). POLST was signed by Family Member 1 (FM1), but did not include the date when it was signed. Resident 1's POLST was also signed by Medical Director (MD) on [DATE]. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool), dated [DATE], indicated Resident 1 had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS also indicated Resident 1 needed extensive assistance (resident was involved in activity, but staff provided weight bearing support) with bed mobility and eating. Resident 1 was totally dependent (full staff performance) with transfer, locomotion, dressing, toilet use and personal hygiene. A review of Resident 1's History and Physical (H&P), dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. During an interview with Certified Nursing Assistant 1 (CNA 1) on [DATE] at 10:59 a.m., CNA 1 stated, she was unaware of the code status of the residents. During an interview with Licensed Vocational Nurse 1 (LVN 1) on [DATE] at 11:27 a.m., LVN 1 stated, on [DATE], CNA 4 informed her Resident 1 had altered level of consciousness (not responding and shallow breathing). LVN 1 stated, she immediately went to Resident 1's room and found Resident 1 to be unresponsive, not breathing and had no pulse. LVN 1 stated, she was not aware of Resident 1's code status so she went to the nurse ' s station to find the resident's chart. LVN 1 stated she called a Code Blue (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a facility-wide alert) by overhead page as she was looking for Resident 1's chart. LVN 1 stated when she found Resident 1's chart, which indicated DNR on the POLST, she returned to Resident 1's room where she saw the Director of Nursing (DON) performing CPR on Resident 1. During an interview with LVN 1 on [DATE] at 11:30 a.m., LVN 1 stated 911 was already called and when Emergency Medical Services (EMS) came to the facility, they did not take Resident 1 because Resident 1's medical record indicated a POLST with a no code status. During an interview with CNA 2 on [DATE] at 12:04 p.m., CNA 2 stated, DNR for a resident means do not resuscitate. If the resident does not have an arm band indicating DNR, then ask the Charge Nurse to check the chart. During an interview with RN 1 on [DATE] at 12:54 p.m., RN 1 stated he would know if a resident was DNR by looking for a pink or bright colored POLST form in the chart or an arm band/bracelet on the resident's wrist. RN 1 stated LVNs and Registered Nurses (RNs) were responsible in knowing the resident's code status and should honor the request if CPR was declined or refused. During an observation on [DATE], at 1:15 p.m., in Resident 1's room, Resident 1 was alert and oriented to name only when called. Resident 1 was observed without an arm band/bracelet. During an interview with the DON on [DATE] at 1:32 p.m., the DON stated, although only licensed nurses have access to the electronic health record (EHR) and the paper chart, all staff were responsible to know the resident's code status. The DON stated, Code Blue was activated because Resident 1 was found unresponsive and not breathing. The DON stated he performed CPR for less than two minutes, while the nurse was getting oxygen for Resident 1. The DON stated Resident 1 was resuscitated (to revive, especially from apparent death or from unconsciousness), then was given oxygen. During an interview with LVN 2 on [DATE] at 2:05 p.m., LVN 2 stated, If the resident was not breathing or does not have a heart rate and you are not aware of the resident's code status, send someone to find out, stay with the resident and start CPR. During a telephone interview with FM1 on [DATE] at 4:00 p.m., FM1 stated prior to Resident 1 receiving CPR, Resident 1's POLST was DNR with Comfort Focused-Measures. FM1 stated, I found out later that my mother had broken five ribs, three on one side and two on the other side. FM1 stated Resident 1 was [AGE] years old with dementia and she did not want Resident 1 to suffer with pain. FM1 stated she was aware that CPR could result in broken ribs, so she chose DNR with Comfort Focused-Measures. FM1 stated, I told the facility that my mother is a DNR, but they do not listen to what they are told. FM1 stated, LVN 1 does not listen and insists on doing things her way. FM1 stated, Resident 1 complained about chest pain when she came to the facility on [DATE] to visit her. During a telephone interview with Medical Doctor (MD) on [DATE] at 10:41 a.m., MD stated he was the primary physician in charge of Resident 1's care at the facility. MD stated he had several discussions about Resident 1's POLST with FM 1 and FM 2. MD stated CPR compressions can lead to rib fractures in Resident 1. MD stated, Resident 1 appeared non-responsive to staff and CPR was initiated on [DATE]. MD stated, as a result of the CPR compressions, Resident 1 sustained left and right side rib fractures. A review of Resident 1's General Acute Care Hospital (GACH ) Emergency Physician Documentation, dated [DATE], entered at 6:05 p.m., indicated Resident 1 does have a POLST which reflected DNR selective treatment. It also indicated chest pain status (resident had experienced previously) CPR for Resident 1 who was DNR. It also indicated there were multiple rib fractures. A review of Resident 1's GACH Computed Tomography (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body), dated [DATE], examination impression was very subtle nondisplaced fractures (cracks in the rib or a jagged edge) of Resident 1's right anterior (right front chest wall) 3rd through 5th ribs and left anterior (left front chest wall) 5th and 6th ribs. A review of facility's policies and procedures (P&P) titled, Cardio-Pulmonary Resuscitation, revised in [DATE], indicated nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: 1. A valid Do Not Resuscitate order is in place. The P&P indicated procedure included was to identify code status/advance directive preferences a. If the resident has a valid advance directive, a POLST form that indicated resuscitation is not desired) or a DNR (Also known as DNAR-Do Not Attempt Resuscitation) order, do not perform CPR. The use of arm band/bracelet to indicate a DNR status was not reflected on the P&P.

Based on observation, interview, and record review the facility neglected to provide care, ensure freedom from physical and verbal abuse for one of four sampled residents (Resident 1). By failing to: 1. Notify Resident 1's physician after the resident fell on [DATE]. 2. Assess Resident 1 from head to toe, identify any injuries, and seek medical care after she fell on [DATE]. 3. Investigate and verify if the cause of Resident 1's right [CONDITION(S)] (broken bone) injury was from Resident 1's fall on 5/5/2021. 4 Ensure Resident 1 was free from verbally and physically aggressive behavior from Certified Nursing Assistant 1 (CNA 1) providing care to her on 5/10/2021. This deficient practice resulted to Resident 1 not being properly assessed to identify any injuries, on 5/5/2021, after Resident 1 fell from her bed landing on the right side of her body under the care of CNA 1. The physical and verbal abuse by CNA1 had the potential to cause permanent psychosocial harm leading to feelings of helplessness, depression, withdrawal, and self-harm as well as broken bones or internal bleeding. On 5/20/21, fifteen days after Resident 1 fell , Resident 1 was sent to the General Acute Care Hospital (GACH). Resident 1 was diagnosed for a right [CONDITION(S)] (broken bone). On 7/22/21 at 3:52 p.m. an Immediate Jeopardy was called (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) in the facility. The Administrator (ADM) and Director of Nursing (DON) were notified of the findings regarding for the neglect of care for Resident 1 after the fall on 5/5/21, and CNA 1 verbally and physically abuse Resident 1 on 5/10/2021. On 7/25/2021 at 6:12 p.m., the facility submitted an acceptable plan of action (POA) that included the following: 1. Resident 1 was discharge on 6/25/2021. CNA 1 was suspended on 5/18/2021. The Social Services Director completed an interview of all residents assigned to CNA1 to determine if any further abuse occurred. All staff received in service training on abuse prevention and management. All licensed nurses received in service training on Situation Background Assessment and Recommendation (SBAR) assessment for residents with changes in condition. All licensed nurses received in service training on reporting abuse and fall incident to the physician. All licensed nurses received in service training on head to toe assessment. The DON and facility administrator received in service training from a nurse consultant on how to complete a thorough investigation for abuse and falls. 2. Daily (Monday - Friday) medical records audits to be performed by medical records designee to ensure complete post change of condition assessments complete, physician notification, and thorough investigations done. Activity Director to review resident's right s monthly with the residents during the Resident Council Meetings. Actives Director to complete a grievance for any complaints voiced during the meeting. Department Manager to conduct daily room rounds daily for two days then weekly thereafter. Daily interviews of alert residents to be conducted for 24 hours, then weekly for three weeks, then monthly thereafter. Staff to be provided with yearly training no change of condition, fall incident and abuse prevention. 3. Results of all audits and interviews to reported to the (Quality Assurance and Performance Improvement) QAPI committee for further review and recommendation. A root cause analysis to be conducted by the QAPI committee to determine further interventions for the deficient practice on abuse prevention and fall management program. QAPI committee to monitor process every month for at least three months and then quarterly. On 7/25/2021 at 6:26 p.m., after verifying and confirming on-site the implementation of the facility's immediate corrective actions within the POA, the Immediate Jeopardy was lifted in the presence of the Administrator, DON, and nursing consultant. Cross Reference: F 656, F689, and F909. Findings: A review of Resident 1's Face Sheet indicated the resident was originally admitted to the facility on [DATE], and readmitted , on 5/24/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's History & Physical (H&P) dated 2/29/2021, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized data collection tool) dated 3/31/2021, indicated Resident 1 was completely dependent on staff for transferring in and out of bed. The MDS also indicated Resident 1 required extensive assistance with turning side to side in bed and positional changes. 1. A review of Resident 1's care plan for Risk for Falls or Injuries, no initiation date, indicated Resident 1 had a Morse fall risk assessment (a rapid assessment tool used to assess a resident's likelihood of falling. A score of 45 or more indicates a high fall risk) score of 75 which was high risk. The care plan interventions included, a one on one (private) sitter (person assigned to watch the resident to alert staff to any needs), may have low bed with floor pad, and provide adequate help with transfer a needed. A review of Resident 1's Change in Condition (COC) evaluation form, dated 5/5/2021 at 6:43 p.m., indicated the Resident 1 suffered a fall. The form indicated a CNA1 reported to the Licensed vocational Nurse (LVN 1) that Resident 1 fell . The form did not indicate how the resident fell or any details concerning the fall. The form indicated Resident 1 had a bump on her right forehead with slight swelling. The form indicated Resident 1's physician was notified at 6:58 p.m. A review of Resident 1's Nurses Notes, dated 5/5/2021 at 6:48 p.m., indicated the physician's answering service was called and LVN 1 requested a call back. A review of Resident 1's Morse Fall Risk assessment dated [DATE] at 7:27 p.m., indicated resident 1 was at moderate risk for falls. A review of the facility's interview form dated 5/5/2021 3-11 pm shift, indicated CNA 1 sated she was in the room with another resident when she heard Sitter 1 say the Resident 1 fell . CNA 1 then assisted the Sitter 1 in returning Resident 1 to bed and went to inform LVN 1. A review of the facility's Interdisciplinary Post Event Review, notes dated 5/6/2021 (no time), indicated Resident 1 was found on the floor by the CNA 1. The notes indicated Sitter 1 informed LVN 1 Resident 1 was leaning on the siderails which malfunctioned, and the resident rolled off the bed and landed on her right side. The notes indicated the circumstances of the fall as the side rails giving way. A review of Resident 1's Nurses Notes from 5/6/2021 to 5/18/2021 indicated no documentation was made that the physician was ever notified of Resident 1's fall on 5/5/2021. 2. A review of Resident 1's care plan for Actual Fall with bump in the head, date initiated 5/5/2021, indicated the fall occurred due to poor communication and comprehension. The care plan interventions included to monitor, document, and report PRN (as needed) for S/Sx (signs/symptom) of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation. The care plan intervention also included neuro checks for 72 hours. A review of Resident 1's Nurses Notes from 5/6/2021 to 5/ 8/2021 indicated Resident 1 was monitored for status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's notes did not indicate what the neuro check finding were and only indicated, Neuro checks done q shift. The nurse notes did not indicate other body parts such as the legs, arms, and hip area were assessed. 3. A review of Resident 1's Nurses Notes, dated 5/20/2021 at 10:25 a.m., indicated Resident 1 was currently on a wheelchair. Resident 1 was with caregiver (Sitter 2) walking around the facility. Resident 1 had no episodes of crying noted and was comfortable. A review of Resident 1's Nurses Notes, dated 5/20/21 at 7 p.m., indicated CNA (CNA 3) reported to the charge nurse (LVN 2) that Resident 1's right hip area had a, Hard bone protruding, very hard to touched. Resident 1 had, Facial grimacing of pain noted upon palpation (touching with hands and applying pressure to feel for broken of protruding bones). Resident was guarding and pushes nurse away when touching the right hip/groin area. Resident 1's physician was notified and ordered for Resident 1 to be transferred to General Acute Care Hospital (GACH). A review of Resident 1's Nurses Notes, dated 5/20/2021 at 8:30 pm, indicated Resident 1 was transferred via ambulance to the hospital. A review of Resident 1's GACH Emergency Department (ED) physician's note, dated 5/20/2021 at 11:28 p.m., indicated Resident 1 was taken to the ED due to a ground-level fall two weeks prior and had not been noticed until 5/20/21. The note indicated Resident had a displaced right hip (the hip joint to become partially or completely dislocated). A review of Resident 1's Computerized Tomography (CT) scan (a diagnostic exam that allows doctors to see inside your body) of the abdomen and pelvis, dated 5/21/2021 at 12:28 a.m., indicated Resident 1 had a displaced fracture of the right femoral neck (top of the long hip bone where the bone connects with the pelvis). A review of Resident 1's GACH's ED Report dated 5/21/2021 at 1:21 a.m., indicated there was a definite possibility that there was an acute (recent) component to the fracture. The note indicated the risk of sedation to repair the right hip dislocation would outweigh the benefits, therefore surgery was unwarranted at that time. A review of Resident 1's Social worker note from the GACH dated 5/21/2021 at 1:09 pm, indicated the GACH social worker was notified by the ED physician and Nurse that Resident 1 had a right [CONDITION(S)] and requested an abuse report be made. A review of Resident 1's Social Worker note from the GACH dated 5/21/2021 at 10:45 pm, indicated a police officer arrived at the ED to investigate an abuse allegation reported by the facility. A review of Resident 1's GACH History and Physical (H&P) from, 5/22/2021 a 9:19 a.m., indicated the physician received report that a CNA 1 was, Very rough with the patient, to the point that it disturbed the caregiver (sitter 2) exceptionally. The H&P indicated the skilled nursing facility called the physician 2 hours after the resident arrived at the facility to tell her they were concerned Resident 1's possibly had a right [CONDITION(S)]. The H&P indicated the physician asked the skilled nursing facility for any old x-rays and was informed they did not have any. The H&P indicated the physician's assessment included a, Questionable episode of abuse/rough behavior by the facility nurse, reported by the patient's private sitter, and the physician unable to determine the age of the fracture. A review of Resident 1's care plan for Fracture of right (R) femur, no initiation date documented, indicated the risk for fracture was unavoidable due to restless behavior. The care plan indicated Resident 1 was not a good candidate for surgery to repair the fracture. The care plan identified interventions which included handling gently, assessing for pain, and notifying physician of changes in condition. A review of Resident 1's medical records indicate no investigation to verify if the cause of Resident 1's right [CONDITION(S)] (broken bone) injury was from Resident 1's fall on 5/5/2021. 4. A review of the facility's Nursing Staffing Assignment and Sign-In Sheet. dated 5/10/2021, for shift 3:00 p.m. to 11:00 p.m., indicated CNA 1 was assigned to care for Resident 1. During a telephone interview on 5/20/2021 at 11:55 a.m., Sitter 2 stated she was assigned to sit with Resident 1 from 10:00 am to 6:30 pm, on 5/10/2021. Sitter 2 state Resident 1 had been calm and cooperative throughout the day shift and around 4:00 pm she asked to have Resident 1 placed in a wheelchair so she could walk her around. Sitter 2 stated at 4:30pm the charge nurse (LVN 1) entered the room to give Resident 1 her medications. Sitter 2 stated Resident 1 refused to take her medications so the medication nurse asked CNA 1 to attempt to give the medications to Resident 1, Sitter 2 stated CNA 1 dipped her finger in the applesauce and put her finger with applesauce on Resident 1's lips. Sitter 2 stated this aggravated Resident 1. Resident 1 then attempted to get out of bed. Sitter 2 sated Resident 1 was also soiled and need to be changed. Sitter 2 stated the LVN 1 and CNA 1 removed the wet bed sheet but did not change the resident. Sitter 2 stated at 5:30 p.m., Resident 1 was still soiled and had not yet been changed so she asked CNA 1 to change her. Sitter 2 stated CNA 1 entered the room at 6:00 p.m. to change Resident 1. Sitter 2 stated CNA 1 was being aggressive with Resident 1 and continuously pushed Resident 1's forehead down to the bed and swung Resident 1's legs over the rail and pushed her legs down against the bed. Sitter 2 sated Resident 1 became more agitated and attempted to hit CNA 1. Sitter 2 stated CNA1 told Sitter 2, She (Resident 1) is, Stupid, the meds (medications) aren't working. During a telephone interview on 5/20/2021 at 1:23 p.m., CNA 1 stated she cared for Resident 1 often and was familiar with her episodes of agitation. CNA 1 stated, on 5/10/2021, Resident 1 was very agitated and had her leg hanging over the side rail so she, Pushed, them over the rail to reposition her, she then, Gently pushed, her shoulder towards the bed to get her to lay down. CNA 1 stated Resident 1 was kicking her (CNA 1) so CNA 1 grabbed her feet and stated, Behave please, behave. CNA 1 stated at times they are asked to give residents medications but would not do so if there was a sitter watching. A review of Resident 1's care plan for emotional distress due to (d/t) abuse allegation 5/20/2021, did not indicated the reason for emotional distress. The care plan listed interventions as administering medications, anticipating needs, providing opportunity for private interactions, frequent visual checks, notifying physician if treatment ineffective, and providing activities. A review of the facility's Investigation Summary, dated 5/22/2021, indicated on 5/18/2021 the facility was informed by their contracted sitter service that a statement was made alleging CNA 1 attempted to give Resident 1 her medication, neglected to provide needed incontinence care by leaving Resident 1 soiled, CNA 1 was also reported forcefully swinging Resident 1's legs into the bed while pushing down her forehead and calling Resident 1, Stupid, on 5/10/2021. The investigation summary indicated actions taken included, notifying physician and responsible party. During a telephone interview, on 5/27/2021at 11:49 a.m., the Administrator stated CNA1 had not been allowed to return to work due to the statement from the sitter (Sitter 2) caring for Resident on 5/10/2021. During a telephone interview on 6/2/2021 at 9:05 a.m., Sitter 1 stated she used to be the regular sitter for Resident 1until early May 2021. Sitter 1 stated CNA 1 would handle the resident roughly when providing care and changing her and would tell her it was because she was tremenda (tremendous) and a handful and would get frustrated and say, Oh esta senora, (oh this lady). Sitter 1 stated Resident 1 would become very agitated and restless, when CNA 1 cared for her. Sitter 1 stated once tried to assist in calming Resident 1 down and was told to leave her alone and let her be. Sitter 1 stated Resident 1 would react to CNA 1 because she was mean and rude to her. Sitter 1 stated she complained to the Administrator almost every shift about Resident 1 being neglected, because she (Sitter 1) would often arrive and find Resident 1 naked and soiled. Sitter 1 stated after that the facility asked her employer not to send her back to the facility because she was, Too demanding. During an observation, on 6/7/21 at 1:32 p.m., Resident 1 was observed in in her room and in her bed, nonverbal, moving bilateral (both sides) upper extremities and minimal movement to lower extremities. Bed observed to have bilateral upper side rails up and a sponge/foam like covering on top part of both rails. The siderail had pads on the inner part of the rails, with zip ties holding the pads in place. During a telephone interview, on 7/14/2021 at 7:50 p.m., LVN 1 stated on 5/5/2021, she was called into Resident 1's room by CNA 1 who informed her the resident had fallen from the bed. LVN 1 stated Resident 1 was in her bed when LVN 1 entered the room. LVN 1 was told the side rail gave way, and Resident 1 fell on her head. LVN 1 stated CNA 1 was told that she (CNA 1) should not have returned Resident 1 to her bed prior to her (LVN 1) assessing Resident 1. LVN 1 stated she did not perform a full body physical assessment on Resident 1 and only did a visual assessment. LVN 1 stated a visual assessment was just looking at the resident. LVN 1 stated CNA 1 told LVN 1 that Resident 1 hit her head after the fall. LVN 1 stated she only focused on Resident 1's head. During a telephone interview, on 7/14/2021 at 7:50 p.m., LVN 1 reviewed Resident 1's Change in Condition (COC) evaluation form, dated 5/5/2021 at 6:43 p.m., LVN1 stated she checked off the boxes for the assessment's findings based on her visual not physical assessment. LVN 1 stated she documented the section about physician notification as physician notified, but that was for the message left for the doctor to call back and did not speak to the doctor at that time. During a telephone interview, on 7/14/2021 at 7:50 p.m., LVN 1 stated she did not complete a Situation Background and Assessment Form (SBAR) for the fall incident on 5/5/2021 incident. LVN 1 stated her post fall assessment on 5/5/2021 was incomplete, the fall was not properly investigated by her, and she did not create a care plan for the fall incident. LVN 1 stated documenting full assessments is important for safety and day to day care of the resident, so that staff may know exactly what happened, and what needed to be monitored and followed up on. LVN 1 stated identification of Resident 1's right [CONDITION(S)] was likely missed because a full physical assessment was not done and day to day assessments following the fall were mostly visual. LVN 1 stated licensed nurses perform visual assessments and rely on CNA's to perform physical assessments during their daily care and inform them of any abnormalities. During the same telephone interview on 7/14/2021 at 7:50 p.m., LVN 1 stated on 5/20/2021 around 6:00 p.m., CNA 3 called her into Resident 1's room to inform her she noticed an abnormal hard bump sticking out of Resident 1's right hip. LVN 1 stated she had not performed a physical assessment up until that point in her shift, she only did a visual assessment when she rounded earlier. LVN 1 stated performing a physical assessment in the beginning of the shift would have provided a baseline picture of Resident 1's condition and would have allowed to find out if something was wrong early on. LVN 1 stated neuro checks were done each shift and were documented in the nursing notes as, Neuro checks done q shift. LVN 1 stated neuro-checks included checking level of consciousness and Looking at pupils. LVN 1 stated detailed neuro-checks findings were not normally documented by nurses. During a telephone interview on 7/15/2021 at 11:05 am, LVN 2 stated she was very familiar with Resident 1 and cared for her often. LVN 2 stated she cared for Resident 1, on 5/20/2021, during the day shift (7 a.m. to 3 p.m.) and did not have any issues during the shift. LVN 2 stated she does her resident assessments early in her shift but does a visual assessment not a hands-on assessment (examining each section of a body by touching and moving each joint to make sure there is no abnormalities or loss of function). LVN 2 stated Resident 1 would act aggressively and would display uneasy movements whenever she was in pain. LVN 2 stated these behavioral cues were never added to the care plan and should have been in order to alert other staff to resident specific signs of pain or distress. LVN 2 stated she was not aware Resident 1 had fallen and potentially hurt her hip until after she was transferred to the hospital. LVN 2 stated nothing was documented in the medical record or care plan, therefore she did not know to assess for any injuries or pain from the fall on 5/5/2021. During a telephone interview, on 7/15/2021 at 4:40 pm, CNA 3 stated on 5/20/2021, she transferred Resident 1 from her wheelchair to her bed around 6:15 p.m. CNA 3 stated she placed her arms around Resident 1's waist, and Resident 1 placed her arms over CNA 3's shoulders. CNA 3 stated the transfer went well with no issues. CNA 3 stated she then proceeded to change Resident 1, and when she was changing her, she noticed an abnormal looking hard bump sticking out of Resident 1's right hip. CNA 3 stated she immediately went to call LVN 1. CNA 3 informed LVN 1 of the hard bump sticking out of Resident 1's right hip. CNA 3 stated she had not cared for the resident in a while and CNA 1 was usually assigned to her. During a telephone interview, on 7/16/2021 at 9:02 a.m., the DON stated CNA 1 was no longer employed with the facility. The DON stated she was not sure if CNA1 quit or was let go, but knew she was no longer employed with the facility because of the abuse allegation. During the same telephone interview, on 7/16/2021 at 9:10 a.m., the DON stated the post fall protocol included not returning the resident to the bed and performing a complete physical assessment. The DON stated CNA1 did not follow the protocol and LVN 1 only assessed the head because that was reported to her. The DON confirmed a complete assessment was not documented for Resident 1 after the fall on 5/5/2021. The DON stated the assessment protocol for the facility included nurses only assessing a resident if a change in condition occurs. The DON stated licensed nurses only do visual assessments and check for behavioral changes. The DON stated CNA's are responsible for physical assessments when they are providing care and they know to notify the nurse if they notice any skin abnormalities or issues. The DON stated the CNA's are not trained in physical assessments but, Are given the idea of what to look for, like discoloration. The DON reviewed Resident 1's Nurses Notes from 5/6/2021 to 5/18/2021 and confirmed communication of the fall to the physician was not documented or followed up on. During the same telephone interview on 7/16/2021 at 9:10 a.m., the DON reviewed all of Resident 1's care plans and confirmed most of them were not dated and was not updated post fall. The DON stated a care plan should have been created after identifying Resident 1 was, Jiggling, the side rail and interventions created for that behavior. The DON stated a creation of the care plan would communicate to the nurses the care that needed to be provided. The DON stated complete documentation of the incident should have been done to let the staff know what happened and what needed to be done. The DON confirmed there was no documentation of the physician being notified and a follow up call should have been made the day after the fall (5/6/2021). During a telephone interview on 7/26/2021 at 3:24 p.m., Resident 1's attending physician stated Resident 1 was her patient both in the facility and when she was transferred to the GACH. The physician stated she did not recall the facility calling her to inform her that the resident fell on [DATE]. The physician stated she recalled being informed of a hip protrusion on 5/202/2021 and immediately ordering an X-ray. The physician stated her post fall protocol was to order X-rays immediately after a fall because at that age bones are easily broken. The physician stated a head injury would also warrant further orders such as a scan. The physician stated if no X-ray was ordered after the fall on 5/5/2021 then she likely was not informed about the fall. The physician also stated another instance in which no X-ray would be ordered would be if the nurse reported no injury at all. During an interview, on 9/3/2021 at 5:30 p.m., the DON stated all policy and procedures provided were the most current policy and procedures. A review of the facility's policy titled Fall Risk assessment dated ,d+[DATE], indicated the facility will complete the fall risk assessment on admission and update after any fall or change of condition. The facility staff will complete a fall risk assessment using the Morse Scale Assessment. A review of the facility' policy and procedure for Fall Prevention, dated 12/2016, indicated the facility will identify interventions related to the resident's specific risks and causes to try to prevent6 the resident from falling and to try to minimize complications from falling. All residents will be assessed following the incident of fall. Care plan interventions should include the treatment prescribed by the physician and interdisciplinary (a group of medical profession involved in the care) recommendation that included resident choice, assistance, activities of daily living, and environmental hazards. Care plan revision included changes in condition such as the ability to make decisions, cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and functional impairment. A review of the facility's policy and procedure for Post Fall Management Program, dated 12/2016, indicated the licensed nurse was to assess for injuries, obtain vital signs (body temperature, pulse rate, respiration rate, blood pressure), assess for range of motion, alert the physician, document circumstances in medical record, complete incident report, notify all team members of fall, and updating the care plan to prevent further falls. The policy also indicate staff needed to identify environmental factors that may have contributed to fall. A review of the facility's policy and procedure for Physician Notification, dated 12/2016, indicated physicians needed to be promptly informed of any change in condition. The policy indicated that if the physician was unavailable the covering on-call physician should be notified. A review of the facility's policy and procedure for Care Plan Conference, dated 12/2016, indicated the care plan conference needed to identify needs and establish obtainable goals. The policy indicated care plan conferences were to be held after any change in status or condition. A review of the facility's policy and procedure for Person Centered Plan of Care, dated 12/2016, indicated the facility needed to provide each resident with a person-centered plan of care. The policy indicated the care plan had to describe services provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psycho-social wellbeing. The policy and procedure indicated the DON was responsible for implementation of the policy. The policy and procedure indicated care plans had to be signed and dated, changes needed to be communicated on an ongoing basis to all members of the interdisciplinary team, re-evaluation and modification of the care plan was to be done to reflect changes in care, and evaluation of the care plan needed to be done in response to changes in the resident's condition. A review of the facility's policy and procedure for Change of Condition, dated 8/2017, indicated it was the facility's policy to promptly notify the physician and representative of any changes in the resident's medical/mental condition and/or status. The policy and procedure indicated a care plan for the change in condition needed to be developed and nurse's notes needed to be documented with information relative to the changes in condition. A review of the facility's policy and procedure for Protection of Resident, dated 12/2017, indicated the facility will provide a safe resident environment from abuse that will protect and monitor residents. The policy and procedure indicated identified characteristics that increased the risk of abuse to included unsympathetic or negative attitudes towards residents, poor or inadequate preparation or training for care giving responsibilities. The policy indicated residents were at higher risk for abuse by staff when they were verbally aggressive towards staff, would scream at staff, or would kick and hit staff. A review of the Facility's policy and procedure for Abuse and Neglect Prohibition Policy, dated 4/2018, indicated abuse as, The willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health. The policy and procedure also identified injuries of unknown origin as a category of abuse. The policy defined injuries of unknown origin by having two conditions. One conditions of injury by unknow origin was the source of the injury was not observed by any person or the source of the injury could not be explained by the resident. The second condition of injury of unknow origin was the injury was suspicious because of the extent of the injury or the location of the injury. A review of the facility's policy and procedure for Initial Nursing Assessment and Re-assessment, dated 8/2019, indicated the licensed nurse would conduct a head to toe assessment upon admission. The policy and procedure indicated any change in the resident's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition.

Based on observation, interview, and record review, the facility failed to prevent avoidable fall accidents for two of four sampled residents who were at risk for falls (Resident 1 and Resident 4). The facility failed to: A. Ensure Resident 1's environment was free of accident hazards. Resident 1's bed side rail (a metal or plastic bar positioned along the side of a bed) was not inspected and maintained in good operating condition, and Resident 1's behavior of jiggling or pulling-on the siderail was not addressed in Resident 1's care interventions. On 5/5/2021, 6:43 p.m., Resident 1 was found lying on the floor. The facility's Interdisciplinary Post Event Review notes, dated 5/6/2021, indicated Resident 1 was leaning on the right siderails which malfunctioned, and Resident 1's right side rail gave way (collapse or broke) and fell . B. Implement interventions to keep Resident 4 safe when Resident 4 used his walker (a tool for disabled or frail people, who need additional support to maintain balance or stability while walking) to go to the bathroom, supervision to prevent Resident 4 from falls when using his walker to ambulate (walk) to use the restroom (bathroom), and Resident 4's walker was kept at the bedside for use when ambulating to the restroom. These deficient practices resulted in: A. Resident 1 falling due to the resident's bed siderail collapsing and sustained a small bump on the forehead on 5/5/2021. On 5/20/2021, 15 days after Resident 1's fall, Resident 1 was found with a protruding bone to right hip area, transferred to the hospital, and had a dislocated right hip fracture (broken bone). B. Resident 4 had three incidents of falls within 18 days. On 5/22/2021 Resident 4 fell sustained a small bump and abrasion on top of his head. On 6/1/21, Resident 4 fell with no injury, and on 6/10/2021, Resident 4 fell sustained a skin tear on top of his head. On 7/22/2021 at 3:56 p.m., an Immediate Jeopardy was called (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the facility. The Administrator (ADM), Director of Nursing (DON), were notified of the findings regarding the facility failing to ensure bed siderail was in good working condition to prevent Resident 1's fall on 5/5/21, and the facility failed to investigate if Resident 1's fall, on 5/5/21 resulted to Resident 1's having a protruding bone on the right hip on 5/20/21. Resident 4 was a sampled resident during the POA submission time. On 7/25/2021 at 6:12 p.m., the ADM provided the Department an acceptable plan of action (POA) that included the following: 1. All licensed nurses received in service training on Situation-Background-Assessment-Recommendation (SBAR) assessment for residents with changes in condition. All licensed nurses received in service training on reporting fall incidents to the physician. All licensed nurses received in service training on head-to-toe assessment. All licensed nurses received in service training on use of and referral of malfunctioning siderail. The DON and facility ADM received in service training from a nurse consultant on how to complete a thorough investigation for abuse and falls. A red star will be placed on residents that are medium to high risk for falls to alert staff of fall potential. 2. All residents with side rails in place had siderails checked by maintenance. Four siderails were found to be Wobbly, and replaced 30, Crank up, beds were removed from the facility and replaced with, Hi-Lo, beds. The DON/designee conducted a review of fall incidents and found one incident. 43 residents require use of siderails, 30 beds replaced, and 13 more beds ordered with soft touch siderails and mattresses. 3. A change of condition audit for fall to be conducted by medical records from Monday to Friday and results reported to the DON and/or administrator. Daily room rounds to be conducted by department manager for two days and weekly thereafter for three weeks then monthly to check siderails. Post fall investigations will be completed by the facility's Interdisciplinary (IDT, a group of professionals who plan, and coordinate a resident's health care delivery) within 72 hours of fall incident. IDT will determine criteria for falling star program and update care plan and interventions. The IDT will conduct a 7-day follow up to review resident status after fall and revise care plan as needed. Residents that have fall risk scores above 50 on the Morse fall Risk Assessment will be placed on the falling star program and reevaluate every three months or with a change of condition. A red star will be placed on the head/foot of the bed of each resident meeting criteria, along with a black wrist band. The IDT will determine need to continue or discontinue program quarterly. All staff will be provided training on fall incidents yearly, to include prevention and management as well as siderail assessments. 4. Medical records designee will report results of all audits for change of condition following an incident of fall to the Quality Assurance and Performance Improvement (QAPI) committee for further review and recommendation. Social Services will report a summary of findings for daily room rounds identifying any siderail issues to the QAPI committee for further review and recommendation. Maintenance director will report summary of siderail checks to the QAPI committee for further review and recommendation. A root cause analysis to be conducted by the QAPI committee to determine further interventions for the deficient practice on fall management and siderail maintenance. QAPI committee to monitor process every month for at least three months and then quarterly. On 7/25/2021 at 6:26 p.m., after verifying and confirming on-site the implementation of the facility's immediate corrective actions within the POA, the Immediate Jeopardy was lifted in the presence of the Administrator and DON. Cross Reference: F 600, F 656, and F 909. Findings: A. A review of Resident 1's Face Sheet indicated the resident was originally admitted to the facility, on 2/22/19, with diagnoses that included [CONDITION(S)] (mental disorder which leads to hallucinations, irrational thoughts and behaviors), anxiety disorder, restlessness and agitation. The Face Sheet also indicated Resident 1 was readmitted to the facility, on 5/24/2021, with a new diagnosis of right femur (thigh bone) fracture. A review of Resident 1's History & Physical (H&P), dated 2/29/2021, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized data collection tool) dated 3/31/2021, indicated Resident 1 was completely dependent on staff for transferring in and out of bed. The MDS also indicated the resident required extensive assistance with turning side to side in bed and changing positions. A review of Resident 1's care plan for Risk for Falls or Injuries, no initiation date, indicated Resident 1 had a Morse fall risk assessment (a rapid assessment tool used to assess a resident's likelihood of falling. A score of 45 or more indicates a high fall risk) score of 75 which was high risk. The care plan interventions included, a one on one (private) sitter (person assigned to watch the resident to alert staff to any needs), may have low bed with floor pad, and provide adequate help with transfer a needed. A review of Resident 1's care plan for, Use of siderails (no date), indicated the siderails for use as boundary to secured resident safety. Resident 1 had bilateral (both, left and right side) half side rails with padding. The care plan interventions included, To evaluate continued use of side rails, attempt to use less restrictive measures, and monitor for any signs of physical discomfort or decline. A review of Resident 1's Nurses Notes, dated 5/5/2021 at 6:43 p.m., indicated the Licensed Vocational Nurse 1 (LVN 1) was called to Resident 1's room by Certified Nursing Assistant 1 (CNA 1). The note indicated the CNA 1 found Resident 1 lying on the floor and was informed by the sitter (Sitter 1) that Resident 4 had fallen and landed on her right side. The notes indicated CNA 1, and the sitter placed the resident back to bed and the licensed nurse assessed the resident with a small bump on the resident's forehead. A review of the facility's Interdisciplinary (IDT, a group of professionals who plan, and coordinate a resident's health care delivery) Post Event Review notes dated 5/6/2021 (no time), indicated Resident 1 was found on the floor by the CNA 1. The notes indicated Sitter 1 informed them Resident 1 was leaning on the right siderails which malfunctioned, and Resident 1 rolled off the bed and landed on her right side. The notes indicated Resident 1's right side rail gave way and fell . The notes indicated Resident 1 sustained a bump to the forehead. The notes indicated new interventions would be to transfer in wheelchair and educate staff. A review of Resident 1's Change in Condition (COC) evaluation form, dated 5/5/2021 at 6:43 p.m., indicated the Resident 1 suffered a fall. The form indicated a CNA1 reported to the charge nurse (LVN 1) that Resident 1 fell . The form did not indicate how the resident fell or any details concerning the fall. The form indicated Resident 1 had a bump on her right forehead with slight swelling. The form indicated Resident 1's physician was notified at 6:58 p.m. A review of the facility's interview form signed by CNA 1, dated 5/5/2021 3 p.m. to 11 p.m. shift, indicated CNA 1 stated she was in the room with another resident when she heard Sitter 1 say the Resident 1 fell . CNA 1 then assisted the sitter in returning Resident 1 to bed and went to inform the charge nurse (LVN 1). A review of Resident 1's Nurses Notes, dated 5/20/2021 at 7:00 p.m., indicated a CNA 3 reported Resident 1 having a protruding bone to right hip area which was hard to touch and uneven to left side, with facial grimacing upon touch. The note indicated the doctor was informed and an order to transfer Resident 1 to the emergency room . A review of Resident 1's Nurses Notes, dated 5/20/2021 at 8:30 p.m., indicated Resident 1 was transferred to the hospital via ambulance. A review of Resident 1's General Acute Care Hospital (GACH) Emergency Department (ED) physician's note, dated 5/20/2021 at 11:28 p.m., indicated Resident 1 was taken to the ED due to a ground-level fall two weeks prior and had not been noticed until 5/20/21. The note indicated Resident had a displaced right hip (the hip joint to become partially or completely dislocated). During a telephone interview, on 6/2/2021 at 9:05 a.m., Sitter 1 stated she was very familiar with Resident 1 and had been her sitter up until early May 2021. Sitter 1 stated she was with Resident 1, on 5/5/2021, at the time of her fall. Sitter 1 stated she was getting ready to leave for the day and had just adjusted Resident 1's head because she was leaning against the right-side rail. Sitter 1 stated she walked away from Resident 1's bed to gather her belongings and heard a loud thump. Sitter 1 stated she saw Resident 1 on the floor. Sitter 1 stated CNA 1 was in the room with another resident and immediately went to help place Resident 1 back in bed. CNA 1 went to get LVN 1. Sitter 1 stated the LVN 1 entered the room and told them (CNA 1 and Sitter 1) that they should have left Resident 1 on the floor. Sitter 1 stated LVN 1 proceeded to assess the bump on Resident 1's forehead. During an observation in Resident 1's room, on 6/7/2021 at 1:32 p.m., Resident 1 was observed in bed, nonverbal, moving bilateral upper extremities and minimal movement to lower extremities. The Resident 1's bed was observed to have bilateral upper bed siderails up with sponge/foam like covering attached to top part of left and right bed siderails. The bed siderails had pads (sponge/foam) on the inner part of the rails with zip ties (a plastic strip that can be threaded through its end and tightened to fasten something) tied to the frame of the bed keeping the pad in place. During a telephone interview, on 7/14/2021 at 7:50 pm, LVN 1 stated, on 5/5/21, she was called into Resident 1's room by Certified Nursing Assistant 1 (CNA 1), who informed her that Resident 1 had fallen from the bed. LVN 1 stated Resident 1 was in her bed when she entered the room and was told Resident 1's right bed siderail gave way, and Resident 1 fell on her head. LVN 1 stated the right bed siderail was dropping on its own. LVN 1 stated she had sent messages to the facility's maintenance staff and her Director of Nursing to inform about the situation (the right bed siderail was dropping on its own) after Resident 1's fall on 5/5/2021. LVN 1 stated zip ties were put on the bed siderails and the bed was pushed against the wall. During a telephone interview, on 7/15/21 at 11:05 a.m., LVN 2 stated she was very familiar with Resident 1 and cared for her often. LVN 2 stated the Resident 1's bed rails had been loose since she began her employment with the facility in February 2021. LVN 2 stated she had informed the facility's maintenance staff about the defective right bed siderail on several occasions before Resident 1's fall on 5/5/2021. LVN 2 stated she felt Resident 1 knew how to Jiggle, the bed siderail to get the bed siderail to release and lower the bed siderail. LVN 2 stated Resident 1 would often do this to let the staff know she wanted to get out of bed. LVN 2 stated the pads were placed over the bed siderails, but the pads were ineffective. LVN 2 stated she never updated the care plan or interventions to reflect Resident 1's behavior (jiggle the side rail to get the siderail to release and lower the side rails). LVN 2 stated interventions should have been made to address both side rails, and Resident 1's behavior to alert staff on the fall risk. LVN 2 stated there was a maintenance log, but she did not document in maintenance log when facility maintenance was informed. LVN 2 stated the facility maintenance staff was only informed verbally. During a telephone interview, on 7/15/2021 at 1:23 p.m., Maintenance Staff 1 (MS 1) stated he is usually informed verbally by staff when a piece of equipment was broken or in need of repair. MS 1 stated there was a maintenance log in each station in which the nurses should document issues with equipment, but maintenance log was rarely used. MS 1 stated he has only seen one or two entries in the log since February 2021. MS 1 stated he was informed on 5/5/2021, that Resident 1's right side rail was broken and gave way causing the resident to fall from her bed. MS 1 stated he went to check Resident 1's bed siderails (no dates given), and MS 1 stated felt they (Resident1's bed siderails) were operational, MS 1 stated perhaps the Resident 1 had figured out how to pull the lever to release them. MS 1 stated he then placed zip ties the bed siderails up to lock the in place. MS 1 stated the bed was not changed, only pushed against the wall by the nursing staff. During a telephone interview, on 7/16/21 at 9:10 a.m., the Director of Nursing (DON) stated she was notified by MS 1 that the right-side rail on Resident 1's bed was broken after Resident 1's fall on 5/5/2021, and DON stated the side rail was repaired by tightening a screw. The DON stated Resident 1 liked to lean on the bed siderail and pull at it, which caused it to loosen often. The DON stated the bed siderail was zip tied and the bed pushed against the wall to prevent the Resident 1 from falling, until they were able to repair the bed. The DON stated zip ties were not acceptable forms of repair, because they prevented the bed siderail from lowering, the nurses could not access the resident, and the resident could not be taken out of the bed. The DON stated they did not change the bed, because the other beds they had were not yet fully assembled. A review of the facility's policy and procedure for Preventative Maintenance, dated 4/2015, indicated the use of maintenance logs were part of the preventative maintenance checklist and could be completed by any employee. The person performing the task was responsible for notifying the employee responsible for the coordinating preventative maintenance. The person ensures resolution of the problem. A review of the facility' policy and procedure for Fall Prevention Program - Fall Prevention Interventions, dated 12/2016, indicated environmental hazards such as unstable furniture needed to be assessed and a, Physically safe, environment needed to be provided. The policy also indicated that staff needed to evaluate the safe application (use) of bed side rails. B. A review of Resident 4's Face Sheet indicated Resident 4 was admitted on [DATE], and readmitted , on 5/25/21 with diagnoses that included history of falling, [CONDITION(S)] (mental illness that interferes with a person's ability to think clearly, manage emotions, and make decisions), and [CONDITION(S)] disorder (mental condition marked by alternating periods of happiness and depression). A review of Resident 4's care plan for, Risk for falls, date initiated 2/24/2019, indicated Resident 4 had problems of confusion, gait/balance, history of falls, and episodes of poor safety awareness. The interventions included anticipate and meet the resident's needs, be sure resident's call light was within reach and encourage the resident to use it (call light) for assistance as needed, review information on past falls and attempt to determine cause of falls, record possible root causes, and remove any potential causes if possible. A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had severe impairment in cognitive (relating to or involving the processes of thinking and reasoning) skills. Resident 4 was not steady with transfers and walking and used a walker (a type of mobility device used to help people who are still able to walk yet need assistance). Resident 4 required supervision and one staff physical assistance for bed mobility, transfer, walking in room, and toilet use. Resident 4's balance during transitions and walking indicated resident was not steady, but able to stabilize without staff assistance. Resident 4 required a walker (a tool for disabled or frail people, who need additional support to maintain balance or stability while walking). Resident 4 was occasionally incontinent (not able to control bladder the urge to urinate) of urine, and always continent of bowel. A review of Resident 4's Interdisciplinary Post Event Review, event date 5/22/21 indicated that Resident 4 was on the floor lying on his back inside his room, face up with head near the closet and feet towards his bed. Resident 4 stated that he fell as he was walking to the bathroom. The record indicated Resident 4 did not use his walker and factors that contributed to the fall was failure to use assistive device and mobility issues. Per IDT comments, the resident will be monitored closely when he returns from the hospital and will be re-educated to push call light when he wanted to go to the bathroom. The conclusion and summary indicated Resident 4's fall cannot be substantiated related to any kind of abuse since he can describe what happened to him. A review of Resident 4's Nurses Notes, dated 5/22/2021 timed at 7:36 a.m. indicated Resident 4 called out for help. Resident 4 was found on the floor. Resident 4 fell while going to the restroom. Resident stated that he hit his head when he fell . Resident 4 was noted with a small bump and abrasion on top of his head. Resident 4 was transferred to the hospital for evaluation. A review of Resident 4's care plan for, Actual Fall, due to unsteady gait, date initiated 5/22/2021, indicated interventions that included neuro-checks (assessments of resident's mental status via observation and through their answers to your questions), pharmacy consult to evaluate medications, and physical therapy consult to evaluate for strength and mobility. A review of Resident 4's IDT Post Event Review, dated 6/1/21, indicated Resident 4 was found on the floor on his right side. Resident 4 stated he was trying to use his walker to go to the restroom. The contributing factors for the fall included improper use or failure to use assistive device (walker). IDT comments indicated Resident 4 was to be transferred to room closer to nursing station, place a bed alarm (a device that makes a loud noise when resident tries to get out of bed) on Resident 4's bed, re-educate resident to use call light, and have physical therapy re-educate resident on how to use walker properly. A review of Resident 4's Nurses Notes, dated 6/1/21, timed at 3:54 p.m., indicated Resident 4 was found lying on floor on right side. The notes indicated Resident 4 stated, I was trying to go to the restroom and my knees got weak. Resident 4 was assessed and had no noted injuries. A review of Resident 4's Status Post Fall Assessment Rehab (rehabilitation, physical therapy (PT) assessment), dated 6/2/2021, indicated Resident 4 fell in his room. The therapist recommendations were to encourage Resident 4 to use the call light and for nursing to assist Resident to get up to the bathroom. Resident 4 was reeducated for the need for assistance for ambulation to prevent falls. A review of Resident 4's care plan for, Non-compliance with using call light to ask for assistance, and Non-compliance with using walker for safety, date initiated 6/2/2021, indicated interventions that included educate Resident 4 of the possible outcome of not complying with treatment or care, encourage as much participation/interaction by the resident as possible during care activities, and give clear explanation of all care activities prior to as they occur during each activity. The care plan did not indicate intervention according to Status Post Fall Assessment Rehab recommendation from PT for nursing to assist Resident to get up to the bathroom. A review of Resident 4's IDT Post Event Review, dated 6/10/21, indicated Resident 4 was on the floor next to the bed. Resident 4 stated he was going to the bathroom and fell . Resident 4 sustained a skin tear on the top of his head. The factors that contributed to fall included the improper or failure to use assistive device. IDT comments indicated to re-educate Resident 4 to use call light, put bed low to floor, move to room near nursing station for closer monitoring. The conclusion and summary indicated not related to abuse since he can describe what happened. A review of Resident 4's Nurses Notes, dated 6/10/21 timed at 3:43 p.m., indicated Resident 4 was on the floor next to the bed, and Resident 4's bed alarm was going off. Resident 4 had a skin tear on top of his head. Resident 4 stated that he was going to the bathroom when he fell . A review of Resident 4's care plan for, Actual Fall Balance problems, Cognitive impairment, that cause skin tear approximately 7 centimeter (cm, unit of measurement), date initiated 6/11/2021, indicated interventions to attach call light within reach and encourage resident to use if for assistance as needed, change room closer to the nurse's station, educate/remind resident to request assistance prior to transfer/ambulation, frequent visual checks (no specific frequency), and provide non-skid sock/shoes. The care plan had no interventions regarding Resident 4's use of walker to the bathroom and for nursing to assist Resident to get up to the bathroom. During an observation in Resident 4's room and concurrent interview, on 7/25/2021 at 1 p.m., Resident 4 was inside his room and no walker was observed inside Resident 4's room. Resident 4's bed was low to the ground, bed alarm was observed on the bed, and no floor mats were observed on either side of the bed. Resident 4 stated he had fallen twice in the past (Resident 4 unable to not recall dates of the falls). Resident 4 stated he got out of bed and fell , and that he did know if he was to call and ask for help to get out of bed. He stated that he walks with a walker. Resident 4 stated did not know where his walker was. During an interview, on 7/25/21 at 1:07 p.m., LVN 3 stated Resident 4 should have a walker and did not know where it was. LVN 3 found walker in Resident 4's old room where he transferred from on 7/21/21. During an interview, on 7/25/21 at 2:46 p.m., the Director of Nursing (DON), stated intervention that was implemented for Resident 4 to prevent falls was to put the resident right in front of nursing station and a bed alarm was placed on his bed, because he was forgetful. DON stated since he came back from hospital (readmitted [DATE]), he has not been attempting to get out of bed, so floor mats were not needed. The DON stated floor mats are more dangerous, and Resident 4 might slide. The DON stated that Resident 4 used a walker and needed a walker. During an interview, on 7/25/21, at 12:20 p.m. the Administrator (ADM) stated Resident 4 had fallen three times. On 5/22/21, 6/1/21, and 6/10/21. ADM stated that Resident 4 was noncompliant, by getting out of bed without assistance, and not using his walker. During an interview, on 9/1/2021 at 12:48 p.m., the DON stated on Resident 4's first fall (5/22/2021) and second fall (6/1/2021), Resident 4 could still follow instructions and was move closer to the nursing station, having a low bed, and reeducating about call light was enough. Resident 4 was forgetful at times. Resident 4 was reeducated about using his walker, and PT also worked with him how to properly use the walker. Resident 4's walker should have been at the bedside that way when Resident 4 tries to stand up, he would be reminded to use the walker. DON stated without the walker, Resident 4 was too weak to stand on his own and he falls. During an interview, on 9/3/2021 at 5:30 p.m., the DON stated facility had no other care plan to provided regarding Resident 4's fall on 5/22/2021, 6/1/2021, and 6/10/2021. The DON stated all policy and procedure provided were the most current policy and procedures. A review of the facility's policy and procedure for Fall Prevention Program, dated 12/2016, indicated if a resident was at risk for falls. It (the risk) will be identified on the care plan. All precautions will be implemented to protect the resident according to the fall prevention and reduction program. Some possible interventions are to implement bowel and bladder programs to decrease urgency and incontinence and consider the use of non-skid floor mats. The policy also indicated care plan intervention should include environmental hazard prevention and monitoring. The policy identified unstable furniture as an environmental hazard. The policy also indicated bedrails contributed to fall risk by creating barriers to resident and their safe application needed to be evaluated. A review of the facility's policy and procedure for Fall Risk Assessment, dated 12/2016, indicated the DON was responsible for implementation and enforcement of Fall Assessments and Management Policy. A review of the facility's policy and procedure for Person Centered Plan of Care, dated 12/2016, indicated the facility needed to provide each resident with a person-centered plan of care. The policy indicated the care plan had to describe services provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psycho-social wellbeing. The policy indicated the DON was responsible for implementation of the policy. The policy indicated care plans had to be signed and dated, changes needed to be communicated on an ongoing basis to all members of the interdisciplinary team, re-evaluation and modification of the care plan was to be done to reflect changes in care, and evaluation of the care plan needed to be done in response to changes in the resident's condition. A review of the facility's policy and procedure for Care Plan Conference, dated 12/2016, indicated the care plan conference needed to identify needs and establish obtainable goals. The policy indicated care plan conferences were to be held after any change in status or condition.

Based on observation, interview and record review the facility failed to ensure a resident's right bed siderail was regularly maintained and checked if the bed siderail was safe for use for one of three sampled residents (Resident 1). Resident 1's right bed siderail was broken and would not stay locked in an upright position. This deficient practice resulted to the Resident 1's right bed siderail gave way, and Resident 1 fell from her bed on to the floor, on 5/5/21. Resident 1 sustained a bump on her head initially, on 5/5/21, and on 5/20/21, Resident 1 was transferred to the hospital due to a fracture (broken bone) of her right hip. On 7/22/2021 at 4 p.m., an Immediate Jeopardy was called (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) in the facility. The Administrator (ADM), Director of Nursing (DON), were notified of the findings regarding failing to ensure siderails were in safe operating condition. Resident 1's bed siderail was broken for a prolonged period (since February 2021), and would not stay locked in an upright position creating a high fall hazard for a resident who was at risk for falls. Failing to properly repair or replace malfunctioning equipment, the facility sip tied Resident 1's siderail to lock it in place and then pushed the bed against the wall, restricting resident and caregiver access to the right side of the bed. On 7/25/2021 at 6:12 p.m., the Administrator submitted an acceptable plan of action (POA) that included the following: 1. All licensed nurses received in service training on reporting of fall incident to physician. All licensed nurses received in service training on use of and referral of malfunctioning siderail. 2. All resident's with bed siderails in place had the siderails checked by maintenance. Four siderails were found to be, Wobbly, and replaced. 30 crank up beds were removed from the facility and replaced with, Hi-Lo, beds. The DON/designee conducted a review of fall incidents and found one incident. 43 residents required use of siderails, 30 beds replaced, and 13 more beds ordered with soft touch siderails and mattresses. 3. Daily room rounds to be conducted by department manager for two days and weekly thereafter for three weeks then monthly to check bedrails. Any nonworking siderails will be referred for service to the maintenance department and will be documented in the maintenance log. All staff will be provided with yearly training on fall incident, prevention and management as well as siderail assessments. 4. Social Services will report a summary of findings for daily room rounds identifying any siderail issues to the QAPI committee for further review and recommendation. Maintenance director will report summary of siderail checks to the QAPI committee for further review and recommendation. A root cause analysis to be conducted by the QAPI committee to determine further interventions for the deficient practice on fall management and siderail maintenance. QAPI committee to monitor process every month for at least three months and then quarterly. On 7/25/2021 at 6:26 p.m., after verifying and confirming on-site the implementation of the facility's immediate corrective actions within the POA, the Immediate Jeopardy was lifted in the presence of the Administrator and DON. Cross Reference: F600, F 656, and F 689. Findings A review of Resident 1's Face Sheet indicated the resident was admitted to the facility on [DATE], and readmitted , on 5/24/21 with diagnoses that included [CONDITION(S)] (mental disorder which leads to hallucinations, irrational thoughts and behaviors), anxiety disorder (mental illness with the feeling of constant worry and fear), and a new diagnosis of right femur (thigh bone) fracture. A review of Resident 1's History & Physical (H&P), dated 2/29/21, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized data collection tool) dated 3/31/2021, indicated Resident 1 was completely dependent on staff for transferring in and out of bed. The MDS also indicated the resident required extensive assistance with turning side to side in bed and positional changes. A review of the facility's Maintenance Log, dated 5/06 (no year), indicated a problem/concern of, Siderail came down. for Resident 1's bed and was signed as completed by the maintenance director. A review of Resident 1's Nurses Notes, dated 5/5/21 at 6:43 p.m., indicated the Licensed Vocational Nurse 1 (LVN 1) was called to Resident 1's room by CNA 1. The note indicated CNA1 found Resident 1 lying on the floor. Sitter 1 informed CNA 1 that Resident 1 had fallen and landed on her right side. CNA 1 and Sitter 1 placed Resident 1 back in bed. The note indicated Resident 1 sustained a small bump on the forehead. A review of Resident 1's Change in Condition (COC) evaluation form, dated 5/5/21 at 6:43 p.m., indicated Resident 1 suffered a fall. The form indicated a CNA 1 reported to the LVN 1 that Resident 1 fell . The form did not indicate how the resident fell or any details concerning the fall. The form indicated Resident 1 had a bump on her right forehead with slight swelling. A review of the facility's interview form signed by CNA 1, dated 5/5/2021 3 p.m. to 11 p.m. shift, indicated CNA 1 stated she was in the room with another resident when she heard Sitter 1 say the Resident 1 fell . CNA 1 then assisted the sitter in returning Resident 1 to bed and went to inform the charge nurse. A review of Resident 1's Fall Risk Assessment, dated 5/5/2021 at 7:27 p.m., indicated Resident 1 was at moderate risk for falls. A review of the facility's Interdisciplinary Post Event Review notes dated 5/6/2021 (no time), indicated Resident 1 was found on the floor by the CNA 1. The notes indicated Sitter 1 informed them Resident 1 was leaning on the right siderails which malfunctioned, and Resident 1 rolled off the bed and landed on her right side. The notes indicated Resident 1's right side rail gave way and fell . The notes indicated Resident 1 sustained a bump to the forehead. The notes indicated new interventions would be to transfer in wheelchair and educate staff. The notes had no interventions or comments regarding maintenance to ensure Resident 1's side rails were maintained and checked if the bedrail was safe for use. A review of Resident 1's Nurses Notes, dated 5/20/2021 at 7:00 p.m., indicated a CNA 3 reported Resident 1 having a protruding bone to right hip area which was hard to touch and uneven to left side, with facial grimacing upon touch. The note indicated the doctor was informed and an order to transfer Resident 1 to the emergency room . A review of Resident 1's nurses notes dated 5/20/2021 at 8:30 p.m., indicated Resident 1 was transferred via ambulance to a local hospital (General Acute Care Hospital, GACH). A review of Resident 1's GACH Emergency Department (ED) physician's note, dated 5/20/2021 at 11:28 p.m., indicated Resident 1 was taken to the ED due to a ground-level fall two weeks prior and had not been noticed until 5/20/21. The note indicated Resident had a displaced right hip (the hip joint to become partially or completely dislocated). A review of Resident 1's Computerized Tomography (CT) scan (a diagnostic exam that allows doctors to see inside your body) of the abdomen and pelvis, dated 5/21/2021 at 12:28 a.m., indicated Resident 1 had a displaced fracture of the right femoral neck (top of the long hip bone where the bone connects with the pelvis). During a telephone interview, on 6/2/21 at 9:05 a.m., Sitter 1 stated she was very familiar with Resident 1 and until recently had been her sitter up until early May 2021. Sitter 1 stated she was with Resident 1, on 5/05/2021, at the time of her fall. Sitter 1 stated she was getting ready to leave for the day and had just adjusted Resident 1's head because she was leaning against the right-side rail. Sitter 1 stated she walked away from Resident 1's bed to gather her belongings and heard a loud thump. Sitter 1 stated she saw Resident 1 on the floor. Sitter 1 stated CNA 1 was in the room with another resident and immediately went to help place Resident 1 back in bed. CNA 1 went to get LVN 1. Sitter 1 stated the LVN 1 entered the room and told them (CNA 1 and Sitter 1) that they should have left Resident 1 on the floor. Sitter 1 stated LVN 1 proceeded to assess the bump on Resident 1's forehead. During an observation, on 6/7/21 at 1:32 p.m., Resident 1 was observed in bed, nonverbal, moving bilateral upper extremities and minimal movement to lower extremities. The Resident 1's bed was observed to have bilateral upper bed siderails up with sponge/foam like covering attached to top part of left and right bed siderails. The bed siderails had pads (sponge/foam) on the inner part of the rails with zip ties (a plastic strip that can be threaded through its end and tightened to fasten something) tied to the frame of the bed keeping the pad in place. During a telephone interview, on 7/14/2021 at 7:50 pm, LVN 1 stated, on 5/5/21, she was called into Resident 1's room by Certified Nursing Assistant 1 (CNA 1), who informed her that Resident 1 had fallen from the bed. LVN 1 stated Resident 1 was in her bed when she entered the room and was told Resident 1's right bed siderail gave way, and Resident 1 fell on her head. LVN 1 stated the right bed siderail was dropping on its own. LVN 1 stated she had sent messages to the facility's maintenance staff and her Director of Nursing to inform about the situation (the right bed siderail was dropping on its own). LVN 1 stated zip ties were put on the bed siderails and the bed was pushed against the wall. During a telephone interview, on 7/15/21 at 11:05 a.m., LVN 2 stated she was very familiar with Resident 1 and cared for her often. LVN 2 stated the Resident 1's bed rails had been loose since she began her employment with the facility in February 2021. LVN 2 stated she had informed the facility's maintenance staff about the defective right bed siderail on several occasions. LVN 2 stated she felt Resident 1 knew how to Jiggle, the bed siderail to get the bed siderail to release and lower the bed siderail. LVN 2 stated Resident 1 would often do this to let the staff know she wanted to get out of bed. LVN 2 stated the pads were placed over the bed siderails, but the pads were ineffective. LVN 2 stated she never updated the care plan or interventions to reflect Resident 1's behavior (jiggle the side rail to get the siderail to release and lower the side rails). LVN 2 stated interventions should have been made to address both side rails, and Resident 1's behavior to alert staff on the fall risk. LVN 2 stated there was a maintenance log, but she did not document in maintenance log when facility maintenance was informed. LVN 2 stated the facility maintenance staff was only informed verbally. During a telephone interview, on 7/15/2021 at 1:23 p.m., Maintenance Staff 1 (MS 1) stated he is usually informed verbally by staff when a piece of equipment was broken or in need of repair. MS 1 stated there was a maintenance log in each station in which the nurses should document issues with equipment, but maintenance log was rarely used. MS 1 stated he has only seen one or two entries in the log since February 2021. MS 1 stated he was informed on 5/5/2021, that Resident 1's right side rail was broken and gave way causing the resident to fall from her bed. MS 1 stated after Resident 4's fall, on 5/5/2021, went to check Resident 1's bed siderails and felt they were operational ( good working condition) and perhaps the Resident 1 had figured out how to pull the lever to release them. MS 1 stated he then placed zip ties the bed siderails up to lock the in place. MS 1 stated the bed was not changed, only pushed against the wall by the nursing staff. During a telephone interview, on 7/16/21 at 9:10 a.m., the Director of Nursing (DON) stated she was notified by MS 1 that the right-side rail on Resident 1's bed was broken after Resident 4's fell on [DATE]. The DON stated the side rail was repaired by tightening a screw. The DON stated Resident 1 liked to lean on the bed siderail and pull at it, which caused it to loosen often. The DON stated the bed siderail was zip tied and the bed pushed against the wall to prevent the resident from falling. until they were able to repair the bed after Resident 4 fell on [DATE]. The DON stated zip ties were not acceptable forms of repair, because they prevented the bed siderail from lowering, the nurses could not access the resident, and the resident could not be taken out of the bed. The DON stated they did not change the bed. During an interview, on 9/3/2021 at 5:30 p.m., the DON stated all policy and procedure provided were the most current policy and procedures. A review of the facility's policy and procedure for Preventative Maintenance, dated 4/2015, indicated the use of maintenance logs were part of the preventative maintenance checklist and could be completed by any employee. The person performing the task was responsible for notifying the employee responsible for the coordinating preventative maintenance. The person ensures resolution of the problem. A review of the facility' policy and procedure for Fall Prevention Program - Fall Prevention Interventions, dated 12/2016, indicated environmental hazards such as unstable furniture needed to be assessed and a, Physically safe, environment needed to be provided. The policy also indicated bed side rails the staff needed to evaluate to safe application of bed side rails. A review of the facility's policy and procedure for Physical Restraint Management, dated 4/2017, defined physical restraints as a manual. Physical, or mechanical device, material or equipment's attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The policy also indicated side rails that keep a resident from voluntarily getting out of bed were a restraint.

Based on interview and record review, the facility failed to notify the physician immediately of the declining change in condition for one of two sampled residents (Resident 1). The Nurse Practitioner (NP), who was providing medical care on behalf of Resident 1's physician, placed Resident 1 on 10 liters per minute (LPM, the rate and amount at which oxygen flows) of oxygen via non-rebreather mask (NRBM, a device used to help in the delivery of oxygen) after a Licensed Vocational Nurse 1 (LVN 1) reported Resident 1's oxygen saturation (a measurement of oxygen level in the blood (normal levels between 95% to 100%)) was 78% on [DATE] at 8:15 PM. At 8:30 PM and 8:45 PM on the same day, LVN 1 observed the Resident 1 removing the NRBM. LVN 1 did not update the NP of the resident's current condition and response to the 10 LPM of oxygen via NRBM for two hours and 15 minutes. She updated the NP after the paramedics were called and CPR (CPR, an emergency procedure that combines chest compression with artificial ventilation (exchange of air between the lungs and the atmosphere) to restore blood circulation and breathing) had been started. This deficient practice resulted in Resident 1, who was having respiratory distress, was found unresponsive and requiring CPR without the Resident's physician being notified of changes in condition, and 911 not being called earlier. The resident died in the facility on [DATE]. Findings: A review of Resident 1's Face Sheet (admission record) indicated the facility admitted the resident on [DATE] and readmitted his on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool) dated [DATE], indicated the resident had severely impaired cognition (ability to think, understand, and reason). The MDS indicated Resident 1 needed extensive assistance (unable to complete independently, requiring help from facility staff to complete) for activities of daily living (ADLs), such as bed mobility, transferring, walking, dressing, and personal hygiene. A review of Resident 1's Nurse Practitioner's evaluation from a General Acute Care Hospital 1 (GACH 1) dated [DATE], indicated Resident 1 had increased congestion, wheezing, and a new condition of [MEDICAL CONDITION] ([MEDICAL CONDITION], the heart is unable to pump enough blood to the body to meet its oxygenation needs and symptoms include shortness of breath). A review of Resident 1's GACH Discharge Instructions dated [DATE], indicated Resident 1 was discharged from the acute hospital with shortness of breath, cough, and acute (sudden) upper respiratory infection (infection that involves the nose and throat). A review of Resident 1's Progress Notes, dated [DATE], indicated the following: a. At 8:15 PM, Resident 1 complained of shortness of breath to LVN 1. Resident 1's vital signs indicated an oxygen saturation level of 78% on room air, blood pressure (BP) ,[DATE] millimeters of mercury (mm/Hg, normal BP is ,[DATE] mm/Hg) and respiratory rate (rate of breathing) of 20 breaths per minute (normal rate is 12 to 20 at rest). The record indicated no assessment of lung sounds. LVN 1 notified the NP and the NP ordered to administer Resident 1 oxygen at 10 LPM via NRBM until the resident was stable for transfer to the GACH 2. LVN 1 documented that NP would arrange Resident 1's transportation to GACH 2. Resident 1's oxygen saturation level went up to 95% after receiving 10 LPM of oxygen via NRBM. b. At 8:30 PM and 8:45 PM, LVN 1 observed Resident 1 removing the NRBM. c. At 9 PM, Resident 1's vital signs indicated a BP of ,[DATE] mm/Hg, RR of 20, pulse oximetry of 95% at 10 LPM. A late entry documentation entered on [DATE] at 9:08 PM, indicated Resident 1's BP was ,[DATE] and oxygen saturation of 87% on 10 LPM on [DATE] at 9 PM. The record indicated no assessment of lung sounds. d. At 9:15 PM, LVN 1 observed Resident 1 trying to remove the NRBM. Resident 1's oxygen saturation level was 95%. e. A late entry documentation entered on [DATE] at 9:08 PM, indicated Resident 1's BP was ,[DATE], heart rate (HR, the speed of the heart beat) of 92 beats per minute (normal range for HR is 60 to 100 beats per minute of BPM), RR of 18, with oxygen saturation level at 95% at 10 LPM of oxygen on [DATE] at 9:30 PM. The record indicates no assessment of lung sounds. f. At 9:37 PM, LVN 1 observed Resident 1 had removed the NRBM and the resident had an oxygen saturation level of 87%. LVN 1 received a call from the ambulance company notifying LVN 1 that the ambulance would be arriving in 90 minutes (to transport Resident 1 to GACH 2). g. At 10 PM, LVN 1 observed Resident 1 with the NRB mask on and an oxygen saturation level of 95%. A late entry documentation entered on [DATE] at 9:08 PM indicated Resident 1's BP was ,[DATE] mm/Hg, HR of 87, RR of 20 and oxygen saturation level of 95% on [DATE] at 10 PM. The record indicates no assessment of lung sounds. h. At 10:17 PM, LVN 1 observed Resident 1 pale and having troubled breathing. LVN 1 called a code STAT (an emergency call to staff that a resident is in cardiopulmonary (heart and lungs) arrest (to stop)). Registered Nurse (RN) 1 and Respiratory Therapist (RT) 1 entered Resident 1's room and started CPR. LVN 1 called for emergency services via 911 telephone number. The progress notes indicated the paramedics (persons trained to give emergency care) arrived and the paramedic continued CPR that lasted for 30 minutes. i. At 10:30 PM, LVN 1 paged the NP and notified the NP that she (LVN 1) called the 911 emergency telephone number (for emergency assistance and transport to a higher level of care than the facility could provide). j. At 10:50 PM, the paramedics spoke to Physician 2 and called Resident 1's time of death at 10:50 PM. During an interview, on [DATE] at 2:54 PM, LVN 1 stated she called and notified the NP of Resident 1's shortness of breath (on [DATE] at 8:15 PM). LVN 1 stated the NP ordered to give Resident 1 oxygen at 10 LPM via NRBM. LVN 1 stated the NP instructed her to wait for the NP to arrange Resident 1's transfer to GACH 2. LVN 1 stated she verbally directed Resident 1 to leave the NRBM on and the resident would respond by nodding his head and stated Ok. LVN 1 stated she did not implement other interventions aside from verbal directions. LVN 1 stated she had to document late entries (on [DATE]) in Resident 1's medical records because she checked the resident's vital signs more often than what she documented in the medical records (on [DATE]). LVN 1 stated she did not notify the NP that Resident 1 was removing the NRBM repeatedly and that his oxygen saturation level kept dropping. During a telephone interview, on [DATE] at 1:30 PM, the NP stated she ordered 10 LPM of oxygen for Resident 1 and she informed LVN 1 that she (the NP) would arrange for Resident 1's transportation to GACH 2. The NP stated LVN 1 notified her that Resident 1 was stable and the resident's oxygen saturation level went up to 96%. The NP stated the facility did not inform her of Resident 1's multiple attempts to remove the NRBM and the drops in the resident's oxygen saturation levels. The NP stated that emergency transport via 911 emergency call was not called to transfer Resident 1 immediately (to the hospital for a higher level of care) because the facility did not update her of Resident 1's condition. The NP stated the next telephone call she received from the facility was after Resident 1 expired (died ). The NP stated the facility should have updated her of Resident 1's condition. During another telephone interview, on [DATE] at 12:15 PM, the NP stated she worked with Resident 1's attending physician (Physician 1). The NP stated she shared the on call duty responsibility in the facility with Physician 1. The NP stated if she had been notified of the drops in Resident 1's oxygen saturation levels while the resident was receiving 10 LPM of oxygen and the resident's several attempts to remove the NRBM, the NP would have instructed the facility to have someone stay one-on-one (one staff monitoring one resident) with Resident 1 and to call for emergency transportation services via 911 call. During an interview, on [DATE] at 10:02 AM, the Director of Nursing Designee (DOND) stated that LVNs should report to the DOND if they were not confident in providing care to residents with changes in condition. The DOND stated that a shortness of breath is a significant change in the resident's condition. The DOND stated, .most importantly, shortness of breath. The DOND stated the facility would usually call the NP because the NP was on call for Physician 1. The DOND stated it is the role of the NP to inform Physician 1 of the changes or updates for Resident 1. During a telephone interview, on [DATE] at 11:20 AM, the NP stated she should have been notified of the Resident 1's change of condition during the first desaturation (which occurred on [DATE] at 9 PM and oxygen saturation dropped to 87%) and Resident 1's attempts to remove the NRBM. The NP stated that Resident 1's frequent attempts to remove the NRBM indicated the intervention was not effective and the resident could be manifesting agitation and irritability from lack of oxygen. The NP stated that emergency transportation via 911 telephone number should be called for this situation. During an interview, on [DATE] at 3:18 PM, LVN 1 stated she called for emergency transportation via 911 telephone number while RN 1 and RT 1 initiated CPR to Resident 1. LVN 1 stated she did not call the DOND or RN 1 when Resident 1 did not respond to the NRBM intervention. A review of the facility's policy and procedure titled, Acute Condition Changes - Clinical Protocol, revised date ,[DATE], indicated, The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust the treatment accordingly. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, revised dated ,[DATE] , indicated the, Nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident physical/emotional/mental condition or with the refusal of treatment.

Based on observation, interview and record review, the facility failed to: 1. Properly supervise Resident 1 who had a history of [REDACTED]. 2. Ensure Resident 1 was using a wander guard (a tracking device worn by residents designed to prevent them from leaving a facility unaccompanied) and initiate and update a care plan for wandering behavior to prevent the resident from eloping from the facility. Resident 1, who did not have the capacity to make decisions, eloped from the facility on 2/14/2020 at 1:32 p.m. On 2/14/2020 at 1:55 p.m., a Good Samaritan (GS) notified a facility staff that Resident 1 fell on the sidewalk, in front of a church, one mile away from the facility. This deficient practice resulted in Resident 1 sustaining an abrasion (scraping or wearing something away) on the left elbow, a laceration (a deep cut or tear in skin) on the left eyebrow, swelling and discoloration (change in color of the skin) below the left eye. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) on the same day for further evaluation and treatment. Findings: A review of Resident 1's Admission Record indicated the facility initially admitted the resident on 12/24/19 and was readmitted the resident on 2/3/2020, with [DIAGNOSES REDACTED]. A review of Resident 1's care plan initiated on 12/25/2019 and revised on 2/14/2020 indicated the resident was at risk for wandering/elopement. The goals were for Resident 1 to have no episode of wandering/elopement and no injury. The care plan interventions included for staff to identify time of day wandering/elopement attempts occur. The interventions did not indicate how facility staff would monitor Resident 1 in the facility. A review of Resident 1's History and Physical (H&P), dated 12/26/2019, indicated the resident had no capacity to make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 12/31/19, indicated Resident 1 was able to repeat three words, and state correct year, month, day and able to recall three words. However, Resident missed some part/intent of message but comprehended most conversation, and had difficulty communicating some words or finishing thoughts but able if prompted or given time. The MDS indicated the wandering, placed Resident 1 at risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility). The MDS indicated Resident 1 required one-person physical assist for walking and transferring, and did not use a wheel chair or walker for mobility. A review of Resident 1's Fall Risk Assessment, dated 2/3/2020, indicated the resident was assessed as high risk for fall with a score of 10 (a score of 10 or greater considered at high risk for potential falls). A review of Resident 1's Wandering Risk Assessment, dated 2/4/2020, indicated the resident had early dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) with short attention span and was forgetful. The assessment indicated Resident 1 received antipsychotic medications (medication for mental illness) and the facility admitted the resident within the last month. The assessment indicated Resident 1 was at risk for wandering. A review of the facility's undated policy titled, Wandering, Unsafe Resident, indicated the facility would identify residents at risk for harm because of unsafe wandering including elopement. The policy indicated staff would assess at risk individuals for potentially correctable risk factors to maintain safety. The resident care plan would indicate the resident is at risk for elopement or safety issue with interventions to maintain the resident's safety including a detailed monitoring plan. A review of the facility's video footage, dated 2/14/2020, with the Medical Records (MR) staff and the Director of Nurses (DON), indicated Resident 1 was standing near the exit door, was passed by CNA 4, and CNA 5 passed by Resident 1 on the hallway. A staff was standing on Station West hallway at station. The video footage indicated Resident 1 exited the facility using the exit door near Station West on 2/14/2020 at 1:32 p.m. A review of GACH's Emergency Documentation, dated 2/14/2020, indicated Resident 1 was somewhat inappropriate verbally during neurologic assessment. A review of the Nurses' Progress Notes, dated 2/14/2020, timed at 1:35 p.m. with LVN 2 indicated Resident 1 was not found in the facility. The notes indicated a GS notified a facility's staff (unidentified male staff) that Resident 1 fell on the sidewalk and was bleeding. The notes indicated Resident 1 hit his head on the sidewalk sustaining a left eye laceration measuring 2 centimeters (cm) x 0.5 cm, left lower eye discoloration, and left elbow abrasion measuring 1 cm x 0.7 cm. The notes indicated Resident 1 was transferred to GACH 1 on 2/14/2020 at 6:26 p.m. for further evaluation. During an interview on 2/14/2020 at 9:38 p.m., Licensed Vocational Nurse 1 (LVN 1) stated the facility readmitted Resident 1 from the same GACH 1, two weeks ago. LVN 1 stated Resident 1 was oriented to name, place, Responsible Party 1's (RP 1) name, but the resident was forgetful. LVN 1 stated the resident wandered around the facility frequently. LVN 1 stated any new admitted /readmitted residents including Resident 1 are at risk for elopement due to new environment and unfamiliar staff. LVN 1 stated Resident 1 needed monitoring for elopement on the initial admitted d 12/24/19 and did not know why. During an interview on 2/14/2020 at 10:31 p.m., Certified Nurse Assistant 2 (CNA 2) stated in the past, when I took care of Resident 1, LVN 1 instructed her to monitor Resident 1 due to the resident was a wanderer and he wanted to leave the facility. A review of GACH 1's Emergency Department Report dated 2/14/2020 indicated Resident 1 sustained a mechanical fall where he fell forward hitting his left face. The resident denied loss of consciousness and no pre-[MEDICAL CONDITION] symptoms (consisting of lightheadedness, muscular weakness, blurry vision, and feeling faint). The report indicated Resident 1 had a left elbow contusion, left arm abrasion, and periorbital ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising). The resident was taking Eliquis (blood thinner medication that can cause bleeding). A review of GACH 1's Visit Information dated 2/15/20 indicated Resident 1's [DIAGNOSES REDACTED]. A review of the GACH 1's Computerized Tomography (CT, special x-ray tests that produce cross-sectional images of the body) of Resident 1 head, dated 2/15/2020 at 12:13 a.m., indicated bilateral mastoid (bone in the ears) and middle ears effusions (abnormal fluid collection), and no acute (sudden) intracranial (inside the head) process (no findings/no changes). A review of Resident 1's Admission/Readmission Data Collection, dated 2/15/20 indicated, the facility readmitted the resident to the facility from GACH 1 on 2/15/20 at 2:58 a.m. with [DIAGNOSES REDACTED]. Resident 1 had left elbow abrasion, measuring 1 cm and 0.7 cm, swelling and discoloration on the left lower eyelid, and left eyebrow laceration, measuring 2 cm by 0.5 cm. During an interview on 2/15/2020 at 12:05 p.m., LVN 3 stated Resident 1 was alert and oriented to person but not to place. LVN 3 stated Resident 1 wandered around the facility and often asked staff to make phone calls to RP 1. LVN 3 stated prior to Resident 1's elopement, the resident verbalized that he wanted to visit RP 1. During an observation on 2/15/2020 at 12:31 p.m., Resident 1 was wearing a wander guard bracelet and was standing near the main entrance door. Resident 1 was walking slowly with a waddle gait (walk with short steps and a clumsy swaying motion). Resident 1 had dressing on the left eyebrow with discoloration and swelling below the left eye. During a concurrent interview, Resident 1 stated he tried to look for RP 1 and went on a job search, but he fell on a concrete sidewalk. Resident 1 stated he was hurt due to the fall and now he has mild pain. During a telephone interview on 2/15/2020 at 12:59 p.m., the GS stated on 2/14/2020 at around 2:05 p.m., she heard someone say Help, Help and saw Resident 1 on the sidewalk in front of a church. The GS stated she walked with Resident 1 to her house and placed a towel to the resident's left eye to stop the bleeding. The GS stated Resident 1 complained of dizziness so she sat the resident on a chair. The GS stated Resident 1's bracelet indicated the resident was at the facility so she contacted the facility and facility's staff picked up the resident up within 10 minutes. A review of a map for a walking direction indicated the distance from the facility to the church, where Resident 1 fell , was one mile and 19 minutes' walk. During a concurrent interview and review of Resident 1's wandering/elopement care plan, dated 12/25/2019, and the facility's policy, titled Wandering, Unsafe Resident, with the DON on 2/15/2020, at 1:06 p.m., she stated the staff was not monitoring Resident 1. The DON stated Resident 1, who was at risk for fall, has [DIAGNOSES REDACTED]. A review of the facility's policy and procedures titled, Safety and Supervision, revised in 7/2017, indicated the care team shall target interventions to reduce resident individual risks related to hazards in the environment, including adequate supervision. The policy includes monitoring the effectiveness of interventions by ensuring interventions were implemented correctly and consistently, and that resident risks and environmental hazards included unsafe wandering. A review of the facility's undated policy titled Wander Guard System, indicated the purpose was to provide a safe mechanism for residents who are at risk for wandering, eloping and /or exit-seeking a safe environment, and to initiate a 1:1 supervision until a wander guard device is placed on the resident.

Based on interview and record review, the facility failed to ensure 75 of 75 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, and 75) are from neglect to ensure care provided by facility staff was not disrupted and ensure residents could continue residing in the facility when an eviction notice was served to the facility by the local law enforcement on 1/31/2020. The eviction notice indicated any occupants residing within the premises would be vacated on 2/5/2020. This deficient practice resulted in placing 75 sampled residents for no pre-arranged discharge with other facilities and had a potential to result in resident's health and safety needs were not being met. Findings: On 1/29/2020, at 1:57 p.m., during a monitoring visit to the facility, an interview was conducted with the director of nursing (DON). The DON stated that they (facility staff) did not receive their paychecks for the payroll due on 1/24/2020. A review of the facility's Daily Census, dated 1/31/2020, indicated the facility had 75 residents in the facility. A review of facility's Ambulatory, Wheelchair, Bedbound Resident List indicated the following information: 1. Ten residents (Resident 3, 18, 29, 32, 56, 61, 68, 69, 70, and 73) were bed bound and required care for a gastrostomy tube feeding ([DEVICE], a tube inserted through the abdomen that delivers nutrition directly to the stomach), [MEDICAL CONDITION] (an opening in the neck in order to place a tube into a person's windpipe for breathing), and ventilator (a machine to assist for breathing thru a breathing tube). 2. Four residents (Residents 37, 40, 49, and 60) were bedbound and required care for [DEVICE] and [MEDICAL CONDITION]. 3. One resident (Resident 36) used wheelchair to propel self and required care for [DEVICE] and [MEDICAL CONDITION]. 4. One resident (Residents 64) was bedbound and required care for [DEVICE] and ventilator. 5. Six residents (Resident 2, 8, 43, 52, 55, and 59) were bedbound and required care for [DEVICE]. 6. Two residents (Resident 21 and 50) used wheelchair to propel self and required care for [DEVICE]. 7. Ten residents (Resident 1, 6, 12, 16, 27, 31, 47, 53, 65, and 71) were bedbound. 8. Six residents (Resident 10, 17, 23, 26, 28, and 38) were ambulatory. 9. Five residents (Resident 13, 15, 35, 44, and 51) were ambulatory with assistance. 10. Three residents (Resident 25, 62 and 75) were ambulatory with a walker. 11. Thirteen residents (Resident 4, 9, 11, 19, 20, 22, 33, 39, 41, 45, 54, 63, and 72) used wheelchair to propel self. 12. Fourteen residents (Resident 5, 7, 14, 24, 30, 34, 42, 46, 48, 57, 58, 66, 67, and 74) used wheelchair and not able to propel self. A review of the local law enforcement agency's Notice to Vacate (Eviction Notice) that was served to the facility, on 1/31/2020, indicated the judgment was for the debtor (Licensee), members of the judgement debtor's household, and any occupants residing with the judgement debtor. The order to vacate the premises was on 2/5/2020. On 1/31/2020, at 9:47 a.m., during an interview, the facility's Property Owner verified that the eviction notice was provided by the County Sheriff Department. The Property Owner stated the facility's Licensee (facility's owner) had not paid fees for the property for four months and had obtained a court order for Licensee to pay. The Property Owner stated the eviction notice was a court order. During an interview on 1/31/2020, at 10:17 a.m. the facility's Administrator stated if the facility's Licensee did not pay the rent, the residents would have to be evicted by 2/5/2020. On 1/31/2020, at 11 a.m., a telephone conference was conducted with the facility's Property Owner, the facility's Licensee, the facility's Administrator, the administration personnel of California Department of Public Health (CDPH) and CDPH legal officers. The eviction notice issue provided by the facility was discussed. The facility's Property Owner and the facility's Licensee did not reach an agreement to solve the eviction notice issue. On 2/3/2020 at 8:10 p.m., during an interview, the Administrator stated they did not develop written plans to discharge the residents to appropriate setting to meet their health and safety needs, after the notice of eviction was served to the facility on [DATE]. On 2/3/2020, at 8:10 p.m., p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the administrator and the director of nursing (DON). The facility failed to ensure 75 of 75 residents had the right to be free from neglect. The facility's Licensee did not meet payroll for 1/24/2020 (non-payment for nursing services). The facility's Licensee failed to maintain control of the property over which the residents resided due to nonpayment of rent for four months. The facility had no written plans to transfer residents safely to other facilities should it become necessary to make an emergency transfer or discharge. As a result, the 75 residents are at risk to be discharged to inappropriate setting (e.g. lower level of care, shelter) and not to receive necessary care, treatment and services, medication, food, and water that could lead to life threatening health complications and eventually death (Cross Refer to F 624). On 2/5/2020, at 11:56 a.m., the California Department Public Health (CDPH) appointed Temporary Management (TM) team and the Health Facility Inspection Division (HFID) team and the Temporary Manager entered the facility and served the documents, Notification of Temporary Management Appointment, to the Administrator. The document indicated the immediate need for a TM was to ensure sufficient staffing to maintain residents due to Licensee's inability to pay staff and the landlord has served the Licensee with an eviction notice, which was due to be enforced on 2/5/2020. On 2/20/2020, at 12:06 p.m. a.m., after the facility submitted an acceptable plan of action (POA), the survey team verified and confirmed on-site the implementation of the POA by record review and interview and confirmed the removal of the immediate jeopardy in the presence of the Administrator. The Administrator provided an acceptable POA as follows: 1. To utilize 8 Skilled Nursing and 4 Sub-Acute Care Facilities within a 30-mile radius to safely accommodate all resident needs, the facility plan, if needed, was to evacuate the residents to an appropriate level of care in a safe and orderly fashion. 2. The facility had made arrangement with transportation companies who agreed to transfer residents should evacuation be necessary. Any resident who could not be placed in an appropriate level of care in an emergency, 911 would be called to transfer to Acute Care Hospitals in the area. 3. The Facility Ombudsman is working with the facility to assist with the discharge of the residents and has been appraised of all recent occurrences. 4. A list was prepared of responsible parties and the status of ambulation for each resident to assist with any transfer in a safe and orderly fashion. 5. The facility Admissions will be responsible to contact the transportation company. 6. Medical Records will be responsible to hand out the prepared envelopes, which include the Face Sheet, History & Physical (H&P), and Physician orders. 7. LVN will prepare and distribute the medication for each resident as they go into the ambulance 8. Dietary will hand out water and snacks to residents 9. The Minimum Data Set (MDS - a care area assessment and screening tool) nurse will document where each resident transfer to. 10. The Social Service Director (SSD) will contact families and responsible parties to update them on situation and to which facility the resident was transferred. A review of the facility's Abuse Prevention Program policy and procedure, revised date 12/2016, indicated the facility residents had the rights to be free from abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administrator will develop and implement policies and procedure to aid the facility in preventing abuse, neglect, exploitation, mistreatment of [REDACTED]. A review of the facility's Staffing policy and procedure, revised date 10/2017, indicated the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

Based on interview and record review, the facility failed to develop discharge plans for 75 of 75 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48 ,49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 67, 68, 69, 70, 71, 72, 73,74, and 75) when an eviction notice was served to the facility by the local law enforcement on 1/31/2020. The eviction notice indicated any occupants residing within the premises to be vacated on 2/5/2020. This deficient practice resulted in placing 75 sampled residents with no pre-arranged discharge to other facilities and at risk for discharging to facilities that do not meet the health and safety needs of residents. Findings: A review of the local law enforcement agency's Notice to Vacate (Eviction Notice) dated 1/31/2020 that was served to the facility, on 1/31/2020, indicated the judgment was for the debtor (Licensee), members of the judgement debtor's household, and any occupants residing with the judgement debtor. The order to vacate the premises was on 2/5/2020. On 1/31/2020, at 9:47 a.m., during an interview, the facility's Property Owner verified that the eviction notice was provided by the County Sheriff Department. The Property Owner stated the facility's Licensee (facility's management operator) had not paid fees for the property for four months and the Property Owner had obtained a court order for Licensee to pay. The Property Owner stated the eviction notice was a court order. During an interview with the facility's Administrator on 1/31/2020, at 10:17 a.m., the facility's Administrator stated a Notice to Vacate was served to the facility by the local law enforcement on 1/31/2020. The facility's Administrator stated if the facility's Licensee did not pay the rent, the residents would have to be evicted by 2/5/2020. On 1/31/2020, at 11 a.m., a telephone conference was conducted with the facility's Property Owner, the facility's Licensee, the facility's Administrator, the administration personnel of California Department of Public Health (CDPH) and CDPH legal officers. The eviction notice issue provided by the facility was discussed. The facility's Property Owner and the facility's Licensee did not reach an agreement to solve the eviction notice issue. On 2/3/2020 at 8:10 p.m., during an interview, the Administrator did not provide a written plan to safely discharge all residents to a destination that is safe and able to meet their individual health and safety needs, after the notice of eviction was served to the facility on [DATE]. A review of facility's Ambulatory, Wheelchair, Bedbound Resident List indicated the following information: 1. Ten residents (Resident 3, 18, 29, 32, 56, 61, 68, 69, 70, and 73) were bed bound and required care for a gastrostomy tube feeding ([DEVICE], a tube inserted through the abdomen that delivers nutrition directly to the stomach), [MEDICAL CONDITION] (an opening in the neck in order to place a tube into a person's windpipe for breathing), and ventilator (a machine to assist for breathing thru a breathing tube). 2. Four residents (Residents 37, 40, 49, and 60) were bedbound and required care for [DEVICE] and [MEDICAL CONDITION]. 3. One resident (Resident 36) used wheelchair to propel self and required care for [DEVICE] and [MEDICAL CONDITION]. 4. One resident (Residents 64) was bedbound and required care for [DEVICE] and ventilator. 5. Six residents (Resident 2, 8, 43, 52, 55, and 59) were bedbound and required care for [DEVICE]. 6. Two residents (Resident 21 and 50) used wheelchair to propel self and required care for [DEVICE]. 7. Ten residents (Resident 1, 6, 12, 16, 27, 31, 47, 53, 65, and 71) were bedbound. 8. Six residents (Resident 10, 17, 23, 26, 28, and 38) were ambulatory. 9. Five residents (Resident 13, 15, 35, 44, and 51) were ambulatory with assistance. 10. Three residents (Resident 25, 62 and 75) were ambulatory with a walker. 11. Thirteen residents (Resident 4, 9, 11, 19, 20, 22, 33, 39, 41, 45, 54, 63, and 72) used wheelchair to propel self. 12. Fourteen residents (Resident 5, 7, 14, 24, 30, 34, 42, 46, 48, 57, 58, 66, 67, and 74) used wheelchair and not able to propel self. On 2/3/2020, at 8:10 p.m., the Department called an Immediate Jeopardy (IJ), a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the administrator and the director of nursing (DON). The facility failed to develop a written plan to safely transfer/discharge all residents to a destination that is safe and able to meet their individual health and safety needs after the notice of eviction was served to the facility on [DATE]. The facility's Licensee failed to maintain control of the property over which the residents resided due to nonpayment of rent for four months. On 2/5/2020, at 11:56 a.m., the California Department Public Health (CDPH) appointed Temporary Management (TM) team and the Health Facility Inspection Division (HFID) team and the Temporary Manager entered the facility and served the documents, Notification of Temporary Management Appointment, to the Administrator. The document indicated the immediate need for a TM was to ensure sufficient staffing to maintain residents due to Licensee's inability to pay staff and the landlord has served the Licensee with an eviction notice, which was due to be enforced on 2/5/2020. On 2/20/2020, at 12:06 p.m., after the facility submitted an acceptable plan of action (POA), the survey team verified and confirmed on-site the implementation of the POA by record review and interview and confirmed the removal of the immediate jeopardy in the presence of the Administrator. The Administrator provided an acceptable POA as follows: 1. To utilize 8 Skilled Nursing and 4 Sub-Acute Care Facilities within a 30-mile radius to safely accommodate all resident needs. Our plan, if needed, is to evacuate the residents to an appropriate level of care in a safe and orderly fashion. 2. The facility had made arrangement with transportation companies who agreed to transfer residents should evacuation be necessary. Any resident who could not be placed in an appropriate level of care in an emergency, 911 would be called to transfer to Acute Care Hospitals in the area. 3. The Facility Ombudsman is working with the facility to assist with the discharge of the residents and has been appraised of all recent occurrences. 4. A list was prepared of responsible parties and the status of ambulation for each resident to assist with any transfer in a safe and orderly fashion. 5. The facility Admissions will be responsible to contact the transportation company. 6. Medical Records will be responsible to hand out the prepared envelopes, which include the Face Sheet, History & Physical (H&P), and Physician orders. 7. LVN will prepare and distribute the medication for each resident as they go into the ambulance 8. Dietary will hand out water and snacks to residents 9. The Minimum Data Set (MDS - a care area assessment and screening tool) nurse will document where each resident transfer to. 10. The Social Service Director (SSD) will contact families and responsible parties to update them on situation and to which facility the resident was transferred. A review of the facility's policy and procedure for Emergency Transfer or Discharge, revised date 2016, indicated should it become necessary to make an emergency transfer or discharge to a hospital or other related institution that included notifying the receiving facility, preparing the resident for transfer, prepare a transfer form to send with the residents, notifying the representative or other family members, and assist in obtaining transportation.

Based on observation, record review, and interviews the facility failed to ensure that one out of 19 sample residents (Resident 12) who was admitted to the facility with a urinary indwelling catheter (tube inserted into the bladder to drain urine), received prompt treatment and care to prevent hospitalization by failing to: *cross-reference F690 1. Appropriately assess, and document Resident 12's urine color, character, and output (amount of urine a resident excretes) as indicated in the physicians orders and in the facility's policy and procedure. 2. Report Resident 12's abnormal urine culture and sensitivity ((C/S) a Culture test identifies bacteria or fungus that caused an infection, and a Sensitivity test identifies the antibiotic that best treat the illness or infection) results to the physician so that the physician can determine the correct medication to treat Resident 12's urinary tract infection ([MEDICAL CONDITION] an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) as indicated in the facility's policy. 3. Appropriately assess Resident 12's symptoms of inability to sleep (change of condition) one day prior Resident 12's hospitalization . Resident 12 complained of pain and burning sensation on his bladder on 6/18/17 (4 days after he was admitted to the facility). Resident 12's urinalysis on 6/19/17 indicated that Resident 12 had a urine infection and on 6/21/17 Resident 12's C/S results indicated that Resident 12's identified bacteria was resistant (not effective) to [MEDICATION NAME] (([MEDICATION NAME]) an antibiotic that is used to treat bacterial infections). Resident 12's physician was not informed regarding Resident 12's C/S results and Resident 12 received [MEDICATION NAME] 500 milligrams (mg) by mouth once daily from 6/21/17 to 6/27/17 (7 days). Resident 12's urine color, character, and output were not appropriately assessed from June 2017 to October 2017. Resident 12 had episodes of inability to sleep prior to his hospitalization [DATE] and the facility did not have any documented evidence that Resident 12 was assessed for his inability to sleep. These deficient practices resulted in a delay in treating Resident 12's UTI, and on 10/6/17 Resident 12 was transferred via 911 (emergency services) to a general acute care hospital (GACH) and was admitted to the GACH with [DIAGNOSES REDACTED]. Findings: On 12/19/17 at 3 p.m., during a tour of the facility, Resident 12 was observed in bed awake and Resident 12's family member (FAM 1) was at bedside and stated that Resident 12 had history of UTI while at the facility and was hospitalized due to UTI. A review of Resident 12's Admission Record indicated that Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 12's Initial History and Physical, dated 6/15/17, indicated that resident had the capacity to understand and make decisions. A review of Resident 12's Minimum Data Set ((MDS), a resident assessment and care-screening tool), dated 6/21/17, indicated Resident 12 had the ability to understand others and required extensive assistance for bed mobility and personal hygiene and was totally dependent for transfers, dressing, and toileting requiring one person to physically assist. A review of Resident 12's physician's orders [REDACTED].) of UTI) or with a negative ((-) absence of s/s of UTI) and to perform Foley catheter care daily. A review of Resident 12's Care Plan titled Foley Catheter, dated 6/15/17, indicated that resident was at risk for infection related to indwelling catheter and that interventions were to assess urine for color, odor, clarity and document. A review of Resident 12's Change of Condition-SBAR (Situation Background Assessment Recommendation) dated 6/18/17, and timed at 8:30 a.m., indicated that Resident 12 complained of burning and pain sensation while voiding bladder. A review of Resident 12's Treatment Sheet dated 6/18/17, indicated that Resident 12 was negative for burning sensation on all shifts. A review of Resident 12's Physician and Telephone Orders dated 6/18/17 and timed at 9 a.m., indicated for staff to collect a urine culture. A review of Resident 12's Diagnostic Laboratories and Radiology Urinalysis (urine test) dated 6/19/17 and timed at 5:33 p.m., indicated that Resident 12's urine tested positive with blood (+3 (normal range was negative)), appearance was turbid (normal range clear), and white blood cell was greater than 50 HPF ((High Power Field normal range 0-5) an increase in white blood cell count (WBC) is due to pus formation as result of fighting an infectious agent and also an indication that there is presence of infection). A review of Resident 12's Diagnostic Laboratories and Radiology Microbiology Report dated 6/21/17 and timed at 2:34 p.m., indicated that Resident 12's urine C/S had greater than 100,000 colonies/ML of [MEDICATION NAME] (group of bacteria) and was resistant to [MEDICATION NAME]. A review of Resident 12's Physician and Telephone Orders dated 6/21/17 and timed at 4:20 p.m., indicated for Resident 12 to receive [MEDICATION NAME] ([MEDICATION NAME]) 500 mg one tablet by mouth daily for UTI for 7 days. A review of Resident 12's Medication Administration Record [REDACTED]. During an interview and a review of Resident 12's record on 12/21/17 at 11:27 a.m., licensed vocational nurse (LVN) (MDS 2) stated that Resident 12's physician was not informed regarding Resident 12's C/S results. MDS 2 stated that Resident 12's C/S results indicated that Resident 12 was resistant to [MEDICATION NAME] and that the nurses were supposed to inform Resident 12's physician regarding the C/S results. MDS 2 stated that Resident 12 was given [MEDICATION NAME] and that the use of [MEDICATION NAME] was considered like a placebo, (a substance that has no therapeutic effect). A review of Resident 12's Change of Condition-SBAR dated 6/21/17 and timed at 3:15 p.m., indicated that Resident 12 had hematuria in the urinary bag. A review of Resident 12's Treatment Sheet dated 6/21/17 indicated that Resident 12 was negative for s/s of hematuria, odor, consistency, burning sensation, and bladder distention. During an interview on 12/21/17 at 2:39 p.m., the facility's director of nursing (DON) stated that Resident 12's Treatment Record dated June 2017 did not reflect Resident 12's pain, burning sensation for 6/18/17 and Resident 12's hematuria on 6/21/17 and that the documentation was questionable. DON stated that the licensed nurses were supposed to assess and document according to Resident 12's s/s (signs and symptoms). During the concurrent interview the DON stated that Resident 12's Diagnostic Laboratories and Radiology C/S results dated 6/21/17 indicated that Resident 12 was resistant to [MEDICATION NAME] and that Resident 12 was not supposed to receive [MEDICATION NAME]; the nurses were supposed to inform Resident 12's physician regarding the C/S results because otherwise the [MEDICATION NAME] would have no use. A review of Resident 12's Treatment Administration Record dated 7/18/17 from the 7 a.m., to 3 p.m., shift, indicated that Resident was positive for s/s of UTI and did not indicate that the physician was notified. A review of Resident 12's Nurse's Notes did not contain any documentation for 7/18/17. A review of Resident 12's Nurse's Notes dated 10/5/17, and timed at 2 p.m., indicated that the nurse (identified) called Resident 12's physician to request a medication for [MEDICAL CONDITION] (inability to sleep) and the same Nurse's Notes did not have evidence that Resident 12 was assessed by a licensed nurse to identify the change of condition. A review of Resident 12's Nurse's Notes dated 10/6/17 and timed at 5 p.m., indicated that Resident 12's family member reported that Resident 12's inability to sleep at night was affecting his morning routine. The same Nurse's Notes did not have any evidence that Resident 12 was assessed for the reason of his inability to sleep. A review of Resident 12's Change of Condition SBAR dated 10/6/17 at 7 p.m. (2 hours later after Resident 12's family member reported Resident 12's inability to sleep), indicated that a certified nursing assistant reported to LVN 2 that resident had a lack of appetite, was lethargic and that the Resident (12) had an elevated temperature of 100.8 and was noted lethargic. The same Change of Condition SBAR timed at 8:20 p.m., indicated that physician ordered for Resident 12 to be transferred to the hospital to rule out (possible condition)[MEDICAL CONDITION] and the same SBAR notes timed at 9 p.m., indicated that the ambulance service called 911 due to Resident 12's low blood pressure. During an interview on 12/21/17 at 4:18 p.m., LVN 2 stated that Resident 12 was lethargic on 10/6/17 and that she went to check on the resident after the CNA told her that Resident 12 did not look good. A review of Resident 12's Treatment Administration Record dated 10/6/17, indicated that Resident 12 was negative for s/s of urinary infection for all three shifts. During the concurrent interview the DON stated that on 10/6/17 Resident 12 was transferred to the hospital via 911 and was readmitted to the facility on [DATE] at 8 p.m., and Resident 12's Treatment Administration Record dated from 10/6/17 to 10/12/17 indicated that Resident 12 was negative for s/s of UTI even though Resident 12 was not physically in the facility. DON stated Resident 12's Treatment Administration Record was questionable and incorrect and nurses were supposed to document immediately after assessing Resident 12 and that any change of condition should be noted after assessing the residents. During an interview and a review of Resident 12's record on 12/22/17 at 8:03 a.m., the DON stated that Resident 12's Intake and Output Record indicated that Resident 12's urine output and weekly evaluation was not done from June 2017 to October 2017 and that nurses were supposed to monitor urine output, color, odor, clarity, consistency and signs and symptoms of infection. A review of Resident 12's GACH record titled Emergency Documentation, dated 10/6/17 and timed at 9:44 p.m., indicated that Resident 12 was admitted on [DATE] and was discharged on [DATE]. The same Emergency Documentation indicated that Resident had a fever of 101.4 degrees Fahrenheit ((F) normal body temperature range from 97.8 degrees F to 99 degrees F for healthy adults) and that paramedics found resident with a blood pressure of 78/40 (low) (normal range between 120/80 and less than 140/90) and a heart rate of 48 ((low) normal range between 60-100). The Emergency Documentation also indicated that Resident 12's urine was cloudy with sediment (particles that may be indicative of an infection), and was likely to [MEDICAL CONDITION] due to UTI. A review of Resident 12's GACH record titled History and Physical dated 10/7/17, and timed 10:08 a.m., indicated that Resident 12 was started with [MEDICATION NAME] (medication for blood pressure control) and had a positive urinalysis with greater than 100 WBCs and that Resident 12 was admitted to the intensive care unit (ICU) with [DIAGNOSES REDACTED]. A review of the facility's policy and procedure titled Urinary Tract Infections/Bacteriuria Clinical Protocol, with a revised date of June 2014, indicated that the facility required nurses to observe, document, and report signs and symptoms (for example, fever or hematuria) in detail and that the physician would help nursing staff interpret the significance of signs, symptoms, and lab results. The same Urinary Tract Infections/Bacteriuria policy, indicated that empirical treatment should be based on a documented description of an individual's symptoms and on consideration of relevant test results and that symptomatic UTIs should be treated and that physician and nursing staff would review the status of individuals who were being treated for [REDACTED]. A review of the facility's policy and procedure tilted Output, Measuring and Recording, with a revised date of October 2017 indicated that facility required staff to accurately determine the amount of urine that a resident excreted in a 24 hour period and should be recorded for each resident with an indwelling catheter and that output records should be evaluated at least weekly and each evaluation should be included in the weekly intake and output record. A review of the facility's policy and procedure titled Test Results, with a revised date of April 2007, indicated that the facility required staff to notify the resident's attending physician of the results of diagnostic tests and that results of laboratory, should be reported in writing to the resident's attending physician. A review of the facility's policy and procedure titled Change in a Resident's Condition or Status, with a revised date of November 2015, indicated that the facility required the nursing staff to record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. According to http://www.uptodate.com/contents/treatment-of-[MEDICATION NAME]-infections, [MEDICATION NAME] species can cause a variety of infections, including urinary tract infections, bacteremia (bacteria in the blood), endocarditis (infection of the inner lining of the heart), and meningitis (infection of the membranes covering the brain and spinal cord). According to http://www.umm.edu/health/medical/reports/articles/urinary-tract-infection, if left untreated, UTIs can develop into very serious and potentially life-threatening kidney infections ([MEDICAL CONDITION]) that can permanently scar or damage the kidneys and the infection may also spread into the bloodstream ([MEDICAL CONDITION]) and elsewhere in the body.

Based on observation, interview, and record review, the facility failed to ensure that one out of 19 sample residents (Resident 12), who was admitted to the facility with an indwelling urinary catheter (tube inserted into the bladder to drain urine) received appropriate care and services to prevent and to promptly treat urinary tract infection ([MEDICAL CONDITION] an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney) as indicated in Resident 12's physician orders, plan of care, and on the facility's policy and procedure by failing to: *cross reference F684 1. Appropriately assess and document Resident 12's urine color, character, and output (amount of urine a resident excretes). 2. Report Resident 12's urine culture and sensitivity ((C/S) a Culture test identifies bacteria or fungus that caused an infection, and a Sensitivity test identifies the antibiotic that best treat the illness or infection) results to the physician so that the physician can determine the correct medication to treat Resident 12's UTI. Resident 12 complained of pain and burning sensation on his bladder on 6/18/17. Resident 12's urinalysis on 6/19/17 indicated that Resident 12 had a urine infection and on 6/21/17 Resident 12's C/S results indicated that Resident 12's identified bacteria was resistant (not effective) to [MEDICATION NAME] (([MEDICATION NAME]) a medication that is used to treat infections). Resident 12's physician was not informed regarding Resident 12's Sensitivity results and Resident 12 received [MEDICATION NAME] 500 milligrams (mg) by mouth once daily from 6/21/17 to 6/27/17 (7 days). These deficient practices resulted in a delay in treating Resident 12's UTI, and on 10/6/17 Resident 12 was transferred via 911 (emergency services) to a general acute care hospital (GACH) and was admitted to the GACH with [DIAGNOSES REDACTED]. Findings: On 12/19/17 at 3 p.m., during a tour of the facility, Resident 12 was observed in bed awake and Resident 12's family member (FAM 1) was at bedside and stated that Resident 12 had a history of [REDACTED]. A review of Resident 12's Admission Record indicated that Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 12's Initial History and Physical, dated 6/15/17, indicated that resident had the capacity to understand and make decisions. A review of Resident 12's Minimum Data Set ((MDS), a resident assessment and care-screening tool), dated 6/21/17, indicated Resident 12 had the ability to understand others and required extensive assistance for bed mobility and personal hygiene and was totally dependent for transfers, dressing, and toileting requiring one person to physically assist. A review of Resident 12's physician's orders [REDACTED]. drainage bag for color, consistency, odor, hematuria (blood in the urine), bladder distention, burning sensation and for staff to document every shift with a positive ((+) presence of signs and symptoms (s/s) of UTI) or with a negative ((-) absence of s/s of UTI) and to perform Foley catheter care daily. A review of Resident 12's Care Plan titled Foley Catheter, dated 6/15/17, indicated that resident was at risk for infection related to indwelling catheter and that interventions were to assess urine for color, odor, clarity and document. A review of Resident 12's Change of Condition-SBAR (Situation Background Assessment Recommendation) dated 6/18/17, and timed at 8:30 a.m., indicated that Resident 12 complained of burning and pain sensation while voiding bladder. A review of Resident 12's Treatment Sheet dated 6/18/17, indicated that Resident 12 was negative for burning sensation on all shifts. A review of Resident 12's Physician and Telephone Orders dated 6/18/17 and timed at 9 a.m., indicated for staff to collect a urine culture. A review of Resident 12's Diagnostic Laboratories and Radiology Urinalysis (urine test) dated 6/19/17 and timed at 5:33 p.m., indicated that Resident 12's urine tested positive with blood (+3 (normal range: negative)), appearance was turbid (normal range clear), and white blood cell (WBC) was greater than 50 HPF ((High Power Field normal range 0-5) an increase in WBC is due to pus formation as result of fighting an infectious agent and also an indication that there is presence of infection). A review of Resident 12's Diagnostic Laboratories and Radiology Microbiology Report dated 6/21/17 and timed at 2:34 p.m., indicated that Resident 12's urine C/S had greater than 100,000 colonies/ML of [MEDICATION NAME] (group of bacteria) and was resistant to [MEDICATION NAME]. A review of Resident 12's Physician and Telephone Orders dated 6/21/17 and timed at 4:20 p.m., indicated for Resident 12 to receive [MEDICATION NAME] ([MEDICATION NAME]) 500 mg one tablet by mouth daily for UTI for 7 days. A review of Resident 12's Medication Administration Record [REDACTED]. During an interview and a review of Resident 12's record on 12/21/17 at 11:27 a.m., licensed vocational nurse (MDS 2) stated that Resident 12's physician was not informed regarding Resident 12's C/S results. MDS 2 stated that Resident 12's C/S results indicated that Resident 12 was resistant to [MEDICATION NAME] and that the nurses were supposed to inform Resident 12's physician regarding the C/S results so that the physician could determine the right treatment. MDS 2 stated that Resident 12 was given [MEDICATION NAME] and that the use of [MEDICATION NAME] was considered like a placebo, (a substance that has no therapeutic effect). A review of Resident 12's Change of Condition-SBAR dated 6/21/17 and timed at 3:15 p.m., indicated that Resident 12 had hematuria (blood in urine) in the urinary bag. A review of Resident 12's Treatment Sheet dated 6/21/17 indicated that Resident 12 was negative for s/s of hematuria, odor, consistency, burning sensation, and bladder distention on all shifts. During an interview on 12/21/17 at 2:39 p.m., the facility's director of nursing (DON) stated that Resident 12's Treatment Record dated June 2017 did not reflect Resident 12's pain, burning sensation for 6/18/17 and Resident 12's hematuria on 6/21/17 and that the assessments and documentation were questionable. DON stated that the licensed nurses were supposed to assess and document according to Resident 12's s/s (signs and symptoms). During the concurrent interview the DON stated that Resident 12's Diagnostic Laboratories and Radiology C/S results dated 6/21/17 indicated that Resident 12 was resistant to [MEDICATION NAME] and that Resident 12 was not supposed to receive [MEDICATION NAME] and that the nurses were supposed to inform Resident 12's physician regarding the C/S results because otherwise the [MEDICATION NAME] would have no use, in treating Resident 12's type of bacteria. A review of Resident 12's Change of Condition SBAR dated 10/6/17 at 7 p.m., indicated that Resident 12 had an elevated temperature of 100.8 and was noted lethargic. The same Change of Condition SBAR timed at 8:20 p.m., indicated that physician ordered for Resident 12 to be transferred to the hospital to rule out (possible condition)[MEDICAL CONDITION] and the same SBAR notes timed at 9 p.m., indicated that the ambulance service staff called 911 due to Resident 12's low blood pressure. A review of Resident 12's Treatment Administration Record dated 10/6/17, indicated that Resident 12 was negative for s/s of urinary infection for all three shifts. During the concurrent interview the DON stated that on 10/6/17 Resident 12 was transferred to the hospital via 911 and was readmitted to the facility on [DATE] at 8 p.m., and Resident 12's Treatment Administration Record dated from 10/6/17 to 10/12/17 indicated Resident 12 was negative for s/s of UTI while Resident 12 was not physically in the facility and that Resident 12's Treatment Administration Record was questionable and incorrect and nurses were supposed to document immediately after assessing Resident 12. During an interview and a review of Resident 12's record on 12/22/17 at 8:03 a.m., the DON stated that Resident 12's Intake and Output Record indicated that Resident 12's urine output and weekly evaluations were not done from June 2017 to October 2017 and that nurses were supposed to monitor urine output, color, odor, clarity, consistency and signs and symptoms of infection. A review of Resident 12's GACH record titled Emergency Documentation, dated 10/6/17 and timed at 9:44 p.m., indicated that Resident 12 was admitted on [DATE] and was discharged on [DATE]. The same Emergency Documentation indicated that Resident 12 had a fever of 101.4 degrees Fahrenheit ((F) normal body temperature range from 97.8 degrees F to 99 degrees F for a healthy adults) and that paramedics found resident with a blood pressure of 78/40 (low; normal range 120/80) and a heart rate of 48 ((low) normal range between 60-100). The Emergency Documentation also indicated that Resident 12's urine was cloudy with sediment (particles that may be indicative of an infection), and was likely to [MEDICAL CONDITION] due to UTI. A review of Resident 12's GACH record titled History and Physical dated 10/7/17, and timed 10:08 a.m., indicated that Resident 12 was started with [MEDICATION NAME] (medication for blood pressure control) and had a positive urinalysis with greater than 100 WBCs. Resident 12 was admitted to the intensive care unit (ICU) with [DIAGNOSES REDACTED]. A review of Resident 12's GACH records titled Final Report, dated 10/12/17, indicated that Resident 12 was discharged to the facility with a resolved septic shock due to UTI. A review of the facility's policy and procedure titled Urinary Tract Infections/Bacteriuria Clinical Protocol, with a revised date of June 2014, indicated that the facility required nurses to observe, document, and report signs and symptoms (for example, fever or hematuria) in details and that the physician would help nursing staff interpret the significance of signs, symptoms, and lab results. The same Urinary Tract Infections/Bacteriuria policy, indicated that empirical treatment should be based on a documented description of an individual's symptoms and on consideration of relevant test results and that symptomatic UTIs should be treated and that physician and nursing staff would review the status of individuals who were being treated for [REDACTED]. A review of the facility's policy and procedure tilted Output, Measuring and Recording, with a revised date of October 2017 indicated that facility required staff to accurately determine the amount of urine that a resident excreted in a 24 hour period and should be recorded for each resident with an indwelling catheter and that output records should be evaluated at least weekly and each evaluation should be included in the weekly intake and output record. A review of the facility's policy and procedure titled Test Results, with a revised date of April 2007, indicated that the facility required staff to notify the resident's attending physician of the results of diagnostic tests and that results of laboratory, should be reported in writing to the resident's attending physician. According to http://www.uptodate.com/contents/treatment-of-[MEDICATION NAME]-infections, [MEDICATION NAME] species can cause a variety of infections, including urinary tract infections, bacteremia (bacteria in the blood), endocarditis (infection of the inner lining of the heart), and meningitis (infection of the membranes covering the brain and spinal cord). According to http://www.umm.edu/health/medical/reports/articles/urinary-tract-infection, if left untreated, UTIs can develop into very serious and potentially life-threatening kidney infections ([MEDICAL CONDITION]) that can permanently scar or damage the kidneys and the infection may also spread into the bloodstream ([MEDICAL CONDITION]) and elsewhere in the body.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received adequate supervision and assistance when repositioning the resident. This deficient practice resulted in Resident 1 falling out of bed and sustained a fracture of the right distal femur (broken bone on lower end of the thigh bone, near the knee). Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Initial History and Physical, dated 4/4/16 indicated Resident 1 has the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment tool, dated 8/17/16 indicated Resident 1 had a brief interview for mental status (BIMS) score of 6 (0-7 indicates cognitively impaired). Resident 1 was totally dependent with two-person physical assist for bed mobility (how resident moves to and from lying position, turns side to side) and transferring from one surface to another. A review of Resident 1's corrected MDS dated [DATE] indicated Resident 1 had a BIMS score of 6, required extensive assistance with two-person physical assist for bed mobility, required total assistance with two-person assist for transferring. A review of Resident 1's Fall Risk Assessment, dated 9/6/16 indicated Resident 1 had a fall risk assessment score of 10 (score of 10 and above indicates high risk for fall) (1 point-requires assist with elimination, 1 point-visually impaired, 2 points-balance problems, 1 point-requires a wheelchair, 2 points-takes high blood pressure and diabetic medications, 3 points-history of [DIAGNOSES REDACTED], cerebrovascular accident (death of brain cells due to blockage of blood flow), and diabetes. A review of Resident 1's Care Plan, dated 3/16/16 indicated Resident 1 was at risk for fall and injuries secondary to impaired mobility and generalized weakness, required bed side-rails up for mobility. Care plan also indicated to turn and reposition Resident 1 while in bed but did not indicate the number of staff required to perform turning and repositioning. A review of Resident 1's Nurse's Notes, dated 11/26/16, indicated on 11/24/16, while Certified Nurse Assistant (CNA) 1 was turning Resident 1 onto her left side, Resident 1 slid slowly out of bed. CNA 1 was unable to stop Resident 1 from falling off the bed. Resident 1 landed on both knees onto the floor. Resident 1 noted to have right knee swelling. During an interview with Resident 1 on 12/8/16 at 11:00 am, Resident 1 stated that CNA 1 turned her to the left side without help from another staff. Resident 1 stated that she usually gets turned by 2 staff and that she does not want CNA 1 to get in trouble. Resident 1 stated that she cannot move her right arm and leg because of stroke (decreased blood flow to a part of the brain). Resident 1 stated that her right leg started to slide down off the bed and she fell with both knees hitting the floor. During an interview with CNA 1 on 12/8/16 at 12:15 pm, CNA 1 stated that Resident 1 needed two-person assist. CNA 1 stated that she did not call anyone for help because everybody was busy. During an interview with CNA 2 on 12/8/16 at 1:00 pm, CNA 2 stated that Resident 1 required two-person assist with turning and repositioning. CNA 2 stated that she always asks for help every time she repositioned and turned Resident 1. During an interview with Registered Nurse (RN) 1 on 12/8/16 at 1:20 pm, RN 1 stated that Resident 1 required two-person assist for all shifts with turning and repositioning. RN 1 also stated that Resident 1 had weakness on the right side of the body due to stroke. A review Resident 1's X-Ray of right knee (photograph to view bone) dated 11/24/16 indicated an acute mildly displaced distal femur supracondylar fracture (broken bone on the lower portion of the thigh bone near the knee). A review of Resident 1's Physician Telephone Orders, dated 11/24/16 indicated to transfer Resident 1 to the general acute care hospital (GACH) for further evaluation. A review of Resident 1's GACH History and Physical, dated 11/25/16 indicated: status [REDACTED]. A review of Resident 1's GACH Orthopedic Consultation Note, dated 11/25/16 indicated a plan of non-weight bearing to the right lower extremity, gentle activity of transfers from bed to bed, recheck to evaluate possible interval displacement (change in alignment of broken bone), if so, would be surgery would be indicated. A review of facility's policy and procedure titled Fall Risk Assessment dated 11/2007 indicated staff will evaluate functional factors that may increase fall risk which included ambulation, mobility and activities of daily living capabilities; staff will identify and address modifiable fall risk factors to try to minimize the consequences of risk factors that are not modifiable.

Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent the development of a pressure ulcer (localized injury to the skin and or underlying tissue, usually over a bony prominence, as a result of pressure) for one of 19 sampled residents (Resident 15) who was at risk for developing pressure ulcer, by failing to: 1. Obtain a physician's order for the use and care of Resident 15's right leg immobilizer (semi-rigid device with straps above and below the knee, used to help prevent unwanted movement that could re-injure the leg or cause harm to the healing area). 2. Assess and monitor Resident 15's skin integrity while using the right leg immobilizer. These deficient practices led to Resident 15 developing the following: 1. Stage I pressure ulcer (intact skin with non-blanchable (does not lose color when you press your finger on it and then remove your finger) redness) of the right knee measuring: 4.0 cm (centimeters) (unit of measurement) in length by 3.0 cm in width. 2. Unstageable pressure ulcer (pressure ulcer with full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure injury in the right knee lateral site measuring: 5.0 cm in length by 2.5 cm in width. 3. Suspected deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) on the right lateral lower leg measuring: 7.0 cm in length by 4.0 cm in width. Findings: Review of Resident 15's Admission Face Sheet indicated the resident was originally admitted on [DATE] and readmitted to the facility on [DATE]. Resident 15's [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) assessment and care screening tool), dated 11/17/16, indicated Resident 15 was severely impaired with cognition as evidenced by a brief interview for mental status (BIMS) score of 6 (a score of 0-7 indicate severe impairment). Resident 15 required extensive assistance with bed mobility and dressing. Resident 15 was totally dependent on the staff for transfer, locomotion, toilet use, hygiene, and bathing. Resident 15 was assessed to have no pressure ulcers. However, Resident 15 was assessed to be at risk to develop pressure ulcers. A review of Resident 15's Braden Scale (tool to predict pressure ulcer risk), dated 11/28/16 indicated a score of 12 (score of 12 or less represents high risk). Further review of the form indicated risk factors included limited sensory perception, activity, and mobility. A review of Resident 15's Wound/Skin Record dated 1/9/17 indicated the following: 1. Stage I pressure ulcer (intact skin with non-blanchable (does not lose color when you press your finger on it and then remove your finger) redness) of the right knee measuring: 4.0 cm in length by 3.0 cm in width. 2. Unstageable pressure ulcer (pressure ulcer with full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure injury in the right knee lateral site measuring: 5.0 cm in length by 2.5 cm in width. 3. Suspected deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) on the right lateral lower leg measuring: 7.0 cm in length by 4.0 cm in width. A review of Resident 15's physician's order, dated 1/9/17 indicated the following: 1. Cleanse right knee non-blanchable redness with normal saline. Pat dry and apply Hydrogel (water in a gel base, which helps regulate fluid exchange from the wound surface), cover with dry dressing daily for 14 days then reevaluate. 2. Cleanse right lateral knee unstageable pressure injury with normal saline. Pat dry, apply Santyl ointment (removes dead tissues from wound) daily. Cover with dry dressing daily X 14 days then reevaluate. 3. Cleanse right lateral lower leg deep tissue injury with normal saline. Pat dry, apply Santyl ointment daily. Cover with dry dressing daily for 14 days then reevaluate. During observation and a concurrent interview with Resident 15 on 1/31/17 at 9:27 a.m., Resident 15 was observed lying in bed with the head of the bed up. According to Resident 15, she used to have the immobilizer on her right leg all the time, but now only uses it when she is up in the wheelchair. Resident 15 also complained of having more pain since the development of the pressure ulcers. During the treatment observation on 1/31/17 at 9:35 a.m., Resident 15 was observed with an unstageable right lateral knee pressure ulcer with slough measuring 2.0 cm x 1.5 cm. Licensed vocational nurse (LVN 4) cleansed the area with normal saline. LVN 4 applied [MEDICATION NAME] 1% ointment (antibiotic that fights bacteria), Santyl, and calcium alginate (destroy/stop the growth of bacteria and maintain a moist environment to promote rapid healing) dressing. Resident 15 was also observed with another unstageable right lower leg pressure ulcer measuring 3 cm x 1.5 cm. Licensed vocational nurse (LVN 4) cleansed the area with normal saline. LVN 4 applied [MEDICATION NAME] 1% ointment, Santyl, and calcium alginate dressing. The right lateral knee pressure ulcer was located close to the knee cap area opening approximately where the top strap of the immobilizer. The right lateral lower leg pressure ulcer was located in the covered area close to the lower strap where the rigid bar of the immobilizer sits. On 1/31/17 at 11:00 a.m., during concurrent record review and interview with LVN 4, he stated, Resident 15 was discharged to the hospital after a fall incident resulting in a femur fracture in November 2016. Surgery was not performed, but Resident 15 was readmitted to the facility with a right leg immobilizer. Resident had another hospitalization and was once again readmitted to the facility on [DATE] and came with a right leg immobilizer, which was a factor for the development of Resident 15's pressure ulcer. Upon further review of the clinical records, LVN 4 acknowledged that there was no physician order for [REDACTED]. Review of Resident 15's physician's order dated 1/10/17 indicated an order to remove brace while in bed and apply while in wheelchair. On 1/31/17 at 11:17 a.m. during interview, LVN 7 stated if a resident was admitted with a brace or an immobilizer, the licensed nurse needs to clarify from the physician when to apply and take off the immobilizer because it places the resident at risk for the development of pressure ulcers. LVN 4 added that nurses are supposed to assess the resident's skin every shift and document on the nurses' notes. On 1/31/17 at 11:20 a.m., during interview, certified nurse assistant (CNA 6) stated that Resident 15 always had the immobilizer on while in bed and on the wheelchair. CNA 6 stated she provided ADL care to Resident 15, but did not check the resident's right leg because she always had the immobilizer on. On 2/1/17 at 11:36 a.m., during interview, registered nurse supervisor (RN Supervisor) stated there should be a physician's order for the use of [REDACTED]. on 4-6 hours per day), and monitoring for skin integrity, pain, and circulation as part of the care and management of residents with an immobilizer. The RN supervisor also stated a care plan should be developed for Residents using an immobilizer. During observation on 1/31/17 at 12:07 p.m., Resident 15 was sitting on the wheelchair in the dining room wearing a right knee immobilizer with the right leg resting on top of a pillow and wheelchair leg rest. The right knee immobilizer had a knee cap area opening. There were two rigid bars on the lateral and medial sides of the leg to prevent bending of the knee. There were two straps attached to the immobilizer above the knee and two straps below the knee. During an interview on 1/31/17 at 2:42 p.m., LVN 4 stated he left the immobilizer on all the time prior to 1/9/17 because there was no order when to take it off. LVN 4 stated he would only remove the immobilizer strap to check the skin for breakdown and circulation, but did not remove the brace totally. Therefore, he was unable to check the lateral area of Resident 15's right leg. LVN 4 stated Resident 15's right leg in its entirety should have been assessed daily to prevent pressure ulcer. Review of Resident 15's clinical record no documentation was found that Resident 15's right leg was being monitored for skin breakdown when the immobilizer was in place. On 2/1/17 at 11:16 a.m., during concurrent record review and interview with the occupational therapist (OTR), he stated aside from Resident 15's precautions of no weight bearing on the right lower extremity and no bending, the use of immobilizer should have been documented on the clinical record, therapy evaluation and ongoing plan. OTR also stated that once a resident is discontinued from physical and occupational therapy, nursing department should have been instructed on how to apply and remove the immobilizer. OTR emphasized on the importance of checking the skin while using the immobilizer to prevent pressure ulcer. Resident 15 was discharged from Physical and Occupational therapy services on 1/2/17 with instructions to keep the leg immobilizer on at all times. There was no documented evidence that the nursing staff were given instructions on how to apply and remove the immobilizer to be able to monitor the skin for pressure ulcer. A review of Resident 15's plan of care titled, Risk to develop Pressure Ulcer, dated 12/3/16, indicated a goal for the resident to have no skin breakdown/pressure ulcer. Staff interventions included to turn and reposition every 2 hours, keep clean and dry at all times, and careful handling during care. A care plan was developed on 1/9/17 addressing Resident 15's unstageable right knee lateral pressure injury, DTI of the right lateral lower leg, and right knee non-blanchable redness with staff interventions to include treatment as ordered, but did not address the care and management of the right leg immobilizer to prevent further deterioration of pressure ulcers. A review of the facility's undated policy titled, Physician's Order, indicated that medications and treatments may not be administered to the resident without written approval from the attending physician A review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown, dated 3/2014 indicated that the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores. It also stipulated that the physician will help the staff review and modify the care plans as appropriate.

Based on interview and record review, the facility failed to ensure that one of one sampled resident (Resident 1) was free from being physically and psychologically abused by Certified Nursing Assistant (CNA 1). CNA 1 held a knife against Resident 1's neck. This resulted in physical and psychological harm to Resident 1. Findings: On 8/11/16, the facility reported an allegation of staff to resident abuse which occurred on 7/30/16. On 8/25/16 at 11:05 am, an unannounced visit was made to the facility to investigate an entity reported incident. A review of the clinical record indicated Resident 1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 7/3/16 indicated Resident 1 was cognitively intact. Resident 1 required limited assistance with one person assistance in performing his activities of daily living. On 8/25/16 at 11:40 am, an interview was conducted with facility social service designee (SSD) who stated Resident 1 told her he was talking with CNA 2 while on his wheelchair in his room. CNA 1 came inside his room and got something from his bedside cabinet. CNA 1 then placed his arm around Resident 1's neck. Resident 1 felt something sharp against his neck. Resident 1 thought it was CNA 1's fingernail but when Resident 1 touched it he felt that it was the blade of a knife. Resident 1 told the SSD at first he thought it was a joke but later on realized CNA 1 was serious and it was not a joke. The SSD stated Resident 1's knife was like a kitchen knife with a blue handle and about a four inch blade. On 8/25/16 at 2:15 pm an interview was conducted with CNA 2. CNA 2 stated she was talking with Resident 1 when the incident happened. CNA 2 stated CNA 1 entered the room and called Resident 1 a cabron (Spanish for as_ _ole). CNA 1 took something out of Resident 1's bedside cabinet and then placed his left arm around the resident's neck and in his other hand he had a knife. CNA 1 pressed the knife onto Resident 1's neck. Resident 1 was not moving and said to CNA 1 Are you trying to kill me? Resident 1 told CNA 2 to take a picture of the scene so you can see him killing me. CNA 2 stated she did not take a picture of the incident. CNA 2 stated she was shocked to see what CNA 1 did. CNA 2 stated CNA 1 did not say anything and removed his arm from around the resident's neck and placed the knife back on the bedside cabinet and left the room. CNA 2 stated she asked Resident 1 how he felt about the incident. Resident 1 told CNA 2 to not report anything to the facility because CNA 1 might have just been playing. On 8/25/16 at 2:35 pm an interview was conducted with Resident 1. Resident 1 stated he was sitting on his wheelchair in his room on 7/30/16 and he was talking with CNA 2. CNA 1 came in and tried to squeeze my neck with his arm. Resident 1 stated he thought CNA 1 was just playing around with him. Resident 1 stated CNA 1 knows me; I'm like a father to him. I have a knife and he knows I have one and where I placed it. That day, I don't know what came into his mind and why he did that to me. Resident 1 stated, CNA 1 went inside his room and got the knife from his bedside cabinet. CNA 1 put his left arm around his neck and said I am going to kill you. while pressing an object onto the left side of his neck. Resident 1 thought it was CNA 1's fingernails, but he felt that it was a sharp object, sharper than a fingernail. Resident 1 stated he told CNA 1 if you are going to kill me, then kill me now. Resident 1 verbalized he got scared and feared for his life. He felt that CNA 1 was going to kill him. Resident 1 stated CNA 1 let go of him, returned the knife without saying anything and walked out the room. Resident 1 claimed the knife touched the left side of his neck but did not cut him. Resident 1 claimed he was thinking about the incident for several days and had a poor appetite after the incident. Resident 1 stated the facility dietitian recognized that his appetite declined. Resident 1 also stated for 3-4 days he could not sleep well thinking about the incident. On 8/26/16 at 2:15 pm, an interview was conducted with facility dietary supervisor who stated Resident 1 told her he was not eating well for a few days after the incident. The dietary supervisor stated she could not remember the exact date when the resident told her he wasn't eating well but it was after the incident with CNA 1. On 9/20/16 at 3:50 pm, an interview was conducted with CNA 1 via phone through a Spanish speaking surveyor. CNA 1 stated Resident 1 had a knife and they were both playing with the knife. CNA 1 stated Resident 1 was his friend and they play around often in the facility. CNA 1 denied placing the knife on the resident's neck. CNA 1 denied that he wanted to kill Resident 1. On 9/23/16 at 1:45 pm an interview with the facility's MDS coordinator was conducted. The MDS coordinator stated Resident 1 was alert, coherent and cognitively intact and he had no history of making false accusations to staff or residents. On 9/23/16 at 2:00 pm, an interview was conducted with the facility's director of nursing (DON). The DON stated the facility staff had been educated to report all allegations of abuse. DON stated CNA 2 did not report because she thought Resident 1 and CNA 1 were playing and she was told by the resident not to report. However, the DON also emphasized that all allegations of abuse should be reported and investigated. A review of the facility's undated policy and procedure titled Abuse indicated residents will not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteer staff, family members, friends or other individuals. Physical abuse includes but not limited to hitting, slapping, pinching, kicking and so on. Physical abuse also includes controlling behavior through corporal punishment of a resident. Mental abuse includes but not limited to humiliation, harassment and threats of punishment or deprivation of a resident. It is the policy of the facility to report and investigate all alleged incidents of resident abuse, mistreatment, neglect, involuntary seclusion and misappropriation of property.