Every finding on record at Green Acres Healthcare Center

Based on interview, observation, and record review, the facility failed to maintain and promote a homelike environment in accordance with the facility's policy and procedure (P&P), titled Homelike environment for one of three sampled residents (Resident 1), who was placed in a resident room with chipped and peeling paint, visible profanity writing on the inside entrance door written by previous resident and locker door with chipped paint on top and bottom of the door. This deficient practice had the potential to affect Resident 1's quality of life by residing in a non-homelike environment. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included Atherosclerotic heart disease of native coronary artery without angina (plaque buildup in your original heart blood vessels that causes no chest pain), unspecified psychosis (usually used to describe the presence of psychotic symptoms that don't perfectly align with a specific diagnosis). During a review of Resident 1's History and Physical (H&P) dated 5/30/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During an interview with on 7/28/2026 at 10:50AM, DON stated Ombudsman (a trained, independent advocate who protects the rights, health, and welfare of residents living in facilities like nursing homes, assisted living communities, and board-and-care homes) had visited the facility and communicated with Facility's Administrator (ADM) about Resident 1's room issues such as chipped and peeling paint, visible writing on the inside entrance door. During an interview on 7/28/2026 at 11:15 AM with Maintenance Assistant (MA), MA stated facility ADM had notified him verbally of the repairs to be done. The MA stated the Ombudsman made the facility aware of the chipped and peeling paint, visible writing on the inside entrance door. The MA stated he scraped some but not all of the writing in Resident 1's inside entrance door but he had not a chance to repaint the door. MA stated he replaced the broken lock in Resident's closet but had not had time to remove chipped paint and repaint the door because the facility was planning on remodeling each room. The MA stated that there was no start date of the remodeling at this time. MA stated the writing on the door with profanity written by the previous resident who went around writing and painting on the walls and doors inside the rooms. During an observation of Resident 1's room on 8/28/2026 at 11:30 AM in the presences of Director of Staff Development and MA, Resident 1 entrance room entrance door inside the room was observed with chipped paint and writing with profanity. MA stated he had removed as many foul words as possible he was able to when he was notified by the ADM but did not have time to remove all the writing or repaint the door. During an observation of Resident 1's locker door was observed with chipped paint on top and bottom of the door. MA stated he was aware of the chipped paints on the locker door but had not had a chance to repaint the door because he was working on another resident's room. During an interview on 7/28/2026 at 12:20 PM with Resident 1, Resident 1 stated she had informed the facility staff before telling the Ombudsman because being in a room with all of that foul language on the door and peeling paint made her feel unsafe. Resident 1 stated she could not feel comfortable in her room because she did not know if all the chipped paint would cause her potential health problems in the future. Resident stated no one should live in a room under these conditions, that is why she had notified multiple people including the facility staff first and then the Ombudsman hoping someone would listen to her and repair the room. During an interview on 7/28/25026 at 1:10 PM with DON, DON stated the room repairs should have been done as soon as the facility was made aware of the issues by the Ombudsman. DON stated it was all the staff's responsibility to do room rounds and report any issues to the administrator, maintenance or himself to ensure the residents in the facility are able to feel safe and comfortable in a homelike environment. During a review of the facility's Policy and Procedure (P&P), titled Homelike environment, undated, the P&P indicated This facility will provide a safe, clean, comfortable and homelike environment

Based on interviews and record reviews, the facility failed to obtain a complete informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administration psychotropic medications (medications that affects mood and behavior) for three of three sampled residents (Residents 10, 72, and 82) and keep the consent in the resident's clinical record by failing to ensure: 1. Resident 10's consent for Divalproex Sodium (medication used to stabilize mood) and Olanzapine (a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]) was signed and dated by the physician who obtained the consent. 2a. Resident 72's informed consent for Haloperidol (medication used to treat schizophrenia ]) Olanzapine and Quetiapine Fumarate (medication to treat schizophrenia, bipolar disorder (mental health condition that causes a person to experience extreme mood changes) and major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interests]) did not have a physician's signature or date since 2/18/2026. 2b. Resident 72's informed consent obtained by the physician for Quetiapine Fumarate did not indicate the probable side effects were explained to the resident or responsible party. 3.Resident 82's informed consent for Bupropion HCL (medication to treat major depressive disorder), Risperdal (medication to treat schizophrenia and bipolar disorder) and Olanzapine did not have a physician's signature or date since 3/6/2026. This deficient practice had the potential for residents to receive psychotropic medications without proper consent, which could result in unwanted treatment and violation of resident rights. Furthermore, this exposed residents to psychotropic medications without being fully informed of risks, benefits, and side effects, which may increase the likelihood of unrecognized or unmanaged adverse drug reactions. Findings: 1. During a review of Resident 10's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease without heart failure (heart problems caused by long-term high blood pressure) and schizoaffective disorder (a chronic mental illness causing significant changes in thoughts, moods, and behaviors). During a review of Resident 10's History and Physical (H&P), signed on 11/07/2025, the H&P indicated the resident was able to make decisions regarding activities of daily living. During a review of Resident 10's Order Summary Report dated 3/12/2026, the report indicated the following orders: Divalproex Sodium (used for treatment of manic episodes associated with bipolar disorder), delayed release oral tablet 375 mg, to be given by mouth twice a day for schizoaffective disorder bipolar type manifested by uncontrolled angry outbursts, with a start date of 12/09/2025. Olanzapine 2.5 mg oral tablet, to be given by mouth at bedtime for psychosis in the setting of schizophrenia manifested by paranoid delusions that people are conspiring against him, with a start date of 12/09/2025. During a review of Resident 10's Psychotherapeutic Drug Informed Consent for Olanzapine 2.5 mg at bedtime for psychosis manifested by paranoid delusions, the prescriber signature area was blank, and the date area was blank. During a review of Resident 10's Psychotherapeutic Drug Informed Consent for Divalproex Sodium 375 mg by mouth twice daily for schizoaffective disorder manifested by aggressive behavior, the prescriber signature area was blank, and the date area was blank. During an interview and record review on 3/12/2026 at 4:40 PM with the Director of Nursing (DON), while reviewing Resident 10's consents for Divalproex Sodium and Olanzapine, the DON stated that per facility policy, the prescribing physician must sign and date psychotropic medication consents immediately upon obtaining consent from the resident or resident representative. The DON stated the consent is not valid unless it includes the prescriber's signature and date. 2.During a review of Resident 72's AR, the facility admitted Resident 72 on 2/18/2026 with diagnoses that included encephalopathy (any diffused disease of the brain that alters brain function or structure) and schizophrenia. During a review of Resident 72's HP, dated 2/20/2026, the HP indicated that Resident 72 had the capacity to make decisions for activities of daily living. During a review of Resident 72's Order Summary Report the order, dated 2/18/2026, indicated that Resident 72 was receiving Haloperidol Oral Tablet 10 mg with instructions to give 1 tablet by mouth three times a day for schizophrenia manifested by paranoid delusions leading to inability to cope with internal stimuli. During a review of Resident 72's Order Summary Report the order, dated 2/18/2026, indicated that Resident 72 was receiving Olanzapine Oral Tablet 20mg with instructions to give 1 tablet by mouth at bedtime for schizophrenia manifested by auditory hallucinations (perceptual experiences in the absence of real external sensory stimuli) of hearing voices telling him to harm himself responding to internal stimuli causing stress. During a review of Resident 72's Order Summary Report the order, dated 2/18/2026, indicated that Resident 72 was receiving Quetiapine Fumarate Oral Tablet 25mg with instructions to give 1 tablet by mouth two times a day for schizophrenia manifested by paranoid delusions (misconceptions or beliefs that are firmly held, contrary to reality) thinking people were whispering responding to internal stimuli causing angry outbursts. During a review of Resident 72's Order Summary Report the order, dated 2/18/2026, indicated that Resident 72 was receiving Quetiapine Fumarate Oral Tablet 50mg with instructions to give 1 tablet by mouth at bedtime for schizophrenia manifested by paranoid delusions of people whispering responding to internal stimuli causing angry outbursts. During a review of Resident 72's Minimal Data Set (MDS, a resident assessment), dated 2/25/2026, the MDS indicated that Resident 72's cognitive (a person's thought process) skills were moderately impaired. The MDS indicated that Resident 72 did not experience any hallucinations or delusions. The MDS indicated that Resident 72 received antipsychotic medications on a routine basis. During a concurrent interview and record review on 3/12/2026 at 9 PM with the Director of Nursing (DON), Resident 72's informed consents for Haloperidol 10 mg, Olanzapine 20 mg, Quetiapine Fumarate 25 mg, and Quetiapine Fumarate 50 mg, all dated 2/18/2026, were reviewed .The DON stated none of the four informed consent forms had a physician's signature or date. The DON further stated the informed consent for Quetiapine Fumarate 50 mg did not contain documented evidence that the medication's probable side effects were explained to the resident or responsible party. During a continued interview and record review on 3/12/2026 at 9 PM, the DON stated the consents were prepared on 2/18/2026, and 22 days had passed without the required physician signatures. The DON stated it was important for the physician to sign the informed consent because the resident and responsible party have the right to be informed of the medication's purpose, potential side effects, and attempted non pharmacological interventions before starting antipsychotic medications. 3.During a review of Resident 82's AR, the facility admitted Resident 82 on 9/20/2021 and readmitted Resident 82 on 3/6/2026 with diagnoses that included bipolar schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and dementia (a progressive state of decline in mental abilities). During a review of Resident 82's MDS, dated [DATE], the MDS indicated that Resident 82's cognitive skills were severely impaired. The MDS indicated that Resident 82 experienced delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated that Resident 82 received antipsychotics and antidepressant medications on a routine basis. During a review of Resident 82's Order Summary Report the order, dated 3/6/2026, indicated that Resident 82 received Bupropion HCL Oral Tablet Extended Release 24 hours with instructions to give 150 mg by mouth one time a day for depression manifested by self-reported feelings of depression causing self-isolation. During a review of Resident 82's Order Summary Report the order, dated 3/6/2026, indicated that Resident 82 received Risperdal Oral Tablet 2mg with instructions to give 1 tablet by mouth two times a day for bipolar schizoaffective disorder manifested by poor reality orientation and negative thoughts due to internal stimuli. During a review of Resident 82's Order Summary Report the order, dated 3/6/2026, indicated that Resident 82 received Olanzapine (Zyprexa) Oral Tablet 10mg with instructions to give 1 tablet by mouth two times a day for bipolar schizoaffective manifested by hallucinations that people were against him causing angry outbursts. During a concurrent interview and record review on 3/13/2026 at 11:05 AM with the DON, Resident 82's Informed Consent for Bupropion HCL Oral Tablet Extended Release 150mg, Risperdal Oral Tablet 2mg, and Olanzapine (Zyprexa) Oral Tablet 10mg, dated 3/6/2026, were reviewed. The DON stated Resident 82's Representative Party (RP) signed Resident 82's antipsychotic informed consents on 3/6/2026 was not signed by the physician signature or date and the resident had been receiving the medications for 6 days. During a review of the facility's policies and procedures (P&P) titled Psychotherapeutic Drug Informed Consent, dated January 2026, the P&P indicated that the informed consents were used to ensure that residents and/or their representatives are fully informed of the benefits, risks, frequency/duration, possible side effects, and alternative approaches before initiating the administration of psychotherapeutic drugs. The P&P indicated that the prescriber must provider the residents or their representatives with information such as the nature, degree, duration, and probability of the side effects and significant risks.

Based on observations, interviews and record review, the facility failed to ensure that accurate and current nurse staffing data [total number and actual hours worked by licensed (Registered Nurses [RNs], License Vocational Nurses [LVNs]) and unlicensed nurses (Certified Nursing Assistant [CNAs])] were posted daily at the beginning of each shift (11 PM - 7 AM, 7 AM - 3 PM, and 3 PM - 11 PM). This deficient practice had the potential to delay recognition of inadequate staffing levels, which may lead to delayed response times, unmet resident needs, and decreased supervision, especially for residents requiring assistance with activities of daily living or safety monitoring. Furthermore, this deficient practice had the potential to impede residents, families, and visitors from accurately assessing staffing availability, which may hinder their ability to raise concerns, request assistance, or make informed decisions about the resident's care environment. Findings: Findings: During an observation on 3/10/2026 at 1:34 PM, a Census and Direct Care Service Hours per Patient Day (DHPPD-a CMS issued document used to record direct care service hours over a 24 hour period) dated 3/09/2026 (one day prior to the observation) was observed posted in the facility's front lobby. The document indicated the facility census was 78. The posted document did not include nursing staffing information by category of licensed and unlicensed staff (RNs, LVNs, CNAs, desk nurse, etc.) directly responsible for resident care for each shift (11 PM-7 AM, 7 AM-3 PM, 3 PM-11 PM). Instead, the posting showed projected nursing hours for licensed and unlicensed staff for 3/09/2026. The document did not list the actual hours worked for each category, type, or shift of nursing staff on 3/09/2026. During a concurrent interview and record review on 3/10/2026 at 1:34 PM with the Director of Nursing (DON), the DON stated the Director of Staff Development (DSD) was responsible for updating, posting, and filing the daily nurse staffing data in the facility's front lobby. The DON stated he had not noticed that the posting had not been updated that day. The DON stated the staffing posting should be updated daily at the beginning of the first shift. During an interview and record review on 3/10/2026 at 1:40 PM with the DSD, the DSD stated she was responsible for ensuring the daily posting of nurse staffing data was updated. The DSD stated she had been instructed upon hire to display the projected staffing hours in the facility lobby and not the actual hours worked for each shift. A review of the facility's Policy and Procedure (P&P) titled Posting Direct Care Daily Staffing Number, revised March 2023, indicated the following: At the beginning of each shift, the number of licensed nurses (RNs and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care shall be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The information recorded on the form shall include, among other details, The actual time worked during that shift for each category and type of nursing staff, and the total number of licensed and non licensed nursing staff working for the posted shift.

Based on observation and interview, the facility failed to ensure foods were properly stored and sealed in accordance with the facility's Policy and Procedure titled Food Receiving and Storage. This deficient practice had the potential to result in food contamination and the growth of microorganisms that could cause foodborne illness. Findings: During a concurrent initial kitchen observation and interview with the Dietary Supervisor (DS) on 3/10/2026 at 8:35 AM, Refrigerator #1 was observed containing an open plastic container with grape jelly that was not sealed, and a container of preserved fruit cocktail that was not sealed properly. The lid on the preserved fruit cocktail container had a visible crack approximately 1 inch in length. During the same interview, the DS stated she observed the open plastic container with grape jelly that was not sealed and the preserved fruit cocktail container that was not sealed properly. The DS stated the preserved fruit cocktail had to be thrown away because the cracked lid exposed the food to air, which could allow bacteria to enter. The DS stated all food products must be sealed and dated to prevent contamination and spoilage according to their policy. During a review of the facility's policy and procedure titled Food Receiving and Storage, revised 11/2022, the policy indicated foods shall be received and stored in a manner that complies with safe food handling practices, and that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated (with a use by date).

Based on interview and record review, the facility failed to ensure advanced directives (ADs-written statements of a person's wishes regarding medical treatment, intended to guide care when the individual is unable to communicate) were obtained and accessible in the residents' medical records for two of two sampled residents (Residents 19 and 30). 1.Resident 19 and Resident 30's signed Advance Directive acknowledgment forms were not located in the residents' medical records. 2. Resident 30's Physician Orders for Life-Sustaining Treatment (POLST-medical order forms that direct medical staff regarding treatment preferences during a medical emergency when the individual cannot speak for themselves) were not completed in accordance with the facility's policy. This deficient practice had the potential to prevent residents' medical treatment preferences from being carried out during emergency situations and/or when a resident was incapacitated (unable to participate meaningfully in medical decision making). Findings: During a review of Resident 30's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] with a diagnosis of motor vehicle accident with altered level of consciousness (not being able to understand or react normally) and traumatic brain injury (TBI - damage to the brain from an injury). During a review of Resident 30's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 2/25/2026, the assessment indicated Resident 30 had severely impaired cognition (thinking). During an interview on 3/11/2026 at 8:30 AM with the Social Services Designee (SSD), the SSD stated attempts were made to contact the Responsible Party (RP) following admission on [DATE] but were unsuccessful, and she could not recall why further attempts were not made. The SSD stated she had confirmed Family Member 2 (FM2) as the RP and reported that FM2 had a diagnosis of dementia. During a review of Resident 30's History and Physical (H&P), signed and dated 3/10/2026, the H&P indicated that Resident 30 was able to make decisions regarding activities of daily living (ADLs - basic activities required for care such as eating and bathing). During a concurrent record review on 3/11/2026 at 8 AM with the Business Office Manager (BOM), Resident 30's hard chart was reviewed. The BOM stated there was an issue identifying the RP. The BOM stated the facility attempted to contact FM2, identified as the RP, but was unsuccessful and left a message. The BOM stated Family Member 1 (FM1) declined the RP role and was listed as Emergency Contact #1. The BOM stated she was unable to explain why additional attempts to contact FM2 were not made. The BOM stated the hard chart did not contain the AD notification form or POLST, as these documents remained unsigned as of 3/10/2026. During a concurrent record review on 3/11/2026 at 8 AM with the SSD, Resident 30's hard chart was reviewed. The SSD confirmed the AD notification form and POLST were not present due to lack of signature and pending contact with the RP. The SSD stated she acknowledged these documents should be maintained in the medical record and that failure to obtain a completed POLST may delay medical interventions during a change in condition (a change in the resident's health). During a concurrent record review on 3/11/2026 at 9 AM with the Director of Nursing (DON), Resident 30's hard chart was reviewed. The DON stated that Resident 30's POLST was not in the chart and was not completed due to the inability to contact FM2. The DON stated a completed and signed POLST ensures Resident 30's medical wishes are known, including life sustaining treatments, resuscitation (DNR - Do Not Resuscitate vs. Full Code), hospital transfers, and other medical interventions. The DON stated that if a medical emergency occurs, staff can follow the resident's wishes immediately instead of guessing or delaying care. A review of the facility's P&P titled Advance Directives, revised 9/2022, indicated that advance care planning is a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own decisions. The P&P indicated that the Physician Orders for Life-Sustaining Treatment (POLST) paradigm provides improved patient care by creating a portable medical order form that records the patient's wishes so emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. The P&P indicated that if the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. If the resident later becomes able to receive and understand this information, he or she will be provided with the same written materials, even if the legal representative has already received them.

Based on interview and closed record review, the facility failed to ensure the required Notice of Proposed Transfer/Discharge (a written notification to the resident or responsible party (RP) that included the reason for the transfer or discharge) was sent to the Long Term Care Ombudsman ( an state agency that advocates for the residents) for one of two sampled residents (Resident 91). The facility did not inform or email the Ombudsman office when Resident 91 was discharged from the facility, This deficient practice violated the resident's rights to have the Long-Term Care Ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) to advocate for Resident 91's transfer or discharge home. Findings: During a review of Resident 91's admission Record (AC), the AC indicated the resident was originally admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (a long-term lung condition that makes it progressively harder to breathe), schizoaffective disorder (a chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors). During a review of Resident 91's Order Summary Report dated 3/12/2026, the Order Summary Report indicated Resident 91 discharged home with resident's Family 1 (FMA)1 with all her medications and belongings and home health follow up with primary physician and psychiatrist with an order date of 1/20/2025. During an interview and record review on 3/12/2026 at 1:10 PM with Medical Record Director (MRD) of Resident 91's Notice of Transfer/discharge date d 1/20/2026 , MRD stated when a resident was transferred or discharged the facility must send a copy of the Transfer/ Discharge form to the ombudsman and keep a copy of the fax confirmation as part of their medical records. MRD stated he did not send the Ombudsman a copy of Resident 91's Transfer/Discharge Notice. During an interview on 3/12/2026 4:50 PM with Director of Nursing (DON), the DON stated it is facility policy to send the Ombudsman a copy of a Residents Transfer or Discharge notice to ensure they are informed of the facility residents who are being transferred and discharged . During a review of the facility's policy and procedure (P&P) titled Transfer or Discharge Notice, dated with a revision March, 2025, the P&P indicated A copy of the notice is sent to the office of the State Long Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 90) was provided with care and treatment in accordance with professional standards of practice by failing to: 1. Implement the Discharge Summary instructions from the General Acute Care Hospital (GACH) 1, dated 12/25/2025 to follow up with the outpatient cardiology to consider resuming beta blocker (medications that decrease heart rate and blood pressure) given Resident 90 had episodes of bradycardia (slow heart rate less than 60 beats per minute) and for placement of Zio Patch monitor (a water-resistant monitor applied to the upper left chest allowing continuous heart rhythm [heart electrical activity measuring the heart rate and any abnormal activity] monitoring with optional symptom logging monitor) 2. Implement interventions for Resident 90's complex medical history related to Coronary Artery Disease (CAD, plaque buildup in arteries [long tubes that transport oxygen and blood to the body]) and bradycardia (slow resting heart rate, less than 60 beats per minute [bpm]; normal heart rate 60 - 100 bpm) HR 20's and refusal of medications at times. 3. Follow up and monitor on Resident 90's Change of Condition (CoC) on 1/5/2026 after Resident 90 had 1 episode of watery colored emesis (vomiting) at 12:30 PM. These failures resulted in the lack of monitoring, medical management, and coordination of Resident 90's overall treatment related to his cardiac history of CHF and episodes of bradycardia.Findings: During a review of Resident 90's admission Record (AR), the facility admitted Resident 90 on 10/6/2025 and readmitted Resident 90 on 12/30/2025 with diagnoses that included Acute Respiratory Failure (ARF, the lungs cannot get enough oxygen into the blood) with hypoxia (not enough oxygen in blood), bradycardia (slow heart rate less than 60 beats/minute) and bipolar schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior). During a review of Resident 90's Minimal Data Set (MDS, a resident assessment), dated 10/13/2025, Resident 90's cognitive (a resident's thought process) skills were moderately impaired that needed moderate assistance (helper does less than half the effort) for ADLs such as toileting, showering, and dressing and needed supervision when transferring from a lying to sitting position in bed. During a review of Resident 90's Change of Condition (CoC) evaluation record, dated 12/21/2025 timed at 12:11 PM, the CoC record indicated at 11: 45 AM Resident 90 was in the dining room, hunched over with eyes closed. The record indicated Resident 90 was nonresponsive and passed out, and a staff member assisted Resident 90 to the floor. The record indicated the facility called 911, and Resident 90 was transferred to GACH 1. During a review of History and Physical record from GACH 1, dated 12/21/2025 timed at 9:23 PM, indicated Resident 90 had CHF and an exacerbation of COPD. During a review of GACH 1's Inpatient Progress Note dated 12/23/2025 timed at 6:45 AM, it indicated that Resident 90 had one episode of bradycardia with a heart rate of 20s while on the way to the Emergency Department. The record indicated that Resident 90 had another episode bradycardia with a heart rate of 20s but returned to normal without interventions. During a review of Inpatient Progress Note record, dated 12/25/2025 timed at 11:13 AM, the record indicated that Resident 90 ECHO (Echocardiogram, ultrasound to show how blood flows through the heart) test result on 12/22/2025, indicated Resident 90's Ejection fraction (EF is a percentage measuring how well the left ventricle pumps blood with each heartbeat, with a normal range typically 50%-70%) a low EF signifies that the heart is not pumping efficiently, which can indicate heart failure, reduced exercise capacity, and symptoms like fatigue and shortness of breath) low at was 32%. During a review of Resident 90's GACH 1 Discharge Summary record, dated 12/25/2025, the record indicated the following outpatient follow up and discharge plans To follow up with the outpatient cardiology to consider resuming beta blocker medication given Resident 90 had episodes of bradycardia and for placement of Ziopatch monitor outpatient. During a review of SNF 1's Nursing Advance Clinical Admission record, dated 12/26/2026 timed at 7 PM, the record indicated Resident 90 was admitted to SNF 1 from GACH 1 alert and oriented but sometimes forgetful, with regular heart rate, and receiving oxygen via nasal cannula (flexible thin tube used to deliver oxygen). The record indicated that Physician 1 was notified on 12/26/2026 of Resident 90's medication reconciliation, assessment findings, and admission to SNF 1. During a review of Resident 90's Nursing Advance Clinical Admission record, dated 12/30/2025 timed at 5 PM, the record indicated that Resident 90 was transferred to the facility from SNF 1 at 5 PM via private transport in a wheelchair. The record indicated that Physician 1 was notified of Resident 90's readmission to the facility from SNF 1 and will continue with all discharge/hospital orders and or treatments. During a review of Resident 90's CoC Evaluation record, dated 1/5/2026 timed at 12:30 PM, the record indicated that Resident 90 had one episode of water colored emesis. The record indicated thatPhysician 1 was notified of Resident 90's emesis and indicated the following order if emesis persists send out to [Emergency Room] for further treatment and evaluation. During an interview on 3/11/2026 at 2:28 PM with Physician 1 (Attending Physician), Physician 1 stated he saw Resident 90 after he was readmitted back to the facility on [DATE], but Physician 1 stated I do not remember if [Resident 90] refused treatments or not. Physician 1 indicated that he was aware Resident had one episode of watery emesis on 1/5/2026 before he passed away, but Physician 1 stated he cannot remember if he gave any specific orders. During a review of Fire Department Incident report, dated 1/6/2026 timed at 7:30 AM, the report indicated that Resident 90 complained of heart burn (burning sensation in the chest or throat caused by stomach acid reflux back into the esophagus) prior to cardiac arrest (abrupt loss of heart function) and the initial heart rhythm was asystole (heart completely stops working, resulting in no heartbeat, pulse, or blood circulation). The report indicated that Resident 90's time of death was 1/6/2026 at 7:58 AM. During the same concurrent interview and record review on 3/11/2026 at 4:20 PM with the DON, Resident 90's care plans were reviewed. The DON stated there was no documented evidence of any care plan related to Resident 90's cardiac medical history related to bradycardia. The DON stated there was no documented evidence of any care plan related to Resident 90's refusals of treatments. The DON stated it was important to create a care plan for Resident 90's cardiac diagnoses to implement specific monitoring related to Resident 90's heart rate and blood pressure. During the same concurrent interview and record review on 3/11/2026 at 4:35 PM with the DON, Resident 90's CoC Evaluation record dated 1/5/2026 timed at 12:30 PM, Progress Notes and Licensed Nurses Notes, were reviewed. The DON stated, the record indicated that Physician 1 was notified of Resident 90's CoC and to continue monitoring Resident 90 for continuous emesis. The DON stated that the Licensed Nurses were expected to document their continued monitoring of Resident 90's continuous emesis in the Licensed Nurses Note. The DON stated, there was no documented evidence in the Progress Notes and Licensed Nurses Notes for Resident 90's continued monitoring for emesis. During the same concurrent interview and record review on 3/11/2026 at 4:55 PM with LVN 2, Resident 90's MAR for January 2026, was reviewed. LVN 4 stated, she checked Resident 90's vital sign once a shift. LVN 4 stated, Resident 90's baseline heart rate was 75 - 80 bpm. LVN 4 stated Resident 90 did not have a specific order for heart rate monitoring. During the same interview on 3/11/2026 at 5 PM with LVN 2, LVN 2 stated she worked on 1/5/2026. LVN 4 stated, it was endorsed to her that Resident 90 had one episode of emesis in the previous shift, but she did not know if there was any specific monitoring related to Resident 90's CoC on 1/5/2026. During a concurrent interview and record review on 3/11/2026 at 5:15 PM with the DON, Resident 90's GACH 1 Discharge Summary record, dated 12/25/2026, was reviewed. The DON stated, Resident 90's discharge instructions included to follow up with the outpatient cardiology consultation regarding Resident 90's medications for CHF outpatient heart rate monitoring, and to continue his breathing treatments twice a day. The DON stated there was no cardiac consultation order and no documentation that Physician 1 was notified of Resident 90's GACH 1 Discharge instructions. The DON stated, I missed the outpatient follow up discharge orders from the [GACH] for outpatient cardiac follow up. During an interview on 3/12/2026 at 4:40 PM with Physician 1, Physician 1 stated it was the physician's responsibility to review the transfer papers from the GACH or outside facility and medications. Physician 1 stated he was Resident 90's admitting physician at the facility not at SNF 1. Physician 1 stated, he received a call readmitting Resident 90 back at the facility and agreed to continue all the medications from SNF 1. Physician 1 stated, he saw Resident 90 on 12/31/2025 and reviewed Resident 90's clinical records including all his transfer documents such the GACH 1 discharge instructions but did not see the record indicating the referral for Cardiology for heart monitoring and medication regimen for CHF. Physician 1 stated the licensed staff did not inform him about the GACH 1's referral of the resident to Cardiology for heart monitoring and CHF treatments. During a concurrent interview and record review on 3/13/2026 at 2:33 PM with LVN 2, Resident 90's Licensed Nursing Notes, were reviewed. LVN 2 stated Resident 90 was readmitted to the facility on [DATE] and remembered on admission, Resident 90 was out of breath upon when being transferred via wheelchair and. LVN 2 stated, she worked from 2 PM to 2 AM, and Resident 90 appeared comfortable and did not complain of shortness of breath. LVN 2 stated, she forgot to do a Licensed Nurses Note for the afternoon shift on 1/5/2026. During a review of the facility's policies and procedures (P&P) titled Change of Condition, date unknown, the P&P indicated that the purpose of a change of condition was to ensure proper assessment and follow-through for any resident with a change of condition. The P&P indicated that change of condition included but not limited to a sudden or marked difference in resident's vital signs, behavior, complaints, and chest condition or shortness of breathing. During a review of the facility's P&P titled Notification of Physician, date unknown, the P&P indicated that the Attending Physician/Alternate will be notified when there is a change in condition. The P&P indicated that the Licensed Nurse will subsequently note and carry out the physician's orders. During a review of the facility's P&P titled Admission/Readmission, dated March 2025, the P&P indicated that the physician and the care planning team will conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan.

Based on observation, interview and record review, the facility failed to maintain a medication error rate less than five (5) percent (%) during medication pass by committing two (2) medication errors on one of five sampled residents (Resident 8) during medication observation with 29 medication opportunities that resulted in a 6.9% medication error rate. This deficient practice had the potential to result in adverse reactions (undesired effect of a drug or other type of treatment), ineffective treatment, worsening of the resident's condition, or potentially serious harm, injury, or death. Exceeding the acceptable error rate indicates a systemic issue in safe medication administration. Findings: During a review of Resident 8's admission Record (AC), the AC indicated the resident was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (blood sugar levels in the blood are higher than normal) and hyperlipidemia (a condition where you have too many fats in your blood). During a review of Resident 8's History and Physical (H&P) signed on 1/2026, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 8's Order Summary Report dated 3/12/2026, the Order Summary Report indicated a medication order for: 1.Metoprolol tartrate (a medication used to treat high blood pressure and control heart rate) oral tablet 25 milligrams (mg-a unit of measurement), give one tablet by mouth one time a day for hypertension. Give with food to minimize risk of orthostatic hypotension (a sudden drop in blood pressure that occurs upon standing from a sitting or lying position). 2. Metformin HCL (medication used to treat high blood sugar) oral tablet 1000 mg, one tablet by mouth two times a day for Diabetes Mellitus, administer with food. During a medication pass observation on 3/12/2026 at 8:18 AM with Licensed Vocational Nurse (LVN 1), LVN 1 was observed administering Metoprolol tartrate oral tablet and Metformin HCL oral tablet to Resident 8 with water without food. Then LVN 1walked back to her medication cart to document in Resident 8's medication administration record. During a concurrent interview and record review with LVN 1 on 3/12/2026 at 8:22 AM, LVN 1 stated she was aware Resident 8's Metformin and Metoprolol medications indicated to administer each medication with food but she assumed it was ok not to give food right now with the medication since Resident 8 had had breakfast around 7AM. During an interview and record review on 3/12/2026 at 10:01 AM with Director of Nursing (DON), The DON stated Resident 8's medication order indicates to administer Metformin and Metoprolol medications with food. DON stated LVN 1 should have given Resident 8 a cracker or cookie if it is not mealtime and not administer the medication without food. The DON stated all licensed nurses administering medication should follow the doctors orders to prevent any undesired side effects in this case for Resident 8 stomach upset or orthostatic hypotension. During a review of the facility's policy and procedure (P&P) titled Med Pass, undated, the P&P indicated prepare the med correctly, administer the med correctly and chart the med pass correctly.

Based on observation, record review, and staff interview, the facility failed to ensure medications were not expired prior to administration for 1 out of 3 sampled residents (Resident 83). An observation of the locked medication refrigerator revealed an expired ABH gel (a compounded topical medication containing Ativan [medication for anxiety], Benadryl [antihistamine], and Haldol [antipsychotic medication]) 1mg-25mg-1mg/1ml with an expiration date of 2/25/2026. Record review indicated the expired medication was administered to Resident 83 seven times over a five day period. This deficient practice had the potential to affect Resident 83 and other residents receiving medications from improperly monitored storage. Findings: During a review of Resident 83's admission Record (AR), the AR indicated the resident was readmitted to the facility on [DATE] with diagnoses of unspecified dementia and mood disorder. During a review of Resident 83's History and Physical (H&P), signed and dated 12/18/2025, the H&P indicated Resident 83 did not have the capacity to understand and make decisions. During a review of Resident 83's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 83 had severely impaired cognition. During a review of Resident 83's Telephone Order dated 1/18/2026, the order indicated ABH Topical Gel (Ativan 1 mg, Benadryl 25 mg, Haldol 1 mg/1 ml) was to be applied every 4 hours as needed for agitation/restlessness, rubbed topically to the inner wrist alternating between right and left, and gloves were to be worn. During a review of Resident 83's Medication Administration Record (MAR) dated 02/2026, the MAR indicated that Resident 83 was administered ABH topical gel on 2/27/2026 at 6:45 AM. During a review of Resident 83's MAR dated 03/2026, the MAR indicated that Resident 83 was administered ABH topical gel on: 3/3/2026 at 7 PM 3/3/2026 at 11:15 PM 3/4/2026 at 7:06 AM 3/6/2026 at 6:40 AM 3/9/2026 at 6:30 AM 3/11/2026 at 6:31 AM During a medication storage observation and interview with the Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN 1) on 3/11/2026 at 1:15 PM, the locked medication refrigerator contained three prefilled 10 ml syringes of ABH Gel (Ativan 1 mg - Benadryl 25 mg - Haldol 1 mg/ml) with an expiration date of 2/25/2026. The DSD and LVN 1 both stated they observed the expired medication. LVN 1 stated that administering expired medication could result in ineffective treatment due to decreased potency. During an interview on 3/11/2026 at 1:30 PM, the DSD stated that expired ABH topical gel could lose potency and may not work as intended. The DSD stated that expired medications should be identified and removed from storage promptly. During a concurrent record review on 3/11/2026 at 2:05 PM, the DSD stated that Resident 83 had received an expired dose of ABH topical gel on 2/27/2026 at 6:45 AM. During a concurrent record review on 3/11/2026 at 2:10 PM, the DSD stated that Resident 83 received ABH topical gel on 3/3/2026 at 7 PM, 3/3/2026 at 11:15 PM, 3/4/2026 at 7:06 AM, 3/6/2026 at 6:40 AM, 3/9/2026 at 6:30 AM, and 3/11/2026 at 6:31 AM, and stated the licensed nurse should have checked the expiration date prior to administration. The DSD stated that expired medications should be removed from stock prior to expiration and that nursing staff are responsible for ensuring medications are current and safe before administration. During an interview on 3/11/2026 at 2:38 PM, the Director of Nursing (DON) stated he acknowledged that Resident 83 received expired ABH topical gel and stated that nursing staff are responsible for verifying expiration dates and removing expired medications from storage. During a review of the facility's policy and procedure titled Medication Storage in the Facility, dated 3/2008, the policy indicated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are to be removed from stock immediately and disposed of according to procedures. During a review of the facility's policy and procedure titled Med Pass, undated, the policy indicated that medications are not to be administered based on memory and are not to be administered solely because they are available.

Based on observation, interview, and record review, the facility failed to ensure one of the two refrigerators (located in the temporary food storage room at nearby facility) temperatures were monitored and documented before and between meal service activities for stable temperatures. This deficient practice placed the facility residents at risk for foodborne illness an (illness that comes from eating contaminated food) due to inconsistent refrigerator temperature monitoring and documentation. Findings: During a follow up kitchen tour on 2/6/25 at 12PM with the Dietary Service Supervisor (DSS) in the temporary food storage room located outside the kitchen, three (3) refrigerators and one (1) freezer were observed in this storage room. Each was observed with one thermometer inside. A Refrigerator and Freezer Temperature Log for February 2025 was observed hanging on the door. The log for 2/4/25 PM through 2/6/25 for Refrigerator 2 was blank. The log for Refrigerator 3 and Freezer was blank from 2/4/25 through 2/6/25. During an interview with on 2/6/25 at 12:10 PM, the DDS stated that the cooks for AM and PM shift are designated for checking all the temperature in the refrigerators and freezers and logs. DSS stated she was not sure if the cooks checked the logs, but the DDS should have not missed daily inspection of the logs. DSS also stated she was responsible for checking the logs and supervising the staffs for keep the log to ensure all the temperature in the refrigerators and freezers being monitored for safe food storage. During a review of the facility's policy and procedure titled, Refrigerators and Freezers dated 11/2022, indicated Monthly tracking sheets include time, refrigerator temperature, temperature of PHF/TCS food, initials, and action taken, The last column will be completed only if temperatures are not acceptable. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.

Based on observation, interview, and record review, the facility failed to ensure residents the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options for four of four sampled residents (Residents 37, 12, 69 and 14) by failing to: 1. Obtain an informed consent for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) medications for Resident 37, who was prescribed Quetiapine (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) for schizophrenia, and Divalproex Sodium (medication used to treat mental/mood conditions) for mood disorder. 2. Ensure the residents, or the responsible party was informed about the Physician Orders for Life-Sustaining Treatment (POLST) for Resident 12, 69 and 14. This deficient practice had violated resident rights to be informed when choosing the type of care or treatment to receive, make decisions on alternative measures the resident or responsible party preferred, which can negatively affect Residents 37,12, 69, and 14's quality of life and/or delay in residents care that could ultimately result to adverse health outcomes. Findings: 1. During a review of the admission record indicated Resident 37 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), psychotic disorder (affect the mind, where there has been some loss of contact with reality), and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and actions). The admission record indicated Resident 37 had a family member that has power of attorney [POA] and is considered the resident's representative [RR] and emergency contact. A review of Resident 37's History and Physical Examination, dated [DATE], indicated Resident 37 did not have the capacity to understand and make decisions. During a review of Minimum Data Set (MDS - a resident assessment tool), dated [DATE], indicated Resident 37 required partial/moderate assistance (helper does less than half the effort) with eating, toileting, personal hygiene, and bathing. During a review of Resident 37 ' s facility document Order Summary Report (OSR), dated [DATE], the document indicated physician orders for: a) Quetiapine 100 mg (unit of weight) to give 1 tablet every 12 hours for schizophrenia ordered [DATE], and b) Divalproex Sodium 500 mg to give 1 tablet every 12 hours for mood disorder, ordered [DATE]. During a concurrent interview and record review, on [DATE], at 9:45 AM, with Registered Nurse (RN) 1, Resident 37's facility document titled Informed Consent for medications Quetiapine and Divalproex sodium, dated [DATE], was reviewed. The documents did not have the signature of the prescriber nor the signature of Resident 37 ' s RR or POA. RN 1 stated, Resident 37 ' s informed consents were not complete, it should have the signature of the prescriber within 24 hours of admission. RN 1 stated, it is important to have a complete informed consent for psychotropic medications to ensure the Resident or the responsible party are aware of the cause and effect of the medications and other alternatives available. During a concurrent interview and record review, on [DATE], at 9:55 AM, with RN 1, Resident 37's electronic health records (EHR) was reviewed from admission[DATE] until [DATE] was reviewed. The EHR did not have any documentation that informed consent for the psychotropic medications Quetiapine and Divalproex sodium was obtained by the prescriber. RN 1 stated, she could not see any documentation specifically stating informed consent for the psychotropic drugs was obtained by the prescriber. During an interview on [DATE] at 10:00 AM with MDS Nurse (MDSN) 1, MDSN 1 stated, the informed consent for psychotropic drugs is not complete without the prescriber ' s signature. MDSN 1 stated, it is important to have informed consent for psychotropic drugs to ensure the resident or the responsible party are aware of the pros (advantages) and cons (disadvantages) of the medication prior to making a decision, it is also for patient safety. During an interview on [DATE] at 10:20 AM with Director of Nurses (DON), the DON stated, Resident 37's informed consent for psychotropic medications Quetiapine and Divalproex sodium was not complete, it should have been signed by the prescriber as soon as possible within 24 hours. The DON stated, he did not have proof consent for psychotropic drugs was obtained by the prescriber from Resident 37 or responsible party. The DON stated, it is to ensure the informed consent was done and the medications was explained to Resident 37 and /or the responsible party about the pros and cons of the medications and other alternative treatments. During a review of the facility's policy and procedure (P&P) titled Informed Consent for Psychotropic Drug Use (undated), indicated: a) prior to prescribing a psychotropic medication, the licensed prescriber shall examine the resident and obtained informed consent either from the resident (if able) or the resident ' s representative, b) the license nurse shall verify written informed consent specifying the disclosure of material information for proper informed consent c) licensed nurse shall verify from the resident and/or legal representative whether the consent has been obtained for the use of psychotropic medication and will sign the form and document the person who gave consent and the date the consent was verified, and d) the licensed prescriber, Resident representative may sign the informed consent using remote technology, if possible and as soon as practicable. 2. A review of Resident 12's Admission Record indicated the facility admitted Resident 12 on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder (symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), Chronic Obstructive Pulmonary Disease (COPD) (a common lung disease causing restricted airflow and breathing problems), and history of urinary tract infection. A review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], indicated that Resident 12's cognitive status (the mental process of thinking and understanding) was moderately impaired. The MDS Indicated Resident 12 required set up or clean-up assistance (helper sets up or clean up resident; resident completes activity. Helper assists only prior to or following the activity) with eating and bathing and required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with toileting and personal hygiene. During a concurrent interview and record review, on[DATE], at 12:27 PM, with Registered Nurse (RN) 1, Resident 12 facility document titled Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE] was reviewed. The POLST indicated DNR (It instructs providers not to do CPR (cardiopulmonary resuscitation) if a patient's breathing stops or if the patient's heart stops beating) status, but it was missing the responsible party ' s signature. RN 1 stated, the POLST is not valid because it is missing the responsible party ' s signature. RN 1 stated, Resident 12 POLST is used as a Physician Order by other medical professionals when Resident 12 goes to the hospital or incase of emergency, not having a valid POLST may delay the care of Resident 12. A review of Resident 69's Admission Record indicated that the facility originally admitted Resident 69 on [DATE] and readmitted on [DATE] with diagnoses that included Dementia (a group of related symptoms associated with an ongoing decline of the brain and its abilities), coronary artery dissection (a condition that affects your heart), and diabetes (lifelong condition that causes a person's blood sugar level to become too high). A review of Resident 's MDS, dated [DATE], indicated that Resident 69's cognitive status (the mental process of thinking and understanding) was moderately impaired. The MDS Indicated Resident 69 required set up or clean-up assistance (helper sets up or clean up resident; resident completes activity, helper assists only prior to or following the activity) with eating, toileting, bathing and personal hygiene. During a concurrent interview and record review, on[DATE], at 12:30 PM, with Registered Nurse (RN) 1, Resident 69 facility document titled Physician Orders for Life-Sustaining Treatment (POLST) dated [DATE] was reviewed. The POLST indicated DNR status, but it was missing the responsible party's signature. RN 1 stated, the POLST is not valid because it is missing the responsible party's signature. RN 1 stated, Resident 69 POLST is used as a Physician Order by other medical professionals when Resident 69 goes to the hospital or in case of emergency, not having a valid POLST may delay the care of Resident 69. During an interview on [DATE] at 2:30 PM with Director of Nurses (DON) , DON stated, the POLST needs to have the signature of the Physician, the Resident or the responsible party to be considered valid. DON stated, the POLST are kept in the Resident physical chart to be used by medical professionals as a Physician Order during transfers to the hospitals and/or during emergency, not having a valid POLST may cause delayed of care. 36925 3. A review of Resident 14's Admission Record indicated that the facility admitted Resident 14 on [DATE] with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], indicated that Resident 14's cognition (mental action or process of acquiring knowledge and understanding) was intact. A review of Resident 14's medical records indicated that the facility prepared a POLST on [DATE] but failed to obtain the signature of the resident before placing it in the resident's chart. During an interview on [DATE] at 3:37 PM, LVN 4 stated that the facility should offer the Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) and the POLST to the resident on admission and have it signed accordingly. LVN 4 stated that without these records in place, the facility would not know the medical interventions the resident wanted during end-of-life situations. During an interview on [DATE] at 3:51 PM, the medical records director (MRD) stated that it was his responsibility to ensure that the facility offered the resident an Advance Directive and a POLST during admission and to have it filled out and signed accordingly before he uploads those documents to the PCC and place them in the chart of the resident. The MRD stated that without these records in place, the staff would not know what end-of-life treatment the resident wanted during emergency situations. The MRD stated that he must have overlooked it. A review of the facility's policy and procedure (P&) titled, POLST dated ,d+[DATE], indicated ; a) the facility follows the guidance attached Quick Reference Guide ON POLST IN NURSING HOME which indicates the POLST isn't valid unless it is signed by a (1) physician, nurse practitioner or physician assistant and (2) the resident, if resident lacks capacity, the resident's legally recognized healthcare decision maker, b) by signing POLST, which becomes a medical order, the physician, nurse practitioner, or physician assistant certifies that the order on the form are consistent with the resident medical condition and preferences, and c) when completed by the patient or legally recognized representative a physician, nurse practitioner or physician assistant the POLST becomes a medical order that should also be included in the patient's medical record. A review of the facility's policy titled, Charting and Documentation, Version 1.2, revised in ,d+[DATE], indicated that documentation in the medical record should be complete and accurate. During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated ,d+[DATE], indicated, federal and state law guarantee certain basic rights to all residents of the facility, these rights included resident rights to: a) be informed about his rights and responsibilities, and b) be informed of his medical condition and of any changes in his condition.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality of two of four sampled residents (Resident 3 and Resident 226) when: 1. Resident 3's suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) urinary bag (urine drainage bag to collect urine) was observed without a urinary catheter bag cover. 2. Resident 226 who was hard of hearing (HOH) and spoke a foreign language that the facility staffs could not understand, and the resident could not understand the common language in the facility was not accurately assessed and provided the proper means of communicating with the staffs and residents. These deficient practices violated the resident's rights to maintain privacy, enhanced self-esteem, self-worth, that resulted in Resident 226 expressed frustration, weeping, and stated she suffered a lot because of poor communication and her needs were not met. Findings: 1. During a review of Resident 3 ' s, Admission Record (AR), dated 2/5/2025, indicated Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including benign prostatic hyperplasia (a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), obstructive and reflux uropathy (obstructive uropathy happens when urine can't flow through the urinary tract, while reflux uropathy occurs when urine flows backward into the kidneys), and history of urinary tract infection. A review of Resident 3 ' s History and Physical Examination (H&P), dated 12/3/2024, indicated Resident 3 does not have the capacity to understand and make decisions. A review of Resident 3 ' s Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 3 ' s cognitive status (the mental process of thinking and understanding) was severely impaired. MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, toileting and personal hygiene, and required partial/moderate assistance (helper does less than half the effort) with bathing. A review of Resident 3 ' s facility document titled Order Summary Report (OSR), dated 2/1/2025, the document indicated Resident 3 had a suprapubic catheter attached to a drainage bag for obstructive and reflux uropathy. During a concurrent observation and interview on 2/5/2025 at 8:20 AM with certified nurse assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 in Resident 3 ' s room, Resident 3 was sitting on his wheelchair with the suprapubic catheter urinary bag was without a urinary catheter bag cover. CNA 1 stated, she did not know where the urinary bag cover was. LVN 1 stated, Resident 3's urinary bag should have a cover, because not having the cover violates the resident ' s rights for privacy and dignity. During an interview on 2/5/2025 at 2:25 PM with Director of Nurses (DON), DON stated, Resident 3 should have a cover for his urinary bag, not having it violates his rights for privacy and dignity. A review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated 3/2023, indicated; a) employees shall treat all residents with kindness, respect and dignity, b) federal and state laws guarantee certain basic rights to all residents which includes, dignified existence, be treated with respect and dignity, and privacy and confidentiality. A review of the facility ' s policy and procedure (P&P) titled, Dignity, dated 2/2021, indicated; demeaning practices and standards of care that compromise dignity is prohibited, staff are expected to promote dignity and assist residents to keep urinary catheter bags covered. 48481 2. During a review of Resident 226 ' s Admission Record indicated Resident 226 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, dementia (a progressive state of decline in mental abilities), Unspecified abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.) During a review of Resident 226 ' s Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing. During a concurrent observation and interview 2/5/2025 at 9:05 AM, Resident 226 was observed writing on a piece of paper in foreign language back and forth with Certified Nursing Assistant (CNA) 1. Resident 226 stated the communication has been difficult between her and staffs, because she has hard of hearing (HOH) and she and the staffs do not understand each other sometimes with her limited English. Resident 226 stated there were times that staffs who didn't understand her language walked out of the room and did not come back. Resident 226 stated she had never been offered communication board, audio or video materials in the language that she speaks. Resident 226 was observed expressing frustration, weeping, and stated she suffered a lot because of poor communication and her needs were not met. During an interview on 2/5/25 at 9:15 AM with CNA 1, CNA 1 stated Resident 226 has HOH, speaks limited language that the facility uses, CNA 1 stated she communicates to the resident in writing when she was called to help translate in the language that the residents speak. CNA1 also stated she had noticed Resident 226 expressed sadness and frustration when complaining to her about not understanding the staffs and not being understood by the staffs. During an interview on 2/5/25 at 9:35AM, with Licensed Vocational Nurse (LVN )4, LVN 4 stated she communicated with Resident 226 via phone translation (connect with a live interpreter via phone for real-time translation), and she was aware the Resident 226 had HOH, and has language communication barrier, sometimes staffs assist translation, LVN 4 stated there was no communication board available at bedside for Resident 226 to use, and stated she does not use phone translation due to Resident 226 had a HOH so the method was not very effective. During an interview on 2/6/25 at 11:00 AM with Registered Nurse (RN) 2, RN 2 stated he uses body language, to communicate with Resident 226. RN 2 stated there was no communication board available. RN 2 stated he couldn ' t always ensure if Resident 226 understood him, sometimes based on translator ' s feedback. During a review of Resident 226 ' s Licensed Nurses Notes, dated 1/9/25 throughout 2/4/25, no documented evidence that indicated a translator and/or communication board was provided to the resident in a foreign language that the resident speaks and understands. During an interview on 2/6/25 at 9:16 AM with Director of Nursing (DON), DON stated when a resident is admitted with communication-sensory or language barrier, admission nursing staff should identify the risk factors, residents ' needs, develop and implement a person-centered care plan. Failure to communicate effectively between staffs and residents will impair resident rights. The DON stated communication is important, staffs should have properly assessed Resident 226 ' s needs, developed and implemented comprehensive care plan, and used effective communication methods to ensure staffs understand her, and Resident 226 can relate to the staffs. It's totally not acceptable to have resident's rights compromised due to any barrier. During a review of the facility ' s policy and procedure titled Resident Rights dated 2/2021, indicated Federal and State laws guarantee certain basic rights to all residents in the facility. These include resident ' s right to: a. be treated with respect, kindness, and dignity. b. be supported by the facility in exercising his or her rights. During a review of the facility ' s policy and procedure titled Dignity dated 2/2021, indicated Each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The facility culture supports dignity and respect for resident goals, choices, preferences, values, and beliefs.

Based on interview and record review, the facility failed to implement its policy and procedure on Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) by failing to ensure the Advance Directive was offered and explained and the signed AD was in the chart for two of four sampled residents (Residents 14 and 39). This deficient practice has the potential to omit the residents ' medical decisions if they become incapacitated (unable to make decision for self) leading to unnecessary or unwanted treatments due to lack of clear instructions regarding their end-of-life care. Findings: 1. A review of Resident 14's Admission Record indicated that the facility admitted Resident 14 on 11/15/2024 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 14's Minimum Data Set (MDS - a resident assessment tool), dated 11/22/2024, indicated that Resident 14 ' s cognition (mental action or process of acquiring knowledge and understanding) was intact. A review of Resident 14's medical records showed that the resident did not have an Advance Directive in his chart or in the facility's Point Click Care database program (PCC, a cloud-based software platform that helps healthcare organizations manage care and services of the residents). A review of Resident 14's Admission Assessment and Nurse ' s Notes, dated 11/15/2024, showed no indication that the facility offered an Advance Directive to Resident 14 during admission. 2. A review of Resident 39's Admission Record indicated that the facility initially admitted Resident 39 on 9/4/2019 and readmitted the resident on 10/31/2024 with diagnoses that included pneumonia (an infection/inflammation in the lungs) and schizophrenia. A review of Resident 39's History and Physical evaluation, dated 10/31/2024, indicated that the resident did not have the capacity to understand and make decisions. A review of Resident 39's MDS dated [DATE], indicated that Resident 39's cognition was intact. A review of Resident 39's medical records showed that the resident did not have an Advance Directive or a Physician's Orders for Life-Sustaining Treatment (POLST, a portable, medical order form that documents a patient's preferences for end-of-life care) in his chart or in the facility's PCC database program. During an interview on 2/4/2025 at 3:10 PM, Licensed Vocational Nurse (LVN) 3 stated that the facility should place the Advance Directive and the POLST in the chart of the resident. LVN 3 stated that she does not know who is responsible in ensuring that these forms are in place. During an interview on 2/4/2025 at 3:37 PM, LVN 4 stated that the facility should offer the Advance Directive and the POLST to the resident on admission and have it signed accordingly. LVN 4 stated that without these records in place, the facility would not know the medical interventions the resident wanted during end-of-life situations. During an interview on 2/4/2025 at 3:51 PM, the medical records director (MRD) stated that it was his responsibility to ensure that the facility offered the resident an Advance Directive and a POLST during admission and have it filled out and signed accordingly before he uploads them to the PCC and puts them in the chart of the resident. The MRD stated that without these records in place, the staff would not know what end-of-life treatment the resident wanted during emergency situations. The MRD stated that he must have overlooked it. A review of the facility's undated policy titled, Advance Directives, version 2.0, revised in 9/2022, indicated that prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. If the resident or representative indicates that he or she has not established advance directives, the facility staff will help in establishing advance directives and the nursing staff will document in the medical record that assistance was offered and the resident ' s decision to accept or decline assistance.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident for two of two sampled residents (Resident 9 and 226) in accordance to the facility's policy and procedure and the resident's rights by [NAME] to ensure: 1. A plan of care was developed to address Resident 9 with behavior of physically aggression towards staffs and the residents and went to other resident's rooms and took their personal belongings. 2. A plan of care was developed to address Resident 226's concern of hard of hearing (HOH) and communication in a foreign language that the facility staffs could not understand, These deficient practices resulted for Resident 9 to have multiple incidents of aggressive behavior that potentially exposed other residents to physical and psychological harm. In addition Resident 226 had verbalized frustration and the potential not to receive the necessary care and services the resident needed especially in an event of emergency. Cross reference to F550 and F740 Findings: 1. A review of Resident 9's Admission Record indicated that the facility initially admitted Resident 9 on 2/27/2012 and readmitted the resident on 1/14/2025 with diagnoses that included schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, indicated that Resident 9's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 9 required partial/moderate assistance (helper does less than half the effort of the task) from a person when performing most of her daily living activities. A review of Resident 9's Change of Condition (COC) assessment, dated 1/16/2025 and 1/28/2025, indicated that Resident 9 showed an aggressive behavior towards the staff and residents. The COC on 1/16/2025 indicated that Resident 9 was trying to attack the staff and residents and went to the room of other residents to take their personal belongings. The COC on 1/28/25 indicated that Resident 9 was again trying to strike out at the staff and residents. A review of Resident 9's medical records indicated that the facility did not create a care plan for Resident 9 ' s COC on 1/16/2025 when Resident 9 tried to attack the staff and residents and went to the rooms of other residents to take their personal belongings. A review of Resident 50's Admission Record indicated that the facility initially admitted on [DATE] and readmitted the resident on 3/13/2025 with diagnoses that included schizophrenia. A review of Resident 50's MDS, dated [DATE], indicated that Resident 50's cognition was moderately intact. The MDS indicated that Resident 50 required partial/moderate assistance (helper does less than half the effort of the task) from a person when performing most of her daily living activities. During an interview with Resident 50 on 2/5/2025 at 10:50 AM, she stated that about three weeks ago, Resident 9 went to her room, took her pillow, and left. Resident 50 stated that on 2/4/2025, Resident 9 went back to her room, stood at the doorway, and refused to leave when she asked her to go back to her room. Resident 50 stated that she reported the incident to one of the licensed nurses. During an interview with licensed vocational nurse (LVN) 4 on 2/5/2025 at 1:51 PM, LVN 4 stated that she initiated a COC for Resident 9 on 1/16/2025 since Resident 9 became physically and verbally aggressive towards the staff and other residents; however, she stated that Resident 9 did not have physical contact with any resident. LVN 4 stated that Resident 9 also went to the rooms of other residents on the same day and took their personal belongings. During an interview with LVN 1 on 2/5/2025 at 1:58 PM, LVN 1 stated that she initiated a COC for Resident 9 on 1/28/2025 since Resident 9 became physically aggressive towards the staff and other residents; however, LVN 1 stated that Resident 9 did not have physical contact with any resident. During an interview and a record review of Resident 9's medical records with the director of nursing (DON) on 2/7/2025 at 7:50 AM, the DON stated that the facility did not conduct an interdisciplinary team (IDT, a group of professionals from different disciplines who work together collaboratively to achieve a common goal) meeting or created a care plan to address Resident 9's behavior on 1/16/2025. The DON stated that the facility should have conducted an IDT meeting and created a care plan for Resident 9 to ensure the safety of the residents, prevent harm, and promote dignity and privacy among the residents. A review of the facility's undated policy titled, Care Plans, Comprehensive Person-Centered, version 2.0, revised in 3/2022, indicated that the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, should develop and implement a comprehensive, person-centered care plan to meet the physical and psychosocial needs of each resident. 48481 2. During a review of Resident 226 ' s Admission Record indicated Resident 226 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, dementia (a progressive state of decline in mental abilities), Unspecified abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.) During a review of Resident 226 ' s Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing. During a review of Resident's 226's Care Plan dated 1/10/25, indicated Resident 226 was at risk of having needs unmet related to difficulty in communication secondary to hard of hearing and spoke a foreign language. 1. Resident will be able to relate to others effectively daily until the next assessment. 2. Resident will have communication needs met by use appropriate interventions daily until the next assessment. During a concurrent observation and interview 2/5/2025 at 9:05 AM, Resident # 226 was observed writing on a piece of paper in foreign language back and forth with Certified Nursing Assistant (CNA) 1. Resident 226 stated the communication has been difficult between her and staffs, because she has hard of hearing (HOH) and she and the staffs do not understand each other sometimes with her limited English. Resident 226 stated there were times that staffs who didn't understand her language walked out of the room and did not come back. Resident 226 stated she had never been offered communication board, audio or video materials in the language that she speaks. Resident 226 was observed expressing frustration, weeping, and stated she suffered a lot because of poor communication and her needs were not met. During an interview on 2/5/25 at 9:15 AM with CNA 1, CNA 1 stated Resident 226 has HOH, speaks limited language that the facility uses, CNA 1 stated she communicates to the resident in writing when she was called to help translate in the language that the residents speak. CNA1 also stated she had noticed Resident 226 expressed sadness and frustration when complaining to her about not understanding the staffs and not being understood by the staffs. During an interview on 2/5/25 at 9:35AM, with Licensed Vocational Nurse (LVN )4, LVN 4 stated she communicated with Resident 226 via phone translation (connect with a live interpreter via phone for real-time translation), and she was aware the Resident 226 had HOH, and has language communication barrier, sometimes staffs assist translation, LVN 4 stated there was no communication board available at bedside for Resident 226 to use, and stated she does not use phone translation due to Resident 226 had a HOH so the method was not very effective. During an interview on 2/6/25 at 11:00 AM with Registered Nurse (RN) 2, RN 2 stated he uses body language, to communicate with Resident 226. RN 2 stated there was no communication board available. RN 2 stated he couldn ' t always ensure if Resident 226 understood him, sometimes based on translator ' s feedback. During a review of Resident 226 ' s Licensed Nurses Notes, dated 1/9/25 throughout 2/4/25, no documented evidence that indicated a translator and/or communication board was provided to the resident in a foreign language that the resident speaks and understands. During an interview on 2/6/25 at 9:16 AM with Director of Nursing (DON), DON stated when a resident is admitted with communication-sensory or language barrier, admission nursing staff should identify the risk factors, residents ' needs, develop and implement a person-centered care plan. Failure to communicate effectively between staffs and residents will impair resident rights. Communication is important, staffs should have properly assessed Resident 226 ' s needs, developed and implemented comprehensive care plan, and used effective communication methods to ensure staffs understand her, and Resident 226 can relate to the staffs. It's totally not acceptable to have resident's rights compromised due to any barrier. During a review of the facility ' s policy and procedure titled Care Plans, Comprehensive Person-Centered dated 3/2022, indicated The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframes. b. Describe services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being. c. Builds on the resident ' s strengths. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and relevant clinical decision making.

Based on observation, interview, and record review, the facility failed to ensure a resident received proper assistive devices to maintain hearing abilities for one of 3 sampled residents (Resident 226) who was not assisted by the facility in arranging a referral for audiologist (a physician specialized in hearing loss) consult. This deficient practice resulted in a delay of services and Resident 226 not being able to hear adequately while communicating with staffs. Findings: During an observation on 2/4/25 at 8:33 AM, Resident 226 was observed alert, lying in bed, with a raised voice speaking to a laboratory staff, who also had to raise volume for Resident 226 to hear the resident. Resident 226 also pulled out pieces of paper and requested to communicate in writing. During an interview on 2/4/25 at 9:31 AM, Resident 226 stated she has hard of hearing (HOH), has no device, to assist her with the difficulty hearing whatever the staffs say to her. During a concurrent observation and interview on 2/5/25 at 9:15 AM with CNA 1, CNA 1 was observed writing on a paper to communicate with Resident 226, CNA 1 stated writing works better than speaking to Resident 226. CNA1 also stated aware that Resident 226 has HOH, speaks limited language formally used in the facility. CNA 1 stated she was often called by staffs to Resident 226 ' s room to help translate in a language that the resident speaks and understands. CNA 1 stated she often hear Resident 226 complained not understanding the staffs and not being understood. During an interview on 2/5/25 at 9:20 AM, LVN 5 stated she aware that Resident 226 was HOH, and has language barrier. LVN 5 stated sometimes she use body gestures to communicate with the resident but can ' t be sure if Resident 226 fully understood what she ' s trying to tell Resident 226. During a review of Resident 226's Admission Record indicated Resident 226 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), Unspecified Dementia (a progressive state of decline in mental abilities), abnormalities of Gait and Mobility (changes to the way a person walks or moves due to injuries, medical conditions, or other reasons.) During a review of Resident 226's Minimum Data Set (MDS - a resident assessment tool) dated 10/1/24, indicated Resident 226 was severely cognitively impaired (a condition that makes it very difficult for a person to think, learn, and remember). The MDS also indicated Resident 226 had moderate difficulty in hearing. During a review of a physician order dated 1/9/25, indicated Resident 226 was referred to Audiology consult PRN (as needed) for hearing problems. During a concurrent interview and record review on 2/6/25 at 8:50 AM with Social Service Director (SSD). SSD stated spoke to Resident 226 and her responsible party upon admission. SSD stated Resident 226 did not have hearing disability, that ' s why ENT (Ear, Nose, Throat) doctor appointment arranged set up necessary. No staffs reported SSD re: hearing disability. During an interview on 2/6/25 at 9:16 AM with Director of Nursing (DON), DON stated when a resident is admitted with communication-sensory barrier, the SSD has to do the assessment, MDS also assess resident upon admission, and reassess if there's discrepancy in the assessments. Then SSD arrange audiology consult and make appointment for resident. Failure to report resident ' s needs for specialty consultation delay the care and services, and impaired resident rights. Communication is important, staffs should have properly assessed Resident 226 ' s needs and used effective communication methods to ensure resident can understand. It's totally not appropriate to have resident's care delayed due to any barrier. During a review of the facility's policy and procedure titled Accommodation of Needs Related to Communication Deficits revision date 3/2021, indicated Communication needs will be identified, and appropriate interventions will be developed in order to accommodate the needs of the residents. Communication needs will be assessed as follows: a. Psycho-Social Assessment form; Resident Identifying Date- Language Spoken b. Rehabilitation Screening- Mode of Expression, etc c. Communication Section on Social Service Progress Notes. During a review of the facility's policy and procedure titled Accommodation of Needs, revision dated 3/2021, indicated that facility ' s environment and staff behavior are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The resident ' s individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis. Interact with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received appropriate treatment and services to prevent urinary tract infection (UTI-when bacteria gets into your urine and travels up to your bladder), in accordance with the facility's policy and procedures (P&P) on Infection Prevention and Control Program. 1. On 2/4/2025, Resident 3 was observed while sitting on his wheelchair, Resident 3's suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) drainage bag (urine drainage bag to collect urine) was hanging on the wheelchair ' s left arm rest (positioned higher than Resident 3's bladder). 2. On 2/5/2025, Resident 3 was observed with the suprapubic catheter tubing wrapped around his left leg while sitting on his wheelchair. This deficient practice had the potential for Resident 3 to have recurrent urinary tract infection and negatively affect Resident 3's quality of life. Findings: During a review of Resident 3's, Admission Record (AR), dated 2/5/2025, indicated Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including benign prostatic hyperplasia (a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), obstructive and reflux uropathy (Obstructive uropathy happens when urine can't flow through the urinary tract, while reflux uropathy occurs when urine flows backward into the kidneys), and history of urinary tract infection (UTI). During a review of Resident 3's History and Physical Examination (H&P), dated 12/3/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 3's cognitive status (the mental process of thinking and understanding) was severely impaired. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, toileting and personal hygiene, and required partial/moderate assistance (helper does less than half the effort) with bathing. During a review of Resident 3's care plan (CP) for suprapubic catheter, at risk for complication from catheter use (i.e. recurrent urinary tract infection) initiated 12/27/2019, the CP indicated staff to maintain proper alignment of the suprapubic catheter to promote proper drainage. During a review of Resident 3's facility document titled NC-COC/Interact Assessment Form (SBAR), dated 9/14/2022, the document indicated Resident 3 had a UTI and was placed on antibiotic (medicines that fight bacterial infections) therapy. During a review of Resident 3's Order Summary Report (OSR), dated 2/1/2025, the OSR indicated, an order date of 11/30/2024 the use of suprapubic catheter attached to drainage bag for obstructive and reflux uropathy. During a concurrent observation and interview on 2/4/2025 at 10:15 AM with Registered Nurse (RN) 1 in the Dining Room, Resident 3 was sitting on his wheelchair, his suprapubic catheter drainage bag was hanging on the wheelchair's left armrest (positioned higher than Resident 3's bladder). RN 1 stated, the urinary drainage bag should not be hanging on the armrest, it should be under the wheelchair seat and must be positioned lower that Resident 3's bladder. RN 1 stated, the position of the urinary drainage bag could cause backflow of urine back to Resident 3's bladder and can cause UTI. During a concurrent observation and interview on 2/5/2025 at 8:20 AM with Licensed Vocational Nurse (LVN) 1, and Certified Nurse Assistant (CNA) 1 in Resident 3 ' s room, Resident 3 while sitting on his wheelchair, noted his suprapubic catheter tubing was wrapped around his left leg. CNA 1 did not have an answer to why the suprapubic catheter tubing was wrapped around Resident 3's left leg, LVN 1 stated, Resident 3's suprapubic catheter tubing wrapped around his leg is not appropriate, the urine will not flow freely and could cause backflow to Resident 3's bladder and had the potential to cause UTI. During an interview on 2/5/2025 at 2:05 PM with the Infection Preventionist (IP), the IP stated, the suprapubic catheter urinary bag should always be positioned below the resident's bladder. The IP stated the suprapubic catheter tubing should not be wrapped around residents' leg because these practices could cause back flow to Resident 3's bladder and had the potential to cause UTI. During an interview on 2/5/2025 at 2:25 PM with the Director of Nurses (DON), the DON stated, the suprapubic catheter urinary bag should not be hanging on Resident 3's wheelchair arm rest, it should always be positioned below Resident 3's bladder, and the tubing should not be wrapped around Resident 3's leg, otherwise it could cause backflow to Resident 3's bladder and cause UTI. During a review of the facility's P&P titled, Suprapubic Catheter Care, dated 10/2010, the P&P indicated; a)the purpose of the procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident ' s urinary tract, b) to review the resident ' s care plan to assess for any special needs of the resident and c) the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. During a review of the facility's P&P titled, Infection Prevention and Control Program revised 4/2023, the P&P indicated; a) the facility established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and b) important facets of infection prevention include instituting measures to avoid complications or dissemination (to spread or scatter).

Based on interview and record review, the facility failed to implement its policy and procedure on behavioral health services by failing to provide one of two sampled residents (Resident 9) a referal to psychiatrist (a physician specialized in mental and behavioral health) consultation evaluation for aggressive behavior towards the staff and residents to attain the resident's highest practicable physical, mental, and psychosocial well-being. This deficient practice had the potential to worsen the mental health symptoms of the resident, increase risk of relapse, decrease quality of life, and increase the likelihood of needing more intensive interventions like hospitalization in the future. Findings: A review of Resident 9's Admission Record indicated that the facility initially admitted Resident 9 on 2/27/2012 and readmitted the resident on 1/14/2025 with diagnoses that included schizophrenia (a mental illness characterized by disturbances in thought and false belief of reality). A review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, indicated that Resident 9's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 9 required partial/moderate assistance (helper does less than half the effort of the task) from a person when performing most of her daily living activities. A review of Resident 9's Change of Condition (COC) assessment, dated 1/16/2025 and 1/28/2025, indicated that Resident 9 showed an aggressive behavior towards the staff and residents. The COC dated 1/16/2025 indicated Resident 9 was trying to attack the staff and residents, went to a resident's room, and took the personal belongings of another resident. The COC on 1/28/2025 indicated that Resident 9 was again trying to strike out at the staff and residents. A review of Resident 9's medical records indicated that the facility created a care plan on 1/28/2025 to address Resident 9's aggressive behavior towards the staff and residents. The interventions in the care plan included a consultation with a psychiatrist to evaluate the resident 's behavior. During an interview with Licensed Vocational Nurse (LVN) 4 on 2/5/2025 at 1:51 PM, LVN 4 stated that she initiated a COC on 1/16/2025 since Resident 9 became physically and verbally aggressive towards the staff and other residents. During an interview with LVN 1 on 2/5/2025 at 1:58 PM, LVN 1 stated that she initiated a COC on 1/28/2025 since Resident 9 became physically aggressive towards the staff and other residents. During an interview and a record review of Resident 9's medical records with the Director of Nursing (DON) on 2/7/2025 at 7:50 AM, the DON stated that the facility created a care plan on 1/28/2025 to address the aggressive behavior of Resident 9 with an intervention to consult a psychiatrist to evaluate the resident. The DON stated that the facility overlooked that intervention and failed to refer Resident 9 to the psychiatrist. A review of the facility's undated policy titled, Behavioral Health Services, version 1.0, revised in 2/2019, indicated that the facility would provide residents with behavioral services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident in accordance with the comprehensive assessment and plan of care.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five (5) percent (%) during medication pass by committing four (4) medication errors on one of six sampled residents (Resident 15) during medication observation with 29 medication opportunity that resulted to a 13.79% medication error rate. This deficient practice had the potential to result in adverse reaction) undesired effect of a drug or other type of treatment) to the medications that could jeopardize the safety of the residents that could lead to serious harm, injury, or death. Findings: A review of Resident 15's Admission Record indicated that the facility initially admitted Resident 15 on 4/3/2024 and readmitted the resident on 10/9/2024 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 12/27/2024, indicated that Resident 15's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. A review of Resident 15's Order Summary Report, indicated that as of 2/1/2025, the physician ordered to administer the following medications to Resident 15: 1. Depakote Sprinkles Oral Capsule Delayed Release Sprinkle (used to treat seizure disorders and mental/mood conditions) 125 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount). Give one capsule by mouth two times a day. 2. Docusate Sodium (a stool softener to treat constipation) Oral Tablet 100 mg. Give one tablet by mouth one time a day. 3. Multivitamin-Minerals (a combination of vitamins and minerals to prevent nutrient deficiencies) Oral Tablet. Give one tablet by mouth one time a day. 4. Sodium Chloride (an electrolyte replenisher) Oral Tablet 1 gram (metric unit of measurement, used for medication dosage and/or amount). Give one tablet by mouth one time a day. During a medication administration observation on 2/6/2025 at 8:42 AM, LVN 3 prepared four (4) oral medications (Docusate Sodium tablet, Depakote Sprinkles capsule, Multivitamin-Minerals tablet, and Sodium Chloride tablet), crushed them, and mixed them in a single container with apple sauce. The surveyor interrupted LVN 3 before she was about to administer the medications to Resident 15. During a concurrent interview with LVN 3, she stated that she realized she was not supposed to mix the medications all together. LVN 3 stated that Resident 15 would not know what medication she would be taking if she crushes and mixes them. During an interview on 2/7/2025 at 1:46 PM, the director of nursing (DON) stated that ideally, the licensed nurse should administer crushed medications separately, unless the resident wants to take them all together in a single container. The DON stated that it is a matter of resident preference whether to administer crushed medications individually or separately. A review of the facility's undated policy titled, Administering Medications, version 2.1, revised in 4/2019, indicated that medications should be administered in a safe and timely manner. The policy did not have a specific instruction or procedure on how to properly administer crushed medications.

Based on observation, interview, and record review, the facility failed to implement its policy and procedure on how to properly and safely store medications and biologicals by failing to separately store Hydrogen Peroxide Topical Solution (an external [outside the body] medication with mild antiseptic used on the skin to prevent infection of minor cuts, scrapes, and burns) on the same shelf with oral (medications given by mouth) medications such as stool softeners and vitamins. This deficient practice had the potential to cause medication errors and expose residents to adverse reactions (an undesired harmful effect) that could lead to serious harm or death. Findings: During an inspection of the facility's East Wing medication storage room with licensed vocational nurse (LVN) 3 on 2/6/2025 at 10:05 AM, a bottle of Hydrogen Peroxide Topical Solution, an external (applied outside the body) medication used on the skin to prevent infection of minor cuts, scrapes, and burns, was observed on the same shelf where oral medications were kept. During a concurrent interview with LVN 3, LVN 3 stated that the facility should not store external medications on the same shelf where oral medications are kept to prevent medication errors. During an interview on 2/7/2025 at 1:56 PM, the director of nursing (DON) stated that the facility should keep oral medications and external medications separately to avoid medication errors. The DON stated that storing oral and external medications together increases the risk of misidentification and accidental ingestion of an external medication, especially if the containers look similar. The DON stated that he did not know who placed the external medication on the same shelf where oral medications were stored. A review of the facility's undated policy titled Medications Storage in the Facility, effective 4/2008, indicated that medications and biologicals should be stored safely, securely, and properly. The policy indicated that orally administered medications should be kept separate from externally used medications, such as suppositories, liquids, and lotions.

Based on observation, interview, and record review, the facility failed to ensure a system in preventing, controlling infections and communicable diseases were in place, when one of two sampled residents (Resident 3) according to the facility's Infection Prevention and Control Program. Resident 3 who was on an enhance barrier precaution (EBP) (taking extra steps to prevent the spread of serious infections, like using gowns and gloves) due to a suprapubic catheter (a tube that drains urine from your bladder by being inserted through a small incision made in your lower abdomen, just above your pubic bone) was observed receiving high contact care (fixing Resident 3 ' s suprapubic catheter tubing and urine drainage bag) from Licensed Vocational Nurse (LVN) 1 and Certified Nurse Assistant (CNA) 1). LVN 1 and CNA 1 failed to use an isolation gown as part of their PPE (Personal Protective Equipment) and proceeded to the Nurses Station without performing hand hygiene (a way of cleaning the hands, which can prevent the spread of germs) after the care. These deficient practices had the potential to cause and/or spread of infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) in the facility. Findings: During a review of Resident 3's, Admission Record (AR), dated 2/5/2025, indicated Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including benign prostatic hyperplasia (a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream), obstructive and reflux uropathy (Obstructive uropathy happens when urine can't flow through the urinary tract, while reflux uropathy occurs when urine flows backward into the kidneys), and history of urinary tract infection. During a review of Resident 3's History and Physical Examination (H&P), dated 12/3/2024, indicated Resident 3 does not have the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool) dated 12/3/2024, the MDS indicated Resident 3's cognitive status (the mental process of thinking and understanding) was severely impaired. MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and or contact guar assistance as resident completes activity) with eating, toileting and personal hygiene, and required partial/moderate assistance (helper does less than half the effort) with bathing. During a review of Resident 3's care plan (CP) for suprapubic catheter, at risk for complication from catheter use (i.e. recurrent urinary tract infection) revised 1/31/2025, the CP indicated intervention included Enhance Standard Precaution due to status post suprapubic catheter. During a review of Resident 3's care plan (CP) for Enhance Barrier Precaution due to suprapubic catheter use, revised 1/31/2025, the CP indicated interventions that included hand hygiene during any direct contact, and providing enhance standard precaution gloves, gowns, mask. During a review of Resident 3's Order Summary Report (OSR), dated 2/1/2025, the OSR indicated; a) an order date of 11/30/2024 the use of suprapubic catheter attached to drainage bag for obstructive and reflux uropathy, and b) an order date of 12/2/2024, Resident 3 was placed on Enhanced Barrier Precautions due to suprapubic catheter in place. During an observation on 2/5/2025 at 8:30 AM in Resident 3's room, Resident 3, who was on an Enhance Barrier Precaution, was receiving a high contact care (fixing Resident 3's suprapubic catheter tubing and urine drainage bag) from two nursing staff (CNA 1 and LVN 1), both nursing staff was not wearing a gown as part of their PPE, then both staff proceeded to the nurses station after the care without performing hand hygiene. During an interview on 2/5/2025 at 8:45 AM with CNA 1, CNA 1 did not have an answer to why she did not wear a gown as part of her PPE prior to taking care of Resident 3, and not performing hand hygiene after taking care of Resident 3. During an interview on 2/5/2025 at 8:50 AM with LVN 1, LVN 1 stated, she was aware that she was supposed to wear a gown as part of her PPE when she took care of Resident 3 who was on EBP, and she was also aware that she was supposed to perform hand hygiene after providing care to Resident 3, she just forgot. LVN 1 stated, not using PPE prior to taking care of Resident 3 and not performing hand hygiene after providing care to Resident 3 had the potential to spread virus and bacteria in the facility. During an interview on 2/5/2025 at 2:05 PM with Infection Preventionist (IP), IP stated, Resident 3 is on enhance barrier precaution because he has a suprapubic catheter, as per policy staff should use PPE's which includes wearing a gown prior to direct care to the resident and practice hand hygiene before and after direct care to Resident 3. IP stated, adhering to EBP policy is for the protection of Resident 3 and other residents and staff, not following the enhance barrier precaution had the potential to cause the spread of virus, bacteria and multi-drug-resistant organisms (MDROs) in the facility During an interview on 2/5/2025 at 2:25 PM with the Director of Nurses (DON), the DON stated, Resident 3 is on an enhance barrier precaution, which means when staff has high contact care with the resident the staff should wear PPE's which includes gloves and gown and perform hand hygiene before and after the care of Resident 3. DON stated, performing care with Residents 3's suprapubic catheter tubing and urine drainage bag are considered high contact care. DON stated, LVN 1 and CNA 1 should have been wearing a gown prior to Resident 3's care and should have performed hand hygiene after the care, these mistakes of the staff had the potential to cause the spread of virus, bacteria and MDROs in the facility. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 6/5/2024, the P&P indicated; a) Enhance barrier precaution are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents, b) gloves and gown are applied prior to performing the high contact resident care activity, and c) example of high-contact resident care activities requiring the use of gowns and gloves for EBP included device care or use (urinary catheter). During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revised 4/2023, the P&P indicated; a) the facility established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and b) important facets of infection prevention include instituting measures to avoid complications or dissemination (to spread or scatter).

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, and sanitary condition to ensure safe and sanitary food preparation and storage practices in Facility 1 ' s kitchen by failing to: 1. Ensure Facility 1 ' s Kitchen was maintained to prevent the subfloor from being completely rotten, and tile from disrepair due to having an old rotten floor, the dishwasher left rusted, and the wooden entrance door frames throughout the kitchen worn out and deteriorating as reported by the local Health Department on 12/14/2023. As a result, Facility 1 was required to start construction renovation to their kitchen on 1/29/2024. The facility did not develop plan on how to maintain food safety for the residents during a construction of the kitchen to ensure the food products being transported from the facility were kept dry and covered to prevent contamination and stored in sanitary condition. 2. Ensure not to store dry food in the dry storage area or store perishable foods (foods that are likely to spoil, decay or become unsafe to consume if not kept in the refrigerator or freezer) are stored in the walk -in refrigerator during the kitchen renovation that was observed visible dust and debris on the shelves and floor and two (2) reach-in freezer and one (1) reach-in-refrigerator with dirt and dust debris on the shelves. 3. Ensure kitchen staff wear a hairnet in the kitchen to protect the food being prepared, preparation surfaces and clean equipment from contamination. 4. Ensure the Dietary Aide (DA) 1 did not touched the towel dispenser handle after handwashing then proceeded to assemble resident ' s trays for breakfast service. 5. Ensure Cook 2 did not wash, rinse, and sanitize the sheet pans and kitchen utensils after washing them in the three (3) compartment sink. 6. Ensure residents trays used for meal service were in good condition without cracks, chips, stains, and black dirt. 7. Ensure the food and serving food items, used, and served to the residents were not left outside the facility exposed to extreme weather and pest. 8. Start set up and provide a designated area for food storage in Facility 2 until 2/7/2024 (10 days after the construction was started) leaving the food supplies in Facility 1 during constructions. These failures resulted in the closure of the Facility 1 ' s kitchen needing the use of Facility 2 ' s kitchen which had the potential to result in cross contamination (a transfer of harmful bacteria from one object to another or one place to another) that could lead to foodborne illness (an illness caused by contaminated food and beverages) in 82 of 82 medically compromised residents who received food from Facility 1 ' s kitchen. On 2/6/2024 at 7:40 p.m., the State Agency (SA) called an Immediate Jeopardy (IJ-a situation in which the facility'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) situation in the presence of the Administrator, the Director of Nursing (DON), and Nursing Consultant. For the facility ' s failure to ensure that the facility ' s kitchen was maintained in sanitary and in good repair and working order to provide dietary services that included food storage, cooking, preparation, and distribution to residents and prepare and execute a plan on how residents food will be maintained, stored, and prepared in sanitary condition during the kitchen renovation, On 2/8/2024, at 5:20 PM, the ADM was notified that the immediacy was removed based on the onsite verification that IJ Removal Plan (a list of steps taken to correct the deficient practices) was implemented. The IJ was removed on 2/8/2024 at 5:20 PM, in the presence of the facility's ADM and DON, while the survey team was onsite at the facility. The Health Recertification Survey exited on 2/9/24. The acceptable IJ Removal Plan, dated 2/8/2024 included the following: a. On 2/6/2024, Administrator (ADM), (Director of Nursing) DON and Director of Staff Development (DSD) initiated notification to the Dietary Department and other staff of the findings stated in the IJ template dated 2/6/2024 regarding Dietary Care. During the in-services, the Administrator emphasized the importance to always keep foods clean and dry. b. On 2/6/2024, The Dietary Supervisor and the Maintenance Supervisor conducted an inspection on the meal tray delivery carts. All carts are in good condition with complete food coverage. c. On 2/6/2024 and 2/7/2024, Administrator notified the Dietary Department and other staff of the findings stated in the IJ template, dated 2/6/2024, regarding Dietary Care and food transportation. During the in-services, the Administrator emphasized the importance of always keeping foods clean and dry. d. On 2/7/2024 the Compliance Officer from the Department of HCAI (Health Care Access Information) made an ocular (visual) visit of the facility to tour the kitchen. Compliance Officer assessed that structural integrity of the kitchen is still safe. e. On 2/7/2024 structural engineer came to the facility kitchen to assess the scope of the projects in preparation for HCAI, CDPH (California Department of Public Health), and EH (Environmental Health) permit applications. f. On 2/7/2024 all dry foods and containers were transferred to the sister facility (Facility 2) for storage. remaining perishable foods and containers that did not fit at new designated storage were discarded. g. On 2/7/2024 the Administrator, DON, RD, and DSS observed food transportation and tray lines, and found no issues during dinner time. h. On 2/7/2024 the Administrator and the Maintenance Supervisor conducted an inspection of the kitchen to ensure that the kitchen is completely secured and off limits to residents and unauthorized personnel. i. On 2/8/2024, remaining perishable food items and containers left behind at employee only patio was also discarded. j. Facility 1 will be sharing the kitchen with adjacent sister Facility 2 for the foreseeable future to ensure timely competition of the kitchen project. k. Future delivery of food will be dropped off at adjacent Facility 2. l. Food will be stored in safe, clean, and well-ventilated designated area (temporarily converted conference room to storage room) with staff access only at San [NAME] Convalescent Center for easy and safe handling of food ingredients during food preparation. m. Designated work area, food preparation area, cooking area, and serving area at Facility 2 will be provided for Facility 1 staff. o. Dietary staff shall ensure that transportation carts are fully sealed, secured, and covered prior to transporting meals to the facility residents. p. The Dietary Supervisor and/or Designee will observe food transportation to ensure that resident food will be always kept clean and dry. q. The Administrator will report all current and future projects to HCAI, CDPH, and Environmental Health and all necessary agencies depending on the scope of each project. r. The Administrator and/or Maintenance Supervisor will check the kitchen to ensure that it remains secured until further notice or until the substantial compliance is achieved. s. The Administrator, Maintenance Supervisor, and/or Designee will track all projects, scope of work, and schedule to ensure timely and compliant completion. t. This will be ongoing, and the Administrator will report recapitulations of any findings to the monthly QAPI committee for review, follow-up, and resolution as indicated. Findings: 1. A review of the Retail Food Official Inspection Report, inspection date 12/14/2023, indicated, corrected action needed to store, prepare, and display or held food so that it is protected from contamination. The report indicated the facility failed to ensure the floors, walls, ceilings of the facility did not have durable smooth, non-absorbent, and washable surface, and were kept clean, in good repair and free of peeling paint. The Retail Food Official Inspection Report indicated for the facility needed to replace the damaged floor and base covering tiles in the kitchen, renovate and replace deteriorating wooden entrance door frames throughout the kitchen. A review of the Maintenance Crew Work Order Form, dated 1/14/2024, indicated Facility 1 had a crucial problem that needed repair in 2 to 14 days to upgrade the kitchen, door and frames need to be metal, walls need have a stainless steel, subfloor is completely rotten, and tile cannot be repaired with old floor, and the dishwasher was very old and rusted. During an entrance conference for the annual recertification survey with the DON on 2/6/2024 at 8AM, the DON stated in an interview on 2/6/2024 at 8AM, that the Facility 1 ' s kitchen was closed for remodeling and residents ' meals were being prepared in Facility 2 ' s kitchen (located next to Facility 1 ' s building) about five minutes ' walk from Facility 1. During an initial kitchen observation on 2/6/2024 at 8:05 AM, the Facility 1 ' s kitchen door was closed and no plastic covering around the kitchen area while reported to be under construction by the DON. During an observation of the refrigerator in Facility 1 ' s on 2/6/2024 at 8:33 AM, food items such as four (4) tubs of mayonnaise, one (1) plastic bin with potatoes, one (1) plastic bin with lemons, one (1) bag of celery, 3 boxes of eggs a bag of grapes and 15 gallons of milk etc., with a built-up ice on the vent of the refrigerator were observed. During an interview on 2/6/2024 at 8:40 AM, Facility 2 ' s Dietary Supervisor (DS) 2 stated the meals for Facility 1 ' s residents were being prepared and cooked in Facility 2 ' s kitchen by Facility 1 ' s kitchen staff. DS 2 also stated this has been going on for a few weeks due to Facility 1 ' s kitchen being closed for remodeling. During an interview on 2/6/2024 at 9:13 AM with DS 2 for Facility 2 stated Facility 1 began using Facility 2 ' s kitchen about 3 weeks ago. DS 2 stated Facility 1 bring their own ingredients, prepares, and cook meals in Facility 2 ' s kitchen. During an observation on 2/6/2024 at 9:50 AM, Facility 1 ' s kitchen was observed with bare walls, and floors. The walls had dark brown and black substance and with exposed plumbing pipes. During an interview on 2/6/2024 at 11:50 AM, with the ADM, the ADM stated, there was an emergency to reinforce the subfloor of the kitchen, the [NAME] (a person in charge of a group of workers on a particular operation) who was hired by the facility assessed the kitchen floor between 1/22/2024- 1/25/2024 and observed the kitchen subfloor underneath the tiles which was soft and needed to tear down the kitchen. The ADM stated, Facility 1 began to use the kitchen in Facility 2 on 1/29/2024, when the renovation started in the kitchen in Facility 1. The ADM stated the residents are currently serve with disposable utensils and plates during meals that comes from the kitchen in Facility 2. The ADM stated he did not inform or submit a proposal to renovate the kitchen to the State Agency or the Department of HCAI (prior to tearing down the kitchen. The ADM stated he did not have a written plan or process on how Facility 1 will safely prepare food, store food items, deliver the food to the residents within an acceptable food temperature to prevent food borne illnesses and to ensure the meals are delivered timely. During an interview on 2/6/2024 at 12:20 PM, the ADM stated, Facility 1 ' s kitchen had been closed for two weeks and the process of food preparation was to cook the food in Facility 2 ' s kitchen, do the tray line, review the meal ticket, put in metal cart and then wheel over to the nursing stations or the dining area where the trays are distributed and reviewed by nurses and CNAs. During an observation and concurrent interview on 2/6/2024 at 1:49 PM, in Facility 2 ' s kitchen, a metal cart with wheels were observed in front of food prep area. Another cart (Cart 2) was observed with two brown plastic bags with bread. The plastic bags were observed with water drops on the outside. During an interview with the Facility 1 ' s Cook (Cook) 1 stated all food for the residents in Facility 1, including refrigerated food and dry goods remained in Facility 1 during the kitchen construction. Cook 1 stated the kitchen staff in Facility 1 brings the food to Facility 2 every day. Cook 1 stated the bag of bread was wet on the outside because we bring the food on carts around the facility. During an interview on 2/6/2024 at 2:15 PM, the Facility 2 ' s Administrator (ADM 2) stated, Facility 2 had been sharing the kitchen with Facility 1 for food preparation and cooking for over 2 weeks. The ADM 2 stated, she was verbally informed by their corporate office that Facility 1 will need to share the kitchen with Facility 2 (sister facility). The ADM 2 stated Facility 1 officially started sharing the kitchen in Facility 2 from 1/21/2024 due to kitchen remodeling and the kitchen in Facility 1 could not be used. The ADM stated she was not informed how long Facility 1 ' s kitchen remodel will last. During an interview and record review of the facility ' s QAPI (Quality Assurance and Performance Improvement (QAPI) proactive approach to quality improvement to ensure services are meeting quality standards and assuring care reaches a certain level) Safety Plan, with the ADM on 2/9/2024 at 4:40 PM, the ADM stated there was no documented evidence that the QAPI Committee developed a plan or interventions to implement and monitor to ensure the residents were provided food safety during the kitchen renovation. 2. During an observation on 2/7/2024 at 8:35 AM outside the southside of Facility 1, two kitchen refrigerators and kitchen tables were in an enclosed area next to Facility 1 building. During an observation of Facility 1 ' s kitchen dry storage area on 2/7/2024 at 10:20 AM, the kitchen floor was under construction and the dry storage room floors and shelves were visibly dusty and dirty. The dry storage area contained the following food items: one (1) container of rice, 1 container of dehydrated (dried or water removed) potatoes, 1 container of Cheerios (a cereal brand), 1 container of raisin bran cereals, two (2) canned grapes, a container of single serve pepper packets, a container of single serve salt packets, 1 canned beets, 1 container of single served crackers, 1 canned corn, three (3) bottles of lemon juice, 1 pack buttermilk biscuit mix, 1 pack corn bread mix, 1 pack of white cake mix, three (3) bottles of pancake and waffle syrup, 30 boxes of sugar, four (4) cans tomato ketchup, 3 cans mashed potatoes, 2 cases of canned goods, and 4 bottles of prune juices while the kitchen was under construction. During an observation of Facility 1 ' s walk-in-refrigerator in the kitchen on 2/7/2024 at 10:24 AM, there were 1 container of celery, 1 container of lemon, 1 container of potatoes, 2 pieces (pcs) of watermelon, 4 tubs of mayonnaise, 1 box of pickle relish, 1 box of mustard, 1 box of sunflower butter, 3 tubs of non-fat assorted flavor of yogurts, one box of margarine, 1 container of red onions, 1 box of whipped butter and 1 box of cucumber in the walk-in-refrigerator while the kitchen was under construction. During a concurrent observation of the dry storage area in the kitchen and interview with the Dietary Supervisor (DS) 1 on 2/7/2024 at 10:29 AM, DS 1 stated they were still using the dry storage area and the walk-in refrigerator in Facility 1 for food storage that was being served for residents in Facility 1, however, they planned on transferring all the food to the kitchen in Facility 2 (a sister facility) storage. DS 1 stated they transported food that they needed from their facility (Facility 1) to Facility 2 ' s kitchen using a utility cart. During a concurrent observation of the Facility 1 ' s meat freezer near DS 1 ' s office and interview with the DS 1 on 2/7/2024 at 11:10 AM, bottom freezer shelves had a visual dirt and dust debris when touched. DS stated the last time the freezer and refrigerator were cleaned on Monday (2/5/2024), but the freezer was not cleaned due to the visible dirt debris. DS stated it was important to clean the freezer to avoid cross-contamination. During a concurrent observation of the Facility 1 ' s vegetable freezer and bread refrigerator near DS 1 ' s office and interview with the DS on 2/7/2024 at 11:12 AM, the freezer and bread refrigerator shelves had dust residues and dirt debris. DS stated the cleaning schedule for all the freezers and refrigerator was on Monday. DS stated the vegetable freezer and bread refrigerator needed to be cleaned to prevent cross-contamination of resident ' s food. A review of the facility ' s P&P titled Cleaning Schedule dated 1/12/202024, indicated All areas and equipment should be cleaned daily. A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) Non-Food-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. During an interview with the DS 1 on 2/8/2024 at 1:27 PM, DS 1 stated that the front patio in front of the medical record office was a temporary area to put food from Facility 1 because the refrigerators in Facility 2 were being cleaned and the plan was to transport the food from the front patio to Facility 2 ' s food storage areas. DS 1 stated she does not know when the Facility staffs moved the food from the food storage area of Facility 1 into the front patio. DS 1 stated that the front patio was not a safe area to put up food even if it was for temporary use as food such as lemons, flour were out in the open and it was not safe due to cross-contamination. During an observation of the front patio in front of the medical record office on 2/8/2024 at 1:38 PM, the front patio area was not enclosed and secured. The following food items were inside the carton box on a table and cart that was and exposed to extreme weather such as heat, rain, and pest in the front patio: one clear uncovered container full of brown potatoes one uncovered container full of red potatoes two (2) pcs. of watermelon one clear container of sugar on tip of the table near a garbage can one clear container full of lemons on top of the table near a garbage can one clear container full of onions on top of the table near a garbage can One container of flour one carton of simply thick easy mix one full green container of pepper packets condiments in an uncovered cart o one container of salt seasoning packets o one container of chopped onions o one container of salt seasoning packets o one container of lemon blend o one open box of iodized salt o one full clear container of equal sweetener packets near a trash can o one full clear container of sugar packets near a trash can o one open box of sugar free beverage crystals cranberry flavor four boxes of orange concentrate on a wooden tray five boxes of sugar two bottles of lime juice 14 assorted canned goods (kernel corn, potatoes, tomato, ketchup, enchiladas) Three bags of dry cereals (1 cheerios, 2 raisin bran cereals) 1 box of uncovered bananas. Assorted paper and disposable products (hinged Styrofoam, Styrofoam bowl, Styrofoam small plates and two-ply dinner napkins). During a concurrent observation of the front patio in front of the medical record office and interview with Maintenance Supervisor (MS) on 2/8/2024 at 1:41 PM, MS stated the food in the front patio was moved on 2/7/202024 in the afternoon from their kitchen (Facility 1 ' s kitchen) and the plan was to transport these foods to the Facility 2 ' s kitchen, however, he was not sure and he needed to ask the Administrator. During an interview with the Administrator (ADM) on 2/8/2024 at 1:53 PM, ADM stated the food in the patio by the medical records area was for disposal and not for resident ' s consumption and was not moved to Facility 2 prior to renovation of the kitchen on 1/29/2024. During concurrent observation of Facility 2 ' s conference room and interview with Facility 1 ' s Registered Dietitian 1 (RD 1) on 2/8/2024 at 3:30 PM, food containers were on the floor, three refrigerators and storage shelves for food were in the conference room. RD 1 stated she was not sure when the staff started to work on the conference room as a food storage however, it was her first day working in the area. RD 1 stated all the foods (listed above) on the floor came from Facility 1 ' s kitchen ' s storage. During an interview with the DS on 2/8/2024 at 3:37 PM, DS stated the three refrigerators were brought in last night and today from the corporate office and the plan was to use the conference room as a food storage area for Facility 1 starting today 2/8/2024, moving forward. During an interview with the ADM on 2/9/2024 at 9:30 AM, ADM stated he submitted a work order for the kitchen construction on 1/4/2024 and the actual kitchen construction started on 1/29/2024. ADM stated the facility did not remove the food in the storage area on the day of the construction because Facility 2 had no space for the food and dietary supplies from Facility 1. ADM stated it was on 2/7/2024 when they started to set up a designated area for food storage. ADM stated the food from the dry storage and walk-in-refrigerator was not safe to use for the residents as it was exposed to the construction area and should had been removed prior to construction of the kitchen. ADM stated the food from the front patio by the medical records office was out overnight during the rain and it was for disposal and donation. ADM stated he notified the staff informally to get the food that they want from the front patio before disposal. ADM stated he designated the conference room at Facility 2 on 2/7/2024 as part of the IJ removal plan. ADM stated everything happened very fast and the storage of food was just executed this way. A review of the facility ' s Policy and Procedure (P&P) titled Sanitation and Infection Control, dated 1/12/2024, indicated, Food Service Employees will follow infection control policies to ensure the department operates under sanitary conditions at all times. A review of the facility ' s P&P titled Refrigerator/Freezer Storage, dated 1/12/2024, indicated (5) Fresh fruits and vegetables should be stored in designated bins in a designated area of refrigerator. (6) All items should be properly covered, dated, and labeled. A review of the facility ' s P&P titled Cleaning Schedule dated 1/12/2024, indicated All areas and equipment in the kitchen should be cleaned daily. A review of Food Code 2017 indicated 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) where is not exposed to splash, dust, or other contamination; and (3) At least 15 centimeter (cm) (6 inches) above the floor. A review of Food Code 2017 indicated 3-305.12 Food Storage, Prohibited Areas (I) Under other sources of contamination. 3. During a concurrent kitchen observation in Facility 2 and interview with DA 1 on 2/7/2023 at 5:20 AM, DA 1 was not wearing a hairnet while setting up resident ' s tray for breakfast service. DA 1 stated he forgot to wear a hairnet because it was cold, and he was wearing a beanie (a soft material used to cover the head) instead. During an interview with DA 1 on 2/7/2024 at 5:51 AM, DA 1 stated it was important to wear hairnet in the kitchen to restrain the hair from getting to the food that could contaminate the resident ' s food. A review of the facility ' s P&P titled Sanitation and Infection Control, dated 1/12/2024, indicated Food Service employees will follow infection control policies to ensure the department always operates under sanitary conditions. PERSONAL HYGIENE: (5) A hair net or head covering which completely covers all hair should be always worn. A review of Food Code 2017 indicated 2-402.11 Effectiveness. (A) except provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designated and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. 4. During an observation of DA 1 ' s handwashing in the Facility 2 ' s kitchen on 2/7/2024 on 5:48 AM, DA 1 touched the towel dispenser handle after washing his hands then prepared resident ' s tray for breakfast meal service. During a concurrent observation of DA 1 ' s handwashing demonstration and interview with DA 1 on 2/7/2024 at 5:55 AM, DA 1 scrubbed and washed his hands for 20 seconds (using a phone timer). DA 1 stated after washing his hands and before going back to work, he should not be touching the water faucet and the towel dispenser handle because it could be contaminated with dirt and could go to resident ' s food. DA 1 stated he was sorry he touched the handle of the towel dispenser earlier. A review of the facility ' s P&P attachments titled Handwashing, dated 1/12/2024, indicated, PROCEDURE: (5) Protect clean hands by turning faucets of with paper towels. A review of Food Code 2017 indicated. 2-301.12 To avoid decontaminating their hands or surrogate prosthetic devices, food employees may use disposable paper towel or similar clean barriers when touching surfaces such as manual operated faucet handles on a handwashing sink or the handle of a restroom door. 5. During an observation of the manual dishwashing of pans and kitchen utensils in the three (3) compartment sink (three separate sink compartments, one for each step of the ware wash procedure: wash, rinse and sanitize) in the Facility 2 ' s kitchen by Cook 2 on 2/7/2024 at 6:11 AM, the three-compartment sink had no water. Cook 2 washed and rinsed a stainless-steel whip and two (2) tray pans. Cook 2 placed the stainless-steel whip and two tray pans in the rack to dry without sanitizing them. During an interview of Cook 2 on 2/7/2024 at 6:20 AM, Cook 2 stated she used the three-compartment sink to wash the kitchenware and the water in each sink needed to be at a certain temperature. Cook 2 stated dishwashing procedure included washing with soap and water then sanitizer. Cook 2 stated she did not follow the process earlier because she did not know how the facility set their sink with sanitizer. Cook 2 stated the utensils and tray pans she washed earlier was not clean and sanitize. Cook 2 stated it was important to follow the dishwashing procedures so there would be no bacterial growth and residue on the dishes when the dishes were used for cooking and meal service for the residents. A review of the facility ' s P&P titled Manual Dish Washing-3 Compartment Sink, dated 1/12/2024, indicated PROCEDURES: (3) The first compartment will be labeled WASH. Fill with hot water of at least 110-120 degrees F. Use detergent in proper concentration per manufacturer ' s instruction. (4) The second compartment will be labeled RINSE. Thoroughly rinse dishes with clean hot water (110-120 degrees F). Change rinse water when it gets cloudy and dirty. (5) The third compartment will be labeled SANITIZE. Sanitize dishes using one of the following methods: (a) Immersion for at least 30 seconds in hot water temperature of at least 171 degrees F, or (b) Immersion for at least 30 seconds in solution containing 100 pm chlorine or (c) Immersion for at least 1 minute in solution containing 200 pm quaternary ammoniums (a sanitizing agent). (7) Wash temperature and sanitizing solution will be taken and recorded A review of Food Code 2017 indicated 4-301.12 Manual Ware washing, Sink Compartment Requirements (A) Except as specified in (C) of this section, a sink with at least 3 compartments shall be provided for manually washing, rinsing, and sanitizing equipment and utensils. A review of Food Code 2017 indicated 4-510.111 Mechanical Ware washing Equipment, Hot Water Sanitization Temperatures. If immersion (submerge) in hot water is used for sanitizing in a manual operation, the temperature of water shall be maintained at 77 C (171 F) or above. A review of Food Code 2017 indicated 4-501.116 Ware washing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. 6. During a Facility 2 kitchen observation of the resident ' s tray cart for Facility 1 on 2/7/2024 at 5:53 AM, resident ' s trays were chipped, cracked, and stained with black color. During a concurrent observation of the resident ' s tray and interview with the DS 1 on 2/8/2024 at 12:19 PM, there were 18 trays that had crack, chip, and black color stain. DS 1 stated she requested a quote for tray replacement, but she did not have a chance to show it to the ADM. DS1 stated it was important to have a chip-free, crack-free and stain-free trays for presentation purposes and it does not look professional. During an interview with the RD 1 on 2/8/2024 at 12:23 PM, RD 1 stated trays should not be chip as it should be whole hence it needed to be replaced for presentation purposes for the residents. During a review of the facility ' s quote to purchase trays, dated 11/17/2023 and interview with DS 1 on 2/8/2024 at 1:15 PM, DS 1 stated she did not order the trays after receiving the quote as the trays were so expensive and there were a lot of holidays and events that she did not get to order it yet. A review of the facility ' s P&P titled Food Preparation, dated 1/12/2024, indicated, (2) Tray set up to be (b) dishes, glasses, flatware are free of rust, chips, cracks. A review of Food Code 201 indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. 7. During an interview with the DS 1 on 2/8/2024 at 1:27 PM, DS 1 stated that the front patio in front of the medical record office was a temporary area to put food in because the refrigerators in Facility 2 were being cleaned and the plan was to transport the food from the front patio to Facility 2 ' s food storage areas. DS 1 stated she does not know as to when the staff moved the food from the food storage area of Facility 1 into the front patio. DS stated that the front patio was not a safe area to put up food even if it was for temporary use as food such as lemons, flour were out in the open and it was not safe due to cross-contamination. DS stated the food in the front patio should be disposed. During an observation of the front patio in front of the medical record office on 2/8/2024 at 1:38 PM, the front patio area was not enclosed and secured. The following food items were inside the carton box on a table and cart that was and exposed to extreme weather of heat, cold and rain and pest in the front patio: one clear uncovered container full of brown potatoes one uncovered container full of red potatoes two (2) pcs. of watermelon one clear container of sugar on tip of the table near a garbage can one clear container full of lemons on top of the table near a garbage can one clear container full of onions on top of the table near a garbage can one carton of simply thick easy mix one full green container of

Based on observation, interview and record review, the facility failed to provide a safe environment for 11 out of 81 residents (Residents 12, 15, 20, 28, 30, 39, 42, 47, 63, 69 and 71), who were assessed at being at risk for falling, staff and visitors by failing to: 1. Ensure that the facility's roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling. 2. Ensure that the ceiling structure inside the building did not become damaged from rainwater leaking in through holes, cracks, and other damage to the roof. 3. Maintain the ceiling structure free from moisture, water damage, active leaking, and degradation due to rainwater penetrating through cracks, holes, or other damaged areas of the roof. 4. Provide documented evidence that the facility routinely performs scheduled maintenance service to all areas in the facility that included the roof inspections. These deficient practices resulted in an outburst of 5 water leaks throughout the facility on 2/5/2024 during a rainstorm resulting in Resident 12, 15, 20, 28, 30, 39, 42, 47, 63, 69 and 71 to be displaced (being forced to leave their home). In addition, these deficient practices had the potential to lead to resident injury from slipping and falling and endangering the lives of the remaining 70 of 81 residents remaining in the facility including the staffs and visitors, by placing them at risk for accidents, electrical shocks, electrical fires, collapsed ceiling and structural damage. subjecting the residents to possible serious injuries. On 2/6/2024 at 4:05 PM, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility'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) situation for the facility's failure to ensure that the facility's roof was well maintained and in working order in order to provide a safe and comfortable environment for the residents in the presences of the Administrator. On 2/9/2024, at 2:05 PM, the facility submitted an acceptable IJ Removal Plan ([Plan of Action] a list of steps taken to correct the deficient practices). The IJ was removed on 2/9/2024 at 2:05 PM, in the presence of the facility's Administrator (ADM) and Director of Nursing (DON), while onsite at the facility, after the surveyor verified and confirmed the facility's approved IJ Removal Plan (a detailed plan to address the IJ findings) was fully implemented through observations, interviews, and record reviews, in a manner that eliminated the likelihood of endangering the lives of the remaining 70 of 81 residents remaining in the facility from electrical shocks, electrical fires, and possible serious structural damage and the 11 residents that were displaced could safely reoccupy their rooms. The acceptable IJ Removal Plan, dated 2/9/2024 included the following: 1. On 2/6/24, the staff immediately removed all residents from Room A, B, C, D, and E 2. On 2/6/24, the staff placed all residents Room A, B, C, D and E in different rooms that are in good condition and without any water leak. 3. On 2/6/24, the Director of Nursing (DON) and the Registered Nurse (RN) supervisor conducted assessments for all residents who previously resided in room A, B, C, D and E. They are all at their baseline condition, without any signs/symptoms of changes in condition. 4. The DON and Maintenance Supervisor (MS) & Housekeeping Supervisor (HS) placed an Authorized Personnel Only signage to the rooms that have water leak. 5. The DON and Maintenance & Housekeeping Supervisor placed a Caution Wet Cone in the hallway that have water leak. 6. On 2/6/24, the MS conducted a roof and electrical inspection with corporate contractor from corporate office compromised areas were marked and ceiling lighting fixture near leak was removed. Electrician informed the facility that no other electrical components were at risk for hazard. 7. On 2/6/24, the MS conducted a roof inspection virtually, with a contractor from the roofing company. The roofing company confirmed that they will came to the facility to repair the roof early in the morning of 2/7/24. 8. On 2/6/24, the ADM and Director of Staff Development (DSD) notified the staff of the findings stated in the IJ template (a report given to the facility regarding the deficient practices of the facility that required immediate action to be corrected) and in-services was provided to the staff regarding hazardous roof leaking and safety. During the in-service, the administrator instructed the staff to make rounds hourly, to check the environment and resident safety, and to notify Maintenance immediately of any signs of hazard. 9. On 2/6/24 the ADM and DON created a monitoring log for environment and resident safety. The staff will make rounds every hour and as needed to ensure compliance. 10. On 2/7/24 Compliance Officer of HCAI (Health Care Access Information-a department that monitors the safety of renovations and construction in the skilled nursing facilities) made an ocular (visual) visit of the facility to tour the kitchen site and leak sites. On 2/7/24 facility completed form [NAME] MANUAL Request for Excluded Work and submitted to HCAI for review. 11. On 2/7/24 the roofing company came to the facility to repatch areas affected by the rain on the previous day. Roofing company utilized a camera which uses infrared thermal imaging (a camera used to help detect water moisture or leaks to show visually the temperature emitted by objects and identifying insulation issues. By utilizing the tool, the roofing company was able to identify compromised areas and repair accordingly. a. Room C - damaged ceiling drywall removed currently allowing wood to completely dry prior to installing new dry wall (a construction material used to create walls and ceilings) and applying joint. b. Room D - ceiling had minor damage and required minor patching using joint compound (also known as drywall mud) c. Hallway in front of Room E - square drywall removed and replaced like for like and joint compound applied. 12. On 2/8/24 HCAI H Class A Hospital Inspector 1 and Class A Hospital Inspector 2 came to the facility for initial review of Rooms C, D, E, and E hallway. Inspectors confirmed revisit for 2/9/24 for final verification. 13. On 2/9/24 HCAI Class A Hospital Inspector 2 came to the facility to verify the framing integrity and covering items used to patch the ceiling were safe for resident quarters. Inspector verified upon completion of patching that Rooms C, D, E, and E hallway are safe for residents to return. 14. On 2/9/24, with the authorization of HCAI Class A Hospital Inspector 2 and CDPH, the facility proceeded to execute room change notifications for cohorted (group together) residents. Upon completion of room change notifications, residents were excited to be placed back to their original rooms. Room changes completed for Wing A- residents at 12:00PM and Wing-B residents at 1:45PM. 15. On 2/9/24 the MS checked all areas of the facility, including the patient rooms, activity rooms, storage rooms, offices, hallways, etc. There were no other areas of water leakage, other than for room D and C and the area leaking from the hallway ceiling in front of room E. 16. The ADM will repeat the in-service regarding roof leak and safety every month for 3 months or until the substantial compliance is achieved. 17. The Administrator and/or Maintenance Supervisor will schedule roof assessment quarterly x 6 months and then annually thereafter. 18. The Administrator will report all current and future projects to CDPH, and Environmental Health and all necessary agencies depending on the scope of each project. 19. The Administrator will report recapitulations of any findings to the monthly QAPI (Quality Assurance and Performance Improvement a proactive approach to quality improvement to ensure services are meeting quality standards and assuring care reaches a certain level) committee for review, follow-up, and resolution as indicated. Findings: 1. During a review of Resident 12's Admission Record indicated the facility originally admitted the resident on 1/30/2009 and readmitted her on 2/15/2023 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations that can result in fast heart rate, rapid breathing, and sweating), and hypertension (high blood pressure). During a review of Resident 12's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/4/2024, indicated the resident had intact memory and cognition (ability to think and reasonably). The MDS indicated the resident required supervision or touching assistance by facility staff with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing, personal hygiene, and could walk 150 feet distance. A review of Resident 12's History and Physical dated 2/17/2023, indicated the resident did not have capacity to make decisions. During a review of Resident 12's Care Plan, revised on 1/9/2024, indicted Resident 12 was at risk for falls/injury and the interventions including staff will provide a safe and clutter-free environment. During a review of Resident 12's Care Plan, revised on 1/9/2024, indicated the Resident 12 sometimes wanders around the facility and confused as to where she is going and what she is doing. To ensure resident safety, the interventions indicated the facility staff will provide clutter free an environment and non-slippery floors. During a review of Resident 12's Care Plan, revised on 1/9/2024, indicated Resident 12 was, at risk for falls/injury related to tremor (involuntary shaking movement and to ensure Resident 12's safety, the facility staff will provide clutter free an environment. A record review of Resident 12's Change of Condition Assessment Form dated 2/6/2024 indicated that at 11:30 AM, resident's room floor noted slightly wet due to roof leaking from the rain. 2, During a review of Resident 15's Admission Record indicated the facility originally admitted the resident on 2/25/2011 and readmitted on [DATE] with diagnoses that included schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly), abnormalities of gait and mobility and anxiety disorder. During a review of Resident 15's MDS, dated [DATE], indicated the resident had moderate levels of memory and cognition (ability to think and reasonably). The MDS indicated Resident 15 required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting. The MDS also indicated that the resident used a wheelchair and required supervision or touching assistance for wheeling the chair for more than 150 feet. A review of Resident 15's History and Physical, dated 2/6/2023, indicated the resident had the capacity to make decisions. During a review of Resident 15's Fall Risk Assessment, dated 9/6/2023, indicated Resident 15 was at a risk for fall. During a review of Resident 15's Care Plan, revised on 9/6/2023, indicted Resident 15 was at risk for falls/injury, and to ensure Resident 15's safety, the staff will provide a safe and clutter-free environment. During a review of Resident 15's Care Plan, revised on 9/6/2023, indicated Resident 15 was at at risk for spontaneous/pathological (when force or impact didn't cause the break to happen) /stress fracture related to osteoarthritis (occurs when flexible tissue at the ends of bones wears down). To ensure Resident 25's safety the facility staff will provide a safe and hazard free environment. 3. During a review of Resident 20's Admission Record indicated the facility originally admitted the resident on 12/6/2013 and then readmitted on [DATE] with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations that can result in fast heart rate, rapid breathing, and sweating). During a review of Resident 20's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/8/2023, indicated the resident had severe cognition impairment and required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting and with walking 10 feet or more. A review of Resident 20's History and Physical dated 7/1/2023, indicated the resident does not have the capacity to make decisions. During a review of Resident 20's Fall Risk Assessment, dated 12/8/2023, indicated the resident was a risk for fall. During a review of Resident 20's Care Plan, revised on 12/14/2023, indicated Resident 20 was at risk for falls/injury, and to ensure Resident 20's safety, the facility staff will provide a safe and clutter-free environment. A review of Resident 20's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:30 AM, room floor noted slightly wet due to roof leaking from the rain. 4. During a review of Resident 39's Admission Record indicated the facility originally admitted the resident on 10/30/2019 and then readmitted on [DATE] with diagnoses that included schizophrenia and anxiety disorder and abnormalities of gait and mobility. During a review of Resident 39's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/29/2023, indicated the resident had severe cognition impairment and required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting and with walking 10 feet or more. A review of Resident 39's History and Physical dated 11/11/2023, indicated the resident does not have the capacity to make decisions. During a review of Resident 39's Fall Risk Assessment, dated 11/2/2023, indicated the resident was a high risk for fall. During a review of Resident 39's Care Plan, revised on 12/20/2023, indicated the resident was at risk for falls/injury, and to ensure safety, the facility staff will provide a safe and clutter-free environment. A review of Resident 39's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:40 AM, room floor noted slightly wet due to roof leaking from the rain. During a review of Resident 42's Admission Record indicated the facility admitted the resident on 12/5/2023 with diagnoses that included schizophrenia anxiety disorder and abnormalities of gait and mobility. 5. During a review of Resident 42's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/12/2023, indicated the resident had severe cognition impairment and required substantial assistance by facility staff with eating, personal hygiene, sit to lying position. The MDS record also indicated Resident 42 required substantial/maximal assistance (where staff does more than half the effort) for toileting, showering, dressing, and bed to chair transfer. A review of Resident 42's History and Physical dated 12/7/2023, indicated the resident did not have the capacity to make decisions. During a review of Resident 42's Fall Risk Assessment, dated 12/6/2023, indicated the resident was a high risk for fall. During a review of Resident 42's Care Plan, revised on 12/6/2023, indicated the resident was at risk for falls/injury, and to ensure safety the staff will provide a safe and clutter-free environment. During a review of Resident 42's Care Plan, revised on 12/6/2023, indicated the resident had a seizure disorder (sudden, uncontrolled burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness) with risk for falls/injury, and the interventions including provide safe environment . free of safety hazards. A review of Resident 42's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:40 AM, room floor noted slightly wet due to roof leaking from the rain. 6. During a review of Resident 47's Admission Record indicated the facility originally admitted the resident on 9/4/2019 and readmitted her on 2/28/2023 with diagnoses that included schizophrenia, seizures and hypertension. During a review of Resident 47's MDS, dated [DATE], indicated the resident had intact memory and cognition. The MDS indicated Resident 47 required setup or clean-up assistance with eating, chair/bed-to-chair transfer, and walk 150 feet, and supervision or touching assistance with oral hygiene, toilet hygiene, lower body dressing and personal hygiene. A review of Resident 47's History and Physical dated 3/2/2023 indicated that Resident 47 did not have the capacity to make decisions. During a review of Resident 47's Fall Risk Assessment, dated 1/12/2024 indicated the resident was at risk for falls. During a review of Resident 47's Care Plan, revised on 1/12/2024, indicated Resident 47 was at risk for falls/injury, and to ensure safety the facility the staff will provide a safe and clutter-free environment. During a review of Resident 47's Care Plan, revised on 1/12/2024, indicated the resident was at risk for injury .because of seizure activity, and the interventions included to provide a safe environment; free of safety hazards. A review of Resident 47's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:30 AM, room floor noted slightly wet due to roof leaking from the rain. 7. During a review of Resident 63's Admission Record indicated the facility admitted the resident on 3/17/2020 with diagnoses that included vascular dementia (condition causes cognitive difficulty with reasoning and judgment), emphysema (a lung condition that causes shortness of breath), and anemia (a blood disorder that can result in symptoms that include extreme tiredness, weakness, and shortness of breath). During a review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/25/2023, indicated the resident required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting and with walking 10 feet or more. A review of Resident 63's History and Physical dated 7/18/2023, indicated the resident does not have the capacity to make decisions. During a review of Resident 63's Fall Risk Assessment, dated 1/3/2024, indicated the resident was a risk for fall. During a review of Resident 63's Care Plan, revised on 1/3/2024, indicated the resident was at risk for falls/injury, and the interventions including staff will provide a safe and clutter-free environment. A review of Resident 63's Change of Condition Assessment form dated 2/6/2024 indicated that at 11:30 AM, room floor noted slightly wet due to roof leaking from the rain. 8. During a review of Resident 69's Admission Record indicated the facility originally admitted the resident on 5/30/2023 and readmitted on [DATE] with diagnoses that included schizoaffective disorder abnormalities of gait and mobility and dementia. During a review of Resident 69's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/6/2023, indicated the resident had moderate levels of memory and cognition (ability to think and reasonably). The MDS indicated Resident 69 required supervision or touching assistance by facility staff with eating, oral hygiene, upper and lower body dressing, sit to standing, toileting, and walking 10 feet or more. During a review of Resident 69's Fall Risk Assessment, dated 11/24/2023, indicated the resident was a risk for fall. During a review of Resident 69's Care Plan, revised on 12/27/2023, indicated the resident was at risk for falls/injury related to generalized weakness, poor safety awareness, and the interventions including staff will provide a safe and clutter-free environment. During a review of Resident 69's Care Plan, revised on 12/27/2023, indicated the resident was at at risk for spontaneous/pathological/stress fracture related to osteoarthritis (occurs when flexible tissue at the ends of bones wears down), and the interventions including provide a safe and hazard free environment. 9. During a review of Resident 71's Admission Record indicated the facility originally admitted the resident on 1/11/2022 and readmitted her on 2/20/2022 with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and hypertension (high blood pressure). During a review of Resident 71's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 1/17/2024, indicated the resident had intact memory and cognition (ability to think and reason). The MDS indicated Resident 71 required setup or clean-up assistance with eating, oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing, personal hygiene, and was able to walk 150 feet distance. During a review of Resident 71's Fall Risk Assessment, dated 1/3/2024, indicated the resident was at risk for fall. During a review of Resident 71's Care Plan, revised on 1/17/2024, indicated Resident 71 was at risk for falls/injury and to provide safety the facility staff will provide a safe and clutter-free environment. 10. During a review of Resident 30's Admission Record indicated the facility originally admitted the resident on 7/28/2021 and readmitted her on 12/04/2023 with diagnoses that included schizophrenia and anxiety. During a review of Resident 30's MDS, dated [DATE], indicated the resident had intact memory and cognition. The MDS indicated Resident required supervision and touching assistance with eating, oral hygiene, chair/bed-to-chair transfer, lower body dressing, personal hygiene, and was able to walk 50 feet distance with two turns. During a review of Resident 30's Fall Risk Assessment, dated 12/19/2024, indicated the resident was at risk for fall. During a review of Resident 30's Care Plan, revised on 12/15/2023, indicated the resident was at risk for falls/injury and the interventions including staff will provide a safe and clutter-free environment. 11. During a review of During a review of Resident 28's Admission Record indicated the facility originally admitted the resident on 10/23/2013 and readmitted her on 12/20/2023 with diagnoses that included schizophrenia and anxiety. During a review of Resident 28's MDS, dated [DATE], indicated the resident had moderately impaired memory and cognitive impairment. The MDS indicated Resident required supervision and touching assistance with eating, and partial/moderate assistance with oral hygiene, toilet hygiene, chair/bed-to-chair transfer, lower body dressing, and was able to walk 10 feet distance. During a review of Resident 28's Fall Risk Assessment, dated 12/23/2024, indicated the resident was at risk for fall. During a review of Resident 28's Care Plan, revised on 12/15/2023, indicated Resident 30 was at risk for falls/injury and the interventions including staff will provide a safe and clutter-free environment. During a review of the facility's record titled, Task Order Proposal, dated 1/14/2024, indicated the following roof assessment: 1. Remove all existing roofing and fascia (a long wooden board behind the gutters on a house) board from the existing roof area. 2. Replace the water damaged roof sheathing (the wooden board that make uo the framing of the roof system) with new sheathing. 3. Furnish and install primed fascia board (a composite or wood that make the exterior house more attractive) and entire roof cave (part of the roof that collapse). 4. Apply completely new Title 24 (State of California Building Standard Code-) compliant- SA mineral surfaced roof system including new perimeter edge flashing, new counter flashing and all other components required for complete roof system. 5. Apply Karnak sealants (brand waterproof sealant coating for the roof) penetrations. During a review of the facility's untitled record used by the facility for maintenance work requests and reports, the report indicated on 2/5/2024, Room C had a new leak by the door and by the window. The record also indicated that on 1/29/2024 there was a previous leak in Room C. During a review of the facility's untitled record used for maintenance requests and reports, the report indicated that on 2/5/2024 leaks were reported in Room D, and Room E and in the hallway adjacent to room E. During an observation on 2/6/2024 at 11:55 AM, trash cans were placed to collect water from leaking ceiling in Room D, E, and the light fixture in the hallway adjacent to Room E near the nursing station. Room D was observed occupied by Resident 39 and 42 and Room E was observed occupied by Resident 15 and 69. During an observation on 2/6/2024 at 11:55 AM, Room A and Room B were connected to Room C. Residents in Room A and Room B must exit through Room C to exit building or to exit into building hallway. In a concurrent interview and observation, Licensed Vocational (LVN5) stated the two trashcans in the hallway in front of the East nursing station were placed there because the ceiling was leaking. LVN 5 stated the trash can positioning was not correct since a water drop fell on his head, which is not where the trash can was located. Water was observed inside trash can and on floor around trash cans. During an interview on 2/6/24 at 12PM, the ADM stated he informed the MS to observe all rooms with water leak from the ceiling, and there were no new water leaks observed in the residents. However, he stated he will continue to observe the other resident's rooms for leakage. During an interview on 2/6/2024 at 12:05 PM, Administrator (ADM) stated that some of the leaks were present last week and that a roofing company was at the facility last week and did some patching of the roof. When requested for the work completed last week, the ADM was unable to produce record of work done from the previous week. During an interview on 2/6/2024 at 12:08 PM, ADM stated that rooms A, B, C, D, E had all been evacuated and that the rooms had been sealed off with caution tape to prevent anyone from going into an area that are dangerous with the potential of falls. He further stated an electrician was coming to assess the safety of the water leaking through the ceiling light fixture. During an interview on 2/6/2024 at 12:14 PM, ADM stated that he gave the directive to the staff to evacuate the affected rooms. (The leaks were identified on 2/5/2024). ADM stated that extra measures needed to be put in place to protect the resident from potential electrical issues until the leaking light could be assessed. During a concurrent observation and interview on 2/6/2024 at 2:34 PM, with the Infection Preventionist (IP) Nurse, IPN stated Residents 28, 71, 63, 20, and 30 were sharing a room (Room A). At the end of the shared room, there were two doors opening to two adjacent rooms where Resident 12 and Resident 47 resided. Residents 12 and 47 had to walk through Resident 28, 71, 63, 20 and 30's shared room to exit from Room A door to reach the hallway. Room A's ceiling was observed with a linear crack (a single narrow crack) and white paint marked with water stain across the ceiling. While Resident 28 was lying on the bed, water was dripping from the ceiling to the floor on the left side of the resident's head of the bed. On the right side of Resident 28's head of the bed, there were two trash bins with plastic liners on the floor to collect the dripping water from the ceiling. Three spots on the ceiling had bulging dry wall and water dripping down to the floor. Resident 28 was lying on the bed while on the right side of Resident 28, water was observed dripping from the ceiling into the two trash bins with plastic liners on the floor. During an observation on 2/6/2024 at 2:35 PM, one green damp towel was spread on the floor under the two trash bins near the exit door. Another two leaking spots were on the right end of the liner white paint mark between Resident 63 and Resident 20's bed, where the water was dripping from the ceiling to the floor, over a pathway to an exit door to the patio outside of the building. These two leaking spots were approximately three inches in length each spot. Two trash bins with plastic liners were on the floor to collect the dripping water from the ceiling and two white wet towels were on the floor between Resident 63 and Resident 20's bed. One white wet towel was spread on the floor next to the right side of Resident 63's head of bed. The exit door to the patio was unlocked from the inside. The IP stated the staff put the trash bins to collect the water and used the towel to keep the floor dry. During a concurrent interview on 2/6/2024 at 2:35 PM, the IP stated the residents should not walk in the area where is wet because they might trip, fall and get injury. The IP stated the wet towel on floor could put residents at risk for tripping and falling too and they should be removed. During a concurrent observation and interview on 2/6/2024 at 2:36 PM, in the shared room, with Resident 71, Resident 71 was sitting on her bed. Resident 71 stated she saw the ceiling was leaking. Resident 71 stated one leaking spot was on her side of bed of the room, another leaking spot was on other side of the room where the exit door was. Resident 71 stated the leaks started when the rain started. Resident 71 stated she was not going to that side of the room. During a concurrent observation and interview on 2/6/2024 at 2:37 PM, in the shared room, with Resident 30, Resident 30 was standing and fixing her bed. Resident 30 stated she knew about the ceiling was leaking, and it started when it rained. Resident stated she used the exit door in the room to exit to the patio. During a concurrent observation and interview on 2/6/2024 at 2:43 PM, in the shared room, Resident 28 was lying on her bed and covered herself with blanket. Resident 28 stated when it rained, the leak started. Resident 28 stated the staff told her they were fixing it, but it was still leaking. During an interview on 2/6/2024 at 2:45 PM, with the housekeeping (HK), HK stated they knew about the leaks for two days now. During an interview on 2/6/2024 at 2:47 PM, with the IP nurse, when surveyor asked if the residents in the shared room were going to stay in the room when the ceiling was leaking, the IP did not respond to the question. During an interview on 2/8/2024 at 8 AM, Registered Nurse Supervisor (RNS) stated that water leaking on the floor created a fall hazard for the residents. During an interview on 2/8/2024 at 8:17 AM, ADM stated that there was supposed to be annual assessment of the facility for structural integrity but was unable to provide any documentation that the assessment had been done. During an interview on 2/8/2024 at 9AM, MS stated that the housekeepers reported the leaks because it happened early morning before he arrived on 2/5/24, which is usually 7-730 am. MS stated it was noted that Room C was leaking early morning [DATE]th. He stated that he came in when he found out and put trash cans in to collect the water. MS stated that he was notified about the leak in Room D later in the day on Monday and they did the same thing (trash cans) try to keep the area dry. MS stated that the leak in the hallway outside Room E Monday occurred almost the same time as Room D. MS stated that Room E water leaked from the ceiling inside the room last week. During an interview on 2/8/2024 at 4:40 PM, RNS stated that the leaks in room D and E started on Monday (2/5/24). During an interview on 2/9/2024 at 8: [TRUNCATED]

Based on interview and record review the facility failed to provide treatment and services to one of two sampled residents (Resident 1) who had a gastrostomy tube GT (GT, a tube surgically inserted into the stomach or small intestines used to deliver fluids and medications) in accordance with current professional standard of practice that was newly placed and inserted on [DATE] and dislodged (pulled out) after two days on [DATE] by failing to: 1. The Director of Nursing (DON) inserting an indwelling catheter (a rubber tube used inserted into the urethra to drain urine from the bladder) into the GT stoma site (opening in the body) and flushing the catheter tubing with 30 cc (cubic centimeter- a unit of measurement) of water after Resident 1's GT had dislodged. 2. The Licensed Vocational Nurses (LVN 1, LVN 2 ) and Registered Nurse (RN 2) flushing fluids and enteral feeding (the delivery of a nutritionally complete feed directly into the stomach and small intestine via tube) on [DATE] after Resident 1's GT had dislodged. 3. The DON and LVN 1 had sufficient skills and competency of the current standard of practice for a GT care after it was dislodged. This deficient practice resulted in Resident 1 being placed at high risk for enteral feeding complications which can (a life-threatening infection of the lining in the abdomen), and perforation (hole made by piercing or boring) in the peritoneal (lining of the abdominal cavity) and spillage of gastric (acidic fluid in the stomach) contents in the abdominal tissue). On [DATE] at 6:45 AM, Resident 1 was found unresponsive by facility staff with oxygen saturation (level of oxygen in the blood) of 40% (normal level ,d+[DATE]%), and no blood pressure (a pressure of the blood in the circulatory system). CPR (Cardiopulmonary Resuscitation - an emergency procedure consists of chest compression and artificial and artificial ventilation to preserve brain function, breathing and blood circulation to the body) was initiated by the facility staff and 911 emergency services was called. Resident 1 was pronounced dead by the paramedics at 7:40 AM on [DATE]. On [DATE] at 4:21 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM), director of nursing (DON), clinical Director of Quality Assurance (QA) and Quality Assurance Nurse (QAN) regarding the facility's failure to follow the standards of practice for GT care and Physician Notification. On [DATE] at 6:12 PM, the IJ situation was removed after the ADM and the QAN submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM, QAN, Regional Consultant (RCN)1 and RCN 2. The acceptable IJ Removal Plan included the following actions: 1. On [DATE] the QAPI (Quality Assurance Program Improvement) and Resident Care Policy Committee of the findings stated in the IJ template dated [DATE] and the need to update Policy: Re-insertion of Gastrostomy Tubes. 2. The Medical Director was communicated and updated on [DATE], policy titled, Re-insertion of Gastrostomy Tubes. The policy has stated that the facility will not reinsert the GT and will transfer the resident to the acute hospital for GT reinsertion. 3. The DON was formally terminated on [DATE] and the facility submitted a formal report to the Board of Nursing upon completion of the investigation. 4. The Acting DON/QA nurse will provide education and in-services on the policies regarding standard of practice. 5. LVN 1 was suspended for 5 days and disciplinary action, including termination considered upon completion of the investigation. 6. During in-services, instructors educated license nurses and explained that all GT reinsertions will be done at the hospital only. 7. On [DATE] CEO (Chief Operating Officer), MD (Medical Director) of the specialized GT services, contracted by the facility for GT care, provided training to all available licensed nurses regarding GT dislodgement. 8. On [DATE] Medical Director participated in QAPI (Quality Assurance Program Improvement-team of staff that plan how to improve the care and quality of life of residents in the facility) and Resident Care Policy Committee to update policy titled Re-insertion of Gastrostomy Tubes to ensure licensed nurses properly follow policy and procedures to obtain the proper care and treatment for residents' with GT care and treatment according to the current standard of practice for residents with dislodged GT. 9. The facility has notified the licensed nurses of the updated policy via in services and on-shift (during the working time) communication. Cross Reference to F693 Findings: A review of Resident 1's Face Sheet (Admission Record) indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted in the facility on [DATE], with diagnoses that included aphasia (unable to speak), blindness, adult failure to thrive (characterized by unexplained weight loss, malnutrition and disability), with gastrostomy tube (a surgical procedure for inserting a tube through the abdomen wall and into the stomach) and chronic duodenal ulcer (a sore that forms in the lining of the duodenum, the first part of your small intestine). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated [DATE], indicated Resident 1 had severely impaired cognition (ability to think, understand and reason) with moderate difficulty of hearing and sometimes could express ideas and wants, and understand others. The MDS indicated Resident 1 was totally dependent with one person assistance on dressing, eating, toilet use and personal hygiene. A review of the GACH record, Resident 1 was admitted to the hospital on [DATE] due to failure to thrive and weakness. On [DATE] Resident 1 had an EGD (Endo gastroduodenoscopy- a procedure in which a tube is inserted into the mouth to visualize the gastrointestinal tract) and placement of the GT. The GACH Physician Discharge Summary Report, dated [DATE], indicated Resident 1 was clinically stable and improved with no signs and symptoms of respiratory distress (difficulty breathing), vital signs (measurement of the heart rate, blood pressure, body temperature) were stable and was cleared for discharge. A review of Resident 1's Order Summary Report, dated [DATE], timed at 9 PM, Enteral Feed Order indicated: 1. Insert indwelling catheter into the GT site PRN (as needed), if GT becomes displaced (dislodged) temporarily, cover with dry dressing until pending reinsertion of GT. 2. Replace GT (if removed/displaced) by specialized GT services. 3. Transfer the resident to the hospital emergency room (ER) if GT becomes displaced/removed. 4. Administer enteral feeding: Jevity (a nutritional formula) 1.2 calorie (unit of energy) bolus feeding (instilling fluid in a fast rate) 400 cc (cubic centimeter-unit of measurement) three times a day to provide 1200cc/kcal (kilo calorie) per day. 5. Flush the enteral tube with 30 cc of water every shift three times a day. A review of Resident 1's Change of Condition (COC) report, dated [DATE], timed at 9 AM, indicated the Charge Nurse reported to the primary physician (PHY 1) that Resident 1 pulled out his GT. The COC indicated PHY1 ordered to re-insert the GT with an indwelling catheter PRN while waiting for the GT to be replaced by the wound specialist. A review of Resident 1's COC report, dated [DATE], timed at 11AM, indicated (Register Nurse) RN 1 made rounds (tour the facility) at 6:45 AM, and Resident 1 was found unresponsive, without vital signs, oxygen saturation was 40%, and CPR was started by the facility staff. The COC report indicated the paramedic arrived within ten minutes after the 911 emergency services were called. At 7:40 AM, Resident 1 was pronounced dead by the paramedics on [DATE]. A review of the Medication Administration Record (MAR) for [DATE], indicated, Resident 1 received 30 cc water flush before and after medication administration on [DATE] at 8AM, 12PM, 4PM and 5 PM, a total of more than 240 cc of fluid and medications. During an interview with the Director of Nursing (DON) on [DATE] at 10:04 AM, the DON stated, she inserted an indwelling catheter on [DATE] between 8 AM to 9 AM, into Resident 1's GT stoma site, when the resident's GT was found dislodged on [DATE]. The DON also stated she flushed the indwelling catheter at the stoma site with 50 ml (milliliter, a unit of measurement) of water without verifying if there was a physician's order to insert an indwelling catheter into the stoma site when the GT was dislodged and flush the tubing. During an interview with the Licensed Vocational Nurse (LVN) 1 on [DATE] at 12:31 PM, LVN 1 validated the DON inserted an indwelling catheter on [DATE] between 8 AM to 9 AM, when Resident 1's GT dislodged and that an X-ray (images or pictures inside of the body using) was not done to check the GT placement after she had inserted the catheter. LVN 1 explained, he contacted the specialized GT services the morning of [DATE] to have the resident's GT replaced after it had been dislodged, however the GT services were unable to see the Resident 1 until [DATE]. During an interview with the Director of Staff Development (DSD) on [DATE] at 1:08 PM, DSD stated as a facility's practice, The DON and any licensed nurse can re-insert a G Tube. A review of Resident 1's Baseline Care Plan (initial care plan developed during admission), dated [DATE], verified with the DON on [DATE] at 2:50 PM, indicated, Resident 1 had nutritional/fluid impairment (poor nutrition and fluid intake) and was placed on GT feeding. To ensure Resident 1 remained adequately nourished and hydrated (absorption of fluid) without unplanned weight loss, the facility would monitor the resident for aspiration (inhalation of fluid and food in the lungs) and tolerance to GT feeding. The resident's care plan did not indicate nursing interventions on how to address or handle the resident's GT site in the event the GT tube becomes dislodged. During a concurrent interview and record review of the Medication Administration Record (MAR) on [DATE] at 5 PM, LVN 1 stated after the indwelling catheter was inserted by the DON, he signed and confirmed that he instilled Jevity 1.2 calorie, 400cc bolus feeding to Resident 1 and flushed 30cc of water into the indwelling catheter tubing on [DATE] between 8 AM and 9 AM. During an interview with the DON and LVN 1 on [DATE] at 5:54 PM and concurrent record review of the Physician's Order Summary Report, dated from [DATE] to [DATE], the DON and LVN 1 validated there was no physician's order to instill bolus feeding, administer medications, into the Resident 1's tubing after inserting the indwelling catheter into the GT stoma. During an interview with the DON and LVN 1 on [DATE] at 5:55 PM and concurrent record review of the facility's policy and procedure for reinsertion of gastrostomy tubes, (dated [DATE]) indicated the facility does not allow licensed nurse to re-insert gastrostomy tubes that become displaced or removed. The procedure indicates if a GT becomes dislodged, removed, or displaced, the GT site will be covered with a clean dressing. If physician orders insertion of indwelling catheter to keep G-Tube orifice open, this will be done; however, no flushing or enteral feedings will be attempted/provided. During an interview on [DATE] at 5:57 PM, the DON stated, it's, common sense to continue the feeding without a physician's order, because Resident 1 will get hungry. During an interview on [DATE] at 7:01 PM, the DON stated, she did not get training or certification for inserting an indwelling catheter in the GT site, because she has been a nurse for many years. The DON stated she flushed the indwelling catheter with 50 cc of water and aspirate (to draw in or out using a sucking motion) after she inserted the indwelling catheter on [DATE] at around 8AM to 9AM. The DON stated she does recall how far she advanced the catheter tubing into the Resident 1's stomach and the placement was not verifying by X ray. During an interview on [DATE] at 9 AM, PHY 1 stated, he was not informed that Resident 1's GT was dislodged on [DATE]. PHY 1 stated he did not order the nurses to insert an indwelling catheter into the resident's stoma when the GT site had dislodged. The physician stated, if the GT was pulled out or became dislodged, he would always order the facility to transfer the resident to emergency room so that the resident can be seen by the gastroenterologist (a physician specialized in GT placement) to have the GT reinserted safely and validate GT placement by doing X ray. PHY 1 further stated he did not place the order to start bolus feeding or instill medications into the tube. PHY 1 stated the risk for inserting an indwelling catheter is the tubing could go to a different area of the stomach that could lead to peritonitis. During an interview on [DATE] at 2:23 PM, CNA 3 stated, he informed the charge nurse (LVN 3) on [DATE] at 5AM, that during the night shift (10 PM to 6:30 AM), Resident 1 was observed getting irritated and tried to pull out his GT. During an interview on [DATE] at 2:36 PM, LVN 3 stated she took care of Resident 1 during the night shift of [DATE] and [DATE]. Resident 1 was swinging his arm and told us to go away. During an interview [DATE] 3:20 PM, Registered Nurse 2 (RN 2) stated, a check mark and initials in the MAR means she administered the medications and fluid were administered. RN 2 stated the night of [DATE], the day shift nurse did not endorse to him that Resident 1's GT had come out and was replaced by a foley catheter. RN 2 was not informed the foley should not be used to administer the medications. During a concurrent interview and record review of the MAR on [DATE] at 3:30 PM, Registered Nurse (RN 2) stated, he signed the MAR that indicated he administered the medications on [DATE] at 4PM, that included Cranberry capsule (helps reduce the frequency of urinary tract infections) 425mg (milligrams- a unit of measurement) 1 tablet, Docusate Sodium (a stool softener) 250 mg 1 capsule, Ferrous Sulfate (iron supplement used treat or prevent low levels of iron in the blood) 1 tablet, Fish Oil ( dietary supplement) 1000mg 1capsule, [NAME]-vite (B complex with C and Folic Acid, multivitamin used to treat nutritional deficiency) 1 tablet, Carbamazepine (used to treat seizure disorder [a sudden, uncontrolled burst of electrical activity in the brain]) 200 mg 1 tablet given and sodium chloride (supplement used to prevent and treat low levels of sodium in your body), and on [DATE] at 8PM, he administered Mirtazapine (used to treat major depression [a feeling of severe sadness and hopelessness] manifested by inability to sleep at night causing stress) 7.5mg 1 tablet and Carbamazepine 200 1 tablet. During a review of a declaration report, dated [DATE] and timed at 11:30 AM, written by LVN 3 indicated, she contacted the DON if there was a physician's order for Resident 1's GT dislodgement that occurred in the morning shift on [DATE], but the DON informed her Do not worry, we will take care of it in the morning. LVN 3 asked, who is he? DON stated, Me and LVN 1. During a concurrent interview and record review of the MAR on [DATE] at 2:25 PM, LVN 2 stated she signed the MAR that indicated on [DATE] at 8AM, she administered Nifedipine (a medication used to treat hypertension [a condition of having a high blood pressure]) tablet 10 mg via GT one time a day, Lexapro 5 mg 1 tablet (used to treat depression), Phenobarbital (use to treat seizure disorder) 32.4 mg 1 tab and sodium chloride (supplement used to prevent and treat low levels of sodium in your body). A review of the Journal of Parenteral and Enteral Nutrition related to ASPEN Safe Practices for Enteral Nutrition Therapy, dated [DATE], indicated if the gastrostomy tube dislodges in the first ,d+[DATE] days after insertion the inserting provider needs to be contacted as soon as possible for further intervention. A dislodged gastrostomy tube can become a medical emergency, as stomach contents are likely to leak into the peritoneum. The tube should not be reinserted blindly at this stage because it may be repositioned into the peritoneum. https://aspenjournals.onlinelibrary.[NAME].com/doi/full/10XXX,d+[DATE] A review of the facility's policy and procedure titled, Gastrostomy Tube Re- insertion, revised on [DATE], indicated, the facility does not allow licensed nurse to re-insert G-tubes; however, indwelling catheter may be placed to keep G-tube stoma open. A review of the facility's policy and procedure titled, Reinsertion of Gastrostomy Tubes, revised on [DATE], indicated the facility does not allow licensed nurse to re- insert gastrostomy tubes that become dislodged/removed. Procedure indicated, if a gastrostomy tube becomes dislodged, removed, or dislodged, the gastrostomy site will be covered with clean dressing. If physician orders insertion of indwelling catheter to keep G-Tube orifice open, this will be done; however, no flushing or enteral feedings will be attempted/provided. Attending physician will be contacted and orders will be obtained to contact GT Replacement Services, or orders obtained for transfer to outpatient facility or ER for replacement of gastrostomy tube, or orders obtained for NP (Nurse Practitioner), PA (Physician Assistant), or physician to come to facility to re-insert gastrostomy tube.

Based on interview and record review the facility failed to ensure a resident who had a Gastrostomy Tube (GT, a tube surgically inserted into the stomach or small intestines used to deliver fluids and medications) receive treatment and services to prevent complications such peritonitis (a life threatening infection of the abdominal lining), and perforation (a hole made by boring or piercing) in the peritoneal (lining of the abdominal cavity) and spillage of gastric (acidic fluid in the stomach) contents in the abdominal tissue) for one of two sampled resident (Resident 1), who had a newly inserted GT placed on [DATE]. On [DATE], Resident 1's GT became dislodged (removal or forced out of position) and Director of Nursing (DON) inserted an indwelling catheter (a rubber tube inserted into the bladder to drain urine) in the resident's GT stoma (opening in the abdomen connected to the stomach or intestine). The DON, the Licensed Vocational Nurses (LVN 1 and LVN 2) and Registered Nurse 2 (RN 2) did not implement the facility's policy and procedure for re-insertion of gastrostomy tubes that indicated not to flush the resident's catheter tube with fluids, instilling (put a substance into something in a form of liquid) Jevity (nutritional formula) and medications through the tubing. As a result of this deficient practice, on [DATE] at 6:45 AM, Resident 1 was found unresponsive by facility staff with oxygen saturation (level of oxygen in the blood) of 40% (normal level ,d+[DATE]%), and no blood pressure (a pressure of the blood in the circulatory system). CPR (Cardiopulmonary Resuscitation - an emergency procedure consists of chest compression and artificial and artificial ventilation to preserve brain function, breathing and blood circulation to the body) was initiated by the facility staff and 911 emergency services was called. Resident 1 was pronounced dead by the paramedics at 7:40 AM on [DATE]. On [DATE] at 4:12 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified, and an IJ template was reviewed in the presence of the Administrator (ADM), DON, clinical Director of Quality Assurance (QA) and Quality Assurance Nurse (QAN) regarding the facility's failure to follow the standards of practice for GT care and Physician Notification by failing to: 1. Notify the physician to obtain an order to transfer Resident 1 to the GACH (general acute hospital), and/or obtain an order for a Nurse Practitioner or Physician Assistant to re-insert GT or obtain an order to contact the GT services in accordance with the facility's policy after Resident 1's GT was dislodged. 2. Verify and confirm with Resident 1's attending physician to have a licensed nurse re-insert an indwelling catheter tube after the resident's GT was dislodged/removed. Re-inserting a GT has been associated with peritonitis. 3. Ensure licensed nurses did not flush Resident 1's GT with water/liquid, enteral feeding (a form of nutrition that is delivered into the digestive system/stomach as a liquid) and administer medications to Resident 1 via indwelling catheter after tube was inserted. On [DATE] at 6:12 PM, the IJ situation was removed after the ADM and the QAN submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementations of the IJ removal plan while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM, QAN, Regional Consultant (RCN 1) and RCN 2. The acceptable IJ Removal Plan included the following actions: 1. The Medical Director was communicated and updated on [DATE], policy titled, Re-insertion of Gastrostomy Tubes. The policy has stated that the facility will not reinsert the GT and will transfer the resident to the acute hospital for GT reinsertion. 2. During in-services, instructors educated the license nurses and explained that all GT reinsertions will be done at the hospital only. 3. On [DATE] CEO (Chief Operating Officer), MD (Medical Director) of the specialized GT services, contracted by the facility for GT care, provided training to all available licensed nurses regarding GT dislodgement. 4. Medical Director was informed on [DATE] of the deficiency and participated in QAPI (Quality Assurance Program Improvement-team of staff that plan how to improve the care and quality of life of residents in the facility) and Resident Care Policy Committee to update the policy, titled Re-insertion of Gastrostomy Tubes, and to ensure licensed nurses properly follow policy and procedures to obtain the proper care and treatment for residents' with GT care and treatment according to the current standard of practice for residents with dislodged GT. 5. The facility has notified the licensed nurses of the updated policy via in services and on-shift (during the working time) communication. Cross Reference to F658 Findings: A review of Resident 1's admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included aphasia (unable to speak), blindness, adult failure to thrive (characterized by unexplained weight loss, malnutrition (poor food intake), and disability), with GT and chronic duodenal ulcer (a sore that forms in the lining of the duodenum, the first part of your small intestine). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated [DATE], indicated Resident 1 had severely impaired cognition (ability to think, understand and reason) with moderate difficulty of hearing and sometimes could express ideas and wants, and understand others. The MDS indicated Resident 1 was totally dependent with one person assistance on dressing, eating, toilet use and personal hygiene. A review of the GACH (General Acute Care Hospital) record, Resident 1 was admitted to the hospital on [DATE] due to failure to thrive and weakness. On [DATE] Resident 1 had an EGD (Endo gastroduodenoscopy- a procedure in which a tube is inserted into the mouth to visualize the gastrointestinal tract) and placement of the GT. The GACH Physician Discharge Summary Report, dated [DATE], indicated Resident 1 was clinically stable and improved with no signs and symptoms of respiratory distress (difficulty breathing), vital signs (measurement of the heart rate, blood pressure, body temperature) were stable and was cleared for discharge. A review of Resident 1's Baseline Care Plan (initial care plan developed during admission), dated [DATE], indicated, Resident 1 had nutritional/fluid impairment (poor nutrition and fluid intake) and was placed on GT feeding. To ensure Resident 1 remained adequately nourished and hydrated (absorption of fluid) without unplanned weight loss, the facility would monitor the resident for aspiration (inhalation of fluid and food in the lungs) and tolerance to GT feeding. The resident's care plan did not indicate nursing interventions on how to address or handle the resident's GT site in the event the GT tube becomes dislodged. A review of Resident 1's Order Summary Report, dated [DATE], Enteral Feed Order indicated: 1. Insert indwelling catheter into the GT site PRN (as needed), if GT becomes displaced (dislodged) temporarily, cover with dry dressing until pending reinsertion of GT. 2. Replace GT (if removed/displaced) by specialized GT services. 3. Transfer the resident to the hospital emergency room (ER) if GT becomes displaced/removed. 4. Administer enteral feeding: Jevity (a nutritional formula) 1.2 calorie (unit of energy) bolus feeding (instilling fluid in a fast rate) 400 cc (cubic centimeter-unit of measurement) three times a day to provide 1200cc/kcal (kilo calorie) per day. 5. Flush the enteral tube with 30 cc of water every shift three times a day. A review of Resident 1's Change of Condition (COC) report, dated [DATE], timed at 9 AM, indicated the Charge Nurse reported to the primary physician (PHY 1) that Resident 1 pulled out his GT. The COC indicated PHY1 ordered to re-insert the GT with an indwelling catheter PRN while waiting for the GT to be replaced by the wound specialist. A review of Resident 1's COC report, dated [DATE], timed at 11AM, indicated (Register Nurse) RN 1 made rounds (tour the facility) at 6:45 AM, and Resident 1 was found unresponsive, without vital signs, oxygen saturation was 40%, and CPR was started by the facility staff. The COC report indicated the paramedic arrived within ten minutes after the 911 emergency services were called. At 7:40 AM, Resident 1 was pronounced dead by the paramedics. During an interview with the Director of Nursing (DON) on [DATE] at 10:04 AM, the DON stated, she inserted an indwelling catheter into Resident 1's GT stoma site, when the resident's GT was found dislodged on [DATE]. The DON also stated she flushed the indwelling catheter at the stoma site with 50 ml (milliliter, a unit of measurement) of water without verifying if there was a physician's order to insert an indwelling catheter into the stoma site when the GT was dislodged and flush the tubing. During an interview with the Licensed Vocational Nurse (LVN) 1 on [DATE] at 12:31 PM, LVN 1 validated the DON inserted an indwelling catheter when Resident 1's GT dislodged and that an X-ray (images or pictures inside of the body using) was not done to check the GT placement after she had inserted the catheter. LVN 1 explained, he contacted the specialized GT services the morning of [DATE] to have the resident's GT replaced after it had been dislodged, however the GT services were unable to see the resident until [DATE]. During a concurrent interview and record review of the Medication Administration Record (MAR) on [DATE] at 5 PM, LVN 1 stated after the indwelling catheter was inserted by the DON, he signed and confirmed that he instilled Jevity 1.2 calorie, 400cc bolus feeding to Resident 1 and flushed 30cc of water into the indwelling catheter tubing on [DATE] at 8 AM. During an interview with the DON and LVN 1 on [DATE] at 5:54 PM and concurrent record review of the Physician's Order Summary Report, dated from [DATE] to [DATE], the DON and LVN 1 validated there was no physician's order to instill bolus feeding, administer medications, into the Resident 1's tubing after inserting the indwelling catheter into the GT stoma. During an interview with the DON and LVN 1 on [DATE] at 5:55 PM and concurrent record review of the facility's policy and procedure for reinsertion of gastrostomy tubes, (dated [DATE]) indicated the facility does not allow licensed nurse to re-insert gastrostomy tubes that become displaced or removed. The procedure indicates if a GT becomes dislodged, removed, or displaced, the GT site will be covered with a clean dressing. If physician orders insertion of indwelling catheter to keep G-Tube orifice open, this will be done; however, no flushing or enteral feedings will be attempted/provided. During an interview on [DATE] at 5:57 PM, the DON stated, It is a common sense to continue the feeding without a physician's order, because Resident 1 will get hungry. During an interview on [DATE] at 7:01 PM, the DON stated, she did not get training or certification for inserting an indwelling catheter in the GT site, because she has been a nurse for many years. The DON stated she flushed the indwelling catheter with 50 cc of water and aspirate (to draw in or out using a sucking motion) after she inserted the indwelling catheter on [DATE] at around 8AM to 9AM. The DON stated she does recall how far she advanced the catheter tubing into the Resident 1's stomach and the placement was not verifying by X ray. During an interview on [DATE] at 9 AM, PHY 1 stated, he was not informed that Resident 1's GT was dislodged on [DATE]. PHY 1 stated he did not order the nurses to insert an indwelling catheter into the resident's stoma when the GT site had dislodged. The physician stated, if the GT was pulled out or became dislodged, he would always order the facility to transfer the resident to emergency room so that the resident can be seen by the gastroenterologist (a physician specialized in GT placement) to have the GT reinserted safely and validate GT placement by doing X ray. PHY 1 further stated he did not place the order to start bolus feeding or instill medications into the tube. PHY 1 stated the risk for inserting an indwelling catheter is the tubing could go to a different area of the stomach that could lead to peritonitis. A review of the National Library of Medicine, article titled Gastrostomy Tube Replacement dated [DATE], indicated once the tube is placed, a fistulous gastrocutaneous tract (a skin tract that form to connect the stomach and the skin) is formed in about ,d+[DATE] weeks. If a percutaneous endoscopic gastrostomy (PEG, a feeding tube inserted through the skin and the stomach wall) tube is dislodged within a month after placement, then endoscopic (a procedure that allows a doctor to view inside of a person's body using a specialized tube with camera) replacement is recommended. If the tube is dislodged within 4 weeks of initial placement, residents are at significant risk of peritonitis and perforation due to peritoneal spillage of gastric (stomach) contents through the immature track, and replacement should not be attempted without surgical consultation. A blind attempt (inserting a tube into the stomach without camera) to re-insert the tube or even indwelling catheter placement in an immature tract can lead to inadvertent placement of the tube into the peritoneal cavity (the space within the abdomen that contains the intestines, stomach, and liver. https://pubmed.ncbi.nlm.nih.gov/29494029/ A review of the Journal of Parenteral and Enteral Nutrition related to ASPEN Safe Practices for Enteral Nutrition Therapy. If the gastrostomy tube dislodges in the first ,d+[DATE] days after insertion the inserting provider needs to be contacted as soon as possible for further intervention. A dislodged gastrostomy tube can become a medical emergency, as stomach contents are likely to leak into the peritoneum. The tube should not be reinserted blindly at this stage because it may be repositioned into the peritoneum. https://aspenjournals.onlinelibrary.[NAME].com/doi/full/10XXX,d+[DATE] A review of the facility's policy and procedure titled, Gastrostomy Tube Re- insertion, revised on [DATE], indicated the facility does not allow licensed nurse to re-insert GT. However, indwelling catheter may be placed to keep G-Tube stoma open. A review of the facility's policy and procedure titled, Re-Insertion of Gastrostomy Tubes, revised on [DATE], indicated, the facility does not allow licensed nurse to re-insert gastrostomy tubes that become displaced/removed. Procedure indicated, if a gastrostomy tube becomes dislodged, removed, or displaced, the gastrostomy site will be covered with clean dressing. If physician orders insertion of indwelling catheter to keep G-Tube orifice open, this will be done; however, no flushing or enteral feedings will be attempted/provided.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the local Department of Public Health's (DPH) guidelines, and facility's COVID-19 Preparedness Policy for 80 of 80 sampled residents (Residents 1-80) by failing to: a. Ensure a response testing which is a COVID-19 testing of all residents (80 residents) and staff (87 staff) regardless of their COVID-19 vaccination status, every 3-7 days, was conducted timely after one healthcare worker received a positive test result for COVID-19 on 8/18/21. b. Submit 40 of 40 COVID-19 test samples to the designated laboratory center (a facility used to test COVID-19 samples and conduct other medical research) for processing to ensure COVID-19 results are received in time by the facility. c. Store laboratory 40 test samples at 2 to 8 degrees Celsius for up to 72 hours after collection in accordance with Centers for Disease Control's (CDC) Guidelines. d. Develop a line listing (a table that summarizes information about person(s) who may be associated with an outbreak) of facility staff and residents test results for the response testing that was conducted on 8/19/2021. These deficient practices had the potential to spread COVID-19 to residents, staff, and visitors that could lead to severe respiratory illness, hospitalization , and/or death. On 8/23/21 at 5:59 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator regarding the facility's failure to implement infection control practices according to the local DPH's guidelines and the facility's policy for COVID-19 Preparedness. On 8/25/21 at 5:26 pm, the IJ was lifted after the Administrator submitted an acceptable Plan of Action (POA, interventions to correct deficient practices). The surveyor verified and confirmed the implementations of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the Administrator. The acceptable POA indicated, as follows: 1. Immediately retested 100% of residents and 100% of staff for COVID-19 and submitted the samples to Curative Laboratories/Labs (name of the laboratory network) the same day. Residents and staff were retested on [DATE] for COVID-19 and the test samples were submitted to Curative Labs the same day. Remaining staff that failed to test by 8/24/21 were removed from the schedule. 2. Infection Prevention Nurse (IPN, a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment) continued to update the line listing, testing log, and COVID-19 test results to ensure timely completion and accuracy of COVID-19 testing procedure and report findings as needed. 3. Converted 80 residents from Green zone (non-COVID 19 cohort) to Yellow zone (quarantine zone, separate or restrict movement of people who have been exposed to a contagious disease to watch and see if they become sick) to monitor for potentially exposed residents who may have been in close contact with the healthcare worker who tested positive for COVID-19. Findings: During observation of the facility on 8/23/21 at 1:00 pm, all resident rooms had a green zone (green zone is zone reserved for residents who do not have COVID-19 or have completed quarantine; cleared isolation from infection) signage posted and staff wore surgical masks with face shields. There were no residents observed under quarantine. During an interview with the Administrator (ADM) on 8/23/21 at 3:00 pm, he stated the Director of Nursing (DON), tested for COVID-19 on 8/16/21 and on 8/18/21, the result came back positive. The ADM stated the DON's last day worked was on 8/13/21. A review of the facility's staff and resident line listings, dated 8/23/21, indicated the line listings did not have information for the response testing of facility's staff and residents. The line listings did not have the test results for the response testing that was conducted on 8/19/2021. The column for positive, negative, pending, inconclusive, and total samples tested were left blank. During a concurrent interview and review of the facility's line listings with the IPN on 8/23/21 at 3:05 pm, the IPN stated response testing started on 8/19/21 but he did not have time to update staff and resident line listings to identify the residents and staff who had already been tested for COVID-19. During a concurrent interview and review of the Curative Labs website (https://drivethru.curativeinc.com/) with the IPN on 8/23/21 at 3:30 pm, the website indicated zero COVID-19 test samples with received status for facility's staff and residents from 8/19/21 to 8/23/21. The IPN stated he was waiting until he had all test samples before he would submit the COVID-19 test samples to the laboratory. The IPN stated he was supposed to submit COVID-19 test samples as they came, but there was, a lot going on, therefore no laboratory samples were turned in to the laboratory center for processing. During a concurrent observation and interview with the IPN on 8/23/21 at 4:06 pm, he stated response testing that was conducted 8/19/21 to 8/22/21 were kept in a bin under a computer desk in the facility's lobby over the weekend and was not turned in to Curative Labs for processing. An observation of the bin under the computer desk showed four Residents' COVID-19 test samples dated 8/19/21 mixed with 36 undated COVID-19 tests samples. The IPN stated COVID-19 test samples were kept in a bin under the computer desk. The IPN stated he had, no idea how accurate the COVID-19 test samples in the bin were. During an interview with the ADM on 8/23/21 at 4:50 pm, he stated that COVID-19 test samples must be turned in to the laboratory center within 24 hours for processing. During an observation on 8/24/21 at 1:50 pm with the Director of Maintenance (DM), the temperature of the area below the computer desk was at 76.6 degrees Fahrenheit (24.7 degrees Celsius). A review of the Center for Disease Control and Prevention (CDC) website, titled Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing, under storing and shipping respiratory specimens, dated 2/26/21, indicated respirator specimens should be stored at 2 to 8 degrees Celsius for up to 72 hours after collection. If a delay in testing was expected, specimen must be stored at negative 70 degrees Celsius or below (https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html). A review of the local DPH's guidelines, titled Skilled Nursing Facilities COVID-19 Procedural Guidance, dated 7/27/21, indicated if a single positive COVID-19 case was identified among either staff or residents, the facility must conduct testing of all residents and staff regardless of vaccination status to identify potential asymptomatic infections. All residents and staff should be tested on ce every 3-7 days. A review of the facility's policy titled COVID-19 Preparedness, dated 8/23/21 indicated outbreak was defined as any new positive case that arise in the facility and all staff and all resident to be tested every 3 to 7 days regardless of vaccination status. The policy indicated for staff to initiate the line listing of any person under investigation and list of residents or employees that may have been exposed.

Based on observation, interview, and record review, the facility failed to ensure that one of three sampled residents, Resident 1, who was identified at risk for elopement (leaving the facility unsupervised and without staff knowledge) was provided supervision to prevent elopement by failing to: 1. Ensure that the care plan for behavior of attempting to climb a fence included interventions to prevent elopement as indicated in the facility's policy titled, Residents at Risk for Elopement. 2. Ensure the facility caregiver monitored Resident 1, who was at the outside patio sitting on a bench, on 8/21/20 at 10 p.m., as indicated in the facility's policy titled, Monitoring Residents. This deficient practice resulted in Resident 1 being left alone outside the facility patio and eloped, on 8/21/20, at 10 p.m. Resident 1 climbed over a fence. Resident 1 was found by police. Resident 1 was walking in the freeway at 11:40 p.m. (missing for 1 hours and 40 minutes at night). Resident 1 was handcuffed, sustained abrasion on the right and left wrists, and was transferred to a General Acute Care Hospital (GACH) for further evaluation. Findings: A review of Resident 1's Admission Face Sheet, printed on 9/9/2020, indicated the facility initially admitted Resident 1, on 11/8/2019 and readmitted the resident, on 9/1/2020, with [DIAGNOSES REDACTED]. A review of Resident 1's Care Plan: Elopement/Wandering Risk, dated 11/8/2019, indicated Resident 1 was for at risk for elopement/wandering due to mental illness and intermittent confusion. The interventions included secured unit rooms, hallways, dining areas, activity rooms, outside patio will be free of hazards. Resident 1's elopement wandering risk will be identified and minimized incidents or accidents due to elopement or wandering episode daily. A review of Resident 1's Care Plan for Elopement Risk, dated 1/17/2020, indicated a resident was an elopement risk for leaving safe area without authorization and leave the premises due to [MEDICAL CONDITION] (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear). The care plan interventions included to monitor resident at frequent intervals, redirect resident to alternatives (activities, watching television, family contact), provide 1:1 (one staff to one resident monitoring) if indicated to redirect behavior. A review of Resident 1's Change of Condition (COC)/Interact Assessment Form, indicated that, on 4/22/2020 at 7:15 p.m., the resident attempted to escape by climbing the fence. A review of Resident 1's Licensed Progress Note, dated 4/22/2020, timed 7:15 p.m., indicated the housekeeper went out to throw trash and saw the resident already up on the bench at the facility patio. A review of Resident 1's Care Plan: Change of Condition manifest by behavior of attempting to escape, dated 4/22/2020, indicate Resident 1 attempted to escape by, Climbing our fence. The interventions (approach) included to communicate with attending physician, notify responsible party verbalize, and provide routine nursing care. The care plan did not indicate interventions to prevent Resident 1 from elopement or attempt to elope. A review of Resident 1's Multidisciplinary (group of health care workers who are members of different disciplines) Progress Record, dated 4/23/2020, timed at 1:30 p.m., indicated late entry for 9 a.m., on 4/23/2020, indicated Resident 1 has been attempting AWOL (absent without official leave) from the facility, and feeling depressed and isolated. The note indicated the facility to transfer the resident to GACH for evaluation for attempting to climb the fence. A review of Resident 1's Multidisciplinary Progress Record, dated 4/23/2020 timed at 2:30 p.m., indicated the facility received a call that the Resident 1 went AWOL from an urgent care and incident was reported to the police department. A review of Resident 1's Multidisciplinary Progress Record, dated 4/24/20, timed at 12:05 p.m., indicated Resident 1 was readmitted from GACH 1 brought by (B/B) police department. Resident 1 was alert and oriented. Resident 1 had a skin tear on the left hand covered with dry sterile dressing (DSD). A review of Resident 1's Multidisciplinary Progress Record, dated 4/24/20, timed at 1 p.m., indicated Nurse Practitioner (NP) was made aware of Resident 1 condition and arranged to transfer resident. Resident 1 was transferred at 3 p.m. A review of Resident 1's GACH 2 Physician Psychiatry (a medical specialty devoted to the diagnosis, prevention, and treatment of [REDACTED]. A review of Resident 1's Multidisciplinary Progress Record, dated 5/14/20 timed at 3 p.m., indicated Resident 1 was readmitted from GACH 2. A review of Resident 1's History and Physical (H&P) dated 5/15/2020, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 8/21/2020, indicated the resident could be understood, understand others, and required supervision with setting up for activities of daily living (dressing, eating and toileting). The MDS indicated Resident 1 did not have a steady gait when moving, walking, turning around, and surface to surface transfer. A review of Resident 1's Licensed Progress Notes, dated 8/21/2020, timed at 10 p.m., indicated a certified nurse assistant (CNA) came through the front gate and noticed Resident 1 sitting on a bench outside the facility. The note indicated the CNA instructed the resident to get inside the facility as it was getting late to be outside. The CNA proceeded inside the facility to clock in and then completed her rounds (checking on residents). The CNA noticed Resident 1 missing from his room after her rounds and notified the licensed nurse. A search team was sent out to search for Resident 1. The Resident 1 was nowhere to be found. The note indicated the Director of Nursing (DON) and the Administrator were notified that Resident 1 was missing. A review of Resident 1's COC/Interact Assessment Form, indicated that on 8/21/2020 at 10:30 p.m., the resident had an actual AWOL episode. A review of Resident 1's COC/Interact Assessment Form, dated 8/22/2020, timed at 11:40 a.m., indicated Resident 1 was brought in by police. Resident 1 was found walking the highway close to East LA (Los Angeles). The resident was belligerent (hostile and aggressive). The plan was to transfer to, Hospital on 5150 (temporary, involuntary psychiatric commitment of individuals who present a danger to themselves). A review of Resident 1's Progress Notes, dated 8/22/2020, timed at 10:40 a.m., indicated the resident was on one to one (1:1) monitoring due to (d/t) escape attempt and the resident had abrasion (scraping or wearing something away) on his right and left wrists. The notes indicated, He (Resident 1) claims from handcuffs. A review of Resident 1's Progress Notes, dated 8/23/2020, timed 11:20 a.m., indicated Resident 1 was transferred to GACH 3. A review of Resident 1's GACH 3 Discharge Summary, indicated GACH 3 admitted Resident 1, on 8/23/2020, on 5150, with [DIAGNOSES REDACTED]. The resident gradually improved with treatment and was discharged , on 9/1/2020. A review of Resident 1's Admission Assessment, dated 9/1/2020 timed at 8:09 p.m., indicated the facility readmitted the resident from GACH 3. During an observation and concurrent interview, on 9/9/2020, timed at 2:03 p.m., the maintenance director observed measuring the facility gate (fence) and stated the measured height of the locked gate from where Resident 1 eloped from was 9 feet and 10 inches high from the ground up. During an interview, on 9/9/2020 at 2:08 p.m., Resident 1 stated he was lonely, sad, and wanted to see his wife and daughter. Resident 1 stated the facility uses a fan when mopping the floor and cannot sleep because, I am not used to noise. The resident stated he was in the marines and used, Muscle, to move the bench sometime after 10 p.m., on 8/21/ . Resident 1 stated he left, and no one saw him. Resident 1 stated he was too fast and felt free. Resident 1 stated he walked at the freeway, when the highway patrol stopped him. During an observation and concurrent interview with the DON, on 9/9/2020 at 2:20 p.m., a large fan was observed in the hallway and making moderate noise. The DON stated the fan can be moved if it bothers the resident. During a phone interview with Licensed Vocational Nurse 3 (LVN 3), on 10/15/2020 at 12:44 p.m., LVN 3 stated CNA 3 saw Resident 1 during her last rounds (end of shift) at 10:00 p.m. LVN 3 stated Resident 1's room was checked, and Resident 1 was not there. LVN 3 stated she checked outside and found a table pushed to the fence with a sheet on top of the fence. LVN 3 stated she informed the DON, the administrator (ADM), the police, and Resident 1's family. LVN 3 stated she saw Resident 1 near the gate at 10:00 p.m. when she clocked in to work. LVN 3 stated Resident 1 was in the patio, stood by the fence and then went back inside the facility. LVN 3 stated Resident 1 would not be able leave because the gate was locked. During a phone interview with CNA 3, on 10/15/2020 at 3:19 p.m., CNA 3 stated she last saw Resident 1 walking up and down the hallway between 10 p.m. and 10:30 p.m., on 8/21/2020, CNA 3 stated she was orienting CNA 4, the night Resident 1 eloped. CNA 3 stated CNA 4 was sitting in the hallway next to a table and left to ask CNA 3 a question about charting. CNA 3 stated CNA 4 noticed the table was missing when she returned. During a phone interview, on 10/15/20 at 3:47 p.m., CNA 4 stated she went to ask CNA 3 a question about charting and when she returned to her table in the hallway, the table was gone. CNA 4 stated she was gone from the table for about three minutes. CNA 4 stated the table was outside on top of the bench and did not see Resident 1. During a telephone interview on 10/22/2020 at 8:37 a.m., the Director of Staff Development (DSD) stated the facility was a locked unit. The DSD stated residents at risk for elopement included residents with [MEDICAL CONDITIONS] (a severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality) and dementia. The DSD staff must always monitor and supervise the residents. The DSD stated there was bench in the patio near the gate that Resident 1 used to climb over the wall to elope. The DSD stated quieter fans can be used to dry the floor to reduce noise level in the facility. During a telephone interview, on 10/22/2020 at 8:50 a.m., the DON stated the facility had a 14 feet tall wall fence and that Resident 1 should not have escaped. The DON stated CNA 3 should not have left the resident unattended, when CNA 3 found the resident outside in the patio, and residents must not be left alone in the patio unsupervised. The DON stated the care plan should reflect on how the facility would prevent elopement for Resident 1. The DON stated no one was monitoring the patio. A review of the facility's undated policy titled, Monitoring Residents, indicated residents identified to have behavioral symptoms potential to conflict and anger shall be monitored in accordance with plan of care. The monitoring of such residents shall be the responsibility of but not limited to direct caregivers, charge nurses, nursing supervisors and members of the interdisciplinary team. A review of the facility's policy titled, Accommodation of needs-Comfortable and Quiet Environment, dated 1/17/2020, indicated efforts will be made to individualize the resident's environment, visit the resident frequently to ensure needs are met and take necessary actions if indicated. The facility will access noise level in the resident's unit and offer the resident to move to another room. A review of the facility's policy titled, Elopement Prevention and Management, dated 1/17/2020, indicated the facility will minimize elopement to maximum extent possible. If resident elopes will prevent bodily injury and death. Provide staff education on dementia program on early warning signs of elopement i.e. agitation, restlessness, attempting to open doors, expression of the desire to leave, wanting to be alone in an isolated area near windows or doors. A review of the facility's policy titled, Residents at Risk for Elopement, dated 1/17/2020, indicated the facility staff will recognize the risk of elopement for proper prevention and intervention of potential elopement and care planned for.

Based on record review and interview, the facility staff failed to provide adequate supervision and assistive devices to prevent accidents for one of three sampled residents (Resident 1), who was at risk for wandering (going about from place to place) and falling by failing to: 1. Redirect Resident 1 when wandering in hallways as indicated in Resident 1's care plan for dementia (an overall diseases characterized by a decline in memory, language, and problem solving). 2. Place the resident's room close to nurse's station and provide a personal assistive device such as a front wheel walker as indicated in Resident 1's Super Star Program (being a severely high risk for falls) care plan. These deficient practices resulted in Resident 1 sustaining a left leg fracture (a break in the bones) and requiring a transfer to a general acute care hospital (GACH) where she underwent an open reduction and internal fixation (ORIF, a surgical repair of broken bones) with a trochanteric femoral (hip area) nail to the left leg. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/21/19, indicated the resident needed partial assistance from another person to ambulate. A review of Resident 1's initial Rehab Fall Risk assessment dated [DATE] indicated the resident showed limited assistance during bed mobility, transferring, and walking. Resident 1 demonstrated proper safety while using an assistive ambulation device. The assessment did not indicate the type of assistive device Resident 1 used to ambulate. The therapist's rehab assessment indicated recommendation for Resident 1 to have a physical therapy evaluation. On 1/17/19 at 12:07 p.m., during an interview and record review with an Occupational Therapist 1 (OT 1, a health professional who is responsible for helping patients regain their ability to perform daily living and work activities), the OT 1 stated that Resident 1's Rehab Fall Risk assessment dated [DATE] indicated that Resident 1 required an assistive device. The OT 1 stated that the assessment did not indicate the type of device Resident 1 required. The OT 1 stated that Resident 1 always needed her walker and that it was important to document the type of assistive device to communicate with other staff caring for Resident 1. On 1/17/19 at 12:07 p.m., during an interview and record review, OT 1 stated that Resident 1's record titled, PT Evaluation & Plan of Treatment, dated 6/18/19, indicated Resident 1 received a physical therapy evaluation indicating that Resident 1 required contact guard assistance (CGA) for bed mobility, transfers, and gait ambulation. A review of Resident 1's care plan titled, Plan of Care - Physical Therapy, dated 6/18/19, indicated Resident 1 required therapeutic exercises, needed bed mobility, transfer, and gait training. A review of Resident 1's History and Physical (H&P) dated 6/19/19, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's care plan titled, Fall Risk initiated on 3/25/19 and revised on 9/15/19, identified the resident as being at risk for falls/injury due to behavioral problems, dementia, poor balance, poor safety awareness and judgment. The interventions included placing the call light and frequently used items within easy reach, observing the resident frequently, and providing a safe and clutter-free environment. A review of another care plan for Resident 1 titled, Dementia/BPSD (Behavioral and Psychological Symptoms of Dementia - such as repetitive disturbed perception, thoughts and behaviors) initiated on 3/25/19 and revised on 9/15/19, indicated Resident 1 as being at risk for wandering. The care plan interventions included providing the resident with redirection. A review of Resident 1's Change of Condition (COC)/Interact Assessment Form- Situation Background Assessment and Recommendation ((SBAR) internal documentation technique to facilitate prompt and appropriate communication) dated 7/13/19 at 2:00 p.m., indicated the resident fell while ambulating. According to the COC-SBAR, the staff did not witness the fall and the resident sustained [REDACTED]. The management plan indicated to observe, monitor, and transfer the resident to a General Acute Care Hospital (GACH) for evaluation of the wound. Resident 1 received staples to the laceration on the back of the head. A review of Resident 1's care plan dated 7/13/19 titled, Post Fall indicated to place the resident in the super star program (being at severely high risk for falls). A review of Resident 1's care plan dated 7/13/19 titled, Super Star Program, indicated to prevent future falls by providing frequent visual monitoring, placing the resident's room close to nurse's station for close observation, and using personal/assistive devices (such as a walker, cane, or grab bars). A review of Resident 1's COC/SBAR dated 9/24/19 at 6:05 a.m. indicated the resident lost her balance, tripped and fell . A review of Resident 1's Multidisciplinary Progress Record dated 9/24/19 at 6:05 a.m., indicated Certified Nurse Assistant 2 (CNA 2) found Resident 1 on the floor in another resident's room. CNA 2 notified Licensed Vocational Nurse 2 (LVN 2) about Resident 1's fall and LVN 2 assessed the resident. When LVN 2 was checking Resident 1's range of motion (ROM; full movement potential), Resident 1 complained of pain in the left leg. At 6:15 a.m., LVN 2 notified the attending physician and received an order for [REDACTED]. A review of Resident 1's Radiology Report dated 9/24/19 at 1:45 p.m., indicated no fracture (break in the bone). A review of Resident 1's Multidisciplinary Progress Record (nurse's notes), dated 9/24/19 at 4 p.m., indicated that the licensed nurse notified Resident 1's physician regarding the results of the radiology report dated 9/24/19. The licensed staff notified Resident 1's physician that Resident 1 still complained of pain. The licensed staff administered [MEDICATION NAME] (a medication used to treat moderate to severe pain) to Resident 1 for pain management. Resident 1's physician ordered a repeat X-ray. A review of Resident 1's radiology report of the left hip, dated 9/25/19, indicated Resident 1 had a [MEDICAL CONDITION] hip with mild loss of alignment (position). A review of Resident 1's Multidisciplinary Progress Record, dated 9/25/19 at 9:30 a.m., indicated the licensed nurse notified Resident 1's physician and received orders to transfer Resident 1 to a GACH for evaluation. On 10/9/19 at 1:20 p.m., during a review of Resident 1's clinical records and concurrent interview, the director of nurses (DON) stated the facility did not have a specific resident assessment for wandering behaviors. The DON stated the facility's interventions for residents wandering in the hallways included redirecting the residents back to their rooms. The DON stated there was no documentation the facility staff provided Resident 1 with frequent visual monitoring, placed the resident's room close to the nursing station for closer observation, or provided the resident with a walker. The DON added LVN 2 should have redirected Resident 1 on 9/24/19 at 6 a.m., back to her room when the LVN 2 saw Resident 1 walking in the hallway. On 10/10/19 at 7:25 a.m., during a telephone interview, LVN 2 stated he observed Resident 1 walking in the hallway on 9/24/19, before the fall without an assistive device. LVN 2 stated he thought it was fine to let the resident walk because she was not at risk for wandering or falling and her gait looked good. LVN 2 added he should have looked at Resident 1's care plan. LVN 2 confirmed that Resident 1 needed visual observation. LVN 2 also stated he would normally communicate to other staff to keep an eye on the resident, but he did not tell anyone to watch her that morning, because the resident looked okay. On 10/10/19 at 11:10 a.m., during an interview, the DON stated the facility does not have a written policy and procedure to provide guidance for residents who have behaviors of wandering. On 2/13/2020 at 2:55 p.m., during a telephone interview, the DON stated that frequent visual monitoring meant staff monitored the resident at a minimum of every two hours. The DON also stated that when staff indicate on resident care plans to provide frequent visual monitoring, it does not provide staff with measurable timeframes to monitor. A review of Resident 1's Emergency Department (ED) Report from the GACH dated 9/25/19, indicated Resident 1 had shortening and external rotation of the left lower extremity (the leg rotates outward, away from the rest of the body). Resident 1 also had tenderness to the left hip and limited range of motion (movement) secondary to deformity (not the normal shape because of injury or illness), and severe pain. A review of Resident 1's GACH untitled procedure report, dated 9/26/19, indicated Resident 1 had an ORIF with a trochanteric femoral nail to stabilize and repair the broken bone in her hip. A review of Resident 1's GACH record titled, Progress Notes, dated 9/29/19, indicated the resident's public guardian preferred Resident 1 not to return to the facility due to the recurring falls.

1. Effectively communicating the current [MEDICATION NAME] (a blood thinning medication used to prevent the formation of a blood clots) dosage, to the physician, after receiving an elevated International Normalization Ratio (INR-a laboratory test to measure the bleeding tendency. Reference range: 2.00 - 3.00) laboratory level of 3.6. According to the National Institute of Health, Blood clots are formed through a series of chemical reactions in your body. [MEDICATION NAME] works by decreasing the activity of vitamin K; lengthening the time, it takes a clot to form. International Normalized Ratio (INR) and [MEDICATION NAME] Time (PT) are laboratory test values obtained from measurements of the time it takes blood to clot. Individuals at risk for developing blood clots take [MEDICATION NAME] to lengthen the usual time it takes for a clot to form; resulting in a prolonged; INR/PT. Doctors usually measure the INR/PT every month in patients taking [MEDICATION NAME] to make sure it stays in the desired range. (http://www.nih.gov). This failure of not effectively informing the physician of the current [MEDICATION NAME] dosage resulted in Resident 6 experiencing vaginal and mouth bleeding, requiring an emergency hospitalization , and a blood transfusion (the process of receiving blood products into one's circulation intravenously) of two units of blood. 2. Failing to ensure that licensed nurses were taking blood pressure before giving [MEDICATION NAME] (an antihypertensive medication used to lower high blood pressure) 1 of 17 sampled residents (11). This failure has the potential of resulting in side effects such as [MEDICAL CONDITION] (low blood pressure) from the blood pressure medication. Findings: On 4/19/16, at 7:55 a.m., during the initial tour, Resident 6 was lying in bed watching television. Two days later, on 4/21/16 at 8:00 a.m., Resident 6 ' s bed was vacant. When asked, Licensed Vocational Nurse (LVN) 3 stated the resident was sent to the emergency room , at a local acute care hospital, on 4/20/16, during the 11 p.m. to 7 a.m. shift, because she was bleeding from her mouth and vagina. A review of Resident 6's Admission Face Sheet indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] The resident [DIAGNOSES REDACTED]. functioning) [MEDICAL CONDITION] embolism (blood clot in the lungs), hypertension (high blood pressure), diabetes mellitus (high blood sugar levels), [MEDICAL CONDITION] (a decrease in the amount of red blood cells ) and [MEDICAL CONDITION] (a type of joint disease that results from breakdown of joint cartilage and underlying bone). A review of an annual Minimum Data Set (MDS), a resident assessment and care screening tool, dated 3/4/16, indicated Resident 6 had memory problems, impaired decision-making, was able to make needs known and understand others. According to the MDS, the resident was assessed as being independent with bed mobility, transferring, locomotion on and off the unit, requiring supervision with eating and limited assistance with personal hygiene. A review of Resident 6's care plan initiated on 2/23/15, identified a problem with a history of gastrointestinal (GI-stomach and intestinal) bleeding. The goal indicated that there would not be any unrecognized signs and symptoms of bleeding or GI distress daily. The interventions were to assess for signs and symptoms of bleeding: blood in urine or stool, and or coffee ground emesis (vomit) and to notify the physician if any of these symptoms were present. Laboratory tests (INR/PT) as ordered and to notify the physician of abnormal results promptly. A review of the physician's orders [REDACTED]. Another physician's orders [REDACTED]. A review of Resident 6's Medication Administration Record [REDACTED]. A review of Resident 6 ' s PT/INR laboratory results indicated the following: Date/TimePTINRINR Preference Range (2 to 3)10/01/15, 7:00 a.m.15.6 1.4210/20/15, 6:55 a.m.35.33.21Above range11/19/15, 6:15 a.m.29.02.6412/03/15, 6:20 a.m.30.82.8001/11/16, 8:40 a.m.34.83.16Above range02/14/16, 6:20 a.m.26.12.3703/09/16, 6:30 a.m.26.32.3904/07/16, 6:30 a.m.42.43.64Above range A review of a physician's order [REDACTED]. The physician gave orders to increase the [MEDICATION NAME] to 7 milligrams by mouth, at bedtime, every Monday, Tuesday, Wednesday, Thursday, and Friday. And to increase the [MEDICATION NAME] to 6 milligrams by mouth, at bedtime, every Saturday and Sunday. The INR was to be repeated in one month. A review of the Multidisciplinary Progress Record, dated 4/21/16 at 1:50 a.m., indicated that Certified Nursing Assistant (CNA) 4 was doing rounds when Resident 6 asked the CNA to change her clothing. CNA 4 noted that Resident 6 was bleeding from her vagina and mouth. CNA 4 cleaned Resident 6 and made her comfortable. The resident denied pain or discomfort and was in no acute distress. CNA 4 reported Resident 6 ' s bleeding to the charge nurse. At 1:55 a.m., the Progress Record indicated the charge nurse notified the physician, about Resident 6 ' s bleeding, and orders were given to transfer her to the emergency room for evaluation. At 3:20 a.m., Resident 6 was transferred to the emergency room of a General Acute Care Hospital (GACH) via ambulance. A review of the emergency room ' s Physician Initial Admitting Order, dated 4/21/16, indicated Resident 6 was admitted to a Medical/Surgical floor for observation with a [DIAGNOSES REDACTED]. A review of Resident 6's emergency room (ER) Medication Administration Record [REDACTED]. A repeated dose of Vitamin K was to be given in the morning. A review of the acute care hospital ' s adult PRN (as needed) medication orders dated 4/21/16 at 5:43 a.m., indicated to transfuse (blood is given through an intravenous (IV) line into one of the blood vessels) fresh frozen plasma (a unit of fresh frozen plasma (FFP) contains all the coagulation (clotting) factors, used for patient who are bleeding or at risk for bleeding). The hospital Progress Notes dated 4/21/16, at 11:00 a.m., indicated Resident 6 received 2 units of fresh frozen plasma. A review of Resident 6 ' s hospital PT/INR laboratory results indicated the following: On 4/21/16, 4:00 a.m. the PT result was > (greater than)120 (Reference Range 9.5-11.5) and the INR was >10 (Reference Range 0.80-1.20), indicating an high INR results. On 4/22/16, 6:00 a.m. the PT result was 22.8 (Reference Range 9.5-11.5) and the INR was 1.99 (Reference Range 0.80-1.20), indicating an high INR results. On 4/22/16 at 1:06 p.m., an interview was conducted with Registered Nurse (RN) 1 from the skilled nursing facility (SNF), who stated she thought the INR level was 3 to 4, but no more than 4. RN 1 was asked what happens if the resident ' s INR is elevated. RN 1 stated she would call the doctor and tell him to discontinue the medication. When asked why Resident 6 ' s [MEDICATION NAME] dosage was increased, when the INR results were elevated. RN stated, I cannot fight the doctor because he is the doctor . On 4/25/16, at 1:23 p.m., a telephone interview was conducted with Physician 1. Physician 1, who is also the medical director at the SNF, stated he thought Resident 6 was receiving 7 milligrams of [MEDICATION NAME] routinely and dropped the [MEDICATION NAME] to 6 milligrams. Physician 1 stated he wasn't aware of the previous [MEDICATION NAME] order. The skilled nursing policy and procedure titled [MEDICATION NAME] therapy , undated, and it stipulated when a resident with [MEDICATION NAME] prescriptions are admitted to the facility, an order for [REDACTED]. The goal is to maintain Pro Time at 1.5 times the normal value. The prolonged use of this medication shall be monitored closely by the physician and the nursing staff. Any sign of bleeding shall be brought to the physician's attention immediately. 2. On 4/19/16 at 9 a.m., Resident 11 was observed waiting in line to receive his [MEDICATION NAME] (medication used to treat high blood pressure) 25 milligrams (mg) one tablet. The nurse gave Resident 11 his [MEDICATION NAME] without first checking his blood pressure. A review of the Resident 11's face sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set, (MDS- a resident assessment and care screening tool) dated 2/29/16, indicated the resident is both cognitive and able to communicate his needs. He was assessed as needing minimal assistance in all activities of daily living (ADLs) such as transferring, locomotion, dressing, toilet use, eating, personal hygiene, and bathing. A review of Resident 11's care plan dated 3/28/11 titled, At risk for cardiac distress related to hypertension , indicated that staff will monitor the resident's pulse rate and blood pressure and assess for signs and symptoms of [MEDICAL CONDITION] (low blood pressure). A physician's order [REDACTED]. The order indicated [MEDICATION NAME] should not be given if the systolic blood pressure (SBP- top number in a blood pressure reading) is less than 110. On 4/19/16, at 7:30 a.m., a review of the Medication Administration Record [REDACTED]. On 4/25/16, at 1:27 p.m., during an interview, LVN 1 stated, The blood pressure was taken prior to medication administration and she knew (the numbers) by heart that it (the blood pressure) was within range. On 4/26/16, at 1:45 p.m., in an interview, the Director of Nurses (DON) stated during a conversation with the medical director, blood pressure medications can be given without taking the blood pressure, if the resident is asymptomatic. He further stated that he did not record the conversation with the medical director and he also did not have documentation on how to assess for signs and symptoms of hypo/hypertension (high or low blood pressure). A review of the facility's undated policy and procedure, titled Blood Pressure: prior to administration of medications, indicates resident's blood pressure (b/p) will be taken prior to the administration of an antihypertensive medication and record blood pressures on the residents Medication Administration Record [REDACTED]